1. ADPH, 2010ADPH, 2010 11
South Central Public HealthSouth Central Public Health
Advanced Crisis Leadership InstituteAdvanced Crisis Leadership Institute
January 14, 2010January 14, 2010
Perdido Beach Resort,Perdido Beach Resort,
Orange Beach, AlabamaOrange Beach, Alabama
By John R. Wible, General CounselBy John R. Wible, General Counsel
Alabama Department of Public HealthAlabama Department of Public Health
Ethics and Public HealthEthics and Public Health
How Public Health ReactsHow Public Health Reacts
Ethically in a DisasterEthically in a Disaster

2. ADPH, 2010 2
OutlineOutline
►Setup and IntroductionSetup and Introduction
►Action PrinciplesAction Principles
►A Quick Ethical ProblemA Quick Ethical Problem
►Sources of Personal EthicsSources of Personal Ethics
►Professional Ethical PrinciplesProfessional Ethical Principles
►The Eye of the Storm – ApplicationThe Eye of the Storm – Application
►An Ethical ExerciseAn Ethical Exercise
►EpilogueEpilogue

3. ADPH, 2010 3
Dire Ethical StraitsDire Ethical Straits
►Hurricane KatrinaHurricane Katrina
 the people have left the buildingthe people have left the building
►Pandemic InfluenzaPandemic Influenza
 the “new and improved disaster”the “new and improved disaster”
►Novel H1N1Novel H1N1

4. ADPH, 2010 4
Question from CDCQuestion from CDC
► What objectives and principles should beWhat objectives and principles should be
considered in pandemic vaccine prioritization?considered in pandemic vaccine prioritization?
► What is the relative importance of the CDC goals?What is the relative importance of the CDC goals?
► Which population should have vaccine priority?Which population should have vaccine priority?
► What is the rationale?What is the rationale?
► How can fairness, equity, efficiency and relatedHow can fairness, equity, efficiency and related
principles be reflected in the determination ofprinciples be reflected in the determination of
priority groupings?priority groupings?
►Who should determine the answers?Who should determine the answers?

5. ADPH, 2010 5
An Ethical PersonAn Ethical Person
►Are you and ethical person?Are you and ethical person?
►From where or whom did you learn yourFrom where or whom did you learn your
ethical principles?ethical principles?
 Hint: “Yo Mama”Hint: “Yo Mama”
►““All I Ever Needed to Know, IAll I Ever Needed to Know, I
learned in Kindergartenlearned in Kindergarten””
►Role of the supervisor as an exampleRole of the supervisor as an example

6. ADPH, 2010 6
Our PurposeOur Purpose
► The purpose of this presentation is to helpThe purpose of this presentation is to help
you discover the answers fromyou discover the answers from withinwithin
yourselfyourself so that you will be able to makeso that you will be able to make
decisions that will allow you to go aboutdecisions that will allow you to go about
living outside yourselfliving outside yourself..
► Look for the “Secret in the sauce.”Look for the “Secret in the sauce.”
Whistlestop Café, Irondale, AL

7. ADPH, 2010 7
The Pareto PrincipleThe Pareto Principle
► The “80-20 Rule” revisitedThe “80-20 Rule” revisited
 10% basically ethical10% basically ethical
 10% basically unethical or “aethical”10% basically unethical or “aethical”
 80% wandering somewhere in the middle80% wandering somewhere in the middle
► The ethical job of the manager – Like aThe ethical job of the manager – Like a
good shepherd:good shepherd:
 Differentiate the animalsDifferentiate the animals
 Lead the sheepLead the sheep

8. ADPH, 2010 8
A Personal Aside -A Personal Aside - YouYou
►Who helped shape your ethical principlesWho helped shape your ethical principles
and how?and how?
►What did he or she teach you?What did he or she teach you?
►What do you think is the most importantWhat do you think is the most important
ethical principle of them all and why?ethical principle of them all and why?

9. ADPH, 2010 9
Group Ethical QuestionsGroup Ethical Questions
►What are some universally accepted ethicalWhat are some universally accepted ethical
concepts?concepts?
►Where did they come from and how do weWhere did they come from and how do we
learn them as individuals?learn them as individuals?
►How does each of us develop his own set ofHow does each of us develop his own set of
ethical principles?ethical principles?
►Do we view those as static or sliding?Do we view those as static or sliding?
►What is the price of each of us? (For howWhat is the price of each of us? (For how
much would you sell out?)much would you sell out?)

10. 10
John’s Five Action
Principles►To tell the truth, the whole truthTo tell the truth, the whole truth
and nothing but the truthand nothing but the truth
 No Delta PrincipleNo Delta Principle
 The Principle of the PlumblineThe Principle of the Plumbline
 Free at Last!Free at Last!
►““We’ll Sing in the Sunshine”We’ll Sing in the Sunshine”
►Casper the Friendly GhostCasper the Friendly Ghost
►It’s not about meIt’s not about me
►The “Nike Principle.”The “Nike Principle.”
ADPH, 2010

11. ADPH, 2010 11
An Ethical Problem atAn Ethical Problem at
St. ElsewhereSt. Elsewhere
►Multitudes presenting at the ED with ILI,Multitudes presenting at the ED with ILI,
flu-like symptomsflu-like symptoms
►Resources and staff exhaustedResources and staff exhausted

12. ADPH, 2010 12
The CharactersThe Characters
 Annie Cavanero - graduateAnnie Cavanero - graduate
 Cathy Martin, RNCathy Martin, RN
 Ben Samuels – autistic boyBen Samuels – autistic boy
 Wayne Fiscus - policemanWayne Fiscus - policeman
 Unknown homeless manUnknown homeless man
 Peter White - janitorPeter White - janitor
 Helen Rosenthal – survivorHelen Rosenthal – survivor

13. ADPH, 2010 13
Ethical Questions PresentedEthical Questions Presented
►Triage:Triage:
 How to sort patients to determine priority forHow to sort patients to determine priority for
treatment?treatment?
 What criteria will be used?What criteria will be used?
 Who will develop those criteria?Who will develop those criteria?
►Staff Participation:Staff Participation:
 Are healthcare workers obligated to work duringAre healthcare workers obligated to work during
an influenza pandemic?an influenza pandemic?
 What can be done to increase staff participationWhat can be done to increase staff participation

14. ADPH, 2010 14
Sources ofSources of PersonalPersonal EthicalEthical
PrinciplesPrinciples
► The Ancient GreeksThe Ancient Greeks
► Religious teachingsReligious teachings
 HinduHindu
 BuddhismBuddhism
 JudaismJudaism
 ChristianityChristianity
 IslamIslam
► Cultural teachingsCultural teachings
-American Historical Documents-American Historical Documents
 Declaration of IndependenceDeclaration of Independence
 United States ConstitutionUnited States Constitution

