Making ethical decisions in a public-health emergency

[Shiloh]

Source: http://www.tahoedailytribune.com/article/20080620/COMMUNITY/644795471/1060/NEWS&parentprofile=-1

Making ethical decisions in a public-health emergency
Jason Eberhart-Phillips

Today, most Americans take it for granted that in a medical emergency, the local health-care system will respond with the best possible treatments, including the world's most advanced medical technology.

We just assume that whatever doctors require to save lives always will be available in ample supply when acute hospital care is called for, whether that is oxygen, IV fluids, medications or life-support machines.

But what will happen to patients caught in a major disaster, such as an earthquake, a flood or a nationwide flu pandemic? How will the limited supply of hospital beds, services and supplies be allocated in such an overwhelming public-health emergency?

These are questions that California public-health officials, critical-care specialists and hospital administrators now are pondering as they anticipate the tremendous needs for medical care that will arise in extreme emergencies. No one here wants a rerun of the health-care calamities that followed Hurricane Katrina in New Orleans three years ago.

How can we be ready? That's what a statewide workgroup that I am part of now is examining. We are thinking about how the usual standards of medical care given in hospitals today would have to change under catastrophic circumstances, and how the new standards could be applied fairly, transparently and ethically.

When the number of critically ill patients exceeds the capacity of trained hospital staff to care for them, how will it be decided who gets intensive care and who doesn't? When the demand for vital equipment such as mechanical ventilators - the machines that breathe for patients unable to breathe for themselves - exceeds the supply, how will doctors determine which patients receive scarce hospital resources and which ones don't?

Questions like these don't have easy answers, but it is certainly better to think through such matters before a disaster strikes than to wait until mass casualties begin to arrive at the hospital door in the midst of a crisis. Having no plan for such emergencies will invite inequities in care and public disdain.

Details of the new "crisis standards of care" are yet to be developed, but certain guiding principles are taking shape. These include:

-- The Duty to Care: No patient needing medical care will be abandoned. When interventions that would save lives under ordinary circumstances are not available, no patient will be left without some level of care. This may require easing some of the licensing restrictions that govern who can provide medical services, so that basic forms of care can be given to all.

-- The Duty to Triage: In mass casualty events, the needs of the whole population will trump those of individual patients. Instead of treating the sickest or the most critically injured first, the focus in a crisis will be to maximize the number of lives saved. A patient's likelihood of survival will be a more critical factor in deciding to provide intensive care than severity of need. Perceptions of a patient's social worth or ability to pay will have no place in deciding what care is provided.

-- The Duty to Inform: The ways that decisions will get made about allocating scarce health-care resources in a disaster must be clear and understood by the public. As guidelines that relax the usual standards for health-care delivery are developed, every effort should be made to inform the community and seek public comment. That's the reason I am writing this column.

If you have some views on this challenging topic, please let me know.

- Jason Eberhart-Phillips, M.D., is the El Dorado County health officer. He can be reached at jeberhart-phillips@edcgov.us.

 

[Thornton]

Re: Making ethical decisions in a public-health emergency

Father Mark Miller is a clinical bioethicist for St. Paul's Hospital in Saskatchewan and writes for the Liguorian Magazine. http://www.liguorian.org/

In the July/August 2008 issue (page 5; not yet on web) he writes "Leveling the pandemic playing field."
In his one page essay he briefly describes the 1918 influenza epidemic and the current risk of a pandemic from avian influenza or other agents. He echoes sentiments expressed elsewhere by Dr. Osterholm that the threats to social infrastructure are just as dangerous if not more so than the virus itself.

Father Miller lists four critical ethical guidelines and one imperative for any pandemic plan.
1. The plan must be transparent. Planning requires experts for technical guidance, but input and consideration of all stakeholders is essential for the plan to have social acceptance once the emergency occurs.
2. The plan should be cooperative. Multiple segments of society are affected, eg health providers, law enforcement schools, businesses etc. It is essential for success that members of the community know and trust each other before the emergency occurs.
3. Decision makers must be held accountable for the plans. "Accountability means that the different options have been considered and one was chosen for justifiable reasons.
4. Particularly important from the Catholic perspective, the plan must include options for the poor. The plans must seek to ensure a just allocation of resources for all citizens.

The concluding imperative in pandemic preparedness is that there must be a plan. Father Miller stresses that for ethical reasons we are all responsible now for developing a pandemic plan because once the pandemic occurs, opportunities for good planning vanish.
Joseph Thornton