Mass Medical Care with Scarce Resources: A Community Planning Guide (continued)

Chapter 2. Ethical Considerations in Community Disaster Planning

By Marc Roberts, Ph.D.^a and Evan G. Renzo, Ph.D.^b

^a Professor of Economy, Department of Health Policy Management, Harvard University.
^b Bioethicist, Center for Ethics, Washington Hospital Center, Washington, DC

Context for the Discussion

We live in a world where a whole range of manmade and natural disasters (and cases that mix the two) are increasingly of concern to communities across America. Terrorism, epidemics, hurricanes, earthquakes, fires, floods—all of these are all too possible in an industrialized and interdependent world. Our settlements increasingly impinge on inherently risky terrain, such as over fault lines or on barrier islands. Ever-improving worldwide transportation and communication systems increase our vulnerability to those motivated by destructive ideologies. These same systems also make possible the "jet spread" of new infectious disease—as Toronto found out during the SARS outbreak.

In such a world, serious and systematic disaster planning and preparedness at the community level is essential. If a disaster does occur, communities must be prepared for the possibility that government assistance may be delayed or may not arrive at all. Government agencies may be overstretched by multiple challenges or have their ability to function degraded by catastrophic events.

One reality is clear. Communities that have not planned and prepared for such an eventuality will be less well-equipped to face its complexities than communities that have. The noted political scientist Richard Neustadt once wrote, "Crises are a bad time to do planning. Only if plans are developed in advance, and then critiqued, rehearsed, and refined, will various agencies and actors be able to respond effectively to a disaster."

Once a planning process is undertaken, it will become clear almost immediately that serious ethical decisions are central to shaping any community's disaster response. This will be true of both the planning phase and the implementation phase. At the planning phase, there will be innumerable issues, each with its own ethical components. Whom do we protect, and to what level of safety? How do we set budgets and priorities? Answers arrived at during the planning stage should be based on ethical analysis that can provide guidance during implementation even if the planned solutions must be altered in real time. Other issues include:

• Who do we evacuate first?
• How do we deal with those who do not want to cooperate?
• When do we stop expending resources on rescue efforts and shift to recovery mode?

The way these questions are answered reflects the ethical perspectives and moral analysis strategies of the planning group(s).

We also need to expect that planning will be imperfect. Unexpected events will occur. Operational failures will develop. Those with field responsibility will have to make on-the-spot decisions that will require ethical judgments. For that reason, it is important that ethical considerations are made explicit during the planning process so that when on-the-spot decisions must be made they can be made consistent with the spirit of the ethical judgments that guided the planning process.

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Ethical Ideas as a Resource for Disaster Preparedness

Human beings have been thinking and writing about ethics in general, disaster management in particular, and the application of ethical ideas to public policy for as long as we have been thinking and writing. Literally 5,000 years ago, the Egyptians struggled with their idea of maat—by which they meant the appropriate good order of society—and the role of the Pharaoh in preserving or restoring that when the annual Nile floods got out of hand.

In the 19th century, various thinkers began to try to apply technical and scientific reasoning to public policy problems. French engineers argued that the value of a bridge across the Seine was what people would pay for it, even if they in fact paid nothing because the bridge was free. Florence Nightingale tried to convince the British government to improve medical care for wounded people in the Crimean War by showing that the cost of replacing a soldier was greater than the cost of saving one. These ideas found clear expression in the English philosopher Jeremy Bentham's utilitarian claim that public policy should maximize the good across the greatest number. Utilitarian theory, or what is often referred to as consequentialist ethics, assesses what is right or good based on whether the consequences of the actions to be taken will be good.

Another strand of thought, arising contemporaneously and in opposition to consequentialist ethics, is the duty-based ethical perspective. Advanced most notably by Immanuel Kant and referred to formally as deontology, duty-based ethics focuses on nonconsequentially based notions of good. In duty-based ethics, deciding what is right or good is based on meeting duties and obligations.