15. The Ancient Greeks -The Ancient Greeks -
The “Seven Sages”The “Seven Sages”
► Solon – “nothing in excess”Solon – “nothing in excess”
► Chilon – “know thyself”Chilon – “know thyself”
► Thales – “to bring suretyThales – “to bring surety
brings ruin”brings ruin”
► Bias – “too many workers spoil theBias – “too many workers spoil the
work”work”
► Cleobulus – “moderation is theCleobulus – “moderation is the
chief good”chief good”
► Pittacus – “know thinePittacus – “know thine
opportunity”opportunity”
► Periander – “forethought in allPeriander – “forethought in all
things”things” ADPH, 2010 15
Mosaic of Socrates and the Seven Sages
Surrounding the Muse, Calliope

16. Socrates, Plato andSocrates, Plato and
AristotleAristotle
►Socrates – “know thyself”Socrates – “know thyself”
►Plato – human well-being, the highest aim ofPlato – human well-being, the highest aim of
moral thought and conductmoral thought and conduct
►Aristotle – apply what we know in socialAristotle – apply what we know in social
settingssettings
ADPH, 2010 16
L:Plato and Aristotle by Raphael
R:Raphael’s Socrates

17. ADPH, 2010 17
Religious Teachings - HinduReligious Teachings - Hindu
► Oldest practiced religionOldest practiced religion
► Dharma – the “right way of living” orDharma – the “right way of living” or
“proper conduct” for each societal segment“proper conduct” for each societal segment
► To live in accord with the principles is to moveTo live in accord with the principles is to move
more quickly to personal liberationmore quickly to personal liberation
► Hindu writingHindu writing
 Acara – daily caste-centered ritualsAcara – daily caste-centered rituals
 Vyavahara – rules about doubt and substantive lawVyavahara – rules about doubt and substantive law
 Prayascitta – penance for rules violationsPrayascitta – penance for rules violations

18. ADPH, 2010 18
Yogic Teachings from the HinduYogic Teachings from the Hindu
Yamas
Moral Restraints
AhimsaAhimsa - do no harm- do no harm
SatyaSatya - do not lie- do not lie
AsteyaAsteya - do not steal- do not steal
Brahmacharya - moderationBrahmacharya - moderation
AparigrahaAparigraha -do not-do not
hoardhoard
Niyamas
Moral observances
SauchaSaucha - cleanliness- cleanliness
SamtoshaSamtosha - contentedness- contentedness
TapasTapas - perserverance- perserverance
SvahhyayaSvahhyaya - self-study- self-study
Ishvara pranidhanIshvara pranidhan
- surrender to the higher being- surrender to the higher being

19. ADPH, 2010 19
BuddhismBuddhism
““Any person who has awakened from theAny person who has awakened from the
‘sleep of ignorance’ by directly realizing the‘sleep of ignorance’ by directly realizing the
true nature of reality is called a buddhatrue nature of reality is called a buddha
Siddhartha Gautama, the Buddha, was theSiddhartha Gautama, the Buddha, was the
most notablemost notable
Life is full of pain, the ultimate goal is toLife is full of pain, the ultimate goal is to
break the cycle, become ‘enlightened’ andbreak the cycle, become ‘enlightened’ and
reach Nirvanareach Nirvana
Thus, one lives a holy lifeThus, one lives a holy life

20. ADPH, 2010 20
Buddhism- Four NobleBuddhism- Four Noble
TruthsTruths
The nature, cause and cessation of sufferingThe nature, cause and cessation of suffering
The way to cessation of suffering is the “TheThe way to cessation of suffering is the “The
Eightfold Path,” foundation of ethics found in threeEightfold Path,” foundation of ethics found in three
divisions: bodily actions, conscious thoughts anddivisions: bodily actions, conscious thoughts and
unconscious thoughtsunconscious thoughts
Right speech, actions and livelihood (do no harm)Right speech, actions and livelihood (do no harm)
Right effort/exercise to improveRight effort/exercise to improve
Right mindfulness/awareness – seeing clearlyRight mindfulness/awareness – seeing clearly
Right concentration -thoughts and understandingRight concentration -thoughts and understanding

21. ADPH, 2010 21
JudaismJudaism
Ten CommandmentsTen Commandments11
You shall have no other gods before Me
You shall not make for yourself an idol
You shall not make wrongful use of the name of your God
Remember the Sabbath and keep it holy
Honor your parentsHonor your parents
You shall not murderYou shall not murder
You shall not commit adulteryYou shall not commit adultery
You shall not stealYou shall not steal
You shall not bear false witnessYou shall not bear false witness
You shall not covet your neighbor's wifeYou shall not covet your neighbor's wife
You shall not covet your neighbor's house...You shall not covet your neighbor's house...
11
Note: The Torah counts 613 “Commandments”Note: The Torah counts 613 “Commandments”

22. 22
ChristianityChristianity
 Jesus said, “ I came not to abolish theJesus said, “ I came not to abolish the
Law, but to fulfill it,” thus reaffirming theLaw, but to fulfill it,” thus reaffirming the
right conduct of the Decalogue.right conduct of the Decalogue.
 Jesus says “righteousness” must be internal, notJesus says “righteousness” must be internal, not
external; conduct is more than negative, it placesexternal; conduct is more than negative, it places
affirmative duties to actively do good even to thoseaffirmative duties to actively do good even to those
who harm you.who harm you.
 The “Golden Rule” – “The “Golden Rule” – “Do unto others as you wouldDo unto others as you would
have them do unto you” or ”love thy neighbor ashave them do unto you” or ”love thy neighbor as
thyself.”thyself.”
 Summary: “Love God and love man.”Summary: “Love God and love man.”
ADPH, 2010

23. ADPH, 2010 23
Christianity- per St. PaulChristianity- per St. Paul
 The Apostle Paul says, to reach God, oneThe Apostle Paul says, to reach God, one
must be righteous, but man is not righteousmust be righteous, but man is not righteous
by nature, thus a spiritual dilemmaby nature, thus a spiritual dilemma
 Paul tells us that it is by taking on the “mindPaul tells us that it is by taking on the “mind
of Christ” that we can be made righteousof Christ” that we can be made righteous
and thus be “bridged” to God.and thus be “bridged” to God.
Perdidio Pass Bridge

24. ADPH, 2010 24
IslamIslam
 Mohammed saw a society on a “slipperyMohammed saw a society on a “slippery
slope” to destruction with the loss ofslope” to destruction with the loss of
traditional valuestraditional values
 Doctrine is based on four sources:Doctrine is based on four sources:
 the Qur'an,the Qur'an,
 thethe sunnahsunnah (“traditions”)(“traditions”)
 ijma'ijma' (“consensus”)(“consensus”)
 ijtihadijtihad (“individual thought”)(“individual thought”)
 Its chief goal is the establishment of aIts chief goal is the establishment of a
“faithful” society by following the “Straight“faithful” society by following the “Straight
Path”Path”

