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Ethics tulane2012


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The Ethics of a Disaster 2012

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Ethics tulane2012

  1. 1. South Central Public Health Advanced Crisis Leadership Institute January 26, 2012 Perdido Beach Resort, Orange Beach, Alabama By John R. Wible, General Counsel (retired) Alabama Department of Public Health Ethics and Public Health How Public Health Reacts Ethically in a Disaster ADPH, 2012
  2. 2. Outline <ul><li>Setup and Introduction </li></ul><ul><li>Action Principles </li></ul><ul><li>A Quick Ethical Problem </li></ul><ul><li>Sources of Personal Ethics </li></ul><ul><li>Professional Ethical Principles </li></ul><ul><li>The Eye of the Storm – Application </li></ul><ul><li>An Ethical Exercise </li></ul><ul><li>Epilogue </li></ul>ADPH, 2012
  3. 3. Disaster! ADPH, 2012
  4. 4. DCH Could Have Been Hit- What If ????? ADPH, 2012
  5. 5. Dire Ethical Straits <ul><li>Katrina </li></ul><ul><ul><li>the people have left the building </li></ul></ul><ul><li>Pandemics and Influenza </li></ul><ul><ul><li>Notable Pandemics in History </li></ul></ul><ul><ul><li>The “new and improved disaster” </li></ul></ul><ul><li>Haiti – 200,000 dead </li></ul><ul><ul><li>And now Cholera </li></ul></ul><ul><ul><li>See paper for Haiti’s disaster timeline </li></ul></ul>ADPH, 2012
  6. 6. Question from CDC <ul><li>What objectives and principles should be considered in pandemic vaccine prioritization? </li></ul><ul><li>What is the relative importance of the CDC goals? </li></ul><ul><li>Which population should have vaccine priority? </li></ul><ul><li>What is the rationale? </li></ul><ul><li>How can fairness, equity, efficiency and related principles be reflected in the determination of priority groupings? </li></ul><ul><li>Who should determine the answers? </li></ul>ADPH, 2012
  7. 7. An Ethical Person <ul><li>Are you and ethical person? </li></ul><ul><li>From where or whom did you learn your ethical principles? </li></ul><ul><ul><li>Hint: “Yo Mama” </li></ul></ul><ul><li>“ All I Ever Needed to Know, I learned in Kindergarten ” </li></ul><ul><li>Role of the supervisor as an example </li></ul>ADPH, 2012
  8. 8. Our Purpose <ul><li>The purpose of this presentation is to help you discover the answers from within yourself so that you will be able to make decisions that will allow you to go about living outside yourself . </li></ul><ul><li>Look for the “Secret in the sauce.” </li></ul>Whistlestop Café, Irondale, AL ADPH, 2012
  9. 9. The Pareto Principle <ul><li>The “80-20 Rule” revisited </li></ul><ul><ul><li>10% basically ethical </li></ul></ul><ul><ul><li>10% basically unethical or “aethical” </li></ul></ul><ul><ul><li>80% wandering somewhere in the middle </li></ul></ul><ul><li>The ethical job of the manager – Like a good shepherd: </li></ul><ul><ul><li>Differentiate the animals </li></ul></ul><ul><ul><li>Lead the sheep </li></ul></ul>ADPH, 2012
  10. 10. John’s Five Action Principles <ul><li>To tell the truth, the whole truth and nothing but the truth </li></ul><ul><ul><li>No Delta Principle </li></ul></ul><ul><ul><li>The Principle of the Plumbline </li></ul></ul><ul><ul><li>Free at Last! </li></ul></ul><ul><li>“ We’ll Sing in the Sunshine” </li></ul><ul><li>Casper the Friendly Ghost </li></ul><ul><li>It’s not about me </li></ul><ul><li>The “Nike Principle.” </li></ul>ADPH, 2012
  11. 11. An Ethical Problem at Princeton-Plainsboro <ul><li>Multitudes presenting at the ED with ILI, flu-like symptoms </li></ul><ul><li>Resources and staff exhausted </li></ul>ADPH, 2012
  12. 12. The Characters <ul><ul><li>Lisa Cuddy- graduate </li></ul></ul><ul><ul><li>Stacy Warner, RN </li></ul></ul><ul><ul><li>Phillip Weber– autistic boy </li></ul></ul><ul><ul><li>James Wilson- policeman </li></ul></ul><ul><ul><li>Unknown homeless man </li></ul></ul><ul><ul><li>Michael Tritter- janitor </li></ul></ul><ul><ul><li>Allison Cameron– survivor </li></ul></ul>ADPH, 2012
  13. 13. Ethical Questions Presented <ul><li>Triage: </li></ul><ul><li>How to sort patients to determine priority for treatment? </li></ul><ul><li>What criteria will be used? </li></ul><ul><li>Who will develop those criteria? </li></ul>ADPH, 2012
  14. 14. Sources of Personal Ethical Principles <ul><li>The Ancient Greeks </li></ul><ul><li>Religious teachings </li></ul><ul><ul><li>Hindu </li></ul></ul><ul><ul><li>Buddhism </li></ul></ul><ul><ul><li>Judaism </li></ul></ul><ul><ul><li>Christianity </li></ul></ul><ul><ul><li>Islam </li></ul></ul><ul><li>Cultural teachings -American Historical Documents </li></ul><ul><ul><li>Declaration of Independence </li></ul></ul><ul><ul><li>United States Constitution </li></ul></ul>ADPH, 2012
  15. 15. The Ancient Greeks - The “Seven Sages” <ul><li>Solon – “nothing in excess” </li></ul><ul><li>Chilon – “know thyself” </li></ul><ul><li>Thales – “to bring surety brings ruin” </li></ul><ul><li>Bias – “too many workers spoil the work” </li></ul><ul><li>Cleobulus – “moderation is the chief good” </li></ul><ul><li>Pittacus – “know thine opportunity” </li></ul><ul><li>Periander – “forethought in all things” </li></ul>Mosaic of Socrates and the Seven Sages Surrounding the Muse, Calliope ADPH, 2012
