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Talk by Omar Ha-Redeye at the 16th World Congress on Disaster and Emergency Medicine on Thursday May 14, 2009. ...

Talk by Omar Ha-Redeye at the 16th World Congress on Disaster and Emergency Medicine on Thursday May 14, 2009.
For more details see Ha-Redeye, O (2009). Assessing the Needs of Health Professionals and Stakeholders. Chapter 6 in Population Health, Communities & Health Promotion (Eds. Sansnee Jirojwong, Pranee Liamputtong). Oxford University Press. ISBN: 9780195560558

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A New Ethical Model for Examining Emergency Medicine Presentation Transcript

  • 1. A New Ethical Model for Examining Emergency Medicine Omar Ha-Redeye AAS, BHA(Hons.), CNMT, RT(N)(ARRT), J.D. Candidate Thursday May 14, 2009
  • 2. Why a New Ethical Model?
    • System for planning, decision-making, evaluating disaster response
    • Method for identifying shortcomings and areas of improvement
  • 3. Agenda
    • Describe bioethical model
      • Different ethical principles
      • Limits of Utilitarian approach
    • Case Study
      • Short Exercise: SARS in GTA
  • 4.
    • “ every discourse about health care has not only a scientific but also a moral dimension, [pandemic influenza] plans also presuppose certain ethical values, principles, norms, interests and preferences”
      • Kotalik, J. Addressing issues and questions relating to pandemic influenza planning: final report and recommendations . Health Canada; 2003.
  • 5. 3 Bioethical Principles Beneficence “ Do Good” Justice “ Do Fair” Autonomy “ Self Rule”
  • 6. Composite Model for Disaster Relief
  • 7. Beneficence
    • Most aid today is strictly beneficent, using a utilitarian ethos
      • Triage= Egalitarian or Utilitarian
    • Egalitarian - first-come, first-serve basis
      • treatment restricted to the easily treated group by queuing or by random selection
    • Utilitarian (reverse) triage - pre-prioritize individuals according to:
      • immediate community contribution; need for urgent, non-urgent, or palliative care
  • 8. Shortcomings of Triage
    • Geneva Conventions and Protocols: casualties “shall be treated…without any adverse distinction…only urgent medical reasons will authorise priority in the order of treatment”.
    • Often ignores principles of autonomy, justice
      • lacks the status of a universal moral obligation, and leads to an impersonal view of the valuing of life.
      • life-saving decisions involve medical, social, economic, and political criteria, and thus perpetuates existing injustices.
      • Incompatible with the liberal political philosophy of liberty and justice for all
  • 9. Justice
    • Corruption of local officials
    • Poor preparedness, early warning, and hazard reduction
    • Funding delays, inequity in distribution
      • Inappropriate distribution of care
      • Disorganized chaotic response
  • 10. Autonomy
    • Most Western aid countries highly individualistic
      • Communal culture provided support mechanisms for survivors
      • Need for outsides with respect for collectivist values
  • 11. Self-Determination
    • Recognize local leadership
    • Consultation of locals
    • Allow self-identification of needs
    • Promote self-direction of programs
  • 12. Human Rights
  • 13. Empowerment
    • Distribute aid directly through vulnerable populations
    • Form social bonds with IDPs and aid communities
    • Understand unique social, cultural situations
    • Seek to meet unique needs ignored by others due to bureaucracy
  • 14. Severe Acute Respiratory Syndrome (SARS)
    • March 5, 2003 Sui-chu Kwan, a 78-year-old woman who had travelled to Hong Kong in February, dies of SARS in Toronto.
    • March 17, 2003 Health Canada announces 11 suspected cases of SARS in Canada. There are nine in Ontario, one in B.C. and one in Alberta.
    • March 19, 2003 Health Canada suggests people should postpone travel to high-risk parts of Southeast Asia, including Vietnam and Singapore. World death toll of SARS estimated at 11.
    • March 26, 2003 Ontario declares a public health emergency and orders thousands of people to quarantine themselves in their homes. There are 27 probable cases of SARS in the province. Toronto hospitals begin barring visitors.
  • 15. Brief Case Study: SARS
    • Alison K Thompson, Karen Faith, Jennifer L Gibson, and Ross EG Upshur. Pandemic influenza preparedness: an ethical framework to guide decision making. BMC Med Ethics. 2006; 7:12.