25. ADPH, 2010 25
Values Sought in theValues Sought in the
Quer’anQuer’an
Values SoughtValues Sought
 Brotherhood in place of bloodBrotherhood in place of blood
relationshipsrelationships
 Fidelity and chastity in placeFidelity and chastity in place
of indecencyof indecency
 HumilityHumility
 Charity towards widows, orphans and poorCharity towards widows, orphans and poor
 Justice to neighborsJustice to neighbors

26. ADPH, 2010 26
American HistoricalAmerican Historical
DocumentsDocuments
►Declaration of IndependenceDeclaration of Independence
►United States ConstitutionUnited States Constitution
1776

27. ADPH, 2010 27
Declaration ofDeclaration of
IndependenceIndependence
Mr. Jefferson’s Declaration:Mr. Jefferson’s Declaration:
► Set forth the “self evident truth” suchSet forth the “self evident truth” such
as “equality”as “equality”
► Established an ethical basis forEstablished an ethical basis for
independenceindependence
► What Locke applied to individuals,What Locke applied to individuals,
Jefferson applied to aJefferson applied to a people – Johnpeople – John
AdamsAdams
► Did not condemn the British peopleDid not condemn the British people
► DidDid notnot address address Africanaddress address African
slaveryslavery

28. ADPH, 2010 28
““Self-Evident” TruthsSelf-Evident” Truths
►““All men are created equal” (All men are created equal” (Really?)Really?)
►Endowed by their CreatorEndowed by their Creator
 LifeLife
 LibertyLiberty
 Pursuit of happinessPursuit of happiness
►Modern ComparisonsModern Comparisons
 Life becomes “human dignity’ in UN CharterLife becomes “human dignity’ in UN Charter
 Life becomes “personal autonomy” in BelmontLife becomes “personal autonomy” in Belmont
ReportReport

29. ADPH, 2010 29
The Declaration’sThe Declaration’s
Purpose for GovernmentPurpose for Government
►““. . . To. . . To secure these rightssecure these rights, governments, governments
are instituted among men . . .are instituted among men . . .
deriving their power from thederiving their power from the consentconsent of theof the
governed . . .governed . . .
to effect theirto effect their safety and happiness.”safety and happiness.”
►As an institution of government, publicAs an institution of government, public
health has a role inhealth has a role in securingsecuring these rightsthese rights

30. ADPH, 2010 30
United States ConstitutionUnited States Constitution
““We the People of the United States, in OrderWe the People of the United States, in Order
to form a more perfect Union, establishto form a more perfect Union, establish
Justice, insure domestic Tranquility, provideJustice, insure domestic Tranquility, provide
for the common Defense, promote thefor the common Defense, promote the
general Welfare , and secure the Blessingsgeneral Welfare , and secure the Blessings
of Liberty to ourselves and our posterity, doof Liberty to ourselves and our posterity, do
ordain and establish this Constitution for theordain and establish this Constitution for the
United States of America.”United States of America.”

31. ADPH, 2010 31
Constitutional PrinciplesConstitutional Principles
►““We, the People” – social contract theory ofWe, the People” – social contract theory of
government based in personal autonomygovernment based in personal autonomy
►““Establish justice” –Establish justice” –
 EquityEquity
 EqualityEquality
 Fair processFair process
►““Insure Domestic Tranquility” – peaceInsure Domestic Tranquility” – peace
►““Promote the General Welfare”Promote the General Welfare”
– the sum of it all– the sum of it all

32. ADPH, 2010 32
Summary of Personal EthicsSummary of Personal Ethics
Right livingRight living
Do no harmDo no harm
Do not lieDo not lie
Do not stealDo not steal
Do not hoardDo not hoard
ModerationModeration
CleanlinessCleanliness
ContentednessContentedness
PerseverancePerseverance
Self-studySelf-study
Higher BeingHigher Being
Right SpeechRight Speech
Right ActionsRight Actions
Right livelihoodRight livelihood
Right effortRight effort
Effort to ImprovementEffort to Improvement
Right mindfulnessRight mindfulness
AwarenessAwareness
Right Mental thoughtRight Mental thought
No gods/idols/swearingNo gods/idols/swearing
Sabbath keepingSabbath keeping
Honor parentsHonor parents
Do not murderDo not murder
Do not commit adulteryDo not commit adultery
Do not stealDo not steal
Do not lieDo not lie
Do not covetDo not covet
†Golden Rule
†Love God/Love man
‫ﺶ‬Brotherhood
‫ﺶ‬Fidelity/chastity
‫ﺶ‬Humility
‫ﺶ‬Charity
‫ﺶ‬Justice
Equality
Life
Liberty
Happiness
Government
Social contract
Equity
Fair process
Peace
General welfare

33. ADPH, 2010 33
Professional EthicsProfessional Ethics
► The Hippocratic Oath and Medical EthicsThe Hippocratic Oath and Medical Ethics
► Augustine’s “Just War”Augustine’s “Just War”
► Nursing EthicsNursing Ethics
► Ethics and EMSEthics and EMS
► Ethics and PharmacistsEthics and Pharmacists
► The Belmont Report and Institutional ReviewThe Belmont Report and Institutional Review
BoardsBoards
► The Public Health Code of EthicsThe Public Health Code of Ethics
► Public Officer and Employee Ethics LawsPublic Officer and Employee Ethics Laws

34. ADPH, 2010 34
The Concept of DeathThe Concept of Death
Is the causing or allowing of deathIs the causing or allowing of death
alwaysalways ethically bad?ethically bad?
 Cain and AbelCain and Abel
 Instructions to wipe out the people ofInstructions to wipe out the people of
CanaanCanaan
 Lex talionis,Lex talionis, cities of refugecities of refuge and theand the
“Avenger of Blood”“Avenger of Blood”

35. ADPH, 2010 35
Common Law Justifications forCommon Law Justifications for
Causing DeathCausing Death
► State Sanctioned ExecutionState Sanctioned Execution
► Defense of Self or AnotherDefense of Self or Another
► Augustine’s “Just War”Augustine’s “Just War”
 Lawful authorityLawful authority
 Defensive in natureDefensive in nature
 Proper motiveProper motive
 Carried out by legitimate governmentCarried out by legitimate government
 proportionalproportional
► Modern Rules of Warfare –Modern Rules of Warfare –
Geneva ConventionsGeneva Conventions
“Gitmo”