  16. 16. Socrates, Plato and Aristotle <ul><li>Socrates – “know thyself” </li></ul><ul><li>Plato – human well-being, the highest aim of moral thought and conduct </li></ul><ul><li>Aristotle – apply what we know in social settings </li></ul>L:Plato and Aristotle by Raphael R:Raphael’s Socrates ADPH, 2012
  17. 17. Religious Teachings - Hindu <ul><li>Oldest practiced religion </li></ul><ul><li>Dharma – the “right way of living” or “proper conduct” for each societal segment </li></ul><ul><li>To live in accord with the principles is to move more quickly to personal liberation </li></ul><ul><li>Hindu writing </li></ul><ul><ul><li>Acara – daily caste-centered rituals </li></ul></ul><ul><ul><li>Vyavahara – rules about doubt and substantive law </li></ul></ul><ul><ul><li>Prayascitta – penance for rules violations </li></ul></ul>ADPH, 2012
  18. 18. Yogic Teachings from the Hindu <ul><li>Yamas </li></ul><ul><li>Moral Restraints </li></ul><ul><li>Ahimsa - do no harm </li></ul><ul><li>Satya - do not lie </li></ul><ul><li>Asteya - do not steal </li></ul><ul><li>Brahmacharya - moderation </li></ul><ul><li>Aparigraha -do not hoard </li></ul><ul><li>Niyamas </li></ul><ul><li>Moral observances </li></ul><ul><li>Saucha - cleanliness </li></ul><ul><li>Samtosha - contentedness </li></ul><ul><li>Tapas - perseverance </li></ul><ul><li>Svahhyaya - self-study </li></ul><ul><li>Ishvara pranidhan </li></ul><ul><li>- surrender to the higher being </li></ul>ADPH, 2012
  19. 19. Buddhism <ul><li>“ Any person who has awakened from the ‘sleep of ignorance’ by directly realizing the true nature of reality is called a buddha </li></ul><ul><li>Siddhartha Gautama, the Buddha, was the most notable </li></ul><ul><li>Life is full of pain, the ultimate goal is to break the cycle, become ‘enlightened’ and reach Nirvana </li></ul><ul><li>Thus, one lives a holy life </li></ul>ADPH, 2012
  20. 20. Buddhism- Four Noble Truths <ul><li>The nature, cause and cessation of suffering </li></ul><ul><li>The way to cessation of suffering is the “The Eightfold Path,” foundation of ethics found in three divisions: bodily actions, conscious thoughts and unconscious thoughts </li></ul><ul><li>Right speech, actions and livelihood (do no harm) </li></ul><ul><ul><li>Right effort/exercise to improve </li></ul></ul><ul><ul><li>Right mindfulness/awareness – seeing clearly </li></ul></ul><ul><ul><li>Right concentration -thoughts and understanding </li></ul></ul>ADPH, 2012
  21. 21. Judaism <ul><li>Ten Commandments 1 </li></ul><ul><li>You shall have no other gods before Me </li></ul><ul><li>You shall not make for yourself an idol </li></ul><ul><li>You shall not make wrongful use of the name of your God </li></ul><ul><li>Remember the Sabbath and keep it holy </li></ul><ul><li>Honor your parents </li></ul><ul><li>You shall not murder </li></ul><ul><li>You shall not commit adultery </li></ul><ul><li>You shall not steal </li></ul><ul><li>You shall not bear false witness </li></ul><ul><li>You shall not covet your neighbor's wife </li></ul><ul><li>You shall not covet your neighbor's house... </li></ul><ul><li>1 Note: The Torah counts 613 “Commandments” </li></ul>ADPH, 2012
  22. 22. Christianity <ul><li>Jesus said, “ I came not to abolish the Law, but to fulfill it,” thus reaffirming the right conduct of the Decalogue. </li></ul><ul><li>Jesus says “righteousness” must be internal, not external; conduct is more than negative, it places affirmative duties to actively do good even to those who harm you. </li></ul><ul><li>The “Golden Rule” – “ Do unto others as you would have them do unto you” or ”love thy neighbor as thyself.” </li></ul><ul><li>Summary: “Love God and love man.” </li></ul>ADPH, 2012
  23. 23. Christianity- per St. Paul <ul><li>The Apostle Paul says, to reach God, one must be righteous, but man is not righteous by nature, thus a spiritual dilemma </li></ul><ul><li>Paul tells us that it is by taking on the “mind of Christ” that we can be made righteous and thus be “bridged” to God. </li></ul>Perdidio Pass Bridge ADPH, 2012
  24. 24. Islam <ul><li>Mohammed saw a society on a “slippery slope” to destruction with the loss of traditional values </li></ul><ul><li>Doctrine is based on four sources: </li></ul><ul><ul><li>the Qur'an, </li></ul></ul><ul><ul><li>the sunnah (“traditions”) </li></ul></ul><ul><ul><li>ijma' (“consensus”) </li></ul></ul><ul><ul><li>ijtihad (“individual thought”) </li></ul></ul><ul><li>Its chief goal is the establishment of a “faithful” society by following the “Straight Path” </li></ul>ADPH, 2012
  25. 25. Values Sought in the Quer’an <ul><li>Values Sought </li></ul><ul><li>Brotherhood in place of blood relationships </li></ul><ul><li>Fidelity and chastity in place of indecency </li></ul><ul><li>Humility </li></ul><ul><li>Charity towards widows, orphans and poor </li></ul><ul><li>Justice to neighbors </li></ul>ADPH, 2012
