The New Orleans Hurricane Katrina disaster demonstrated the urgency not only of expanding the nation’s medical disaster preparedness and response plans, but it also highlighted the necessity of incorporating an ethical framework to guide decision-making into existing and emerging preparedness programs and policies. 

Hurricane Katrina stranded New Orleans’ Memorial Medical Center in ten feet of floodwater without sufficient food, fresh water and/or power for ventilators and lights. Doctors and nurses faced emotionally, psychologically and ethically challenging choices for which they had no training or experience.  Dr. Anna Pou and two nurses believed that they and their patients had been abandoned and that no large-scale evacuation of their hospital would occur, as few boats and/or helicopters arrived to evacuate patients and many of their fellow hospital staff failed to show up to work (Naphin & Textor, 2006).  After four grueling days in which many patients died from the heat and from dehydration, Dr. Pou and the nurses responded to the critical situation by administering what proved to be lethal doses of pain medicine to three of the ‘abandoned’ acute care patients before they themselves were evacuated.  Dr. Pou was subsequently charged with nine counts of second-degree murder, which were only cleared after a harrowing and public ten-month legal process, however, all three still face civil suits. Such extreme moral dilemmas are rarely necessary in routine clinical settings, but they are an expected and distressing component when practicing medicine in a disaster (Larkin, 2003).

                Similar difficult decisions and liability risks are expected during an influenza pandemic. Experts agree that a pandemic “is a real and significant threat …  not a question of if, but of when (GAO, 2008).”  A flu pandemic, like all disasters, will involve a severe shortage of resources (CDC, 2007; Burkle, 2006; US Department of Health and Human Services, 2008; McNeil, 2006), especially ventilators and hospital staff. The national Pandemic Preparedness Plan states that, in a worst-case scenario, the country will need 742,500 ventilators—essential for survival of this deadly flu strain—while only 105,000 ventilators are currently available (100,000 are used during a normal flu season).  Roughly, only one in seven people could receive a necessary ventilator in a pandemic (HHS, 2008). According to Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University “This is a life-or-death issue… we don’t have any ventilators and there isn’t much chance we’re going to get them (McNeil, 2006).” 

The questions of who will receive ventilator care? When and under what conditions?  are fundamental to ethical disaster and pandemic planning.  A practical ethical framework is necessary to guide these difficult decisions.  In fact, all levels involved in disaster decision-making have identified the lack of an ethical framework as an essential gap in disaster preparedness. On the federal level, the US Government Accountability Office (GAO) identified ethical decision-making as a “major gap” in pandemic preparedness. The GAO recommends that the HHS and DHS help states address this gap in their planning.  Both the HHS and DHS concur with this recommendation (GAO, 2008) and many states have requested federal assistance in addressing ethical issues within their plans. For example, the Indiana State Department of Health hosted a Summit, “Confronting the Ethics of Pandemic Influenza Planning: The 2008 Summit of the States” with funding from the Centers for Disease Control and Prevention (CDC), and Kansas similarly hosted a Hospital Disaster Preparedness Conference in which it identified ethics as a gap in preparedness (University of Kansas, 2006).

                The federal Agency for Healthcare Research and Quality (AHRQ) also recommends that hospitals address ethical issues in their planning process.  The CDC created a pandemic planning checklist for hospitals, containing three major categories for proper preparedness. Two of the three categories specified the need for ethical guidance (HHS Checklist).  The CDC published limited ethical guidance in an attempt to fill general ethics needs, but the topic of ventilator allocation was not addressed (CDC, 2007). While many states and government agencies have made efforts to discuss and identify ethical issues associated with mass casualty events, particularly the specter of a pandemic influenza, no standardized and/or or nationally accepted ethical framework has emerged.

In 2006, Bioethics International (BEI) began researching the possibility of providing an ethical framework to guide clinical decision-making during catastrophic events, in response to concerns about the medical ethics issues raised during the Hurricane Katrina response.  Based on review and analysis of multiple approaches to medical decision-making (such as utilitarianism, deontology, sociobiology, contractualism, principlism, Aristotle’s virtue theory, et al.), the Person-Centered approach, a collection of six ethical principles, was assessed to be an appropriate fit for disaster triage and decision-making (Sgreccia, 1999; Mounier, 1952).  BEI collaborated with leading expert advisors to develop clinical cases to reflect the difficult decisions and scenarios likely to occur during a pandemic.   Designed to illustrate the ethical framework, the clinical cases were  incorporated into a brief training program suitable for hospital delivery, for example during a Grand Rounds.  At the same time, BEI was also assisting on the review and revision of hospital pandemic policies and guidelines.