36. ADPH, 2010 36
Oath of Hippocrates –Oath of Hippocrates –
Medical EthicsMedical Ethics
►““Primum non nocere” – first do no harmPrimum non nocere” – first do no harm
►AlwaysAlways look to the good of the patientlook to the good of the patient
►Place a high value on human lifePlace a high value on human life
►Perform only within one’s training and skillPerform only within one’s training and skill
►Refrain from improper relations with patientRefrain from improper relations with patient
►Maintain patient’s secrets inviolateMaintain patient’s secrets inviolate
►Do not violate community laws or moralsDo not violate community laws or morals

37. ADPH, 2010 37
Medical Ethics in a DisasterMedical Ethics in a Disaster
AMA Policy Statement E-9.067AMA Policy Statement E-9.067
► There is a duty to provide urgent careThere is a duty to provide urgent care
► The physician workforce is not unlimitedThe physician workforce is not unlimited
► Therefore, balance is requiredTherefore, balance is required
 Live to fight another dayLive to fight another day
 Are physicians requiredAre physicians required merelymerely stay and not run awaystay and not run away
 Or to volunteer to come back in and help?Or to volunteer to come back in and help?

38. ADPH, 2010 38
Some CanadianSome Canadian
ThoughtThought
► The ability of physicians and health care workersThe ability of physicians and health care workers
to provide care is greater than that of the public,to provide care is greater than that of the public,
thus increasing their obligation to provide carethus increasing their obligation to provide care
► By freely choosing a profession devoted to careBy freely choosing a profession devoted to care
for th ill, they assume risksfor th ill, they assume risks
► The profession has a social contract that calls onThe profession has a social contract that calls on
members to be available in times of emergencymembers to be available in times of emergency
► Equated with police officers and fire fightersEquated with police officers and fire fighters
 Note: They largely work in publicly supported systems inNote: They largely work in publicly supported systems in
many countries (remember these are Canadians writingmany countries (remember these are Canadians writing
this report.)this report.)

39. ADPH, 2010 39
Nurse’s Ethics in ProvidingNurse’s Ethics in Providing
CareCare
►Provide care in a “non-Provide care in a “non-
discriminatory mannerdiscriminatory manner
►There are limits to the amount ofThere are limits to the amount of
personal harm required to riskpersonal harm required to risk
►Cannot abandon a patientCannot abandon a patient
►Personal risk may depend on the individualPersonal risk may depend on the individual
condition of the nursecondition of the nurse
►A “sacred duty”A “sacred duty”
 American Nursing Association – DecemberAmerican Nursing Association – December
19941994

40. ADPH, 2010 40
Nurses Criteria for LimitsNurses Criteria for Limits
►The client is in significant risk of harm . . . ifThe client is in significant risk of harm . . . if
the nurse does not assistthe nurse does not assist
►The nurse’s intervention is directly relevantThe nurse’s intervention is directly relevant
to prevent harmto prevent harm
►The nurse’s care will probably preventThe nurse’s care will probably prevent
harm. . .harm. . .
►The benefit the client will gain outweighsThe benefit the client will gain outweighs
any harm the nurse might incur and doesany harm the nurse might incur and does
not present more than an acceptable risk tonot present more than an acceptable risk to
the nursethe nurse

41. EMS Ethical PrinciplesEMS Ethical Principles
► Fundamental responsibility-conserve life,Fundamental responsibility-conserve life,
alleviate suffering, promote health, do not harmalleviate suffering, promote health, do not harm
► Respect human dignity w/o regard to statusRespect human dignity w/o regard to status
► Never harm the public well beingNever harm the public well being
► Be a good citizen and work well with othersBe a good citizen and work well with others
► Assume responsibility for individual actionsAssume responsibility for individual actions
► Maintain confidencesMaintain confidences
► Do not delegate to a less qualified personDo not delegate to a less qualified person
► Expose incompetence of others ethicallyExpose incompetence of others ethically
► Advertise ethicallyAdvertise ethically
ADPH, 2010 41

42. PharmacistsPharmacists
►““Hold the health and safety ofHold the health and safety of
patients to be of the firstpatients to be of the first
consideration”consideration”
butbut
►““Duty to distribute in aDuty to distribute in a fair andfair and
equitableequitable manner”manner”
ADPH, 2010 42
Hygieia

43. ADPH, 2010 43
Researchers EthicsResearchers Ethics
► The Tuskegee Experiment – “Bad Blood”The Tuskegee Experiment – “Bad Blood”
► Tuskegee by the numbers:Tuskegee by the numbers:
 600 men in the study600 men in the study
 399 infected with syphilis and untreated399 infected with syphilis and untreated
 201 without syphilis201 without syphilis
 100 dead of causes “related to” syphilis100 dead of causes “related to” syphilis
 74 men survived74 men survived
 40 wives contracted syphilis40 wives contracted syphilis
 19 children born with congenital syphilis19 children born with congenital syphilis
 9,000,000 dollars paid out in direct damages9,000,000 dollars paid out in direct damages
 1 good result – The Belmont Commission1 good result – The Belmont Commission

44. ADPH, 2010 44
The Belmont Commission Studied:The Belmont Commission Studied:
► The boundaries between biomedical andThe boundaries between biomedical and
behavioral research and the accepted and routinebehavioral research and the accepted and routine
practice of medicine,practice of medicine,
► The role of assessment of risk-benefit criteria inThe role of assessment of risk-benefit criteria in
the determination of the appropriateness ofthe determination of the appropriateness of
research involving human subjects,research involving human subjects,
► Appropriate guidelines for the selection of humanAppropriate guidelines for the selection of human
subjects for participation in such research andsubjects for participation in such research and
► The nature and definition of informed consent inThe nature and definition of informed consent in
various research settingsvarious research settings

45. ADPH, 2010 45
Other International WorksOther International Works
► Nuremberg Code –Nuremberg Code – ex post factoex post facto guidance toguidance to
judge WWII Nazi war criminalsjudge WWII Nazi war criminals
 Boundaries between research andBoundaries between research and
practicepractice
 Ethical researchEthical research
 Ethical practiceEthical practice
► Declaration of Helsinki (1964)Declaration of Helsinki (1964)
 Informed consent as the ethical standardInformed consent as the ethical standard
 ““Surrogate” consent defined and allowedSurrogate” consent defined and allowed
 Research should only be performed when “necessary toResearch should only be performed when “necessary to
promote the health of the population represented”promote the health of the population represented”
 Laid the foundation for the establishment of IRBsLaid the foundation for the establishment of IRBs

46. ADPH, 2010 46
The “Common Rule”The “Common Rule”
(Based on the Belmont Report)(Based on the Belmont Report)
►Established boundaries between researchEstablished boundaries between research
and practiceand practice
►Defined ethical practice based on threeDefined ethical practice based on three
principles to include:principles to include:
 Respect for personsRespect for persons
 BeneficenceBeneficence
 JusticeJustice

