Disaster, Ethics, Rationing, Triage



  1. Grimaldi, Mary Elizabeth BS, BSN, RN, CNOR


Healthcare providers are faced with increasing ethical challenges in providing care for patients during times of disaster and other public health emergencies. The code of ethics for most healthcare professions is somewhat ambiguous when addressing the responsibilities of healthcare providers during these times. The American Medical Association has created new, stronger language addressing physicians' duty to care for patients since the events of September 11, 2001, but other professions have not followed suit. Until such time, healthcare providers will continue to be faced with making challenging ethical decisions with little direction.


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Healthcare workers have always faced many challenges. Dating back to ancient times, communicable diseases have presented risks for those individuals whose task it was to provide care for the afflicted. Throughout history, healthcare workers have placed themselves in danger as they care for their patients, whether it be the medic on the battlefield, the research scientist searching for a cure for the highly contagious disease, the phlebotomist drawing a blood sample from the patient infected with the Hepatitis B virus, the surgical team performing a procedure on the patient infected with human immunodeficiency virus, or the emergency department nurse in New Orleans who remains on duty during Hurricane Katrina, knowing that the hospital will be receiving mass casualties and not knowing the fate of her own home, family, or even herself if she does not evacuate the area soon. While healthcare workers have always placed themselves at the forefront of dangerous situations and placing the well-being of their patients before their own well-being, it seems that since September 11, 2001, this has become an ethical dilemma for many. With the threat of biological weapons, such as anthrax, Ebola, and ricin, that can be as deadly to the exposed healthcare worker as it is to the primary victim, and the events of 9/11 still fresh in our memories, along came Hurricane Katrina and with it the idea of making ethical decisions in times of disaster suddenly has become a reality that healthcare workers must be prepared for every day.


Some professions have a code of ethics to provide guidance with these decisions. A code of ethics is based on standards of best practice guidelines, which are developed on the basis of the fundamental principles and values of the particular profession.1 A code of ethics is sometimes referred to as an instrument of soft law since it is nonlegislative in nature.2 Because of this, a code of ethics should serve only as a guide for ethical reasoning and how to treat individual patients rather than a directive of mandatory treatment or behavior.3


The American Medical Association has made attempts to address the issue of duty to care by adopting several new ethics policies that directly address the physician's obligations and responsibilities during public health emergencies. The following is from a policy adopted by the American Medical Association in 2004:


National, regional, and local responses to epidemics, terrorist attacks and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with the ability to care for patients in the future.4


The American Medical Association is the first medical association or professional organization to even try to provide guidance for its members by stating physicians' obligations. It is unknown whether other healthcare professions will also take a stand.


The American Nurses Association addresses 9 provisions in its code of ethics and leaves a good deal of room for individual interpretation in its ambiguity. Provision 3 states: "The nurse promotes, advocates for and strives to protect the health, safety, and rights of the patient."5 In Provision 5 of the code, the nurse's obligations to self are addressed. "The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth."5 While stating that the nurse has an obligation to provide care for their patients in Provision 3, they clearly state that nurses are obligated to care for themselves in Provision 5. This does not provide clear guidance. Nurses may ask, "When does my duty to care for my patients usurp my duty to care for me?" According to the American Nurses Association, We have an ethical duty to care for our patients, but also an ethical duty to care for self and family. How do we choose to do what is right? Furthermore, what is right?


Wynia6 lists 3 primary ethical challenges facing the healthcare provider during public health emergencies, rationing, restrictions, and responsibilities. Rationing deals specifically with the allocation of resources. Triage would fall under this challenge. Triage is the action of prioritizing medical treatment and management of patients, based on a rapid diagnosis and prognosis for each patient, taking into account available resources, medical needs, and capabilities. Triage can pose an ethical dilemma because there may be limited resources in relation to a large number of persons in need of treatment. Some may even question whether triage is ethical. Patients who can be saved and whose lives are in immediate danger should be treated first. Patients who cannot be saved are not treated.7 If you were the medical professional triaging patients in an emergency, would you be able to classify a friend or a family member as one who will not receive treatment?


The second challenge, restrictions, deals with isolation and quarantine. These are strategies that may need to be implemented during disease outbreak or suspected biological weapon use. Restrictions can limit freedom and liberty in both the patient and the healthcare worker.


The third ethical challenge is responsibilities. This is perhaps the biggest challenge since it is hard to predict what people will do during times of crisis.8 As stated earlier, the code of ethics for most of the healthcare professions only suggest that the care providers carry out their obligation to their patients, while at the same time they are ambiguous by stating that there also exists a duty to take care of oneself. Some hospitals in New York have declared that they would not treat patients presenting with suspected smallpox.9 Should there be laws passed to mandate that healthcare providers take care of these patients? Legal enforcement should not be the method we use to ensure care is provided to patients. Even when there is no public health emergency, healthcare providers place themselves at risk every day with every patient they care for. The only way to avoid these risks would be to change professions. Some may do just that. Others realize that there is risk and they are willing to live with it.


There is no easy solution to the ethical issues surrounding the duty to care for healthcare professionals. It may be easier if professional organizations were to take a stronger position, but it appears that for now, they will continue to provide guidance with little or no direction so the healthcare professional will still have to make these challenging decisions on their own. "We are not heroes, we are just doing our job."10




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3. Kluge EH. Codes of ethics and other illusions. Can Med Assoc J. 1992;146:1234-1235. [Context Link]


4. American Medical Association: Physician obligation in disaster preparedness and response. Accessed April 1, 2007. [Context Link]


5. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001:5-7. [Context Link]


6. Wynia MK. Ethics and public health emergencies: Rationing. Am J Bioeth. 2006;6(6):4-7. [Context Link]


7. The World Medical Association. Policy: World Medical Association Statement on medical ethics in the event of disasters. Published 2006. Accessed April 3, 2007. [Context Link]


8. Wynia MK. Ethics and public health emergencies: restrictions on liberty. Am J Bioeth. 2007;7(2):1-5. [Context Link]


9. Herrick T. Some hospitals plan to rebuff bioterror cases. Wall Street J. 2003;16:B1. [Context Link]


10. Littleton MR, Wright C. Doc: Heroic stories of Medics, Corpsmen and Surgeons in Combat. St Paul, MN: Zenith Press; 2005. [Context Link]