Ethics and Disasters

1. Ethics and Disasters Patricia Reynolds Director, Bishopric Medical LibrarySarasota Memorial Hospital Sarasota, FL

2. Ethics and Disasters: a topic of epic proportions • Disasters and emergencies are: • International and local • Multicultural, multi-ethnic, multi-religious • Environmental and man made • Involve governments, NGO’s, corporations, victims, workers, and the press • Ethics implications are at the core of preparation, policies, response and recovery

3. Ethics and Disasters • What is a disaster? • Why do we need to know the ethical basis of disaster preparation and response? • What is special about disasters that motivates people to act and respond ethically? How is this manifested? • What are the relevant ethical principles that form the basis of our actions and reactions?

4. What is a Disaster? • “A disaster is an event (or series of events) that harm or kills a significant number of people or otherwise severely impairs or interrupts their daily lives in civil society. Disasters may be natural or the result of accidental or deliberate human action. Disasters include, but are not limited to, fires; floods ; storms; earthquakes; chemical spills; leaks of, or infiltration by, toxic substances; terrorist attacks by conventional, nuclear or biological weapons; epidemics; pandemics; mass failures in electronic communications; and other events that officials and experts designate “disasters”” • “Disasters always occasion surprise and shock; they are unwanted by those affected by them, although not always unpredictable. Disasters always generate narratives and media representations of the heroism, failures and losses of those who are affected and respond.” Zack, N. (2009). Ethics for disaster. Lanham, Maryland: Rowman & Littlefield Publishers, Inc.

5. Emergencies • Emergencies are typically local and can be dealt with local resources • Emergencies are typically of a shorter duration • A declaration of a state of emergency is usually done for disasters –   not emergencies.

6. Our Social Contract • “Government has an obligation, based on the justification of its origins, to prepare citizens for survival in second states of nature caused by disaster. Such preparation requires implementation through public policy.” John Locke • These rights are presumed in the US Declaration of Independence and protected by the first ten amendments of the constitution. Zack, N. (2009). Ethics for disaster. Lanham, Maryland: Rowman & Littlefield Publishers, Inc.

7. What is special about disasters that motivates people to act and respond ethically? • Basic human values of • Compassion, • Empathy, • Respect for dignity of others • Professional codes of conduct • “There but for the grace of God, go I” • More??

8. Ethical theories and ethical principles • Ethics is not about what is - but what should be. • Ethical relativism: morality varies between people and societies according to their cultural norms • Universalist or objectivist moral theories: fundamental principles that are invariant through out time and space. • “People have a basic right to safety and it is a fundamental obligation of all governments to ensure that their citizens are protected to a reasonable degree from known risk, and that citizens are informed and warned of any risks known to governmental officials that threaten public safety.” • “To respect the equal dignity of all human beings, recognizing a basic right to life and subsistence” • “The condemnation of coarse public sector corruption” • “The obligation to respect human autonomy” The Search for Principles of Disaster Management. Etkin D, Davis I,

9. Relevant Ethical Principles Procedural Principles Reasonable Open and transparent Inclusive Responsive Accountable “Stand on Guard for Thee. Ethical considerations in preparedness planning for pandemic influenza”. A report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. 2005 Substantive Principles • Individual liberty • Protection of the public from harm • Proportionality • Privacy • Duty to provide care • Reciprocity • Equity • Trust • Solidarity • Stewardship

10. General Ethical Principles • Solidarity • Joint responsibility • Non-discrimination • Humanity • Impartiality • Neutrality • Co-operation • Territorial sovereignty • Prevention • Fairness • Respect for person • Limiting harm • Role of the media

11. History of Ethics in Medicine and Healthcare

12. Hippocratic Oath – classic 1 I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: • To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. • I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. • I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

13. Hippocratic Oath – classic 2 Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, byLudwig Edelstein. Baltimore: Johns Hopkins Press, 1943. • I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. • Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. • What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. • If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

14. “Ethical Directives for the Practice of Medicine 1”Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004 • Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004 • 4th century B.C.E – Early 20th century • Oath of Hippocrates 4th century B.C.E. • Oath of initiation • Oath of Asaph • Advice to Physician • 17 Rule of Enjuin • Five Commandments and Ten Requirements 1617 • A Physician’s Ethical Duties from Kholasah al Hekman • Daily Prayer of a Physician (prayer of Moses Maimonidies) 1793 • Code of Ethics AMA 1847 • Venezuelan Code of Medical Ethics, National Academy of Medicine 1918