47. ADPH, 2010 47
Respect for PersonsRespect for Persons
►People are treated as autonomous agentsPeople are treated as autonomous agents
►Protection for those of diminished capacityProtection for those of diminished capacity
►Informed consent definedInformed consent defined
►Period reviews of status of subjects requiredPeriod reviews of status of subjects required

48. ADPH, 2010 48
BeneficenceBeneficence
►Look out for the “broader good”Look out for the “broader good”
of the subjectof the subject
►Do no harmDo no harm
►Does it actually do some good?Does it actually do some good?
►Balance the risks against the benefitsBalance the risks against the benefits
“Beneficence” –
Ball State
University

49. ADPH, 2010 49
JusticeJustice
► Applies the allocation of risk orApplies the allocation of risk or
burden to benefit to the subject andburden to benefit to the subject and
to the proposed benefited populationto the proposed benefited population
 Are these welfare patients,Are these welfare patients,
 from a particular socio-economic or ethic background,from a particular socio-economic or ethic background,
 confined populations such as prisonersconfined populations such as prisoners
► Formulations for distributing benefits and burdens:Formulations for distributing benefits and burdens:
 to each person an equal share,to each person an equal share,
 to each person according to his or her need,to each person according to his or her need,
 to each person according to societal contributions pastto each person according to societal contributions past
and futureand future
 to each person according to (perceived) meritto each person according to (perceived) merit

50. ADPH, 2010 50
ApplicationApplication
►Informed, knowing consentInformed, knowing consent
►Detailed risk analysis with varied elementsDetailed risk analysis with varied elements
 physical,physical,
 psychological,psychological,
 legal,legal,
 socialsocial
 economiceconomic
►Detailed and fair subject selection criteriaDetailed and fair subject selection criteria

51. ADPH, 2010 51
Public Health Code of Ethics (2002)Public Health Code of Ethics (2002)
►Health: “a state of complete physical,Health: “a state of complete physical,
mental, and social well-being, and notmental, and social well-being, and not
merely the absence of disease or infirmity.”merely the absence of disease or infirmity.”
 Preamble to the Constitution of the WorldPreamble to the Constitution of the World
Health Organization as adopted by theHealth Organization as adopted by the
International Health Conference, New York, 19-International Health Conference, New York, 19-
22 June 1946, and entered into force on 7 April22 June 1946, and entered into force on 7 April
1948.1948.
 As affirmed by theAs affirmed by the CodeCode

52. ADPH, 2010 52
TheThe Code’sCode’s TwelveTwelve
PrinciplesPrinciples1.1. Addresses fundamental causes of disease,Addresses fundamental causes of disease,
aiming ataiming at prevention.prevention.
2.2. Respects theRespects the rights of individualsrights of individuals in the community.in the community.
3.3. UtilizesUtilizes community inputcommunity input to develop policies, programs, andto develop policies, programs, and
priorities.priorities.
4.4. AdvocatesAdvocates “empowerment”“empowerment” of disenfranchised community members.of disenfranchised community members.
5.5. Seeks theSeeks the informationinformation needed before acting.needed before acting.
6.6. Provides the community with informationProvides the community with information to make decisions.to make decisions.
7.7. Acts in aActs in a timelytimely manner on the information.manner on the information.
8.8. A variety of approaches anticipate and respectA variety of approaches anticipate and respect diversity.diversity.
9.9. Programs and policies to enhance the physical & socialPrograms and policies to enhance the physical & social
environment.environment.
10.10. ConfidentialityConfidentiality - Exceptions must be justified.- Exceptions must be justified.
11.11. Professional competence.Professional competence.
12.12. Work collaborativelyWork collaboratively to build the public's trust.to build the public's trust.

53. ADPH, 2010 53
Public Health ValuesPublic Health Values
► Reaffirms theReaffirms the Declaration of Human RightsDeclaration of Human Rights
 Everyone has the right to a standard of living adequate for theEveryone has the right to a standard of living adequate for the
health and well-being of himself and his familyhealth and well-being of himself and his family
► Humans are inherently social and interdependent,Humans are inherently social and interdependent,
thus the principle of “communitythus the principle of “community
► Community is perpetually balanced as against the rights ofCommunity is perpetually balanced as against the rights of
the individualthe individual
► Public trust and transparencyPublic trust and transparency
► People and their environment are interdependentPeople and their environment are interdependent
► Upheld by the science of preventionUpheld by the science of prevention
► Appropriate gathering, use and dispersion of knowledgeAppropriate gathering, use and dispersion of knowledge
► TheThe CodeCode requiresrequires actionaction

54. ADPH, 2010 54
Public Officer and EmployeePublic Officer and Employee
Ethics lawsEthics laws
No public official or public employee shall use or cause to beNo public official or public employee shall use or cause to be
used his or her official position or office to obtain personalused his or her official position or office to obtain personal
gain for himself or herself, or family member of the publicgain for himself or herself, or family member of the public
employee or family member of the public official, or anyemployee or family member of the public official, or any
business with which the person is associated unless thebusiness with which the person is associated unless the
use and gain are otherwise specifically authorized by law.use and gain are otherwise specifically authorized by law.
Personal gain is achieved when the public official, publicPersonal gain is achieved when the public official, public
employee, or a family member thereof receives, obtains,employee, or a family member thereof receives, obtains,
exerts control over, or otherwise converts to personal useexerts control over, or otherwise converts to personal use
the object constituting such personal gainthe object constituting such personal gain
 Code of Ala.1975Code of Ala.1975, § 36-25-5, § 36-25-5

55. ADPH, 2010 55
Nature and ScopeNature and Scope
of Public Ethics Lawsof Public Ethics Laws
►Very narrowly constructedVery narrowly constructed
and construedand construed
►Contrasted with the broadContrasted with the broad
sweep of professionalsweep of professional
codescodes

56. ADPH, 2010 56
Summary – Professional EthicsSummary – Professional Ethics
► DeathDeath
acceptableacceptable
Do no harmDo no harm
Patient firstPatient first
Value on lifeValue on life
Proper relationsProper relations
ConfidentialityConfidentiality
Follow law &Follow law &
moralsmorals
Duty to careDuty to care
BalanceBalance
Use InformationUse Information
TimelinessTimeliness
DiversityDiversity
ConfidentialityConfidentiality
CollaborationCollaboration
CompetenceCompetence
Public trustPublic trust
InterdependenceInterdependence
Not abuse publicNot abuse public
positionposition
Not discriminateNot discriminate
Not abandonNot abandon
““Sacred duty”Sacred duty”
►Respect personRespect person
►BeneficenceBeneficence
►JusticeJustice
Individual rightsIndividual rights
CommunityCommunity
EmpowermentEmpowerment