  26. 26. American Historical Documents <ul><li>Declaration of Independence </li></ul><ul><li>United States Constitution </li></ul>1776 ADPH, 2012
  27. 27. Declaration of Independence <ul><li>Mr. Jefferson’s Declaration: </li></ul><ul><li>Set forth the “self evident truth” such as “equality” </li></ul><ul><li>Established an ethical basis for independence </li></ul><ul><li>What Locke applied to individuals, Jefferson applied to a people – John Adams </li></ul><ul><li>Did not condemn the British people </li></ul><ul><li>Did not address address African slavery </li></ul>ADPH, 2012
  28. 28. “ Self-Evident” Truths <ul><li>“ All men are created equal” ( Really?) </li></ul><ul><li>Endowed by their Creator </li></ul><ul><ul><li>Life </li></ul></ul><ul><ul><li>Liberty </li></ul></ul><ul><ul><li>Pursuit of happiness </li></ul></ul><ul><li>Modern Comparisons </li></ul><ul><ul><li>Life becomes “human dignity’ in UN Charter </li></ul></ul><ul><ul><li>Life becomes “personal autonomy” in Belmont Report </li></ul></ul>ADPH, 2012
  29. 29. The Declaration’s Purpose for Government <ul><li>“ . . . To secure these rights , governments are instituted among men . . . </li></ul><ul><li>deriving their power from the consent of the governed . . . </li></ul><ul><li>to effect their safety and happiness.” </li></ul><ul><li>As an institution of government, public health has a role in securing these rights </li></ul>ADPH, 2012
  30. 30. United States Constitution <ul><li>“ We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common Defense, promote the general Welfare , and secure the Blessings of Liberty to ourselves and our posterity, do ordain and establish this Constitution for the United States of America.” </li></ul>ADPH, 2012
  31. 31. Constitutional Principles <ul><li>“ We, the People” – social contract theory of government based in personal autonomy </li></ul><ul><li>“ Establish justice” – </li></ul><ul><ul><li>Equity </li></ul></ul><ul><ul><li>Equality </li></ul></ul><ul><ul><li>Fair process </li></ul></ul><ul><li>“ Insure Domestic Tranquility” – peace </li></ul><ul><li>“ Promote the General Welfare” – the sum of it all </li></ul>ADPH, 2012
  32. 32. Summary of Personal Ethics <ul><li>Right living </li></ul><ul><li>Do no harm </li></ul><ul><li>Do not lie </li></ul><ul><li>Do not steal </li></ul><ul><li>Do not hoard </li></ul><ul><li>Moderation </li></ul><ul><li>Cleanliness </li></ul><ul><li>Contentedness </li></ul><ul><li>Perseverance </li></ul><ul><li>Self-study </li></ul><ul><li>Higher Being </li></ul><ul><li>Right Speech </li></ul><ul><li>Right Actions </li></ul><ul><li>Right livelihood </li></ul><ul><li>Right effort </li></ul><ul><li>Effort to Improvement </li></ul><ul><li>Right mindfulness </li></ul><ul><li>Awareness </li></ul><ul><li>Right Mental thought </li></ul><ul><li>No gods/idols/swearing </li></ul><ul><li>Sabbath keeping </li></ul><ul><li>Honor parents </li></ul><ul><li>Do not murder </li></ul><ul><li>Do not commit adultery </li></ul><ul><li>Do not steal </li></ul><ul><li>Do not lie </li></ul><ul><li>Do not covet </li></ul><ul><li>Golden Rule </li></ul><ul><li>Love God/Love man </li></ul><ul><li>Brotherhood </li></ul><ul><li>Fidelity/chastity </li></ul><ul><li>Humility </li></ul><ul><li>Charity </li></ul><ul><li>Justice </li></ul><ul><li>Equality </li></ul><ul><li>Life </li></ul><ul><li>Liberty </li></ul><ul><li>Happiness </li></ul><ul><li>Government </li></ul><ul><li>Social contract </li></ul><ul><li>Equity </li></ul><ul><li>Fair process </li></ul><ul><li>Peace </li></ul><ul><li>General welfare </li></ul>ADPH, 2012
  33. 33. Professional Ethics <ul><li>The Hippocratic Oath and Medical Ethics </li></ul><ul><li>Augustine’s “Just War” </li></ul><ul><li>Nursing Ethics </li></ul><ul><li>Ethics and EMS </li></ul><ul><li>Ethics and Pharmacists </li></ul><ul><li>The Belmont Report and Institutional Review Boards </li></ul><ul><li>The Public Health Code of Ethics </li></ul><ul><li>Public Officer and Employee Ethics Laws </li></ul>ADPH, 2012
  34. 34. The Concept of Death <ul><li>Is the causing or allowing of death always ethically bad? </li></ul><ul><ul><li>Cain and Abel </li></ul></ul><ul><ul><li>Instructions to wipe out the people of Canaan </li></ul></ul><ul><ul><li>Lex talionis, cities of refuge and the “Avenger of Blood” </li></ul></ul>ADPH, 2012
  35. 35. Common Law Justifications for Causing Death <ul><li>State Sanctioned Execution </li></ul><ul><li>Defense of Self or Another </li></ul><ul><li>Augustine’s “Just War” </li></ul><ul><ul><li>Lawful authority </li></ul></ul><ul><ul><li>Defensive in nature </li></ul></ul><ul><ul><li>Proper motive </li></ul></ul><ul><ul><li>Carried out by legitimate government </li></ul></ul><ul><ul><li>proportional </li></ul></ul><ul><li>Modern Rules of Warfare – Geneva Conventions </li></ul>“ Gitmo” ADPH, 2012
