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Ethics: At the Core of Emergency Planning and Response

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Brandon Danz
September 12, 2014

Since the turn of the century, federal, state and municipal governments have made significant advancements in emergency preparedness planning efforts. However, development of streamlined incident command systems, logistical strategies and contingency plans have largely occurred with minimal consideration for important ethical questions involved with disaster management. This article will examine the importance of ethical considerations as part of emergency planning efforts.

Disaster plans are designed to be comprehensive. But successful plans should acknowledge that they will almost always fail to foresee every possible circumstance. Resources will be scarce and will not be sufficient to meet demand. Further, when decision makers are in the midst of a disaster and their plan includes no direction for their dire circumstance, there will certainly be strong ethical dilemmas to navigate.

In the week prior to Hurricane Katrina, New Orleans hospitals dusted off their emergency plans and began their execution. Many of these hospitals had backup generators located in basements – below sea level. Yet none of these plans included a contingency should basements flood, causing backup systems to fail. These systems did fail and hospitals were left completely without power, forcing flashlight-wielding physicians into an ethical quandary. How do you decide which patients to hand pump with oxygen? What is your obligation in emergency circumstances to get a morbidly obese patient, in a terminal condition, up several flights of stairs to the helicopter landing pad? Which patients do you save and which ones receive palliative care? These real ethical questions transcended traditional medical triaging and forced physicians in New Orleans hospitals to make snap judgments since none of the questions were addressed in emergency planning documents.

The ethical dilemmas faced during Hurricane Katrina are well-known, yet ethics remains an elusive topic in most emergency preparedness planning efforts. I reviewed two comprehensive government after-action reports on Hurricane Katrina from the Department of Homeland Security and Congress, totaling 582 pages and found zero references to “ethics,” “autonomy” or “justice” (excluding references to the Department of Justice) in any of them. A 2008 Hastings Center briefing reports that there are few references to ethical concepts in federal and state influenza pandemic plans. Should a severe influenza pandemic occur in the United States, the Government Accountability Office (GAO) estimates the number of patients requiring hospitalization would easily exceed the capacity of available hospital beds. Yet, the GAO interviewed 20 states and found few of them to include ethical guidance in their plans. The difficulty of addressing complex ethical dilemmas is a major barrier to including these ethical issues in emergency plans.

Ethics should be addressed head-on during the emergency planning process so that ethical expectations are clear to all staff. There are many important ethical considerations to make and these depend largely on unique circumstances.

Duty to the Individual or Duty to the Greatest Good for the Greatest Number? The ethical question of balancing our duty to maximize benefits across a population and our duty to each individual should be examined during emergency preparedness efforts. Many emergencies are considered successfully managed when government acts to maximize the greatest good for the greatest number of people. While this strict utilitarianism is a worthy goal, it comes with limitations and much subjectivity. If all human lives have worth and if we act to treat citizens as an end and not a means, then we owe some minimum level of duty to each person regardless of the opportunity costs involved. The autonomy of individual citizens cannot be put aside for the sake of helping the many. Given a range of tactical options during an emergency situation, determining the greatest utility for the greatest number can be difficult because benefits and costs are unknown and there is no time to calculate these factors.

Fortunately, a balance to utilitarianism is found in deontology, Immanuel Kant’s approach to ethics, which obligates us to act from our sense of duty. In times of crisis, government officials must act to defend the autonomy and sovereignty of each individual. Duty-based ethics assures that the rights of the few are not compromised for the good of the many. In concert with utilitarianism, a deontological perspective achieves the balance that is necessary for government actors to meet our ethical obligations during emergencies. With these two strategies in balance, the goal becomes to maximize good across a population while assuring at least a minimum level of assistance and respect for each individual.

Triaging systems help to reduce subjectivity by creating standardized assessment tools that maximize resources, minimize risk and simplify administration. First responders use a triaging system during mass casualty incidents called “simple triage and rapid treatment” (START). It includes four categories:

Color Code: Severity of need: Description:
Red Immediate Life-threatening injury that requires immediate intervention within 60 minutes.
Yellow Delayed Serious injury but status not expected to deteriorate over the next hour.
Green Ambulatory / walking wounded Relatively minor, non-life-threatening injury.
Black Deceased / Unsalvageable Deceased or unlikely to survive given severity of injury regardless of medical intervention. Palliative care administered to provide comfort and relief from pain.

This system assures that limited resources are used most efficiently by prioritizing aid to those who most need it, while also defining minimum levels of assistance for each person. However, the START system has been criticized for emphasizing physical health over mental health and those citizens with special needs, showing that no system is perfect.

In a civil society, when there is a conflict between efficiency and fairness, fairness must prevail. After all, after every disaster, order and the values of normal life are restored, and sunshine is shed on the practices and decisions that took place during the emergency. Vulnerable circumstances are never an excuse for shaky ethics. Ethical deliberations should be made explicit throughout emergency preparedness planning efforts so that when emergencies do occur, there is an existing ethical protocol to guide the process.

Author: Brandon Danz, M.P.A., is special advisor to the Secretary of the Pennsylvania Department of Public Welfare and an ASPA member. He is a graduate of the master of public administration program at Shippensburg University of Pennsylvania. Danz is seeking a master of health administration degree from The Pennsylvania State University (Harrisburg) with a focus on health care policy development and cost containment. Danz can be reached at [email protected].

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