57. ADPH, 2010 57
-The Eye of the Storm--The Eye of the Storm-
What Really Happens in a DisasterWhat Really Happens in a Disaster

58. ADPH, 2010 58
So, what really happens?So, what really happens?
► How do people’s relationships change?How do people’s relationships change?
► Do people think and react differently?Do people think and react differently?
► Are the consequences the same as if you hadAre the consequences the same as if you had
reacted “in the sunshine?”reacted “in the sunshine?”
► The “Outback Steakhouse Question,” are thereThe “Outback Steakhouse Question,” are there
really “no rules?”really “no rules?”
► How can you “rank” people in order or precedenceHow can you “rank” people in order or precedence
to receive vaccine, ventilators or treatmentto receive vaccine, ventilators or treatment
according to ethical principles?according to ethical principles?
► Can you invoke “altered standards of care?Can you invoke “altered standards of care?
► What are the rights of staff to desert?What are the rights of staff to desert?

59. ADPH, 2010 59
Effects on VictimsEffects on Victims and Staffand Staff
Psychological, physiological and physiological Symptoms:Psychological, physiological and physiological Symptoms:
► Irritability or anger, blaming or denial, mood swings, fear ofIrritability or anger, blaming or denial, mood swings, fear of
recurrence, hyperactivity, feeling stunned, helpless, numb,recurrence, hyperactivity, feeling stunned, helpless, numb,
or overwhelmed;or overwhelmed;
► Loss of appetite and energy, headaches, chest pain, andLoss of appetite and energy, headaches, chest pain, and
fatigue;fatigue;
► Isolation, withdrawal, diarrhea, stomach pain, nausea;Isolation, withdrawal, diarrhea, stomach pain, nausea;
► Increase in alcohol or drug consumption;Increase in alcohol or drug consumption;
► Nightmares and inability to sleep;Nightmares and inability to sleep;
► Concentration and memory problems;Concentration and memory problems;
► Sadness, depression and grief;Sadness, depression and grief;
All leading to BAD CHOICESAll leading to BAD CHOICES

60. ADPH, 2010 60
Are there Really No RulesAre there Really No Rules
?

61. ADPH, 2010 61
EuthanasiaEuthanasia
►Is euthanasiaIs euthanasia everever an option foran option for
suffering victims?suffering victims?
►What is it?What is it?
►Assuming the answer is “yes,” How wouldAssuming the answer is “yes,” How would
youyou justify it?justify it?
►Is it a fair balance between individual rightsIs it a fair balance between individual rights
and the rights of society?and the rights of society?
Dr. Kevorkian

62. ADPH, 2010 62
A Seminal Case –A Seminal Case –
Jacobson v. MassachusettsJacobson v. Massachusetts
►FactsFacts
 Rev. Jacobson refused to be vaccinated againstRev. Jacobson refused to be vaccinated against
smallpox in Cambridge, MA.smallpox in Cambridge, MA.
 Fined $5.00 and appealed to the United StatesFined $5.00 and appealed to the United States
Supreme Court.Supreme Court.
►Question presented for review:Question presented for review:
 What are the limits of how far the state can goWhat are the limits of how far the state can go
to protect the public health?to protect the public health?

63. ADPH, 2010 63
Summary of the HoldingSummary of the Holding
The Court found this aThe Court found this a
legitimate use of statelegitimate use of state
powers and establishedpowers and established
a floor of constitutionala floor of constitutional
protections thatprotections that
consists of fourconsists of four
standards:standards:
► NecessityNecessity
► reasonable meansreasonable means
► ProportionalityProportionality
► harm avoidance.harm avoidance.
Are the secured rightsAre the secured rights
“fundamental?”“fundamental?”
►If “no,” the state mayIf “no,” the state may
impose limits “reasonablyimpose limits “reasonably
related to a legitimaterelated to a legitimate
state interest”state interest”
►If “yes,” the rightsIf “yes,” the rights
cannot legally be violatedcannot legally be violated

64. ADPH, 2010 64
This brings up the question of “No”This brings up the question of “No”
Authorities, citing the experience at MemorialAuthorities, citing the experience at Memorial
Hospital in New Orleans – short of aHospital in New Orleans – short of a
pandemic – your worst case scenario andpandemic – your worst case scenario and
Supreme Court authority . . .Supreme Court authority . . .
►Advises that in the question of whetherAdvises that in the question of whether
euthanasia is an option, the answer is “no,”euthanasia is an option, the answer is “no,”
►Euthanasia isEuthanasia is nevernever an optionan option
((Unless it is the end of the world as we know itUnless it is the end of the world as we know it
and it doesn’t matterand it doesn’t matter))
“The Big Bang”

65. ADPH, 2010 65
Let’s Just Let them Eat Cake*Let’s Just Let them Eat Cake*
OK, so we can’t “depopulate” the victims, canOK, so we can’t “depopulate” the victims, can
we just let them die – a philosophicalwe just let them die – a philosophical
interlude: Utilitarianism vs. Egalitarianisminterlude: Utilitarianism vs. Egalitarianism
** Quote from Marie Antoinette someQuote from Marie Antoinette some
time before her executiontime before her execution..

66. ADPH, 2010 66
Utilitarianism vs.Utilitarianism vs.
EgalitarianismEgalitarianism
► Jeremy Bentham’s theory ofJeremy Bentham’s theory of
utilitarianism what is right or goodutilitarianism what is right or good
based on whether the consequencesbased on whether the consequences
will be goodwill be good
► Immanuel Kant’s egalitarianismImmanuel Kant’s egalitarianism
theory focuses on non-theory focuses on non-
consequentially based notions ofconsequentially based notions of
good - deciding what is right or goodgood - deciding what is right or good
is based on meeting duties andis based on meeting duties and
obligationsobligations
► These contradistinguished ideas willThese contradistinguished ideas will
clash over and overclash over and over

67. ADPH, 2010 67
History of TriageHistory of Triage
► TriageTriage, (, (to sort out) ,to sort out) , a French military medical terma French military medical term
based on the utilitarian principles the mostbased on the utilitarian principles the most
good for the most peoplegood for the most people
► Adapted to modern militaryAdapted to modern military and civilianand civilian medicinemedicine
► Originally, triage grouped casualties into four groups basedOriginally, triage grouped casualties into four groups based
on care needed: immediate, minimal, delayed, expectant.on care needed: immediate, minimal, delayed, expectant.
► Use must be done without regard to rank, age, race, socialUse must be done without regard to rank, age, race, social
worth or income or such distinctionworth or income or such distinction
► Not based on the social worth of individual, butNot based on the social worth of individual, but
on societal needon societal need
Baron Larrey,
Father of Triage

68. ADPH, 2010 68
Modern Disaster TriageModern Disaster Triage
►In disasters there is a switch fromIn disasters there is a switch from
standard medical ethics with thestandard medical ethics with the
primary focus onprimary focus on IndividualIndividual
autonomyautonomy to an ethics of public health withto an ethics of public health with
a primary focus on thea primary focus on the health of thehealth of the
communitycommunity
►The overarching goal is toThe overarching goal is to minimizeminimize
morbidity and mortality during the pandemicmorbidity and mortality during the pandemic
(according to CDC)(according to CDC)
►Will it beWill it be most goodmost good oror greatest needgreatest need??

