Advanced Regional Response Training center

1
Ethics and Public HealthHow Public Health Reacts
Ethically in a Disaster

• Advanced Regional Response Training center
• University of South Alabama
• Mobile, Alabama
• June, 2007
• By John R. Wible, General Counsel
• Alabama Department of Public Health

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Outline

• Setup and Introduction
• Action Principles
• A Quick Ethical Problem
• Sources of Personal Ethics
• Professional Ethical Principles
• The Eye of the Storm Application
• An Ethical Exercise
• Epilogue

3
Dire Ethical Straits

• Hurricane Katrina
• the people have left the building
• Pandemic Influenza
• the new and improved disaster

4
Question from CDC

• What objectives and principles should be
  considered in pandemic vaccine prioritization?
• What is the relative importance of the CDC goals?
• Which population should have vaccine priority?
• What is the rationale?
• How can fairness, equity, efficiency and related
  principles be reflected in the determination of
  priority groupings?
• Who should determine the answers?

5
An Ethical Person

• Are you and ethical person?
• From where or whom did you learn your ethical
  principles?
• Hint Yo Mama
• All I Ever Needed to Know,
  I learned in Kindergarten

6
Our Purpose

• The purpose of this presentation is to ask you a
  lot of questions and help you discover the
  answers from within yourself so that ultimately,
  you will be able to make decisions that will
  allow you to go about living outside yourself.

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The Pareto Principle

• The 80-20 Rule revisited
• 10 basically ethical
• 10 basically unethical or aethical
• 80 wandering somewhere in the middle
• The ethical job of the manager
• Differentiate the animals

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A Personal Aside - You

• Who helped shape your ethical principles and how?
  
• What did he or she teach you?
• What do you think is the most important ethical
  principle of them all and why?

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Group Ethical Questions

• What are some universally accepted ethical
  concepts?
• Where did they come from and how do we learn them
  as individuals?
• How does each of us develop his own set of
  ethical principles?
• Do we view those as static or sliding?
• What is the price of each of us? (For how much
  would you sell out?)

10
Johns Five Action Principles
D

• The No Delta Principle
• To tell the truth, the whole truth and nothing
  but the truth
• Well Sing in the Sunshine
• Be a Square
• Its not about me.

11
Sources of Personal Ethical Principles

• Religious teachings
• Cultural teachings
• American Historical Documents
• Declaration of Independence
• United States Constitution

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American Historical Documents

• Declaration of Independence
• United States Constitution

1776
13
Declaration of Independence

• Set forth the self evident truth such as
  equality
• Established an ethical basis for independence
• What Locke applied to individuals, Jefferson
  applied to a people John Adams
• Did not condemn the British people
• Did not address address African slavery

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Self-Evident Truths

• All men are created equal (Really?)
• Endowed by their Creator
• Life
• Liberty
• Pursuit of happiness
• Modern Comparisons
• Life becomes human dignity in UN Charter
• Life becomes personal autonomy in Belmont Report

15
Constitutional Principles

• We, the People social contract theory of
  government based in personal autonomy
• Establish justice
• Equity
• Equality
• Fair process
• Insure Domestic Tranquility peace
• Promote the General Welfare
  the sum of it all

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Summary of Personal Ethics

• Golden Rule
• Love God/Love man
• Brotherhood
• Fidelity/chastity
• Humility
• Charity
• Justice
• Equality
• Life
• Liberty
• Happiness
• Government
• Social contract
• Equity
• Fair process
• Peace
• General welfare

• Right living
• Do no harm
• Do not lie
• Do not steal
• Do not hoard
• Moderation
• Cleanliness
• Contentedness
• Perseverance
• Self-study
• Higher Being

• Right Speech
• Right Actions
• Right livelihood
• Right effort
• Effort to Improvement
• Right mindfulness
• Awareness
• Right Mental thought
• No gods/idols/swearing
• Sabbath keeping
• Honor parents
• Do not murder
• Do not commit adultery
• Do not steal
• Do not lie
• Do not covet

17
Professional Ethics

• The Hippocratic Oath and Medical Ethics
• Augustines Just War
• Nursing Ethics
• The Belmont Report and Institutional Review
  Boards
• The Public Health Code of Ethics
• Public Officer and Employee Ethics Laws

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The Concept of Death

• Is the causing or allowing of death always
  ethically bad?
• Cain and Abel
• Instructions to wipe out the people of Canaan
• Lex talionis, cities of refuge and the Avenger
  of Blood

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Summary of Medical Ethics

• Non-maleficence, doing no harm
• Beneficence, doing what is best for the
  patient
• Autonomy, allowing the patient the informed
  right to choose
• Justice, treating everyone alike

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Medical Ethics in a Disaster

• AMA Policy Statement E-9.067
• There is a duty to provide urgent care
• The physician workforce is not unlimited
• Therefore, balance is required
• Live to fight another day
• Are physicians required merely stay and not run
  away
• Or to volunteer to come back in and help?