  36. 36. Oath of Hippocrates – Medical Ethics <ul><li>“ Primum non nocere” – first do no harm </li></ul><ul><li>Always look to the good of the patient </li></ul><ul><li>Place a high value on human life </li></ul><ul><li>Perform only within one’s training and skill </li></ul><ul><li>Refrain from improper relations with patient </li></ul><ul><li>Maintain patient’s secrets inviolate </li></ul><ul><li>Do not violate community laws or morals </li></ul>ADPH, 2012
  37. 37. Medical Ethics in a Disaster <ul><li>AMA Policy Statement E-9.067 </li></ul><ul><li>There is a duty to provide urgent care </li></ul><ul><li>The physician workforce is not unlimited </li></ul><ul><li>Therefore, balance is required </li></ul><ul><ul><li>Live to fight another day </li></ul></ul><ul><ul><li>Are physicians required merely stay and not run away </li></ul></ul><ul><ul><li>Or to volunteer to come back in and help? </li></ul></ul>ADPH, 2012
  38. 38. Some Canadian Thought <ul><li>The ability of physicians and health care workers to provide care is greater than that of the public, thus increasing their obligation to provide care </li></ul><ul><li>By freely choosing a profession devoted to care for the ill, they assume risks </li></ul><ul><li>The profession has a social contract that calls on members to be available in times of emergency </li></ul><ul><li>Equated with police officers and fire fighters </li></ul><ul><ul><li>Note: They largely work in publicly supported systems in many countries (remember these are Canadians writing this report.) </li></ul></ul>ADPH, 2012
  39. 39. Nurse’s Ethics in Providing Care <ul><li>Provide care in a “non-discriminatory manner </li></ul><ul><li>There are limits to the amount of personal harm required to risk </li></ul><ul><li>Cannot abandon a patient </li></ul><ul><li>Personal risk may depend on the individual condition of the nurse </li></ul><ul><li>A “sacred duty” </li></ul><ul><ul><li>American Nursing Association – December 1994 </li></ul></ul>ADPH, 2012
  40. 40. Nurses Criteria for Limits <ul><li>The client is in significant risk of harm . . . if the nurse does not assist </li></ul><ul><li>The nurse’s intervention is directly relevant to prevent harm </li></ul><ul><li>The nurse’s care will probably prevent harm. . . </li></ul><ul><li>The benefit the client will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse </li></ul>ADPH, 2012
  41. 41. EMS Ethical Principles <ul><li>Fundamental responsibility-conserve life, alleviate suffering, promote health, do not harm </li></ul><ul><li>Respect human dignity w/o regard to status </li></ul><ul><li>Never harm the public well being </li></ul><ul><li>Be a good citizen and work well with others </li></ul><ul><li>Assume responsibility for individual actions </li></ul><ul><li>Maintain confidences </li></ul><ul><li>Do not delegate to a less qualified person </li></ul><ul><li>Expose incompetence of others ethically </li></ul><ul><li>Advertise ethically </li></ul>ADPH, 2012
  42. 42. Pharmacists <ul><li>“ Hold the health and safety of patients to be of the first consideration” </li></ul><ul><li>but </li></ul><ul><li>“ Duty to distribute in a fair and equitable manner” </li></ul>Hygieia ADPH, 2012
  43. 43. Researchers Ethics <ul><li>The Tuskegee Experiment – “Bad Blood” </li></ul><ul><li>Tuskegee by the numbers: </li></ul><ul><ul><li>600 men in the study </li></ul></ul><ul><ul><li>399 infected with syphilis and untreated </li></ul></ul><ul><ul><li>201 without syphilis </li></ul></ul><ul><ul><li>100 dead of causes “related to” syphilis </li></ul></ul><ul><ul><li>74 men survived </li></ul></ul><ul><ul><li>40 wives contracted syphilis </li></ul></ul><ul><ul><li>19 children born with congenital syphilis </li></ul></ul><ul><ul><li>9,000,000 dollars paid out in direct damages </li></ul></ul><ul><ul><li>1 good result – The Belmont Commission </li></ul></ul><ul><li>Similar Experiment with Guatemalans </li></ul>ADPH, 2012
  44. 44. The Belmont Commission Studied: <ul><li>The boundaries between biomedical and behavioral research and the accepted and routine practice of medicine, </li></ul><ul><li>The role of assessment of risk-benefit criteria in the determination of the appropriateness of research involving human subjects, </li></ul><ul><li>Appropriate guidelines for the selection of human subjects for participation in such research and </li></ul><ul><li>The nature and definition of informed consent in various research settings </li></ul>ADPH, 2012
  45. 45. Other International Works <ul><li>Nuremberg Code – ex post facto guidance to judge WWII Nazi war criminals </li></ul><ul><ul><li>Boundaries between research and practice </li></ul></ul><ul><ul><li>Ethical research </li></ul></ul><ul><ul><li>Ethical practice </li></ul></ul><ul><li>Declaration of Helsinki (1964) </li></ul><ul><ul><li>Informed consent as the ethical standard </li></ul></ul><ul><ul><li>“ Surrogate” consent defined and allowed </li></ul></ul><ul><ul><li>Research should only be performed when “necessary to promote the health of the population represented” </li></ul></ul><ul><ul><li>Laid the foundation for the establishment of IRBs </li></ul></ul>ADPH, 2012