69. ADPH, 2010 69
Utilitarianism Says:Utilitarianism Says:
►The goal is to help those for whom you canThe goal is to help those for whom you can
do thedo the mostmost good following the long-good following the long-
established standard in military medicineestablished standard in military medicine
►Advantages: follows a clear, simple,Advantages: follows a clear, simple,
community-recognized goal in a potentiallycommunity-recognized goal in a potentially
chaotic environmentchaotic environment
►Disadvantages: situations will arise with noDisadvantages: situations will arise with no
clear utility-based answer that may lead toclear utility-based answer that may lead to
“unintended, insidious discrimination”“unintended, insidious discrimination”

70. ADPH, 2010 70
Egalitarianism Says:Egalitarianism Says:
►Goal: to help those inGoal: to help those in greatest needgreatest need
►Ranks patients based on severity ofRanks patients based on severity of
illness, with patients in the mostillness, with patients in the most
severe condition receiving thesevere condition receiving the
medical attentionmedical attention
►The ultimate goal such as limitingThe ultimate goal such as limiting
morbidity and mortality during themorbidity and mortality during the
pandemic ispandemic is de-prioritizedde-prioritized in orderin order
to preserve the egalitarian principlesto preserve the egalitarian principles
“It’s all about the process” –
Saban, 2008 Coach of the Year

71. ADPH, 2010 71
Hybrid TriageHybrid Triage
►Uses both conceptsUses both concepts
 Utilitarian approachUtilitarian approach
 Egalitarian methodsEgalitarian methods
►Requires sorting out into 3-4 groupsRequires sorting out into 3-4 groups
►Treat those in the group before going to theTreat those in the group before going to the
next lower groupnext lower group

72. ADPH, 2010 72
Examples of MethodsExamples of Methods
► CERT training advises four groupsCERT training advises four groups
► SOFA’s four level sorting is based on organ failureSOFA’s four level sorting is based on organ failure
► Current EMS (START) model has four levelsCurrent EMS (START) model has four levels
► Hospital Emergency Department – five levelsHospital Emergency Department – five levels
► Canadian and Alabama Method – four levelsCanadian and Alabama Method – four levels
Delayed urgent immediate questionable deadDelayed urgent immediate questionable dead

73. ADPH, 2010 73
Ethical Responsibilities in TriageEthical Responsibilities in Triage
►Plan NOW! See “Bryant’s Rule”Plan NOW! See “Bryant’s Rule”
►Establish a Triage Review CommitteeEstablish a Triage Review Committee
 PlanPlan
 OverseeOversee
 Evaluate post-eventEvaluate post-event
►Engage the public in the discussionEngage the public in the discussion
►An experienced triage officerAn experienced triage officer

74. ADPH, 2010 74
Altered Standards of CareAltered Standards of Care
When it permissible from an ethical and legalWhen it permissible from an ethical and legal
standpoint to provide less than the carestandpoint to provide less than the care
normally pr traditionally expected or held tonormally pr traditionally expected or held to
be what is referred to in both the medicalbe what is referred to in both the medical
and legal professions as the “standard ofand legal professions as the “standard of
care”?care”?

75. ADPH, 2010 75
Goals of Altered StandardsGoals of Altered Standards
►Maximize the number of lives saved.Maximize the number of lives saved.
►Changes necessary to allocate resourcesChanges necessary to allocate resources
►Basis for allocation - fair and clinically soundBasis for allocation - fair and clinically sound
►Process for decisions - transparent and fairProcess for decisions - transparent and fair
►Protocols flexible and “scalable”Protocols flexible and “scalable”
►Staff concerns addressed pre-eventStaff concerns addressed pre-event
Goal!

76. ADPH, 2010 76
Focus Change in Altered StandardsFocus Change in Altered Standards
►Critical :Critical : Focus Changes fromFocus Changes from
doing to best for each patient todoing to best for each patient to
maximizing the most lives savedmaximizing the most lives saved
►TheThe systemsystem becomes the pt.becomes the pt.
►Affect current patients already in hospitalAffect current patients already in hospital
►The scope of practice changesThe scope of practice changes
►Equipment, meds and supplies rationedEquipment, meds and supplies rationed
►Record-keeping changesRecord-keeping changes

77. ADPH, 2010 77
Ethical ConsiderationsEthical Considerations
► KeepKeep the health care system functioningthe health care system functioning andand
deliver “acceptable” quality of care to preserve asdeliver “acceptable” quality of care to preserve as
many lives as possiblemany lives as possible
► The plan must be community wideThe plan must be community wide
► There must be an adequate legal framework toThere must be an adequate legal framework to
allow for the altered standards of careallow for the altered standards of care
► The rights of individuals must be protected to theThe rights of individuals must be protected to the
extent possible and reasonable under theextent possible and reasonable under the
circumstancescircumstances
► The public must be informed on planning andThe public must be informed on planning and
decision making pre, during and post eventdecision making pre, during and post event

78. ADPH, 2010 78
Legal Concerns of Altered StandardsLegal Concerns of Altered Standards
How to make it legal:How to make it legal:
►Change the laws at federal andChange the laws at federal and
state levels directlystate levels directly
►Change laws to allow for regulatoryChange laws to allow for regulatory
changeschanges
►Consider pre-drafting emergency orders forConsider pre-drafting emergency orders for
the Governor to sign in an event invokingthe Governor to sign in an event invoking
the altered standards of carethe altered standards of care

79. ADPH, 2010 79
CDC’s Plan for RationingCDC’s Plan for Rationing
VaccineVaccine
►CDC scares us with their predictionsCDC scares us with their predictions
►The system of manufacturing vaccine is oldThe system of manufacturing vaccine is old
and tiredand tired
►CDC has devised priority groups withCDC has devised priority groups with
subgroupssubgroups
 Health care workersHealth care workers
 Public service workersPublic service workers
 High risk populationsHigh risk populations

