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Ethical Issues in Disaster Medicine

Gregory Luke Larkin

OVER V IEW

Disaster situations present numerous moral and ethical chal- lenges at the micro, meso, and macro levels. These dilemmas embroil not only patients and their providers, but they also involve a variety of stakeholders outside the doctor–patient dyad: peers, provider organizations, the press, the general public, pay- ers, policymakers, politicians, public health leaders, and even corporate interests in the private sector. This group of moral agents may be considered the “Ten Ps” (Table 5.1).1 The prin- ciples and concepts in this chapter are relevant to all candidate stakeholder and disaster organizations as well as individuals. This chapter first acknowledges the spectrum of medical–ethical and moral problems inherent in disaster preparedness and response, while focusing primarily on those that impact healthcare workers as individuals working in the trenches. After exploring some of the disaster-relevant bioethical principles and codes of conduct, it describes the fundamental virtues that inform ethical decision making in clinics, hospitals, and emergency departments and in the field in the immediate aftermath of a disaster.

CURRENT STATE OF THE ART

The Spectrum of Disaster Dilemmas

Although thoughts of disaster ethics generally conjure up visions of distributing life vests on a sinking Titanic, there are many other less dramatic examples of ethical challenges that confront the clinician working in the wake of a catastrophe. The broad array of potential ethical dilemmas in a disaster situation is vast and involves both individual and corporate actions. For example, providers may face ethical dilemmas when working as agents of individual patients, within hospitals, as members of medical response teams, as public health providers, in inci- dent command centers, with nongovernmental organizations (NGOs), and as local or global volunteers with such entities as the U.S. Medical Reserve Corps or Médecins Sans Frontières (Table 5.2).

The ideal resolution to any given dilemma is also determined along a spectrum that is both time and situation dependent.

An earthquake registering 7.0 on the Richter scale in Kabul, Afghanistan may create different challenges than an earthquake of similar magnitude in Los Angeles. In addition to differences of setting and culture, varying legal, political, and economic norms and values make any overarching description of disaster duties and rights challenging. Like etiquette itself, disaster ethics is sometimes subject to the particularities and practicalities of different baseline economies, governments, cultural norms, and religious contexts that impact how moral values and community goals are used to weigh alternative disaster responses or prioritize particular preparedness policies.

Although it would seem impossible to address every poten- tial disaster conflict and ethicolegal situation herein, an overall approach incorporating key concepts can illuminate ethical con- flicts regardless of the setting or disaster situation. The balance of this chapter provides an underlying moral framework for ana- lyzing ethical challenges that can be applied in a given disaster context or circumstance. To provide such a framework, extant theories of ethics that are applicable to medicine more gener- ally and disaster medicine, in particular, are first described. To be solvable, dilemmas require careful consideration and under- standing of key ethical principles, codes of ethics, and virtues that together form a quantum of guidance, a common denominator across the moral quotient. Once these moral tools are under- stood, they can be applied and prioritized to minimize harm and maximize positive outcomes based on the particular values and exigencies of a given disaster context.

THEORIES OF MEDICAL ETHICS

Bioethics is the modern extension of philosophical ethics applied to the life sciences, rising to prominence in the decades after the World War (WW) II Nazi war crimes were exposed at Nurem- berg.2 Today, one of the most common and arguably the most popular bioethical theories in developed western democratic societies is the application of ethical principles or Principlism.3

Under the influence of this theory, three bioethical principles have dominated clinical decision making within the confines of the doctor–patient relationship (Table 5.3).

62 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 12:20:33.

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Table 5.1: Stakeholders in Disaster Ethics: 10 Ps

1. (Individual) Patients 2. (Individual) Providers 3. Provider groups/peers/remote disaster response teams 4. Provider organizations/Local volunteer healthcare providers 5. Public health 6. Policymakers/Politicians 7. Payers/Insurers 8. Private sector/NGOs 9. Press/Mass media

10. Populace/General public

These principles, first articulated by Beauchamp and Chil- dress in the United States, could ideally inform most individ- ualized, everyday, micro-level doctor–patient interactions. Such principles are common tools of bioethics consultants who have time to deliberate on ethics consultation services for days and even weeks on individual cases of institutionalized patients, deciding for example, whether patients such as Karen Ann Quin- lan (1954–1985) or Terri Schiavo (1963–2005) may be taken off ventilators while in persistent vegetative states.4,5 Ranking the relative merits of the principles takes considerable time in a given clinical situation; however, opportunities for reflection on competing principles are rare in disaster contexts, making Prin- ciplism problematic.

The Disaster Context

In contrast to day-to-day bioethics practices, true disaster sit- uations are frequently characterized by a relative lack of time as well as other resources; hence, one does not generally have the luxury of ethicolegal consultation or time-intensive deliber- ation. Although the trinity of aforementioned bioethical prin- ciples still applies in extreme situations of austerity, their rela- tive weights and priorities change dynamically both within and between different types of disaster events. Disaster magnitude, and the aforementioned setting, resources, population, culture, and expertise also play roles in how the principles of bioethics apply. The southeast Asian Hmong population, for example, does not value the principle of respect for individual autonomy in the same sacrosanct sense as either the European or African American population.6 The Hmong value community and tra- ditions in ways unknown to most other cultures and yet, similar to many other immigrants, they have now settled in several large cities in the west. Beyond multicultural concerns domestically, disasters frequently occur in far-away places with diverse pop- ulations and societies with different priorities and worldviews than many of the would-be healthcare worker respondents from abroad.