21
Nurses Ethics in Providing Care

• Provide care in a
  non-discriminatory manner
• There are limits to the amount
  of personal harm required to risk
• Cannot abandon a patient
• Personal risk may depend on the individual
  condition of the nurse
• A sacred duty
• American Nursing Association December 1994

22
Researchers Ethics

• The Tuskegee Experiment Bad Blood
• Tuskegee by the numbers
• 600 men in the study
• 399 infected with syphilis and untreated
• 201 without syphilis
• 100 dead of causes related to syphilis
• 74 men survived
• 40 wives contracted syphilis
• 19 children born with congenital syphilis
• 9,000,000 dollars paid out in direct damages
• 1 good result The Belmont Commission

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The Belmont Commission Studied

• The boundaries between biomedical and behavioral
  research and the accepted and routine practice of
  medicine,
• The role of assessment of risk-benefit criteria
  in the determination of the appropriateness of
  research involving human subjects,
• Appropriate guidelines for the selection of human
  subjects for participation in such research and
• The nature and definition of informed consent in
  various research settings

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The Common Rule (Based on the Belmont Report)

• Established boundaries between research and
  practice
• Defined ethical practice based on three
  principles to include
• Respect for persons
• Beneficence
• Justice

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Public Health Code of Ethics (2002)

• Health a state of complete physical, mental,
  and social well-being, and not merely the absence
  of disease or infirmity.
• Preamble to the Constitution of the World Health
  Organization, 1948 as affirmed by the Code.
• The Codes 12 Principles
• Family Values

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Public Officer Conduct Laws

• Nature and Scope of Public Ethics Laws
• Very narrowly constructed
  and construed
• Contrasted with the broad sweep of
  professional codes

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Summary Professional Ethics

• Death acceptable
• Do no harm
• Patient first
• ?Value on life
• Proper relations
• Confidentiality
• Follow law morals
• Duty to care
• Balance

• Use Information
• Timeliness
• Diversity
• Confidentiality
• Collaboration
• Competence
• Public trust
• Interdependence
• Not abuse public position

• Not discriminate
• Not abandon
• Sacred duty
• Respect person
• Beneficence
• Justice
• Individual rights
• Community
• Empowerment

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-The Eye of the Storm-What Really Happens in a
Disaster
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Effects on Victims and Staff

• Psychological, physiological and physiological
  Symptoms
• Irritability or anger, blaming or denial, mood
  swings, fear of recurrence, hyperactivity,
  feeling stunned, helpless, numb, or overwhelmed
• Loss of appetite and energy, headaches, chest
  pain, and fatigue
• Isolation, withdrawal, diarrhea, stomach pain,
  nausea
• Increase in alcohol or drug consumption
• Nightmares and inability to sleep
• Concentration and memory problems
• Sadness, depression and grief
• All leading to BAD
  CHOICES

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Are there Really No Rules
?
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Euthanasia

• Is euthanasia ever an option for suffering
  victims?
• What is it?
• Assuming the answer is yes, How would you
  justify it?
• Is it a fair balance between individual rights
  and the rights of society?

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This brings up the question of No

• Authorities, citing the experience at Memorial
  Hospital in New Orleans short of a pandemic
  your worst case scenario and Supreme Court
  authority . . .
• Advises that in the question of whether
  euthanasia is an option, the answer is no,
• Euthanasia is never an option
• (Unless it is the end of the world as we know it
  and it doesnt matter)

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Lets Just Let them Eat Cake

• OK, so we cant depopulate the victims, can we
  just let them die a philosophical interlude
  Utilitarianism vs. Egalitarianism
• Quote from Marie Antoinette
  some time before her execution.

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Utilitarianism vs. Egalitarianism

• Jeremy Benthams theory of utilitarianism
  (consequentialist ethics) assesses what is right
  or good based on whether the consequences of the
  actions to be taken will be good
• Immanuel Kants deontology theory (principlism or
  egalitarianism) focuses on non-consequentially
  based notions of good - deciding what is right or
  good is based on meeting duties and obligations
• These contradistinguished ideas will clash over
  and over

35
Modern Disaster Triage

• In disasters there is a switch
  from standard medical ethics with
  the primary focus on Individual
  autonomy to an ethics of public health with a
  primary focus on the health of the community
• The overarching goal is to minimize morbidity and
  mortality during the pandemic (according to CDC)
• Will it be most good or greatest need?

