Sandy response points to possible bigger role for ethics during disasters
Sandy response points to possible bigger role for ethics during disasters
Ethics is central to disaster planning
There is nothing like a mandatory hospital evacuation to underscore the importance of including ethics in emergency preparedness, according to Kenneth W. Goodman, PhD, professor and director of the Bioethics Program at University of Miami (FL). "Indeed, the most difficult decisions might have less to do with transportation, logistics, or resources, but everything to do with ethics," he says. "This is applied ethics on steroids: Life and death in the balance, and no dithering permitted. This is why preparedness is so important. You don't want to have to make these calls on the fly."
Decisions range from "Who goes first?" to "Who doesn't get to go at all?"— questions which must be answered by focusing on ethics, evidence, and available resources, says Goodman. "The ethical foundations include saving as many lives as possible while not perpetuating disparities," he explains. "The evidence will tell us who is most likely to survive and who is not. Knowing what resources you have will provide the glue for linking the two."
Hospital evacuations confront the ethical challenge of balancing risk and uncertainty with the risk of physically moving patients balanced with the risk of staying in place, says Amy Fairchild, PhD, MPH, professor at the Center for the History and Ethics of Public Health at the Columbia University Mailman School of Public Health in New York, NY.
"Moving a critically ill patient carries a health risk, and trying to move someone in the midst of a hurricane, of course, increases the risks," she says, noting that providers at NYU Langone Medical Center carried premature babies down nine flights of stairs while nurses hand-pumped oxygen. "Providers don't want to move such fragile infants dependent on respirators for survival until the risk of staying outweighs the risk of moving them. The same is also true of the frail or elderly."
There have been instances in which nursing home patients have been moved and suffered heart attacks, adds Fairchild. "We do have a special ethical duty to people made vulnerable by sickness or deteriorating health or cognition," she says. "There is little question that once the decision has been made to evacuate, patients have no choice in the matter."
Allocation of resources
The central ethical issue with providing care during a hurricane and other disasters is allocation of scarce resources, says Gregory R. Moore, MD, MPH, senior director of Stamps Health Services at Georgia Institute of Technology in Atlanta. "This is essentially triage, in which you assess the needs and the resources and then try to match them to provide the most benefit to the most people," he says. "In the most severe situations, it can come down to who lives and who dies."
Rationing of medical care occurs whenever resources aren't enough to serve medical needs, but what differs in emergency evacuations is that such decisions have to be made very unexpectedly and very quickly, says H. Steven Moffic, MD, author of The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997), and former professor of psychiatry and family and community medicine at the Medical College of Wisconsin in Milwaukee.
For instance, a decision must be made as to who is to be evacuated first and last, and whether this should be based on the severity of illness, on the basis of those likely to recover from their illness, or the patient's age. "Apparently, at NYU Langone Medical Center, the youngest and sickest were evacuated first, including some 20 babies in neonatal intensive care," Moffic says.
While the most widely accepted bioethical principles are patient autonomy, non-maleficence, beneficence, and justice, these seem to be of limited usefulness in an emergency evacuation, says Moffic, as there may not be enough time for patients to understand their choices and everyone can't be taken care of in the same way at the same time. "Harm, to some degree, is a likely byproduct of the evacuation itself," he adds. "Justice will be influenced by chance and unexpected circumstances or consequences."
Natural disasters and public health emergencies transform not only the usual and customary approaches to patient care, but also the prevailing ethics of patient care, according to Ben A. Rich, JD, PhD, professor and School of Medicine Alumni Association Endowed Chair of Bioethics at University of California — Davis Health System.
"The underlying presupposition is that the exigencies of the event do not permit all patients to receive the prevailing standard of care for their medical condition," he says. "Tough decisions must be made about how to allocate scarce human and material resources." Rich says the guiding principle should be: What would a reasonable institution or health care professional do under the circumstances to minimize risk to all of the patients under the circumstances as they appear at the critical point in time?
"This last point is important, since the key decision makers may have incomplete or perhaps even inaccurate information upon which they might have to base their decisions," says Rich.
Role of ethicists
Bioethicists have a clear role in contributing to the development of institutional policies and procedures to govern an institution's response to disasters and public health emergencies, as "in real time, there is less opportunity for 'stat' ethics consults," says Rich.
Ethicists should be involved in the decision-making process for hospital evacuations, as they can identify ethical trade-offs that might not otherwise be considered, argues Fairchild. "They can use ethical principles to answer the question: 'What would be the bigger ethical — as opposed to political — mistake?'" she says. "Is it creating hardship and potentially contributing to some casualties by [evacuating] or accepting the potential for misery and death by failing to take decisive steps?"
Individuals in various positions of power might have differing priorities that need to be reconciled by an ethicist, says Moffic. "Politicians will not want to be blamed for being ill-prepared, whereas administrators may tend to be more concerned with the entire hospital and institution, rather than the individual patient of most concern to the doctor and nurse," he says. Ethicists can also be a source of moral support for the healthcare professionals involved in a disaster, he adds.
"Most hospitals have an ethics committee that deliberates tough medical decisions, but these deliberations are usually not as time-sensitive," says Moffic. He argues that hospitals should consider having ethicists on-call for disasters, just like other medical and administrative personnel.
"For now, their role in such a crisis is both to review the emergency responsiveness after the fact, as well as to suggest ways to prepare better for the next," says Moffic. "It is to help share the God-like responsibility of deciding who may live and who may die when life-threatening choices need to be made."
Sources
Amy Fairchild, PhD, MPH, Center for the History and Ethics of Public Health, Columbia University Mailman School of Public Health, New York, NY. Phone: (212) 305-1724. Fax: (212) 342-1986. E-mail: [email protected].
Kenneth W. Goodman, PhD, Professor and Director, Bioethics Program, University of Miami (FL). Phone: (305) 243-5723. Fax: 305-243-6416. E-mail: [email protected].
H. Steven Moffic, MD, Milwaukee, WI. Phone: (414) 352-1985. E-mail: [email protected].
Gregory R. Moore, MD, MPH, Senior Director, Stamps Health Services, Georgia Institute of Technology, Atlanta. Phone: (404) 894-1420. E-mail: [email protected].
Ben A. Rich, JD, PhD, Professor, School of Medicine Alumni Association Endowed Chair of Bioethics, University of California — Davis Health System. Phone: (916) 734-6135. E-mail: [email protected].
There is nothing like a mandatory hospital evacuation to underscore the importance of including ethics in emergency preparedness, according to Kenneth W. Goodman, PhD, professor and director of the Bioethics Program at University of Miami (FL).Subscribe Now for Access
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