  46. 46. The “Common Rule” (Based on the Belmont Report) <ul><li>Established boundaries between research and practice </li></ul><ul><li>Defined ethical practice based on three principles to include: </li></ul><ul><ul><li>Respect for persons </li></ul></ul><ul><ul><li>Beneficence </li></ul></ul><ul><ul><li>Justice </li></ul></ul>ADPH, 2012
  47. 47. Respect for Persons <ul><li>People are treated as autonomous agents </li></ul><ul><li>Protection for those of diminished capacity </li></ul><ul><li>Informed consent defined </li></ul><ul><li>Period reviews of status of subjects required </li></ul>ADPH, 2012
  48. 48. Beneficence <ul><li>Look out for the “broader good” of the subject </li></ul><ul><li>Do no harm </li></ul><ul><li>Does it actually do some good? </li></ul><ul><li>Balance the risks against the benefits </li></ul>“ Beneficence” – Ball State University ADPH, 2012
  49. 49. Justice <ul><li>Applies the allocation of risk or burden to benefit to the subject and to the proposed benefited population </li></ul><ul><ul><li>Are these welfare patients, </li></ul></ul><ul><ul><li>from a particular socio-economic or ethic background, </li></ul></ul><ul><ul><li>confined populations such as prisoners </li></ul></ul><ul><li>Formulations for distributing benefits and burdens: </li></ul><ul><ul><li>to each person an equal share, </li></ul></ul><ul><ul><li>to each person according to his or her need, </li></ul></ul><ul><ul><li>to each person according to societal contributions past and future </li></ul></ul><ul><ul><li>to each person according to (perceived) merit </li></ul></ul>ADPH, 2012
  50. 50. Application <ul><li>Informed, knowing consent </li></ul><ul><li>Detailed risk analysis with varied elements </li></ul><ul><ul><li>physical, </li></ul></ul><ul><ul><li>psychological, </li></ul></ul><ul><ul><li>legal, </li></ul></ul><ul><ul><li>social </li></ul></ul><ul><ul><li>economic </li></ul></ul><ul><li>Detailed and fair subject selection criteria </li></ul>ADPH, 2012
  51. 51. Public Health Code of Ethics (2002) <ul><li>Health: “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” </li></ul><ul><ul><li>Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948. </li></ul></ul><ul><ul><li>As affirmed by the Code </li></ul></ul>ADPH, 2012
  52. 52. The Code’s Twelve Principles <ul><li>Addresses fundamental causes of disease, aiming at prevention. </li></ul><ul><li>Respects the rights of individuals in the community. </li></ul><ul><li>Utilizes community input to develop policies, programs, and priorities. </li></ul><ul><li>Advocates “empowerment” of disenfranchised community members. </li></ul><ul><li>Seeks the information needed before acting. </li></ul><ul><li>Provides the community with information to make decisions. </li></ul><ul><li>Acts in a timely manner on the information. </li></ul><ul><li>A variety of approaches anticipate and respect diversity. </li></ul><ul><li>Programs and policies to enhance the physical & social environment. </li></ul><ul><li>Confidentiality - Exceptions must be justified. </li></ul><ul><li>Professional competence. </li></ul><ul><li>Work collaboratively to build the public's trust. </li></ul>ADPH, 2012
  53. 53. Public Health Values <ul><li>Reaffirms the Declaration of Human Rights </li></ul><ul><ul><li>Everyone has the right to a standard of living adequate for the health and well-being of himself and his family </li></ul></ul><ul><li>Humans are inherently social and interdependent, thus the principle of “community </li></ul><ul><li>Community is perpetually balanced as against the rights of the individual </li></ul><ul><li>Public trust and transparency </li></ul><ul><li>People and their environment are interdependent </li></ul><ul><li>Upheld by the science of prevention </li></ul><ul><li>Appropriate gathering, use and dispersion of knowledge </li></ul><ul><li>The Code requires action </li></ul>ADPH, 2012
  54. 54. Public Officer and Employee Ethics laws <ul><li>No public official or public employee shall use or cause to be used his or her official position or office to obtain personal gain for himself or herself, or family member of the public employee or family member of the public official, or any business with which the person is associated unless the use and gain are otherwise specifically authorized by law. Personal gain is achieved when the public official, public employee, or a family member thereof receives, obtains, exerts control over, or otherwise converts to personal use the object constituting such personal gain </li></ul><ul><ul><li>Code of Ala.1975 , § 36-25-5 </li></ul></ul>ADPH, 2012
  55. 55. Nature and Scope of Public Ethics Laws <ul><li>Very narrowly constructed and construed </li></ul><ul><li>Contrasted with the broad sweep of professional codes </li></ul>ADPH, 2012
