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

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

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.

“ 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

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

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

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

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

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

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.

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.

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

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

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

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

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

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

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

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

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)

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

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

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)

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

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]

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]