by Craig Klugman, Ph.D.
This is a time of disaster. Last week Hurricane Harvey devastated Southeast Texas, a place where I did my doctoral studies. This week we are awaiting Hurricane Irma, the strongest hurricane to head toward South Florida in 25 years. My family lays in the path of that coming storm. I first became interested in natural disaster in 1989 when my college campus was jolted by a 7.1 earthquake in Northern California.
Bioethics has a role in responding to and preparing for these natural disasters. Most every state, large city and county, and most hospitals have been working on crisis standards of care plans. In 2009 and again in 2012, the Institute of Medicine recommended governments to undertake such planning. Many of us working in bioethics have been involved in these efforts. More specifically, we have been involved with developing ethical frameworks for decision-making, policy-making, and operations during emergency planning.
I worked with Texas during its planning for pandemic flu and for the last 3 years have been part of the ethics subcommittee of Illinois’ workgroup, most recently as chair. Similar groups have produced excellent reports in many places such as Delaware, North Carolina, Michigan, Minnesota, Tennessee, Texas and Toronto. They offer guidance and justification for a varied set of guiding principles and ethical frameworks. All of them hold certain core ideals in common.
First, all of the reports agree that transparency and open communication is essential. Planning needs to involve not only government officials, but also community members. In Illinois, we have been running focus groups during each of the last three years in towns of all sizes and compositions across the state. The results have informed the policies and procedures we have written to deal with disaster. Having co-written the aspirational ethical principles which our response should follow, it can be helpful to see how the public reacts to the ideas and whether they embrace them. For example, an early value was that all people should be treated equally, meaning if there were two patients in need—a civilian and a first responder—that there should be no preference based on one’s role in society. However, we learned from outreach that first responders will give preference to their own—they feel that putting their lives on the line to help others gives them a claim to limited resources and priority in receiving medical care. That reality aligned with our principle of reciprocity—that a community owes those who put themselves in harm’s way to help others. Thus, we rebalanced reciprocity with equality, the preferential treatment holds only if the first responder can quickly go back to the job of helping others. Conversations with community stakeholders not only gave us these insights, but also helped us to explain our reasoning. The goal is to keep the public in the loop so that they know how the plans are made, what the plans say, and what happens when they are enacted.
A second commonality is the need to treat people without reference to socioeconomic status, race, ethnicity, education, religion, documentation, gender, sex, nationality or other. The idea that undocumented people would be treated the same as native citizens is important since all people have need in a disaster. Although members of the Illinois team thought this might be controversial, the idea has been embraced. We also struggled with the reality of health inequality: A disaster plan cannot eliminate inequality but a plan should do all that it can to not exacerbate it.
A third commonality is that individual liberty should be protected but can be overridden by community and public health needs. Thus, in preparation for an emergency, all elective surgeries should be canceled and patients sent home to create surge capacity to treat patients from the disaster. Ideally, a person might want surgery or an MRI scan sooner rather than later. However, the necessity of having to support victims of the disaster fills the principle of solidarity—the community coming together to minimize morbidity and mortality. Commonality also means that the situation may call for triage—balancing medical need with outcome and allocation of resources. Thus, a seriously ill patient who needs a long, involved surgery with a low chance of survival may be given comfort care measure only so that a patient with a better likelihood of survival can use the limited surgical resources.
Perhaps the most challenging part for this third commonality is getting physicians on board. Physicians are trained to think in terms of the individual patient and the principles of biomedical ethics. Asking them to take a broader, public health perspective that puts the community first can be a challenge. Thus, education needs to occur before the disaster strikes.
Consider that you might have a patient appear with need for a ventilator. That patient’s need may be greater (and with a higher chance of good outcome) than that of someone already on a vent. Public health ethics would argue that in this scenario the person with lesser need and lower chance of a good outcome be removed from the ventilator to help the person with a greater likelihood of survival. In Illinois and many other states, the law actually does not permit a physician to do this, so the task force is working with the legislature to draft laws and regulations to support the plan.
A fourth commonality is trust. During the disaster, public health officials, elected officers and health care providers need to be trusted by the public that they are doing the best that they can to achieve solidarity. This requires good community relations (see transparency above) and having built good relationships. Without trust, people will not act orderly, will not follow triage for treatment, and taking care of any patient will become impossible.
From trust and transparency comes the fifth commonality, stewardship. During disaster, the public needs to know that all healthcare resources, both public and private, are being used wisely to benefit the most people. Decisions will be made quickly and will change as the news and updated information becomes available. When the disaster is over, health decision-makers will need to be able to account for the choices they made and how wisely they used the limited resources that were available.
During the disaster, it is important to have a flexible system for making decisions as facts become evidence. For example, in Illinois, the ethics group suggested that no one person make decisions in a disaster. A lesson from Katrina is that when health care providers are stretched and try to make decisions alone, that those choices are often not the best ones. The decision-makers on the ground do not need to be ethicists, but they do need to be thoughtful persons with some training in public health and ethics. Adopting a strategy of making decisions with others can help increase rational decision-making in crisis situations. For example, the only doctor on a unit can pull in a nurse or even an orderly to help make choices. Also, our plan includes have an ethics person available in the crisis center to help make decisions on the ground as events are happening.
In another example, one response to Harvey has been that the Texas Medical Board allowed health care providers licensed in other states to treat patients in Texas as long as the disaster is in effect. In normal times, a physician would need a state-specific license or at least sponsorship to practice in another state. Some states also plan to allow medical and nursing students to assist in providing care in declared disasters.
What most plans neglect is that eventually crises come to an end and a return to normal operations becomes necessary. The hospitals in Houston have suffered damage of space, equipment, and supplies. But they are also returning to more normal operations where everyday ethics, i.e. the four principles, provide moral guidance. It’s also possible that some parts of the city and of a single hospital (OB, outpatient clinics) will return to normal operations quickly and others (trauma surgery, ED) will take longer.
As bioethicists, we can offer the most assistance with helping cities, counties, and states to plan. A key skill is an understanding of public health and public health ethics as well as communication skills (a key part of clinical ethics) to bring together various stakeholders. Beyond offering a set of principles or a method for decision-making, it is helpful to community health care providers (doctors, EMTs, public health, etc.) to see real-life scenarios and how the principles and decision-making tools would assist in those situations. They are less interested in the philosophy than in the application.
I do not, however, recommend that a PhD or JD bioethicist travel to a disaster area to offer our services (MD-ethicists have clinical care skills to offer). In effect, we need to know when we can be helpful and when we will just be in the way. The worst thing we can do is to become one more person who needs saving by being somewhere that we are not needed. If you have strong need or desire to help in a disaster, many community agencies offer volunteer training certification.
Those of us in bioethics, especially in clinical ethics, have experience in making difficult choices and these skills can benefit our communities in preparing for disaster, dealing with a disaster, and recovery.