  56. 56. Summary – Professional Ethics <ul><li>Death acceptable </li></ul><ul><li>Do no harm </li></ul><ul><li>Patient first </li></ul><ul><li> Value on life </li></ul><ul><li>Proper relations </li></ul><ul><li>Confidentiality </li></ul><ul><li>Follow law & morals </li></ul><ul><li>Duty to care </li></ul><ul><li>Balance </li></ul><ul><li>Use Information </li></ul><ul><li>Timeliness </li></ul><ul><li>Diversity </li></ul><ul><li>Confidentiality </li></ul><ul><li>Collaboration </li></ul><ul><li>Competence </li></ul><ul><li>Public trust </li></ul><ul><li>Interdependence </li></ul><ul><li>Not abuse public position </li></ul><ul><li>Not discriminate </li></ul><ul><li>Not abandon </li></ul><ul><li>“ Sacred duty” </li></ul><ul><li>Respect person </li></ul><ul><li>Beneficence </li></ul><ul><li>Justice </li></ul><ul><li>Individual rights </li></ul><ul><li>Community </li></ul><ul><li>Empowerment </li></ul>ADPH, 2012
  57. 57. -The Eye of the Storm- What Really Happens in a Disaster ADPH, 2012
  58. 58. So, what really happens? <ul><li>How do people’s relationships change? </li></ul><ul><li>Do people think and react differently? </li></ul><ul><li>Are the consequences the same as if you had reacted “in the sunshine?” </li></ul><ul><li>The “Outback Steakhouse Question,” are there really “no rules?” </li></ul><ul><li>How can you “rank” people in order or precedence to receive vaccine, ventilators or treatment according to ethical principles? </li></ul><ul><li>Can you invoke “altered standards of care? </li></ul><ul><li>What are the rights of staff to desert? </li></ul>ADPH, 2012
  59. 59. Effects on Victims and Staff <ul><li>Psychological, physiological and physiological Symptoms: </li></ul><ul><li>Irritability or anger, blaming or denial, mood swings, fear of recurrence, hyperactivity, feeling stunned, helpless, numb, or overwhelmed; </li></ul><ul><li>Loss of appetite and energy, headaches, chest pain, and fatigue; </li></ul><ul><li>Isolation, withdrawal, diarrhea, stomach pain, nausea; </li></ul><ul><li>Increase in alcohol or drug consumption; </li></ul><ul><li>Nightmares and inability to sleep; </li></ul><ul><li>Concentration and memory problems; </li></ul><ul><li>Sadness, depression and grief; </li></ul><ul><li>All leading to BAD CHOICES </li></ul>ADPH, 2012
  60. 60. Are there Really No Rules ? ADPH, 2012
  61. 61. Euthanasia <ul><li>Is euthanasia ever an option for suffering victims? </li></ul><ul><li>What is it? </li></ul><ul><li>Assuming the answer is “yes,” How would you justify it? </li></ul><ul><li>Is it a fair balance between individual rights and the rights of society? </li></ul>Dr. Kevorkian ADPH, 2012
  62. 62. A Seminal Case – Jacobson v. Massachusetts <ul><li>Facts </li></ul><ul><ul><li>Rev. Jacobson refused to be vaccinated against smallpox in Cambridge, MA. </li></ul></ul><ul><ul><li>Fined $5.00 and appealed to the United States Supreme Court. </li></ul></ul><ul><li>Question presented for review: </li></ul><ul><ul><li>What are the limits of how far the state can go to protect the public health? </li></ul></ul>ADPH, 2012
  63. 63. Summary of the Holding <ul><li>The Court found this a legitimate use of state powers and established a floor of constitutional protections that consists of four standards: </li></ul><ul><li>Necessity </li></ul><ul><li>reasonable means </li></ul><ul><li>Proportionality </li></ul><ul><li>harm avoidance. </li></ul><ul><li>Are the secured rights “fundamental?” </li></ul><ul><li>If “no,” the state may impose limits “reasonably related to a legitimate state interest” </li></ul><ul><li>If “yes,” the rights cannot legally be violated </li></ul>ADPH, 2012
  64. 64. This brings up the question of “No” <ul><li>Authorities, citing the experience at Memorial Hospital in New Orleans – short of a pandemic – your worst case scenario and Supreme Court authority . . . </li></ul><ul><li>Advises that in the question of whether euthanasia is an option, the answer is “no,” </li></ul><ul><li>Euthanasia is never an option </li></ul><ul><li>( Unless it is the end of the world as we know it and it doesn’t matter ) </li></ul>“ The Big Bang” ADPH, 2012
  65. 65. Let’s Just Let them Eat Cake* <ul><li>OK, so we can’t “depopulate” the victims, can we just let them die – a philosophical interlude: Utilitarianism vs. Egalitarianism </li></ul><ul><ul><li>* Quote from Marie Antoinette some time before her execution . </li></ul></ul>ADPH, 2012
  66. 66. Utilitarianism vs. Egalitarianism <ul><li>Jeremy Bentham’s theory of utilitarianism what is right or good based on whether the consequences will be good </li></ul><ul><li>Immanuel Kant’s egalitarianism theory focuses on non-consequentially based notions of good - deciding what is right or good is based on meeting duties and obligations </li></ul><ul><li>These contradistinguished ideas will clash over and over </li></ul>ADPH, 2012
  67. 67. History of Triage <ul><li>Triage , ( to sort out) , a French military medical term based on the utilitarian principles the most good for the most people </li></ul><ul><li>Adapted to modern military and civilian medicine </li></ul><ul><li>Originally, triage grouped casualties into four groups based on care needed: immediate, minimal, delayed, expectant. </li></ul><ul><li>Use must be done without regard to rank, age, race, social worth or income or such distinction </li></ul><ul><li>Not based on the social worth of individual, but on societal need </li></ul>Baron Larrey, Father of Triage ADPH, 2012