Both theoretical perspectives have obvious applicability to planning for mass-casualty situations. Both have weaknesses, however, that need to be taken into account when either is invoked as a justification for proposed policy. Consequentialism suffers from two main weaknesses. First, it is difficult to predict consequences. Especially under emergency conditions, reality often looks little like what was expected. Second, in maximizing the good across the greatest number, the rights and welfare of the few can be ignored or, worse, trampled. Duty-based ethics provides a counterweight but one that is imperfect also. The main weaknesses of uncritical application of duty-based justifications are that duties and obligations are difficult to delineate and that even when they are delineated, invariably conflict. In planning for a mass disaster, for example, it will be difficult for communities to clarify the scope of obligations for the multiple players involved. Even where duties and responsibilities are clear, it is likely that persons and organizations will have conflicting duties, such as physicians to patients as well as to their own families.

Nonetheless, applying these theoretical perspectives in systematic ways can address our contemporary concerns for upholding important ethical principles and values, such as fairness and equity, and for the role such principles and values play in disaster preparedness. Making explicit and transparent the ethical perspectives raised during the planning process can build commitment to any plan that is created.

As this overview suggests, the ethical ideas that are widely shared in our culture are neither simple nor consistent. It is easy to invoke the notion of the greatest good, but attempting to maximize the good while providing universal assistance is a complex task indeed. That is, how do we incorporate the various appreciations of doing good into concrete policies in disaster preparedness planning? For example, do we measure "good" by lives saved or years of life saved? Our priority setting would be very different depending on how we answered that question. The same is true of concerns about "rights" and "fairness." How much are we obligated to spend to save people from a flood who refuse to evacuate when told to do so?

How do we balance maximum gain against fairness when these conflict? Such decisions need to be based on sound ethical judgment. All of this implies that using ethical ideas to guide disaster preparedness is a complicated business. The process will inevitably involve judgment and compromise. The broad ideas will have to be made applicable to specific contexts, refined, and defined in operational terms. And these realizations have important implications for what communities need to do, in both planning and implementing disaster plans, if they are to act in an ethically responsible manner.

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What Would It Mean to Plan for and Act Ethically in a Disaster Situation?

The ethical obligations of the professionals in a community responsible for disaster planning and preparedness obviously begin well before any disaster actually occurs. The first of these has to do with what might be called "ethical preparedness." We have noted the ambiguity and conflict inherent in some of the principal ethical norms that planners might want to invoke to guide their actions. This implies that waiting for a disaster to occur to face these challenges means waiting too long. We all know that buses or radios or vaccine stores cannot be conjured up at the last minute. By the same token, the reality of a catastrophic event will play out differently than could have been imagined so that tough choices will have to be made in the midst of crisis. Sound planning can take this expectation into account by providing ethical guidelines and principles for making tough choices in a real-time environment.

Thus, it is advisable that the planning process anticipate judgments that will have to be made and then model making such judgments explicit and shared widely. Applying and practicing applying such transparency serves multiple purposes. First, like any other "strategy" or "mission" statement, being open about guiding ethical principles can be an important management tool. It can serve to coordinate activity and produce more consistent implementation when decisionmaking has to be decentralized to frontline workers and their supervisors. That often will be the case in a disaster situation.

Transparency also serves the goal of accountability. Priority-setting judgments are not purely technical matters. In a democratic society, citizens have a right to know what decisions public institutions make on their behalf—especially when the stakes are high as in the life-or-death choices that a disaster can produce. Such public knowledge also serves to open the process to public feedback, criticism, and discussion. This can help professionals ensure that their plans reflect community values and concerns.

Public discussion also serves the vital purpose that some have called "democratic education" or "civic capacity building." Only when the public openly discusses and debates difficult choices does the capacity of community members to fulfill their roles as "citizens" become appropriately enhanced. We can expect the public to accept and support difficult choices in difficult times only if they have become knowledgeable bout and committed to those choices beforehand and if they feel they have had some input into the process. Transparency is a prerequisite to such outcome.

