Barriers to Integrating Crisis Standards of Care Principles into International Disaster Response Plans: Workshop Summary by Bruce M. Altevogt

Author:Bruce M. Altevogt
Language: eng
Format: epub
Tags: ebook
Publisher: The National Academy Press
Published: 2012-12-24T00:00:00+00:00

Ethical Framework

Haraguchi stressed that ethics is the foundation of crisis standards of care. He applied classical philosophy to the question of ethics in disaster medicine, citing the concepts of utilitarianism, or “the greatest good for the greatest number of people,” proposed by Bentham and Mill, and the Maximin Principle of Rawls, which seeks justice or fairness by providing the greatest benefit to those who are the worst off.

Hanfling added that respect for the host nation or region is paramount. Response planning needs to be done in the context of the existing capabilities, with an understanding of the local strengths, weaknesses, gaps, culture, etc. The goal is to develop an ethical framework for thinking about the delivery of care in crisis. Burkle noted that the basic disaster cycle is “prevention, response, and recovery,” but Australia has added “anticipation” and “assessment” to the front end of the cycle (Rogers, 2011). Specifically, information on communities is collected at the national level to better understand the different characteristics and risks of different communities. The time for such assessment, Burkle stressed, is before a crisis so that when something happens, needs are already known.

Poncelet said that ethical standards of care can be more readily agreed to among neighboring and similar countries whose income, technical capacity, and approach to care are similar. It is easier to be fair, Poncelet said, when everyone is operating in an environment that is limited by the same conditions and functionality. Crisis standards of care should be at least as fair as conventional standards in day-to-day operations.

The international response to the 2010 earthquake in Haiti provides several examples of the ethical dilemmas faced in trying to provide the highest level of care to the greatest number of victims in a disaster response. Hanfling cited an article on the Israeli field hospital in Haiti (Merin et al., 2010), which described their basic triage approach: how urgent is the patient’s condition, are there adequate resources to meet the patient’s needs, and can the patient’s life be saved with the interventions offered? The U.S. government (Bureau for Medicine and Surgery of the U.S. Navy and the U.S. Navy Ship Comfort), working with the Ministry of Public Health in Haiti (Ministere de la Santé Publique et de la Population), recognized the dilemma of implementing short-term solutions (i.e., amputation) and the effect these had on long-term impacts, and discouraged practitioners from offering complex medical treatments or surgical interventions that could not be sustained in Haiti after the end of the international disaster relief effort (Etienne et al., 2010). Poncelet noted that as each country assesses its mass casualty management plan or response using their own criteria, it can be very difficult to address questions of ethics. In the case of Haiti, for example, serious ethical questions persist regarding standards of care and the resulting amputee crisis.

Many difficult ethical questions need to be considered, Poncelet said. For example, should a foreign medical team work below its capacity to be fair and provide care comparable with another country’s

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