The hospital training was piloted in May of 2006 at St. Vincent’s Medical Center (CT) with approximately 400 hospital staff.  The framework was later fully integrated into disaster plans at Hamot Hospital (PA) and St. Vincent’s Health System (PA) and the first pilot studies on the efficacy of the framework were initiated. To date, the framework has been delivered to approximately 700 hospital staff and administrators.

In two of the last five training programs, BEI began assessing the efficacy of providing an ethical framework to guide pandemic decision-making. As a result of all of BEI’s activities and the two pilot studies, BEI identified the lack of an ethical framework as a key gap in hospital and clinician preparedness.  The following issues were noted and require formalized analysis:

(1)    Hospital clinicians lack training on an ethical framework to guide their decision-making.

(2)    Prior to the provision of an ethical framework, clinicians routinely fail to allocate ventilators in a pandemic scenario in accordance with basic triage protocol, that is they fail to prioritize the patients most in need of and most likely to benefit from an allocated ventilator. For example, BEI’s pilot studies demonstrate clinicians’ tendency to allocate a ventilator to a mother with young children and a survivability rate of 10%, over a patient without children and a higher survivability rate of 20-40%.  This inaccurate triaging potentially increases mortality rates and legal liability exposure to anti-discrimination laws regarding gender, marital status etc. (Civil Rights Act, 1964).

(3)    Prior to ethics training, clinicians fail to consider informed consent procedures. For example, we found that clinicians have a propensity for disconnecting an eighty-year-old ventilator dependent non-flu patient from his/her ventilator without consent, resulting in his/her premature death, for reallocation to a ten-year-old flu patient. This potentially exposes providers to legal liability from anti-discrimination and informed consent mandates (Civil Rights Act, 1964).

(4)    Post ethics training, clinicians are more likely to allocate ventilators in a pandemic scenario in accordance with basic triage protocol, minimizing personal bias based-decisions regarding age, gender, parenting status etc.

(5)    Post ethics training, clinicians are more likely to obtain informed consents from patients before withdrawing ventilators or they do not withdraw ventilators from dependent patients.

These findings are supported by the literature. For example, Barr (2007) concluded that neonatologists’ personal fears of death were related to their attitudes about hastening death for newborns destined for severe disability (for whom treatment is deemed non-beneficial). Kaplan (1996) similarly concluded that clinicians’ personal characteristics, such as race, training, practice volume, etc. influence their practice and decision-making process. Crane (1999) measured improved  ethical decision-making capabilities following ethics training within a business setting, and Fraedrich et al. (2005) also measured a ‘significant but small’ improvement on cognitive moral development post ethics training within a business setting.

Yet there is a gap in knowledge regarding ethical decision-making in a medical context and as to whether the provision of an ethical framework would yield compliance with the framework and changes in behavior and decision-making practices, if necessary, by clinicians. Moreover, compliance with the framework and/or changes in clinical behaviors and decision-making practices need to be studied longitudinally.  Clinicians may initially adapt and adhere to an ethical framework, but subsequently revert to their habitual patterns of action and thought. It has been assumed that the provision of a framework will increase compliance with basic triage protocols and principles by explaining the “why” behind the “what to do”, but this also remains to be studied and determined.  Furthermore, the generally presumed benefits listed below also remain to be studied.

An effective ethical framework for hospitals would have several benefits including: (1) improving the quality of patient care and patient surge management in a disaster response, (2) enabling uniform and fair resource allocations, (3) increasing clinicians’ likelihood of obtaining informed consents from disaster patients, (4) minimizing legal liability for providers, (5) increasing clinician compliance with existing triage protocols and principles, and (6) responding to the need identified by the federal government, state and local communities, nonprofit organizations, the private sector, and healthcare practitioners.

                It is the recommendation of Biothics International that further study and analysis is needed on the efficacy, outcome, and suitability of including ethical frameworks in triage training programs as a means for increasing triage protocol compliance during pandemics and other public health emergencies.

Miller, Jennifer, Bioethics International © 2008