80. ADPH, 2010 80
Ethical Look at the CDC PlanEthical Look at the CDC Plan
►A hybrid systemA hybrid system
 Utilitarian goalUtilitarian goal
 Egalitarian executionEgalitarian execution
►Allows local input should theyAllows local input should they wantwant inputinput
►Buck-passing and the failure to plan will beBuck-passing and the failure to plan will be
a catastrophic ethical failurea catastrophic ethical failure
►Ethical Issues: fairness and equity,Ethical Issues: fairness and equity,
reciprocity and flexibilityreciprocity and flexibility

81. ADPH, 2010 81
Rationing VentilatorsRationing Ventilators
► Alabama plan to be triggered by declarations byAlabama plan to be triggered by declarations by
government or activation of the National PI Plangovernment or activation of the National PI Plan
► Three tiers based on respiratory failureThree tiers based on respiratory failure
 Withhold ventilators starting with Tier 1Withhold ventilators starting with Tier 1
 WithdrawWithdraw ventilators starting with Tiers 2 and 3ventilators starting with Tiers 2 and 3
► What would St. Augustine say?What would St. Augustine say?
► The same discussion applies to all suchThe same discussion applies to all such
allocations of medicines, supplies or equipmentallocations of medicines, supplies or equipment

82. ADPH, 2010 82
Alabama’s “Top Down” DevelopmentAlabama’s “Top Down” Development
► Plan written at State level, ourPlan written at State level, our
“day job”“day job”
► Partnership with HospitalPartnership with Hospital
AssociationAssociation
► Added to the State EOPAdded to the State EOP
► Invoked by Governor’s orderInvoked by Governor’s order
► Grants immunity to professionalsGrants immunity to professionals
► Legislation would be “surer” – NewLegislation would be “surer” – New
YorkYork
1971 Triumph Spitfire
–Top Down

83. ADPH, 2010 83
More Help from Canada -More Help from Canada -
An Ethical GuideAn Ethical Guide
Based on Toronto’s SARS experience, “Stand OnBased on Toronto’s SARS experience, “Stand On
Guard for Thee” offers an Ethical guide in massGuard for Thee” offers an Ethical guide in mass
events dealing with issues:events dealing with issues:
►Individual libertyIndividual liberty
►Protection of the publicProtection of the public
►ProportionalityProportionality
►PrivacyPrivacy
►Duty to Provide CareDuty to Provide Care
►ReciprocityReciprocity
►EquityEquity
►TrustTrust
►SolidaritySolidarity
►StewardshipStewardship
What historical ethical principles do you see in each?What historical ethical principles do you see in each?

84. ADPH, 2010 84
The Right to Desertion –The Right to Desertion –
“When is it time to go to the house”“When is it time to go to the house”
►Practical dilemmas faced personally – whatPractical dilemmas faced personally – what
are my obligations to me and my family?are my obligations to me and my family?
►Professional dilemmas – conflicting ethicalProfessional dilemmas – conflicting ethical
principlesprinciples
 Autonomy vs. non-maleficenceAutonomy vs. non-maleficence
 Autonomy vs. beneficenceAutonomy vs. beneficence
 Autonomy vs. justiceAutonomy vs. justice

85. ADPH, 2010 85
The Problem Won’t GoThe Problem Won’t Go
AwayAway
►If you don’t come to work, theIf you don’t come to work, the
problem doesn’t go awayproblem doesn’t go away
►In fact, the problem only gets worseIn fact, the problem only gets worse
►Every employee will make a difference byEvery employee will make a difference by
contributing his or her partcontributing his or her part
►All employees must ask themselves, ‘If IAll employees must ask themselves, ‘If I
don’t work in times of crisis, then who will?’don’t work in times of crisis, then who will?’

86. ADPH, 2010 86
A SuggestionA Suggestion
►Take a deep breathTake a deep breath
►Look for the balanceLook for the balance
►Remember John’s principle ofRemember John’s principle of
living outside yourself based on the truthliving outside yourself based on the truth
within yourselfwithin yourself
 (This assumes you(This assumes you knowknow the truth)the truth)
►Planners and facility administrators mustPlanners and facility administrators must
“think outside the box” – but“think outside the box” – but do it nowdo it now

87. ADPH, 2010 87
Exercise -Exercise - The KobayashiThe Kobayashi
MaruMaru
In the Star Trek fictional universe,In the Star Trek fictional universe,
thethe Kobayashi MaruKobayashi Maru is a starshipis a starship
that serves as the subject of athat serves as the subject of a
graded training exercise atgraded training exercise at
Starfleet Academy.Starfleet Academy.
The termThe term Kobayashi MaruKobayashi Maru is ais a
shorthand for no-win scenarios.shorthand for no-win scenarios.
Questions presented by the exercise:Questions presented by the exercise:
►Given the scare resources, who gets whatGiven the scare resources, who gets what
resources?resources?
►Who decides who gets what resources?Who decides who gets what resources?
►What is your rationale for your decision?What is your rationale for your decision?

88. ADPH, 2010 88
John’s Five Action
Principles►It’s all about the TruthIt’s all about the Truth
 There is absolute truthThere is absolute truth
►““We’ll Sing in the Sunshine”We’ll Sing in the Sunshine”
 Plan in the sunshinePlan in the sunshine
►Casper the Friendly GhostCasper the Friendly Ghost
 TransparencyTransparency
 AccountabilityAccountability
►It’s not about meIt’s not about me
►The “Nike Principle” – “just do it”The “Nike Principle” – “just do it”

89. Who Am I?Who Am I?
89
2-4-6-0-1
ADPH, 2010

90. ADPH, 2010 90
EpilogueEpilogue
The Eagle soars above the din,The Eagle soars above the din,
of mankind's rushing out and in,of mankind's rushing out and in,
And lesser creatures left to spin,And lesser creatures left to spin,
The Eagle soars from deep within.The Eagle soars from deep within.
His course is true as gaffer's pike,His course is true as gaffer's pike,
His keen eye pierces like a spike,His keen eye pierces like a spike,
His quest surrounds him like a dike,His quest surrounds him like a dike,
The Eagle soars, but phantomlike.The Eagle soars, but phantomlike.
Those who on the Earth have stood,Those who on the Earth have stood,
Thinking that they never could,Thinking that they never could,
Nor many even perhaps should ... but,Nor many even perhaps should ... but,
The Eagle soars because he would.The Eagle soars because he would. - John R. Wible, 1981- John R. Wible, 1981

91. ADPH, 2010 91
The Eagle has LandedThe Eagle has Landed

92. For A Paper on this SubjectFor A Paper on this Subject
►See “Ethics Paper Continuous” a downloadSee “Ethics Paper Continuous” a download
on Slideshareon Slideshare 77
►http://www.slideshare.net/jwiblehttp://www.slideshare.net/jwible
ADPH, 2010 92
7Slideshare