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Utilitarianism Says

• The goal is to help those for whom you can do the
  most good following the long-established standard
  in military medicine
• Advantages follows a clear, simple,
  community-recognized goal in a potentially
  chaotic environment
• Disadvantages situations will arise with no
  clear utility-based answer that may lead to
  unintended, insidious discrimination

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Egalitarianism

• Goal to help those in greatest need
• Ranks patients based on severity of illness, with
  patients in the most severe condition receiving
  the medical attention
• The ultimate goal such as limiting morbidity and
  mortality during the pandemic is de-prioritized
  in order to preserve the egalitarian principles

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Hybrid Triage

• Uses both concepts
• Utilitarian approach
• Egalitarian methods
• Requires sorting out into 3-4 groups
• Treat those in the group before going to the next
  lower group

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Ethical Responsibilities in Triage

• Plan NOW! See Bryants Rule
• Establish a Triage Review Committee
• Plan
• Oversee
• Evaluate post-event
• Engage the public in the discussion
• An experienced triage officer

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Altered Standards of Care

• When it permissible from an ethical and legal
  standpoint to provide less than the care normally
  or traditionally expected or held to be what is
  referred to in both the medical and legal
  professions as the standard of care?
• Goals
• Focus

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Ethical Considerations

• The aim is to keep the health care system
  functioning and to deliver an acceptable
  quality of care to preserve as many lives as
  possible
• The plan must be community wide
• There must be an adequate legal framework to
  allow for the altered standards of care
• The rights of individuals must be protected to
  the extent possible and reasonable under the
  circumstances
• The public must be informed on planning and
  decision making pre, during and post event

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Legal Concerns of Altered Standards

• How to make it legal
• Change the laws at federal and
  state levels directly
• Change laws to allow for regulatory changes
• Consider pre-drafting emergency orders for the
  Governor to sign in an event invoking the altered
  standards of care

43
CDCs Plan for Rationing Vaccine

• CDC scares us with their predictions
• The system of manufacturing vaccine is old and
  tired
• CDC has devised priority groups with subgroups
• Health care workers
• Public service workers
• High risk populations

44
Ethical Look at the CDC Plan

• A hybrid system
• Utilitarian goal
• Egalitarian execution
• Allows for local input should the locals want
  input
• Buck-passing and the failure to plan will be a
  catastrophic ethical failure

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Rationing Ventilators

• The American Association of Respiratory Care has
  a recommended plan. Consider one states draft
  plan to recommend to hospitals
• Triggered by declarations by government edit,
  activation of National PI Plan or local hospital
  HEICS

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Legal Issues

• What is legal may not necessarily
  be what is ethical and what is
  ethical may not necessarily be what is
  legal
• Legal Issues will be criminal, civil and
  regulatory and administrative law issues
• Changes to the laws and legal precedents made per
  se, to allow rules to be changed or by executive
  directive such as PDD
• Change will require consensus or at least
  consultation with all stake-holders

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The Right to Desertion When is it time to go
to the house

• Practical dilemmas faced personally what are my
  obligations to me and my family?
• Professional dilemmas conflicting ethical
  principles
• Autonomy vs. non-maleficence
• Autonomy vs. beneficence
• Autonomy vs. justice

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Professor Tabery Says

• If you dont come to work, the problem doesnt go
  away. In fact, the problem only gets worse. In a
  disaster situation or a pandemic, every employee
  will make a difference by contributing his or her
  part to providing care. All employees must ask
  themselves, If I dont work in times of crisis,
  then who will?

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A Suggestion

• Take a deep breath
• Look for the balance
• Remember Johns principle of
  living outside yourself based on the truth within
  yourself
• (This assumes you know the truth)
• Planners and facility administrators must think
  outside the box but do it now

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Summary- Johns Five Action Principles
D

• The No Delta Principle
• To tell the truth, the whole truth and nothing
  but the truth
• Well Sing in the Sunshine
• Be a Square
• Its not about me.

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Epilogue

• The Eagle soars above the din,
• of mankind's rushing out and in,
• And lesser creatures left to spin,
• The Eagle soars from deep within.
•  
• His course is true as gaffer's pike,
• His keen eye pierces like a spike,
• His quest surrounds him like a dike,
• The Eagle soars, but phantomlike.
•  
• Those who on the Earth have stood,
• Thinking that they never could,
• Nor many even perhaps should ... but,
•  
• The Eagle soars because he would. - John R.
  Wible, 1981