Abstract
Disasters are inevitable. Health-care providers operating in disaster zones must make decisions that are unique and different from those encountered in their routine health-care work environment. Treatment decisions made under disaster conditions must reflect available resources. Clinical practice is mainly concerned with individuals while the focus of humanitarian aid is on populations. In the context of disasters with limited resources there might be a conflict between individual rights and community benefit. Teams operating in devastated zones should be aware that their health-care providers will become fully engaged with such dilemmas. Ethical issues should be identified, and individuals should be prepared to confront them. Preparedness to deal with these will allow: better medical care, higher ethical standards, and better accountability to patients. Awareness and identification of ethical issues will help health care personnel to alleviate some of the burden of confrontation with these expected issues. It is strongly recommended to organizations involved in humanitarian assistance to set clear international standards such as those by Sphere and the WHO and to train personnel to deal with these issues.
Introduction
A field hospital can be deployed under different scenarios including response to natural disasters (e.g., earthquakes, typhoons), infectious disease outbreak, war/conflict zones, and in support of health and medical needs of developing nations. Each circumstance brings with it a set of different and unique ethical challenges.
The ethical framework that governs the deployment of these resources under these various settings will require a variety of different considerations. These range from the macro-level of organizational support (budget allocation, personnel recruitment, supply, equipment acquisition and maintenance, travel, and so on) to the micro-level (how health care will be provided to patients at the bedside)[1].
Ethical codes and expectations in disaster response are well described in the literature, and are considered a part of the expected practice of medicine under such conditions. The large international organizations – World Medical Association[2], International Committee of the Red Cross (ICRC) and Red Crescent[1,3], American Medical Association[4] – all have documents relating to ethical codes in disasters.
Commonalities across these ethical “position statements” that relate to the expectations of victims of disaster can be found centered on the importance of distributive justice. These include the following: transparency in decision-making and consistency in the application of decisions, especially as it relates to triage decisions and the access to care; accountability of decision makers; and the notion that access to health care ought to be considered a “human right.” Conventional medical ethical tenets highlighted earlier in this chapter may not always apply in the context of disasters, and they may present certain tensions. For example, can patient autonomy be maintained when there is a need to share information for the public good? Can an individual patient’s medical needs be met, when the decision to support one may adversely impact the ability to support many?
Tenets of medical ethics including the Hippocratic oath, Geneva conventions (GCs), and human research protections may have within them certain inconsistencies when examined in the context of managing large numbers of victims of disaster events. For example, in the Hippocratic oath, and the Geneva Declarations that are its modern equivalent, the centrality of a health-care provider’s adherence to ethical principles is highlighted. After so many examples of horrors perpetrated under genocidal regimes (Nazi Germany, Cambodia, and Rwanda) to victims of war in the twentieth century, it was clear that a renewed focus on the centrality of ethics in the context of managing victims of disaster was required. Yet, under the duress of a disaster response, regardless of whether this is due to a natural event or an industrial accident, is it possible to achieve ethical clarity? How will the rights of the individual and principles of autonomy be balanced against the decisions taken that may result in more widespread benefit to society? In the allocation of scarce resources, are certain population groups to be promoted for access to such resources over others? Is the refusal to provide care – for example, to terrorist perpetrators of acts of mass violence – permissible? What about the withdrawal of care? Or the withholding of information from patients, their families, and the public at large?
A common framework used in the analysis of medical ethics is the “four principles” approach postulated by the philosophers Tom Beauchamp and Jim Childress[5]. It recognizes four basic moral principles, which are to be judged and weighed against each other, with attention given to the scope of their application. The four principles are:
1. Respect for autonomy: Acknowledge a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs. The patient has the right to refuse or choose his or her treatment.
2. Justice: Treat others equitably, distribute benefits/burdens fairly. Concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).
3. Nonmaleficence: Obligation not to inflict harm intentionally: “First, do no harm” (primum non nocere).
4. Beneficence (do good): Provide benefits to persons and contribute to their welfare. Refers to an action done for the benefit of others. A practitioner should act in the best interest of the patient.
The need to establish international standards to protect the dignity of disaster victims has been raised in the international community. One of the commonly used approaches developed for and by the international humanitarian assistance community are the “Sphere standards” contained in the Sphere handbook: Humanitarian charter and minimum standards in humanitarian response[6]. The Sphere standards are a set of minimum standards and guidelines based on human rights and developed to guide the aid and assistance community during humanitarian crisis. This project is a joint effort by the ICRC, Red Crescent, and NGOs. The Sphere principles are predicated on the notion that human actions and interactions should be based on a set of shared core values. In the context of humanitarian assistance to disaster areas, these include the importance of upholding certain ethical principles; chief among them accountability, transparency, and neutrality. One should acknowledge the fact that some of these values may conflict with each other. Humanitarian actors, therefore, might confront dilemmas which can lead to moral distress.