Transparency alone, however, will not suffice. The processes for making decisions themselves also have to meet their own ethical tests. Here, two ideas about democratic participation seem especially relevant. First is the need for the collaborative involvement of elected officials from all levels of government with local planners and citizens groups. Elections are, after all, the method democracies use to choose their leaders and, in the process, to resolve important value controversies. Different from the role of governmental agency officials is the equally important role of technical experts. Technical expertise is essential for clarifying options and being clear about alternatives. But what technical experts are expert about is the science: how influenza viruses are likely to mutate, the storm resistance of levees, or the atmosphere transport of radioactivity. They are not "moral experts." When it comes to making ethical judgments under stressful and complex conditions in which diverse value perspectives must be harmonized, technical expertise confers no special moral importance during ethical discussions. For community commitment to congeal round a disaster preparedness plan that will include judgments about complex moral problems such as tradeoffs between cost-effectiveness and fairness or the relative importance of prioritizing attempts to save one population group before another, we rely on politics—the combined actions of those we elect, those who are appointed, and local citizens working together.

Responsible elected leaders do need input, however, both on the science and on community values. Elected bodies (city councils, State legislatures) have their virtues and values in this regard. Further, there will be a role for more direct citizen participation. What is at issue here is an opportunity for discussion among a cross-section of community leaders, both those with a special competence and responsibility and those with an especially large stake in disaster planning decisions. Such a group can bring knowledge, sensitivity, and realism to the process that more general political bodies do not possess.

It is vital to remember that all community-planning and participatory processes are subject to certain risks. One risk is that those groups with more resources or expertise will dominate. Another risk is that some will seek to hold up the process by refusing to cooperate unless their narrow demands are met. All this suggests a need for careful planning, effective outreach, impartial staff support, and other now-well-understood prerequisites if the right kind of discussion is to occur.

The ethics of disaster planning apply not only to the process but also to the plan itself. In fact, almost all participants in the planning process face conflicting interests, if not frank conflicts of interest. Politicians seek political support, care-giving institutions want additional resources, and various first-responder agencies (State and local, police and fire) will maneuver for authority and leadership. The standard to which the resulting plan should be held is not that of meeting any one player's interests. Rather, the standard should be whether it meets some broader ethical tests and concerns, as we discuss further below.

Only a plan that transcends narrow interests will convince citizens that the public leadership entrusted with disaster preparedness is meeting its responsibilities. Those responsibilities include not just the exercise of technical "competence" but what the economist Kenneth Arrow called "conscience" while he was discussing clinical medicine, an argument that applies similarly here. A doctor or a disaster manager knows more than his or her patient or the at-risk public. As a consequence, the manager asks his or her experts to act as his or her "agents." This means asking the expert to make decisions in keeping with the goals and values of the "principal" who retained them. And "conscience" is required when the agent has to disregard his or her own interests to fulfill the trust placed in the agent; for example, by not ordering an unnecessary test or by risking one's own life in a burning building. As Woodrow Wilson said about the treaty to end World War I, "open covenants openly arrived at" serve everybody's interests.

Perhaps one of the most important roles of effective planning is to shape citizen expectations appropriately. When leaders are not realistic, the government's performance fails to live up to expectations, and citizens' trust in collective responses to community problems seriously erodes. Realistic plans and expectations, in contrast, can build public trust. The government then can meet those expectations, and a community's belief in its own capacity is thereby enhanced. The resulting "social capital" (to use Robert Putnam's phrase) is a valuable resource that communities surely will need if or when a real disaster does occur.

A good disaster plan, however, does more than just explicitly confront tough choices. A good plan also will minimize the need for such choices by putting adequate resources and effective arrangements in place. In desperate situations, resources will indeed be overwhelmed. Moreover, resources are always scarce. Preparedness has to compete with schools and prisons and highways and environmental protection for limited public dollars. There never will be enough money to do everything, but the better the plan, the less wrenching and difficult it will be to carry out that plan when adverse events do occur. In that sense, disaster planners need to defend both their own interests and those of their communities through the planning process.