15. “Ethical Directives for the Practice of Medicine 2” Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004 Oath of Soviet Physicians 1971 Solemn Oath of a Physician of Russia 1992 Regulations on Criteria for Medical Ethics and their Implementation – China – 1988 Ethical and Religious Directives for Catholic Health Facilities 1971 – rev. 2001 Health Care Ethics Guide, Catholic Health Assoc. of Canada 1991 Oath of a Muslim Physician, Islamic Medical Assoc. of North America 1977 Islamic Code of Medical Ethics, Kuwait Document, Islamic Organization for Medical Sciences 1981 • Declaration of Geneva, World Medical Assoc 1948 • Intl Code of Medical Ethics 1949 • Principles of Medical Ethics AMA 1957 • Declaration of Professional Responsibility: Medicine’s social contract with humanity AMA 2001 • Charter on Medical Professionalism (2002) ABIM, ACP, etc • Code of Ethics, Am Osteopathic Assn 1998 • Code of Ethics and Guide to Ethical Behaviour of physicians.Canadian Medical Assoc 1996; New Zealand Medical Assoc. 2002 • Chile – 1983 • Brazil - 1988 • Norway – 2000 • Japan 1991

16. Global Ethics • Human Rights first explicitly declared internationally in 1948 in the United Nations’(UN’s) Declaration of Human Rights. • Not an international law – global paradigm • United Nations Charter • Health for All in the 21st Century” World Health Organization (WHO) • 1985 Tokyo Declaration by the World Medical Association against physicians being involved in torture • 1988 United Nations Resolution, the “Right to Intervene” • International Humanitarian Law (IHL) (IHL comprises the Geneva Conventions and the Hague Conventions) • The Helsinki Declaration protects the patients’ rights and integrity with regard to research. Ethics Landmark but not practical for disasters • endorsed at the General Assembly of the World Medical Association in Helsinki, Finland in 1964 HEALTH DISASTER MANAGEMENT Guidelines for Evaluation and Research in the Utstein Style Chapter 8: Ethical issues. PrehospDisast Med 2002;17(Suppl 3):128–143.

17. Professional codes of ethics • “Professions governed by Codes of Ethics approved by their members function on the assumption that these codes will not be violated in practice. When they are violated, practitioners may be guilty of malpractice, incurring criminal as well as civil and professional, penalties” Zack, Naomi Ethics for Disaster, 2009 Rowman & Littlefield Publishers. Series: Studies in Social, Political, and Legal Philosophy

18. Complex times Exportation of hazards constitutes an ethical issue and also, from time to time, a legal issue. Bhopal Famine in Africa

19. Solidarity • Deliberate and freely chosen unity among certain, groups or populations. This presupposes the awareness of unity and the acceptance of the consequences of unity. “When referring to healthcare, solidarity means the obligation to share the financial risks of illness and handicap with others not necessarily of one’s own social group.” • “Solidarity of interests is based on the principle of reciprocity: people share risks that are common to each other” • The principles of solidarity will be particularly applicable to memorandums of understanding with local organizations.

20. Joint Responsibility and Non-discrimination • Joint responsibility • Emergency management is not solely the domain of emergency management agencies; rather, it is a shared responsibility between governments, communities, businesses and individuals. • Non-discriminationNon-discriminationPrinciples of the Law (FEMA)http://www.fema.gov/iv-non-dscrimination-principles-law • Federal civil laws rights in Section VI of this Guide require equal access for, and prohibit discrimination against, people with disabilities in all aspects of emergency planning, response, and recovery. To comply with Federal law, those involved in emergency management should understand the concepts of accessibility and nondiscrimination and how they apply in emergencies.

21. The Guiding Principles on Internal Displacement The Guiding Principles seek to protect all internally displaced persons in internal conflict situations, natural disasters and other situations of forced displacement Unanimously adopted by The UN Commission and the General Assembly Internally displaced persons shall enjoy, in full equality, the same rights and freedoms under international and domestic law as do other persons in their country. These Principles shall be applied without discrimination of any kind, such as race, color, sex, language, religion or belief, political or other opinion, national, ethnic or social origin, legal or social status, age, disability, property, birth, or on any other similar criteria. Certain internally displaced persons, such as children, especially unaccompanied minors, expectant mothers, mothers with young children, female heads of household, persons with disabilities and elderly persons, shall be entitled to protection and assistance required by their condition and to treatment which takes into account their special needs. http://www.brookings.edu/about/projects/idp/gp-page Hurricane Katrina, New Orleans