To alleviate some of these conflicts, adherence to a code of behavior and assurance of accountability are suggested strategies.
Code of Conduct
With the aim to establish common standards in disaster relief, the “code of conduct” for The International Red Cross and Red Crescent Movement and NGOs in Disaster Relief, was developed and agreed on by eight of the world’s largest disaster response agencies in the summer of 1994[7]. This identifies the alleviation of human suffering as the prime motivation for humanitarian assistance, which must be provided on the basis of need alone and not as an instrument of government or foreign policy.
This code seeks to safeguard high standards of behavior and maintain independence and effectiveness in disaster relief. It lays down ten points of principle, which all humanitarian actors should adhere to in their disaster response work, and goes on to describe the relationships that agencies working in disasters should seek with donor governments, host governments, and the UN system. The principles are as follows:
1. The humanitarian imperative comes first.
2. Aid is given regardless of the race, creed, or nationality of the recipients, and without adverse distinction of any kind. Aid priorities are calculated based on need alone.
3. Aid will not be used to further a particular political or religious standpoint.
4. Humanitarian responders should endeavor not to act as instruments of government foreign policy.
5. Humanitarian responders should respect culture and custom. (We suggest adding respect of religion as this might have direct impact on patient treatment.)
6. Humanitarian response agencies should attempt to build disaster response on local capacities.
7. Ways shall be found to involve program beneficiaries in the management of relief aid.
8. Relief aid must strive to reduce future vulnerabilities to disaster, as well as meeting basic needs.
9. Humanitarian organizations should hold themselves accountable to both those we seek to assist and those from whom we accept resources.
10. In our information, publicity, and advertising activities, humanitarian organizations shall recognize disaster victims as dignified human beings; not hopeless objects.
Accountability
Accountability of disaster responders is part of the ethical framework they are obligated to follow. When responding to a disaster, providers must follow international standards and protect the dignity of the victims. Examples of this include consent for treatment, proper documentation for continuity of treatment, and feedback from the beneficiaries.
The number of foreign field hospitals (FFHs) and international medical teams mobilized in SODs has increased. While they have been beneficial in many situations, they have also been frequently questioned regarding their timeliness, self-sufficiency, ability to adapt to the local system, or even the quality of service provided[8].
Much has been written about the international response to the Haiti 2010 earthquake. In that case, personnel and equipment that were mobilized and utilized in the response were not necessarily matched to the true needs[9,10,11].
Recognition of these issues gave rise to an initiative in creation of the Foreign Medical Teams (FMT) Working Group, and now referred to as the Emergency Medical Teams (EMT) initiative, under the auspices of the global health cluster (GHC) and the World Health Organization (WHO). They commissioned a document, Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters, which provides trauma and surgical care in the first month following a sudden-onset disaster (SOD)[12].
To promote accountability, teams should follow well-established international standards, such as those of WHO. Other important codes that teams are urged to follow are those set by the Core Humanitarian Standard on Quality and Accountability. This is an initiative in which the Humanitarian Accountability Partnership International, People In Aid, and the Sphere project joined forces to seek greater coherence for users of humanitarian standards[13].
Ethics in the Predisaster Phase
Developing a preventive ethics approach in the predisaster phase helps to reduce conflicts during the disaster phase.
One reality is clear. Communities that have not planned and prepared for such an eventuality will be less well-equipped to face its complexities than communities that have. The noted political scientist, Richard Neustadt, wrote, “Crises are a bad time to do planning. Only if plans are developed in advance, and then critiqued, rehearsed, and refined, will various agencies and actors be able to respond effectively to a disaster[14].”
Development of clinical practice guidelines in the predisaster phase and use of guidelines-based criteria in health resource allocation in the response phase may minimize potential ethical conflicts that arise during decision-making in disasters.
Once disaster strikes, teams preparing to deploy must take some practical decisions, which will have a direct impact on the ethical dilemmas they will encounter: notably the type of medical equipment and types of personnel, and numbers of responders, that will deploy. These decisions will significantly influence the type and level of care that can be delivered. An example of an ethical dilemma an EMT might confront is treatment of preterm labor. If a team has both the right personnel and equipment to treat such cases, the ethical dilemma that will arise in the context of a deployment will center around the many resources that would be required to manage a single patient. Deciding beforehand not to take part in the treatment of neonates, for example, explicitly relieves the response team from having to encounter such a dilemma, although the urge and instinct to provide care, no matter how basic, will likely still exist.
We need to expect that planning will be imperfect. Unexpected events will occur, necessitating making on-the-spot ethical decisions during deployment. For this reason, it is important that ethical considerations are made explicit during the planning process so when ethical and clinical judgment is required in the field, it will be consistent with the spirit that guided the planning process.