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Ethical Principle I: Focus on Consequences

As noted previously, often the first ethical principle invoked in disaster situations is Bentham's "greatest good for the greatest number," which is commonly interpreted as requiring us to save the most lives, but again, the devil is in the details. Do we measure "good" by lives, years of life, or quality-adjusted years of life? If we use years of life, the young take precedent over the old. At any given age, the healthy would be saved before the sick and women before men—since the former has a longer life expectancy than the latter.

Those who pursue a utilitarian approach to policy development define the "good" strictly in terms of maximization of benefits for the many. In the case of utilitarian economists, for example, most want to measure "good" subjectively—based on how people feel about various alternatives as expressed in their market choices. Thus, if someone prefers to remain in his or her home during a hurricane, some economists would say that that represented the "greatest good" for that individual.

Public health specialists, engineers, and disaster managers who also have a philosophical preference for consequentialist analysis tend to focus on objective measures of the "good" of the "greatest number"—on lives saved or safety margins or probabilities. This contrast helps us understand what is at issue whenever someone asks, "Why can't I build my house in a flood plain if I am willing to take the risk?" Disaster planners in this case are confronting someone who believes that decisions on what is good are best decentralized to the individual. One consequentialist way for disaster planners to proceed is to pick some metric of gain and then to design plans to produce maximum "expected value." (For each possible choice, consider the weighted sum of the gains produced by each possible outcome—with the outcomes weighted by their probabilities. Then take the choice when that magnitude is greatest.) A considerable field of literature in areas like decision theory and operations research addresses the technical details of using this approach—on choosing metrics, assigning values, and estimating probabilities.

Uncritically applying a utilitarian understanding to such values preferences, however, will not capture the breadth of ethical assumptions embedded in planning approaches to addressing this concrete prospect. Moreover, there are limits to the appeal of the impartial brutality of "the greatest good" approach—even in a disaster situation. Much real planning and decisionmaking revolves around other ethical ideas. We need to understand these as well to be better equipped to provide for effective disaster preparedness.

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Ethical Principle II: Focus on Duties and Obligations

Utilitarianism is often not the only basis for much public policymaking. For example, our willingness to restrict, or not, individual choice both before and during a disaster can have a utilitarian justification but it is just as likely to be deeply influenced by duty-based concerns. The core idea here begins with the need to respect all human beings. Different writers root that respect in either a religious argument (the possession of an immortal soul) or a secular one (the human capacity for reasoned choice). Regardless of its origins, however, that respect is said to require us to treat every human being as "an end in themselves" (to use Kant's famous phrase). This means we cannot sacrifice some for the sake of others—unless they volunteer. For example, economists argue for individual choice in part because they presume that each person's decisions affect only themselves. Many disaster-related decisions, however, have what economists call "externalities"—they affect others beyond the decisionmaker. In particular, those who build in flood plains or refuse to follow evacuation orders may impose the cost of expensive search, rescue, and recovery efforts on the community.

Deciding how and why to divert resources from some sector of community need to others should rest not only on predictions of what will produce the best outcome for the most persons but also should include considerations of how the resource distribution process will work to ensure that obligations citizens vest in their Federal, State, and local governments are met. This balance between utilitarian and duty-based assumptions is at work in our ethical considerations about allocating scarce influenza immunizations. A policy aimed at "lives" would give priority to the old and the sick, since they are most at risk from influenza. A policy aimed at "years of life" might be somewhat different—prioritizing the vulnerable young. A policy that took account of economic consequences would raise the priority of workers who mattered most in economic terms (too bad for the unemployed). The potential real-world outcomes of balancing and interweaving these two ethical perspectives are highlighted in thinking about influenza vaccination of health care providers. In a serious crisis, those health care workers who cared for influenza patients might get priority—on the grounds that each of them could save several other individuals through their care. If we were serious about such a rationale, however, cardiac surgeons and other subspecialists would be further down the queue because it might be reasoned that the obligation to provide primary care to our most vulnerable citizens comes before performing more resource-demanding procedures, regardless of the numbers in either group.

In practice, our sense of humanitarian responsibility will not allow us to ignore "stay-behinds" or refuse rebuilding help to those whose houses have come to grief in a storm because of shared cultural understandings of obligations that governments have to citizens and that neighbors have to neighbors.

