Question

2. Describe the ethical preparation, plans or activities of the family to disasters prior to, during and after the
2.1. outbreak
2.2. epidemic
2.3. pandemic

Answer 1

Ethical guidance, alongside legal and medical frameworks, is an increasingly common component of disaster response plans. This systematic review examines how frequently ethical guidance is offered for crisis standards of care (CSCs) during disaster response. A CSC declaration is a recognition that resources are limited, and that everyday standards of clinical care are not possible under the circumstances.

After the terrorist attacks of September 11, 2001, and the subsequent distribution of anthrax through the postal service, public health agencies and health care organizations in the United States began preparing in earnest for public health emergencies. Discussions initially focused on bioterror attacks, but attention soon shifted to pandemic influenza planning and then broadened to include natural disasters. Of particular interest are mass casualty events (MCEs), “act[s] of bioterrorism or other public health or medical emergenc[ies] involving thousands, or even tens of thousands, of victims.”1^(p5) A diverse array of crises may constitute MCEs. Some events—natural disasters such as earthquakes or floods, or terrorist attacks such as detonation of “dirty bombs” (radiological dispersal devices)—have sudden impact, with significant casualties at the outset of the event. Other events, such as influenza pandemics or acts of terrorism involving mass exposure to anthrax, have an extended impact, with casualties building to potentially catastrophic numbers over time. What these diverse events have in common is their potential to overwhelm the public health and health care systems, and thus to require rationing of scarce resources. Such events require responses that deviate significantly from typical standards of care.

In 2004, the US Department of Health and Human Services convened key experts in the fields of bioethics, emergency medicine and management, health administration, law and policy, and public health to offer guidance for planning for CSCs for MCEs (then referred to as “altered standards of care”).The resulting report posits that the goal of the response to an MCE should be “to maximize the number of lives saved,” and calls for attention to fairness, openness, transparency, and accountability in allocation of resources, and protection of the rights of individuals with respect to privacy, confidentiality, and imposition of limitations on personal freedom. Although the report identifies these ethical expectations, it does not offer substantive analyses justifying them or exploring their practical implications for implementing emergency response plans.

In 2009, the Agency for Healthcare Research and Quality released Mass Medical Care With Scarce Resources: The Essentials, to provide tools and models for emergency planners. The report includes a brief but more explicit discussion of ethical issues than the earlier Department of Health and Human Services report. It outlines key ethical considerations to consider in planning, contending that a “balance must be struck between utilitarian (the greatest good for the greatest number) and duty-based (respect for all human beings) planning assumptions.” An algorithm is presented to address areas in which ethical disagreements could occur in the planning process; this tool highlights norms such as respect for persons, beneficence, nonmaleficence, justice, truth telling, liberty, opportunity, and reciprocity. The report advocates that planners must provide clear and well-documented answers to ethical questions.

The primary justification offered for CSCs is one of necessity: given resource and staffing constraints in MCEs, public health or health care providers may not be able to adequately provide care to all patients who need it. A shift must occur in which the system moves from a primary focus on meeting the needs of individual patients to overall promotion of the public’s health—both current and likely future patients. Implementing CSCs may involve altered scopes of practice, modified staffing ratios, allocation of scarce resources, and choices to not employ extremely scarce resources that are staff-intensive (e.g., extracorporeal membrane oxygenation or potentially some forms of mechanical ventilation).20 All of these measures have ethical implications and so are appropriately addressed in an ethics framework for CSCs. The IOM notes that CSC plans should identify conditions that trigger the enactment of CSCs. Scholars are less concerned by that triggering process than what comes next—the ethical issues related to clinicians’ shift to a different mindset.