Dilemmas During Deployment in Disaster Zones
Ethical issues are inherent in humanitarian action. Confronting a large number of patients in a disaster zone mandates adjusting medical care. Not all can be treated, and for those who will receive medical care the standard of care might need to be adjusted.
These two major dilemmas – resource allocation and standard of care – will be discussed from the ethical perspective.
Triage Ethics
Mass-casualty triage needs to be implemented when available resources are insufficient to meet the needs of all patients in a disaster situation. The basic principle is to do the maximum good for the most casualties with the least amount of resources. Disasters require physicians to shift to “utilitarian-based ethics” in which medical decisions are based on available resources, much in the way that a triage system prioritizes victims who are predicted to have the best chance of survival[15]. The World Medical Association (WMA) statement on medical ethics in disasters recognizes these unique situations and notes, “The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum[2].” Such situations will inevitably lead to serious ethical dilemmas. Efforts will be needed to achieve a balance between individual and collective rights. There is generally a conflict between autonomy of the individual and the desire to protect and promote public health. This “dual loyalty” also exists in many disaster situations. It is necessary to develop a system that identifies patients by their medical/surgical needs and the likelihood of benefit, especially in the context of disaster response, but also during short-term initiatives.
Because of the complexity of triage in such conditions, the basic concept underlying the process should be decided before departure. In addition, the process must be fair, transparent, and meet the principles of distributive justice[16]. Triage can conflict with human rights legislation, and even with humanitarian laws, but “accountability for reasonableness” can temper the disagreements on the setting of priorities. Triage in a disaster setting, however, requires a basic change in thinking. Of necessity, this adjustment includes dealing with ethical dilemmas for which most medical personnel are not adequately prepared[17,18].
Two fundamental goals guide triage decisions:
1. Utilitarianism:
To do the greater good for the most. One can argue whether the meaning of this principle is chiefly intended to maximize the number of lives saved, or the “life years” saved. If we measure the likelihood of years of life that would be saved, then an approach that favors the young may take precedence over providing care to the elderly. However, such an approach requires a discussion regarding what constitutes “old.” Another approach would be to consider the quality of life saved and then prioritize treatment for patients who will have better life quality. In practical terms, this suggests that patients with nonreversible injuries (for example, spinal cord injuries) should not be prioritized in a setting of scarce resources. However, this may raise another moral difficulty specifically pertaining to those with chronic diseases: should we deprive such patients of lifesaving treatment under scarce resource conditions? At any given age, the healthy would be saved before the sick, since the former are expected to have a longer life expectancy. While it does sound reasonable to advocate for the preferential treatment of a young, otherwise healthy person as compared to an elderly patient with a terminal disease, this may open a Pandora’s box of ethical challenges: what are the boundaries to this? One cannot “computerize” the various factors: disability expected, quality of life expected, and life-years saved. These are distinctly “unknowable” outcomes, which are not easily determined. The imperfections of decision-making, even with the best intentions in mind, are likely to be exposed.
Balancing all these goals is nearly impossible. There is an inherent conflict between efforts intended to save the maximum number of patients as compared with the decisions required to save patients based on preserving the maximum quality of life. Therefore, the process will inevitably involve judgment and compromise.
In the setting of disaster response, more factors can be brought into this “equation” while trying to implement the utilitarianism principle. These factors include decisions taken to help prioritize patients. If age and prognosis are not used, should decisions simply be based on a first come, first served approach?
Moreover, if a patient, within limited resources, is triaged to treatment, but then along his or her treatment course he deteriorates, does the patient warrant reevaluation and reconsideration under existing triage criteria? Meaning, should one reconsider again and again who should get the limited resources at that point in time? Can a patient who was previously allotted for treatment lose this entitlement? Treating physicians are accustomed and culturally educated to give patients the best possible treatment once that treatment is initiated. The implication of retriage and potential withdrawal of care may be very hard for caregivers and families to accept. Teams must find a way, in a deteriorating patient who reaches a point of extremely limited survival chances, to consider withdrawal of treatment, aiming to save other patients.
Is it ethically permissible to withdraw care from one patient to provide that care to another patient who may be more likely to survive? This ethical dilemma is certainly a debatable issue: there are opinions that one can never hasten death of a person by an act, even if it is done to save someone else. For example, is it unacceptable to withdraw life-support measures from a dying patient with very poor prognosis to obtain his or her organs to save someone whose prognosis with the transplant might be much enhanced? Nevertheless, one can argue that, in the unique situation of two people in front of our eyes – one with close to zero chances to survive even with the available – however limited – resources, and another one with much greater chances to survive provided he or she would receive the lifesaving measures given to the first one – it would be morally justified to do so.
The chapter authors’ opinion is that, given the complexity of issues raised along religious, political, and ethical lines, such decisions must be contemplated by medical, legal, and ethics experts in the local community/host country.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 24 – Intensive Care Unit Buildup Within a Field Hospital Setting
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