22. Impartiality • The American Red Cross, as a member of the International Red Cross and Red Crescent Movement, adheres to the Fundamental Principles of the International Red Cross and Red Crescent Movement. http://www.redcross.org/portal/site/en/menuitem.d229a5f06620c6052b1ecfbf43181aa0/?vgnextoid=f5195032f953e110VgnVCM10000089f0870aRCRD&vgnextchannel=d18859f392ce8110VgnVCM10000030f3870aRCRD • Specifically, the Principle of Impartiality states, “It makes no discrimination based upon nationality, race, religious beliefs, class, or political opinions. It endeavors to relieve the suffering of individuals, being guided solely by their needs, and to give priority to the most urgent cases of distress.”

23. Red Cross

24. Code of Conduct for International Red Cross • The Code of Conduct for International Red Cross and Red Crescent Movement and NGOs in Disaster Relief was drawn up in 1992 by the Steering Committee for Humanitarian Response http://en.wikipedia.org/wiki/Steering_Committee_for_Humanitarian_Response to set ethical standards for organizations involved in humanitarian work. In 1994, the SCHR http://en.wikipedia.org/wiki/SCHR adopted the code and made the signing of it a condition for membership in the alliance. • 492 Signatories as of now - 2012

25. Standard of Care 1 • What is the meaning of “standard of care”? • How did Hurricane Katrina affect our understanding of the ethical implications of Standard of care? • How is the concept of triage affected by crisis standards of care? • What are the legal implications of crisis standards of care ?

26. Standard of Care 2 • The Standard of Care is a case- and time-specific analytical process in medical decision-making, reflecting a clinical benchmark of acceptable quality medical care. This benchmark, which is used to evaluate and guide the practice of medicine, encompasses the learning, skill and clinical judgment ordinarily possessed and used by prudent health care providers or payors of good standing in similar circumstances. • The standard of care must reflect the art (consensus of opinion of clinical judgment) and science (published peer reviewed literature) of medicine and must be uniform for all health care personnel whether they are providing direct clinical care or reviewing the medical necessity of past, present or future medical care. • A violation of standard of care may result in under-utilization of medical care, but also occurs when unnecessary care (over-utilization) is provided. • The standard of care has a national and clinical basis, rather than a local provider community or payor review basis. American College of Medical Quality, policy 3 http://www.acmq.org/policies/policies3and4.pdf

27. Crisis Standards of Care • 2009 – Institute of Medicine and the AHRQ sought national public input in creating a unified standard of care for disaster and emergencies. • Originally called Altered Standards of Care – changed to Crisis Standards of Care for legal reasons Crisis Standards of Care: Summary of a Workshop Series 2009 http://iom.edu/Reports/2009/Crisis-Standards-of-Care-Summary-of-a-Workshop-Series.aspx

28. Recommendations 1: • Develop consistent state crisis standards of care protocols with 5 key elements • A strong ethical grounding • Integrated and ongoing community and provider engagement, education and communication • Assurances regarding legal authority and involvement • Clear indicators, triggers and lines of responsibility • Evidence based clinical processes and operations IOM: Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report 2009 http://www.iom.edu/~/media/Files/Report%20Files/2009/DisasterCareStandards/Standards%20of%20Care%20report%20brief%20FINAL.pdf

29. Recommendations 2: • Seek community and provider engagement • special attention should be given to vulnerable populations • Adhere to ethical norms during crisis standards of care. • Conditions of overwhelming scarcity limit autonomous choices for both patients and practitioners regarding the allocation of scarce resources, but do not permit actions that violate ethical norms • Provide necessary legal protections for healthcare practitioners and institutions implementing crisis standards of care • Ensure consistency in crisis standards of care implementation • Triage teams, etc , Palliative care, Mental health support, Attention to vulnerable populations, Real time information sharing • Ensure intrastate and interstate consistency among neighboring jurisdictions

30. Institute of Medicine • Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations – Letter Report 2009 • Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response -2012 • vital templates to guide the efforts of professionals and organizations responsible for CSC planning and implementations • http://www.iom.edu/Reports/2012/Crisis-Standards-of-Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx

31. IOM: Continuum of incident care

32. “Crisis Standards of Care” A Community Conversation

33. How do disasters differ? Disaster” Defined What do disasters have in common? • People’s needs exceed available resources • Help cannot arrive fast enough • Some are long-lasting and widespread (flu pandemic) • Others are sudden and geographically limited (earthquake, terrorist attack)

34. Preparing for Disasters: The Challenge • Disasters can lead to shortages of critical medical resources • Shortages require hard decisions, for example— • Who should be at the front of the line for vaccines or antiviral drugs? • Which patients should receive lifesaving ventilators or blood? • In extreme cases, some people will not receive all of the treatment they need How do we give the best care possible under the worst possible circumstances?

