Disaster Planning: Shifts in Ethical Priorities

1. Disaster Planning: Shifts in Ethical Priorities Jan C. Heller, Ph.D. Ethics and Theology Providence Health & Services

2. Introduction • It can be hard to define disasters precisely • A working definition: A disaster is what we have when our emergency response systems fail • Also, no easy way to categorize them • Natural and human (though war and terrorism are sometimes excluded from list) • Sudden and slow (earthquake vs. climate change) • Winners and losers (certain Latinos vs. African Americans after Hurricane Katrina) • Mass casualties with or with out hospital involvement (9/11 vs. Severe Acute Respiratory Syndrome [SARS])

3. Introduction • A key distinction: Ethics of/in disasters • N B King, The Ethics of Biodefense, Bioethics 19 2005: 432-446 • Ethics of disasters • Evolution in understanding disasters…current thinking is that humans cause all disasters, even natural disasters • “Human beings, not nature, are the cause of disaster losses. The choices that are made about where and how human development will proceed actually determine the losses that will be suffered in future disasters.” • Dennis S. Meleti, Disasters by Design: A Reassessment of Natural Hazards in the United States, p. 27.

4. Introduction • But, deciding how to allocate moral accountability (or blame) for disasters is harder than we might think… • “We live in a morally flawed world, one full of regrets and reproaches. Some of the things we regret, or for which we are reproached, we bring about intentionally and on our own. But our lives are increasingly complicated by regrettable things brought about through our associations with other people or with the social, economic, and political institutions in which we live our lives and make our livings.” • Christopher Kutz, Complicity: Ethics and Law for a Collective Age, p. 1.

5. Introduction • Our focus today is on ethics in disasters • Ethical issues that hospitals and medical personnel are likely to encounter in or during disasters, especially those triggered by epidemics or pandemics • Presentation largely dependent on • Task Force for Mass Critical Care, Chest 2008: 133; 51-66 (American College of Chest Physicians)

6. Introduction • Not discussed today…but still very important medically and ethically • Empirical review of preparedness (we’re not even close!) • Technical aspects of modified standards of care for emergency mass critical care (EMCC) (these have been worked on, but need more research and refinement) • The “stuff,” “staff,” and “space” requirements for responding to surge during EMCC (e.g., access to protective gear and vaccines for clinicians)

7. Setting the Stage • Assumptions • Disaster declared, (epidemic or pandemic) with mass casualties requiring hospitalization in critical care units • Authorization for execution of EMCC plan • At least triple the usual ICU capacity • Must deliver EMCC for at least 10 days without external assistance

8. First Shift: A Paradigm Shift • Traditional medical ethics may not be adequate… • Traditional medical ethics • Typically focused on an individual’s health • Often reveals preference for individual autonomy or preferences • Public health ethics • Typically focused on health of populations • More concerned with maximizing benefits and social justice • Can more easily justify use of coercion • Baum, Gollust, Goold, and Jacobson, “Looking Ahead: Addressing Ethical Challenges in Public Health Practice,” Journal of Law, Medicine, and Ethics (Winter 2007): 657-667.

9. First Shift: A Paradigm Shift • Behind this shift is the role that scarcity plays in moral analysis… • No scarcity (or abundance) • Ideal situation: no ethical trade-offs required • Moderate scarcity • Assumed in medical ethics, leads to procedural fixes • Radical scarcity • Assumed in disaster ethics, leads to very hard choices

10. First Shift: A Paradigm Shift • Keep this shift in mind as we discuss the issues below • Most of us working in health care share an individualistic bias • Two possible implications… • In a disaster, to save more (and different?) people we may have to violate some of our long-held ethical principles • On a theoretical level, note that circumstances can make a profound difference on our moral choices

11. Second Shift: Loss of Physician Autonomy • Physician’s traditional role of choosing a course of treatment and advocating for his or her patient will yield to the authority of triage officer • Triage officer… • Is in charge • Assesses all patients • Assigns level of priority for each • Directs attention to highest-priority patients