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Ethical Principle III: Rights and Fairness

In addition to having any disaster preparedness planning process make explicit consequentialist and duty-based theoretical notions, refined understandings of what is meant by rights and fairness will be needed as well. Just as most decisions will include some mix of consequentialist and duty-based justifications, most decisions will include a complex of intertwined notions about rights and fairness.

At least in Western philosophical traditions, "rights" refers to the belief that human beings have universal rights regardless of jurisdiction or other characteristics such as gender, ethnicity, or religious belief. Such rights are often defined by international and national laws and legislation. The difficulty for communities engaged in disaster preparedness planning is that one common criticism of rights thinking is that rather than being truly universal, or universalizable, it is prone to cultural relativity. For example, universal primary school education or health care insurance is considered by some nations a right of all their citizens. In other nations they are not seen as such. Laws and social programs, however, have boundaries while mass disasters do not. Moreover, rights and the perceived responsibility of an agency, organization, or individual will differ across State, national, and continental borders. The same problem arises in focusing on defining the concept of fairness. Nonetheless, preparedness planning groups will need to devote substantial effort in coming to at least their own definitions for these ethical principles if they are to devise plans to which the affected communities can commit.

For example, the rights arguments have moved from just advocating the "negative" right to be left alone to concentrating more forcefully on a relatively expansive set of "positive" rights. These rights involve the expectation that the government will ensure everyone some minimum scope of opportunity for living a meaningful life. Indeed, most governments in industrial countries help their citizens—to varying degrees—with food, housing, education, and health care based on such arguments. And such efforts are often focused and financed in a way that is redistributive. Quite typically, upper-income groups cross-subsidize lower-income groups based on notions of "fairness" and "social responsibility" (or, in Europe, "solidarity").

These notions are almost certain to come into play when disaster planners face issues of priority setting. For example, any consideration of property values, in allocating resources, would dictate that less attention be paid to low-income neighborhoods. Yet, as Katrina demonstrated, it is likely to be poorer residents who have the fewest resources of their own and who therefore are most in need of public assistance.

Once issues of fairness or equity are accepted as relevant, it is still necessary for community leaders to decide what fairness requires of them. One view (sometimes called "relative equity") is that any difference in treatment (or in this case, say, of risk) is inherently unacceptable. An alternative perspective (termed "absolute equity") requires governments to provide some minimum level of opportunity to all citizens. If that goal is achieved, then on this second view, the rich or talented can be allowed to have opportunities above the minimum level.

In fact, disaster preparedness almost inevitably has to be concerned with "absolute" equity—with providing some minimum level of protection to all. Inevitably, those with stronger houses, houses on higher ground, or money for comfortable hotels out of town will do better than some of their fellow citizens. Thus, one of the questions planners will have to focus on is not whether any differences exist, but whether appropriately delineated obligations have been met for those segments of the population where such differences result in disproportionate harms.

Of course, just what those obligations are will be a matter of much debate. Again, open processes, explicit decisions, transparent reporting, and political accountability—all of these become especially important when such difficult issues have to be decided.

Here also is where the decentralized structure of disaster preparedness can become somewhat problematic. Poor jurisdictions are likely to have less in the way of equipment, personnel, and financial reserves than their more prosperous counterparts. Fairness in such cases may require that planners at the regional or State level take account of these realities when decisions are made about allocating resources from higher-level jurisdictions. For example, in a crisis, it well might be that the poorest communities are the ones most in need of help from a State's National Guard assets, precisely because they have fewer of their own resources on which to rely.

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Ethical Principle IV—Respect Community Norms

While consequences, duties, rights, and beliefs about what is fair often dominate discussions of public policy, these ideas do not exhaust the ethical considerations that are potentially relevant in such situations. In addition, there is the question of respecting the particular norms and values of a community.

The ideas we have been considering so far are avowedly universalistic in their claims. Their proponents say they apply to everyone, everywhere. There are also ethical ideas that are particular to a given society and express the society's particular sense of itself as a whole or of its separable communities. These, too, have a role to play in disaster preparedness.