35. Recent Examples Hurricane Katrina • Hospital overload H1N1 Pandemic • Vaccine shortage

36. The Response: “Crisis Standards of Care” Guidelines developed before disaster strikes— To help healthcare providers decide how to administer... THE BEST POSSIBLE MEDICAL CARE …when there are not enough resources to give all patients the level of care they would receive under normal circumstances.

37. When Might We Need Crisis Standards of Care? • Extreme Crisis • Hurricane • Flu Pandemic • Earthquake • Bioterrorism • Scarce Medical Resources • Blood • Ventilators • Drugs • Vaccines • Staff

38. Focus of Normal Care Focus of Crisis Care How Are Crisis Standards of Care Different?

39. Possible Reasons for Crisis Standards of Care • To make sure that critical resources go to those who will benefit the most • To prevent hoarding and overuse of limited resources • To conserve limited resourcesso more people can get the care they need • To minimize discrimination against vulnerable groups • So all people can trust that they will have fair access to the best possible care under the circumstances

40. Possible Strategiesto Maximize Care • Space • Put patient beds in hallways, conference rooms, tents • Use operating rooms only for urgent cases • Supplies • Sterilize and reuse disposable equipment • Limit drugs/vaccines/ventilators to patients most likely to benefit • Prioritize comfort care for patients who will die • Staff • Have nurses provide some care that doctors usually would provide • Have family members help with feeding and other basic patient tasks

41. When there isn’t enough to save everyone… how should we decide who gets what? Some options-- • First-come, first-served? • Lottery? • Save the most lives possible by giving more care to people who need it the most? • Favor certain groups? • The old OR the young? • Healthcare workers and other emergency responders? • Workers who keep society running (utility workers, transportation workers, etc.)?

42. Where Do You Come In? Community Conversations help policy makers: Understand community concerns about the use of limited medical resources during disasters Develop crisis standards of care guidelines that reflect community values and priorities

43. Preparing for Disaster Crisis Standards of Care (“CSC”)---a piece of the puzzle

44. The Deadly Choices at MemorialBy SHERI FINK Aug 25, 2009 New York Times Which of the following ethical considerations do not apply to the Pou case • Informed Consent • Immunity for healthcare workers • Palliative care • Allocation of scarce resources • Neutrality

45. What type of evacuation triage was set up in Memorial? • Sickest first • Lottery • Sickest last • Random selection

46. Ethical Principles Applied Prior to Disasters Disaster prevention in recreation and tourist areas Disaster prevention in public places – schools and hospitals Special prevention measures for the most vulnerable groups Organization of and participation in emergency drills Preventive evacuation of populations Ethical Principles on Disaster Risk Reduction and People’s Resilience, Prieur M. European and Mediterranean Major Hazards Agreement (EUR-OPA) http://www.coe.int/t/dg4/majorhazards/ressources/pub/Ethical-Principles-Publication_EN.pdf • Introduction of prevention measures • Importance of good quality healthy environment • Education, training and awareness raising • Participation – public input at national and local level • Freedom of expression • Access to justice • Disaster prevention at the workplace

47. Preparing for different types of disasters • Pandemics • Natural disasters • Burns, bombs and explosions • Biological • terrorism

48. Preparations • Random Selection – Lottery • As part of the preparation, planning must occur before a disaster to help alleviate any influences by immediate pressures that could cloud moral judgment. • The planning must be general in scope, but not too general that morally or factually is vacuous. • The planning ought to express our best moral principles and not go against them and be practical and possible to execute. • Make the plan optimistically and not violate existing moral principles.

49. Community Strategy for Pandemic Influenza Mitigationhttp://www.globalsecurity.org/security/library/report/2007/pr015-09.htm

50. Ethical Approach to Allocation of Scarce Resources and Triage • Fairness – inherently just to all individuals • Duty to care duty to steward resources • Duty to attempt to obtain best outcome for the greatest number of patients with available resources – does not mean save the most lives – a comfortable death may be a good outcome. • Transparency • Consistency • Proportionality • Accountability Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012 Mar;59(3):177-87. Epub 2011 Aug 19. Review. PubMed PMID: 21855170.