  68. 68. Modern Disaster Triage <ul><li>In disasters there is a switch from standard medical ethics with the primary focus on Individual autonomy to an ethics of public health with a primary focus on the health of the community </li></ul><ul><li>The overarching goal is to minimize morbidity and mortality during the pandemic (according to CDC) </li></ul><ul><li>Will it be most good or greatest need ? </li></ul>ADPH, 2012
  69. 69. Utilitarianism Says: <ul><li>The goal is to help those for whom you can do the most good following the long-established standard in military medicine </li></ul><ul><li>Advantages: follows a clear, simple, community-recognized goal in a potentially chaotic environment </li></ul><ul><li>Disadvantages: situations will arise with no clear utility-based answer that may lead to “unintended, insidious discrimination” </li></ul>ADPH, 2012
  70. 70. Egalitarianism Says: <ul><li>Goal: to help those in greatest need </li></ul><ul><li>Ranks patients based on severity of illness, with patients in the most severe condition receiving the medical attention </li></ul><ul><li>The ultimate goal such as limiting morbidity and mortality during the pandemic is de-prioritized in order to preserve the egalitarian principles </li></ul>“ It’s all about the process” – Saban, 2008 Coach of the Year ADPH, 2012
  71. 71. Hybrid Triage <ul><li>Uses both concepts </li></ul><ul><ul><li>Utilitarian approach </li></ul></ul><ul><ul><li>Egalitarian methods </li></ul></ul><ul><li>Requires sorting out into 3-4 groups </li></ul><ul><li>Treat those in the group before going to the next lower group </li></ul>ADPH, 2012
  72. 72. Examples of Methods <ul><li>CERT training advises four groups </li></ul><ul><li>SOFA’s four level sorting is based on organ failure </li></ul><ul><li>Current EMS (START) model has four levels </li></ul><ul><li>Hospital Emergency Department – five levels </li></ul><ul><li>Canadian and Alabama Method – four levels </li></ul><ul><li>Delayed urgent immediate questionable (dead?) </li></ul>ADPH, 2012
  73. 73. Ethical Responsibilities in Triage <ul><li>Plan NOW! See “Bryant’s Rule” </li></ul><ul><li>Get a Triage Review Committee </li></ul><ul><ul><li>Plan </li></ul></ul><ul><ul><li>Oversee </li></ul></ul><ul><ul><li>Evaluate post-event </li></ul></ul><ul><li>Engage the public in the discussion </li></ul><ul><li>An experienced triage officer </li></ul>ADPH, 2012 Coach Bryant
  74. 74. Altered Standards of Care <ul><li>When it permissible from an ethical and legal standpoint to provide less than the care normally pr traditionally expected or held to be what is referred to in both the medical and legal professions as the “standard of care”? </li></ul>ADPH, 2012
  75. 75. Goals of Altered Standards <ul><li>Maximize the number of lives saved. </li></ul><ul><li>Changes necessary to allocate resources </li></ul><ul><li>Basis for allocation - fair and clinically sound </li></ul><ul><li>Process for decisions - transparent and fair </li></ul><ul><li>Protocols flexible and “scalable” </li></ul><ul><li>Staff concerns addressed pre-event </li></ul>Goal! ADPH, 2012
  76. 76. Focus Change in Altered Standards <ul><li>Critical : Focus Changes from doing to best for each patient to maximizing the most lives saved </li></ul><ul><li>The system becomes the pt. </li></ul><ul><li>Affect current patients already in hospital </li></ul><ul><li>The scope of practice changes </li></ul><ul><li>Equipment, meds and supplies rationed </li></ul><ul><li>Record-keeping changes </li></ul>ADPH, 2012
  77. 77. Ethical Considerations <ul><li>Keep the health care system functioning and deliver “acceptable” quality of care to preserve as many lives as possible </li></ul><ul><li>The plan must be community wide </li></ul><ul><li>There must be an adequate legal framework to allow for the altered standards of care </li></ul><ul><li>The rights of individuals must be protected to the extent possible and reasonable under the circumstances </li></ul><ul><li>The public must be informed on planning and decision making pre, during and post event </li></ul>ADPH, 2012
  78. 78. Legal Concerns of Altered Standards <ul><li>How to make it legal: </li></ul><ul><li>Change the laws at federal and state levels directly </li></ul><ul><li>Change laws to allow for regulatory changes </li></ul><ul><li>Consider pre-drafting emergency orders for the Governor to sign in an event invoking the altered standards of care </li></ul>ADPH, 2012
  79. 79. CDC’s Plan for Rationing Vaccine <ul><li>CDC scares us with their predictions </li></ul><ul><li>The system of manufacturing vaccine is old and tired </li></ul><ul><li>CDC has devised priority groups with subgroups </li></ul><ul><ul><li>Health care workers </li></ul></ul><ul><ul><li>Public service workers </li></ul></ul><ul><ul><li>High risk populations </li></ul></ul>ADPH, 2012