12. Second Shift: Loss of Physician Autonomy • Triage officer is expected to make decisions that benefit the greatest number of patients given limited resources, even though these decisions may not necessarily be best for an individual patient • A utilitarian assumption, to be explored more deeply below… • No appeal process for clinical decisions, though some appeal possible if officer violates triage rules

13. Third Shift: Use of Triage • Purpose of triage: Optimize flow through system and protect “downstream” resources from being overwhelmed • Note what’s missing…the needs of the individual patient (but recall, this impersonal approach is intended to address a population of patients) • Focus today on tertiary triage • Primary: EMTs, probably in a field hospital • Secondary: ED • Tertiary: Controls access to critical care units

14. Third Shift: Use of Triage • Assumptions • Triage “algorithm” based on objective and quantitative criteria • During disaster conditions, applies equally to all patients needing critical care, regardless of reason • Inclusion criteria for admittance to critical care • Patients must require active critical care interventions • “Observation only” patients should not be included • Those included treated on “first come, first served” basis • Return to this below…

15. Third Shift: Use of Triage • Exclusion criteria • Very high risk of death or little likelihood of long-term survival, and • Low likelihood of benefit from critical care resources • Sequential Organ Failure Assessment (SOFA) score • Severity of chronic illness • Consider also likely duration of critical care needed • Longer duration of one patient uses resources that could be used for multiple, shorter-duration patients

16. Third Shift: Use of Triage • Two interesting exceptions… • Those already on ventilators in long term care settings would not be removed from them, unless they became infected, at which point they would be triaged as any other patient • Euthanasia, or intentionally causing death to relieve suffering, is ruled out for ethical reasons, though all patients excluded by triage should receive palliative care

17. An Emotional Interlude • Try to imagine how you’re going to feel as a clinician working in such conditions • In theory, these criteria apply equally to you, if you get infected, and to your family and friends • Patients, whoever they may be, who are not responding to treatment quickly enough will have to be removed from ventilators, even though they might have been saved under normal conditions • What have we done to prepare ourselves emotionally for making such choices? • Is there anything we could do to prepare?

18. Evaluating Triage Ethically • Prima facie, justified by circumstances of radical scarcity, and after all other possibilities (e.g., transferring, sharing resources) have been exhausted • Supported by public (transparent), objective physiologic criteria, fairly and impartially applied • Regularly evaluated for fair application of criteria to promote provider compliance

19. Evaluating Triage Ethically • This said, should we try to save the most lives, as implied by the Chest guidelines? • Consider three principles proposed to guide our triage efforts… • Save the most lives principle • Chest’s utilitarian recommendation • Life cycle allocation principle • Investment refinement, public order principle • E J Emanuel and A Wertheimer, “Who Should Get Influenza Vaccine When Not All Can?” Science, 312 (12 May 2006): 854-5.

20. Evaluating Triage Ethically • Save the most lives principle • Values human life equally, regardless of age, disability, class, or employment • Justifies giving higher priority to vaccine production and health care workers • Not because they’re socially better, but to save more people (like including a few sailors in lifeboats) • Next priority goes to those in highest need (traditional need-based criterion)

21. Evaluating Triage Ethically • Save the most lives principle is good when urgency does not allow for deliberation, but consider… • Life cycle allocation principle • Life cycle principle claims that each person should have an opportunity to live through all stages of life and enjoy opportunities during each stage • Gives greater priority to younger over older patients

22. Evaluating Triage Ethically • But a “pure” life cycle principle needs refinement, too… • Grants priority to 6 mo. infant over 2 year old or adolescent • Investment refinement, public order principle • Gives priority to people between early adolescence and middle age • Public order qualification focuses on public safety and provision of necessities such as food and fuel • To provide for people generally and to speed recovery

23. Questions and Discussion