    • Leo J Paquin. Was WHO SARS-related Travel Advisory for Toronto Ethical? Canadian Journal of Public Health. 2007;98:3.
    • Peter A Singer, Solomon R Benatar, Mark Bernstein, Abdallah S Daar, Bernard M Dickens, Susan K MacRae, Ross E G Upshur, Linda Wright, Randi Z Shaul. Ethics and SARS: Lessons from Toronto. BMJ. 2003; 327.
    • Thomson et al. Stand on Guard for Thee. Ethical Considerations in Preparedness Planning for Pandemic Influenza. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. November 2005.
    • Gostin LO, Bayer R, Fairchild AL. Ethical and Legal Challenges posed by severe acute respiratory syndrome: Implications for the control of severe infectious disease threats. JAMA. 2003; 290:24.
  • 16. Ethical Costs
    • Costs of not addressing ethical concerns during SARS in GTA included:
      • loss of public trust
      • low hospital staff morale
      • confusion about roles and responsibilities
      • stigmatization of vulnerable communities
      • misinformation
  • 17. SARS
    • Duty to Provide Care
    • Professional duty to respond-in tension with barriers (personal; organizational; societal)
      • SARS revealed tensions
      • Is there a difference in obligations when risk is known Vs. unknown?
      • Need for decision review process
  • 18. SARS
    • Equity
    • All patients have equal claim-in tension with need to prioritize (triage) during crisis
      • Preserve equity as much as possible
      • Procedural fairness-maximize buy-in
      • Fair criteria
      • Stewardship
  • 19. SARS
    • WHO Travel Ban
    • U.N. states, “liberty of movement is an indispensible condition for the free development of a person”
    • 5/6 cases of Canadian contracted SARS were people leaving Toronto
    • Cost GTA $1.1 billion
  • 20. SARS
    • Individual Liberty
    • Autonomy rights
      • in tension with public good
    • Limitations to rights of individual during public health crisis
    • Proportionality, protecting public good, least restrictive means, without discrimination to certain groups
  • 21. SARS
    • Proportionality
    • Personal liberty/rights
      • in tension with restrictions
    • Restrictions to individual/group in proportion to risk to public health
    • Justifies use of more coercive measures when least coercive measure have failed to achieve appropriate “ends”
    • “ Collateral Damage” of thousands in Toronto denied care
    • Severe illnesses; cancer, heart disease
  • 22. SARS
    • Protection of the Public From Harm
    • Public well-being & safety-in tension with individual autonomy
    • Compliance of individuals for public good
    • Rationing –priority setting
    • Least restrictive means used
    • Transparency of consequences
    • Individual’s interest in the well-being of community
  • 23. SARS
    • Privacy
    • Right to privacy
      • in tension with demands of crisis for shared information
    • Protection from stigmatization
    • Disclose only that which is necessary to protect public health
  • 24. SARS
    • Solidarity
    • Interdependence
      • in tension with territoriality (individual/department/institutions)
  • 25. SARS
    • Reciprocity
    • Support for those enduring a disproportionate burden during crisis
      • Measures taken to address/minimize burden where-ever possible
  • 26. SARS
    • Trust
    • Fundamental value on all levels from bedside to boardroom
      • Maintaining trust
        • in tension with having to impose limits
  • 27. SARS
    • Stewardship
    • Decision-makers have obligations when allocating resources to:
      • Avoid/minimize collateral damage
      • Maximize benefits
      • Protect and develop resources
    • Good stewardship entails consideration of:
      • Good outcomes (benefits to the public good)
      • Equity (fair distribution of benefits and burdens)
  • 28. Decision Review
    • Essential Features:
    • Transparency
      • Access for decision review
      • Criteria for review
      • Review process/leadership
    • Accountability :
      • Monitoring outcomes
  • 29. For More Information
    • Ha-Redeye, O (2009). Assessing the Needs of Health Professionals and Stakeholders. Chapter 6 in Population Health, Communities & Health Promotion (Eds. Sansnee Jirojwong, Pranee Liamputtong). Oxford University Press. ISBN: 9780195560558
    • [email_address]