  80. 80. Ethical Look at the CDC Plan <ul><li>A hybrid system </li></ul><ul><ul><li>Utilitarian goal </li></ul></ul><ul><ul><li>Egalitarian execution </li></ul></ul><ul><li>Allows local input should they want input </li></ul><ul><li>Buck-passing and the failure to plan will be a catastrophic ethical failure </li></ul><ul><li>Ethical Issues: fairness and equity, reciprocity and flexibility </li></ul>ADPH, 2012
  81. 81. Rationing Ventilators <ul><li>Alabama plan to be triggered by declarations by government or activation of the National PI Plan </li></ul><ul><li>Three tiers based on respiratory failure </li></ul><ul><ul><li>Withhold ventilators starting with Tier 1 </li></ul></ul><ul><ul><li>Withdraw ventilators starting with Tiers 2 and 3 </li></ul></ul><ul><li>What would St. Augustine say? </li></ul><ul><li>The same discussion applies to all such allocations of medicines, supplies or equipment </li></ul>ADPH, 2012
  82. 82. Alabama’s “Top Down” Development <ul><li>Plan written at State level, our “day job” </li></ul><ul><li>Partnership with Hospital Association </li></ul><ul><li>Added to the State EOP </li></ul><ul><li>Invoked by Governor’s order </li></ul><ul><li>Grants immunity to professionals </li></ul><ul><li>Legislation would be “surer” – New York </li></ul>1971 Triumph Spitfire –Top Down ADPH, 2012
  83. 83. More Help from Canada - An Ethical Guide <ul><li>Based on Toronto’s SARS experience, “Stand On Guard for Thee” offers an Ethical guide in mass events dealing with issues: </li></ul><ul><li>Individual liberty </li></ul><ul><li>Protection of the public </li></ul><ul><li>Proportionality </li></ul><ul><li>Privacy </li></ul><ul><li>Duty to Provide Care </li></ul><ul><li>Reciprocity </li></ul><ul><li>Equity </li></ul><ul><li>Trust </li></ul><ul><li>Solidarity </li></ul><ul><li>Stewardship </li></ul>What historical ethical principles do you see in each? ADPH, 2012
  84. 84. The Right to Desertion – “When is it time to go to the house” <ul><li>Practical dilemmas faced personally – what are my obligations to me and my family? </li></ul><ul><li>Professional dilemmas – conflicting ethical principles </li></ul><ul><ul><li>Autonomy vs. non-maleficence </li></ul></ul><ul><ul><li>Autonomy vs. beneficence </li></ul></ul><ul><ul><li>Autonomy vs. justice </li></ul></ul>ADPH, 2012
  85. 85. The Problem Won’t Go Away <ul><li>If you don’t come to work, the problem doesn’t go away </li></ul><ul><li>In fact, the problem only gets worse </li></ul><ul><li>Every employee will make a difference by contributing his or her part </li></ul><ul><li>All employees must ask themselves, ‘If I don’t work in times of crisis, then who will?’ </li></ul>ADPH, 2012
  86. 86. A Suggestion <ul><li>Take a deep breath </li></ul><ul><li>Look for the balance </li></ul><ul><li>Remember John’s principle of living outside yourself based on the truth within yourself </li></ul><ul><ul><li>(This assumes you know the truth) </li></ul></ul><ul><li>Planners and facility administrators must “think outside the box” – but do it now </li></ul>ADPH, 2012
  87. 87. Exercise - The Kobayashi Maru <ul><li>In the Star Trek fictional universe, the Kobayashi Maru is a starship that serves as the subject of a graded training exercise at Starfleet Academy. </li></ul><ul><li>The term Kobayashi Maru is a shorthand for no-win scenarios. </li></ul><ul><li>Questions presented by the exercise: </li></ul><ul><li>Given the scare resources, who gets what resources? </li></ul><ul><li>Who decides who gets what resources? </li></ul><ul><li>What is your rationale for your decision? </li></ul>ADPH, 2012
  88. 88. John’s Five Action Principles <ul><li>It’s all about the Truth </li></ul><ul><ul><li>There is absolute truth </li></ul></ul><ul><li>“ We’ll Sing in the Sunshine” </li></ul><ul><ul><li>Plan in the sunshine </li></ul></ul><ul><li>Casper the Friendly Ghost </li></ul><ul><ul><li>Transparency </li></ul></ul><ul><ul><li>Accountability </li></ul></ul><ul><li>It’s not about me </li></ul><ul><li>The “Nike Principle” – “just do it” </li></ul>ADPH, 2012
  89. 89. Who Am I? 2-4-6-0-1 ADPH, 2012
  90. 90. Epilogue <ul><li>The Eagle soars above the din, </li></ul><ul><li>of mankind's rushing out and in, </li></ul><ul><li>And lesser creatures left to spin, </li></ul><ul><li>The Eagle soars from deep within. </li></ul><ul><li>  </li></ul><ul><li>His course is true as gaffer's pike, </li></ul><ul><li>His keen eye pierces like a spike, </li></ul><ul><li>His quest surrounds him like a dike, </li></ul><ul><li>The Eagle soars, but phantomlike. </li></ul><ul><li>  </li></ul><ul><li>Those who on the Earth have stood, </li></ul><ul><li>Thinking that they never could, </li></ul><ul><li>Nor many even perhaps should ... but, </li></ul><ul><li>  </li></ul><ul><li>The Eagle soars because he would. - John R. Wible, 1981 </li></ul>ADPH, 2012
  91. 91. The Eagle has Landed ADPH, 2012
  92. 92. For A Paper on this Subject <ul><li>See “Ethics Paper 2012” a download on Slideshare 7 </li></ul><ul><li>See this presentation also </li></ul><ul><li> </li></ul>7 Slideshare ADPH, 2012