One of the most important areas in which such local norms apply is in our expectations of first responders and other disaster personnel. There are many examples of situations where rescue personnel put their own lives in danger on behalf of others or for the greater good of the community. The large number of police and fire casualties in New York on 9/11 testifies to the power of these ideals.

Indeed, when disaster managers try to implement "greatest good" policies, often it is front-line personnel, imbued with professional pride and responsibility, who resist. Experienced senior firefighters will tell you that one of their most difficult tasks can be to get their people out of a compromised structure when that becomes the prudent course of action.

On the other hand, some societies have high expectations of even unwilling disaster professionals. During the SARS epidemic in Hong Kong, doctors and nurses at the designated receiving hospital were quarantined inside the building (including some who were confined unwillingly). Several of the staff members of that hospital died in the epidemic.

Another example of the power of the particularity of social ethical norms is revealed by the very high expenditure made post-Katrina on recovering and identifying those who died. While no comprehensive estimates have been made, informal calculations suggest figures in the range of $10,000 to $20,000 per recovered and identified body. Such expenditure is not easy to explain on either "greatest-good" or "positive-rights" principles, since only the living count in such analyses.

Local norms also can affect recovery and rebuilding efforts. After the recent hurricanes, Mississippi and Louisiana have had to confront the question of whether their rules restricting gambling to off-shore locations should be maintained. There have been press reports that efforts to move some Mississippi shrimp boats back into the Gulf are being hampered by a reluctance to disturb a Native American burial ground. Again, where disaster planners and managers decide to respect (or not) local community values, obligations of transparency, explicitness, and accountability clearly apply.

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Summary and Conclusions

This review introduces some of the major, substantive, and competing ethical ideas that community disaster planners and managers are likely to find relevant to their efforts. At best, the review identifies some of those ideas in the broadest terms and sketches some of the more specific issues that each of these perspectives raises. How do you measure good? How far do you go to be fair? When are community norms to be respected or overridden?

In so doing, we argue for making explicit a set of norms that need to apply to how the planning process is conducted.

The arguments for such a process are justifiable by both utilitarian and deontological ethical theories. On the deontological or duty-based side, respect for individual autonomy requires that citizens subject to the power of government be able to influence how that power is used and be protected from its misuse. That can occur through both general political structures and ad hoc participatory processes. If considerations of equity are to be respected, special efforts need to be made to ensure underresourced and underrepresented segments of the community have their say. Corporations and upper-middle-class citizen groups will appear at meetings and file comments, for example, but what about residents of public housing projects?

Whether one comes to the planning process with a (perhaps unarticulated) philosophical or psychological preference for either a utilitarian or consequentialist perspective, broad participation and accountability have several potential benefits. Local residents may have knowledge and insight about local conditions. Businesses know well what resources they might contribute. Front-line disaster responders and their first-level supervisors will be painfully aware of gaps in their own training and equipment. Maximizing the good across the greatest number and meeting individual and organizational duties and obligations will take the contributions of the many.

Participation and transparency also will help educate citizens and prepare them both to participate in and to accept the implementation of plans when a disaster occurs. They will know what to do, and because they will have been involved, they will understand and therefore more readily will commit to the reasoning behind the plan. They will have more realistic expectations and thus will be more prepared both psychologically and practically.

The process of democratic government, at its best, involves what political scientists call "deliberation." In such conversations, both facts and values are explored, alternatives are examined, and meanings are clarified. When done well, deliberation not only produces good plans but also enhances a community's capacity for self-government. Disaster planning offers a clear opportunity for advancing such goals.

Finally, it is important to remember that in a disaster, difficult choices will have to be made, and that the better we plan, the more ethically sound will be the choices. There is no cookbook for combining conflicting ethical ideas. There is no "one-size-fits-all" method of priority setting, but community disaster planners need to see the opportunities as well as the difficulties that such a situation implies. There is room here for responsibility and choice, for ethical concern and technical excellence, for process skills and scientific expertise. It is surely worth doing and worth our best efforts to do it well.

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