by Craig Klugman, Ph.D.
An Ebola epidemic rages through Western Africa. Civil unrest and terrorist turmoil rocks Syria/Iraq, Libya, Israel/Gaza, and Ferguson, Missouri. A 6.1 earthquake damages Napa and shakes the entire San Francisco Bay Area. All of these events are examples of crisis—a catastrophic disaster (natural or human-made) that disrupts the regular operating of a region.
In terms of health, a crisis is a “state of being that indicates a substantial change in health care operations and the level of care than can be delivered in a public health emergency, justified by specific circumstances” (IOM, Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response 2012). In other words, these are situations that strain the ability of the health care system to provide needed treatment to all patients. An epidemic of a deadly disease, civil unrest (whether because of invasion, terrorism, or uprising), and natural disasters are all situations where the regular infrastructure collapses and the ability to provide a regular standard of care is compromised threatening high rates of morbidity and mortality as well as a shortage of supplies and personnel.
In 2013, the Institute of Medicine released its third report on crisis preparedness and management: “Crisis Standards of Care: A Toolkit for Indicators and Triggers” is a framework for states and cities to develop plans for dealing with mass casualty situations. The IOM program requests conversations between and among state and local governments, EMS programs, hospitals, care systems, and the public for planning in the event of crisis.
Many locales have already started such planning: California, Maryland, Michigan, Minnesota, New York, Ohio, Utah, King County Washington, Harris County Texas, North Texas, Maricopa County Arizona, and Chicago have all developed frameworks for decision-making. Many have also hosted mock mass casualty events to test their designs.
Last month, I was invited by one large state to participate in developing their framework as called for by the most recent IOM toolkit. The toolkit describes three modes of operating: Conventional (regular everyday—emphasis on autonomy and individual patient care), contingent (making substitutions, drawing on resource stockpiles, keeping an eye on how care for one patient would impact having resources available for others), and crisis (minimizing population morbidity and mortality, lack of trained staff, damaged facilities, lack of critical supplies).
The task given to the task force is to decide when the community moves from one status to another. What are the trigger events denote a need to change operations of the health system from working in convention to contingency or crisis mode? What indicators allow moving from crisis back to conventional?
In addition to changes in the way that care is provided, issues of justice become more important on the crisis spectrum: Rationing becomes more important as resources are increasingly in short supply and reinforcements become unavailable. What does an emergency medical services system look like when thousands of people have been injured and are in need of care? How does a burn unit operate when 500 people have been badly burned in a chemical explosion?
This is where the expertise of those who have worked in bioethics comes in. Planning requires thinking about different operating models of justice in distributing resources. In conventional settings, medical resources are given to those who are in need or those who can pay for it. In a crisis situation, “need” needs to be triaged, and distributing now scarce resources takes on greater import. Providing grounded theories and methods for making these difficult life and death decisions takes is necessary because the scale of impact is so great. A clinical ethics consultation usually involves a patient, a family, and a health care team. Clinical ethics in crisis means deciding whether 10,000 people get access to emergency surgery or are provided comfort while they die. Does this entail a move from a deontological or principlist way of thinking to a utilitarian or communal theory? What are the triggers that require that change in thinking? How does the provision and reception of health care change?
These task forces and planning sessions also looks at communication, coordination (how do you get the often combative medical and public health systems and private hospitals to work together), and public engagement. Making these plans ahead of time is time consuming, but useful in beginning conversations and setting up plans to maximize the response and minimize time needed to get there. No crisis will be exactly like the exercise or the plan. The plan is merely a guideline for thinking based on careful moral deliberation. When the crisis hits, there will not be time for the kind of long-term critical reasoning that these task forces and toolkits permit. Decisions will have to be made quickly. Having a well crafted plan and ethical framework in place will make these very tough choices a little easier.
The world is politically, economically, militarily, and naturally uncertain. Having these conversations is one way to try to get a grip on tremendum that such events represent. For those who have to make these tough decisions as to where to send resources and who to save, having a well-reasoned ethical framework will make the task less burdensome. For the community to come together to create these plans means there will be buy-in from the stakeholders and perhaps a way to explain to a sobbing mother why her daughter is not getting surgery because of her triage assessment. Ignoring this opportunity is ethically negligent. There is an ethical obligation to undertake this process to plan for the worst, and hope for the best.