A New Ethical Model for Examining Emergency Medicine

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

Why a New Ethical Model?
System for planning, decision-making, evaluating disaster response
Method for identifying shortcomings and areas of improvement

Agenda
Describe bioethical model
Different ethical principles
Limits of Utilitarian approach
Case Study
Short Exercise: SARS in GTA

“ 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.

3 Bioethical Principles Beneficence “ Do Good” Justice “ Do Fair” Autonomy “ Self Rule”

Composite Model for Disaster Relief

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

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

Justice
Corruption of local officials
Poor preparedness, early warning, and hazard reduction
Funding delays, inequity in distribution
Inappropriate distribution of care
Disorganized chaotic response

Autonomy
Most Western aid countries highly individualistic
Communal culture provided support mechanisms for survivors
Need for outsides with respect for collectivist values

Self-Determination
Recognize local leadership
Consultation of locals
Allow self-identification of needs
Promote self-direction of programs

Human Rights

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

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.

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.

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

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

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

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

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

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

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

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

SARS
Solidarity
Interdependence
in tension with territoriality (individual/department/institutions)

SARS
Reciprocity
Support for those enduring a disproportionate burden during crisis
Measures taken to address/minimize burden where-ever possible

SARS
Trust
Fundamental value on all levels from bedside to boardroom
Maintaining trust
in tension with having to impose limits

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)

Decision Review
Essential Features:
Transparency
Access for decision review
Criteria for review
Review process/leadership
Accountability :
Monitoring outcomes

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]

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A New Ethical Model for Examining Emergency Medicine

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