Beyond multicultural concerns, it is vital to remember that mass casualty events easily threaten the ethical underpinnings of routine, individualized, and patient-centered healthcare. Work- ers, who only moments earlier may have been seeing three patients per hour, can instantly find themselves working in a sea of casualties where they must contend with basic lifeboat issues of triage, quarantine, system overload, and the thornier determinations of who will be given every chance to live and who will be allowed to die.

Distributing Scarce Resources: The Prominence of Justice

Disasters disrupt the normative functioning of civil society in general and impact the usual supply of healthcare goods and ser- vices in particular. Additionally, mass casualty events intrude on everyday principles of bioethics and their focus on individuals, thereby requiring the entry of a fourth, population-based princi- ple into the bioethical calculus: justice. Justice has been famously described by the late Harvard Law professor John Rawls (1921– 2002) as a relative fairness in the equitable (not equal) distribu- tion of resources, according to relative need.7 Disasters frequently redraw both the geographical and the bioethical landscape, less- ening somewhat the importance of individual patient autonomy in deference to population health and the often-competing inter- ests of multiple parties. The entry of justice into the conversation does not negate the relevance of beneficence and nonmaleficence; however, proportion and fairness matter a great deal when sur- vival is threatened on a large scale. For instance, the ordering principle on the rubble of a Pakistani earthquake may be that of distributive justice whereas the first consideration in a modern intensive care unit 5 weeks after an earthquake may be nonmalef- icence (avoiding harm).

Justice – Only a Partial Answer Although an important guide in settings of resource scarcity,

justice alone does not solve the problems of caring for whole pop- ulations in disaster situations. In fact, a misapplication of justice would demand that patients with the greatest need (expectant and moribund) are therefore deserving of the most resources just because they are so needy. Not so. Although platitudes of “every- one gets a fair share” or “treat all the same” sound reassuring, egalitarian arguments have a relatively small role in the ethics of disaster planning and response at the macro level. Severely ill and injured patients, such as those in cardiopulmonary arrest for example, should receive neither equal nor equitable treatment as doing so during a disaster can be expected to result in wast- ing needed resources for salvageable others. Heroic attempts to save lives in futile cases squander time, supplies, safety, and fre- quently entail huge opportunity costs; therefore, extraordinary attempts to save life must generally be discouraged. Disasters may leave many dying (expectant) patients in their wake who cannot be justly saved. Expectant status is itself a moving tar- get, depending on shifts of contingent material, human, and intellectual resources over time. Hence, any Rawlsian notion of justice that gives the least advantaged top priority as a matter of routine is fraught with difficulty. An omnibus and functional ethical theory must be expandable to incorporate considera- tions of overall population needs within the disaster context; maximizing global goods and minimizing global harms is one consideration.

Triage and Rationing: Greatest Good for the Greatest Number

Disasters’ greatest challenges revolve around the need for triag- ing and rationing to maximize population outcomes. Classically, the guiding ethic is one of utilitarianism. Famously described by the English philosopher Jeremy Bentham (1748–1832), utilitari- anism underlines the notion of providing the greatest benefits to the greatest number to maximize human felicity or happiness.8

Bentham’s student and acolyte, John Stuart Mill (1806–1873),

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 12:20:33.

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Table 5.2: Ethical Challenges in Disaster Medicine

Provider–Patient (Micro) Level 1. Care of anxious, hypochondriacal, or “walking-wounded” patients who request extra care 2. Defining “expectant” and other triage categories within a dynamic situation 3. Balancing palliative care needs of expectant patients amid family requests to “do everything” 4. Care of noncitizens, foreigners, military, prisoners, or perpetrators of terror or other disasters 5. Prioritizing care of “VIPs,” civil servants, leaders, military, blood relatives, friends, and healthcare personnel 6. Maintenance of privacy in the midst of crowding, surveillance, quarantine, and mass media “right to know” pressures 7. Reporting and surveillance requirements that impact individual patient liberty, confidentiality, and privacy rules 8. Conducting academic research and procuring informed consent from disaster-exposed patients under duress 9. Treating victims who are contaminated or contagious, or working in an environment with other potential safety threats to the individual

provider’s health 10. Triaging rapidly, objectively, accurately, and ethically given limited information and time 11. Standard of care issues at the limits of surge capacity or system saturation 12. Balancing primary provider roles with roles as agents of state or public health 13. Balancing duties to individual patients with duties to preservation of self and family amid infrastructure collapse, pandemic influenza, nuclear

fallout, or other personally threatening disasters 14. Role stress and temptation to push scope of practice envelope and provide heroic intervention for patients in need 15. Balancing integrity with empathy/duty to individual disaster victims seeking compensation for damages and/or disability

Provider–Provider (Meso) Level 1. Assisting colleagues, public health officials, and hospital staff – even when doing so may endanger oneself 2. Role shifts, power struggles, turf battles, and misunderstanding of social, legal, hierarchical, and teamwork requirements in and out of hospital

or under incident command system 3. Dealing with provider impairment, recklessness, unprofessionalism, and absenteeism of both leaders and subordinates 4. Trainee/employee safety and physical and mental health before, during, and after terrorist attacks 5. Occupational exposure, reporting requirements, and privacy concerns 6. Optimizing communication among first responders, consultants, organizations, and healthcare provider staff at all levels 7. Conflicts of interest within and between organizations competing for local, state, or federal funding 8. Magnanimity and goodwill toward colleagues and coworkers under stress 9. Correcting overzealous providers from mistriage, over- or undertreatment, and inappropriate resource allocation

10. Addressing mental hygiene, safety, and wellness needs for oneself and other providers 11. Policies for quarantine and reciprocity for disability, lost wages, family risk, and time off work 12. Balancing recruitment of skilled labor with the threat of oversubscription and convergent volunteerism 13. Determining how a disaster response is constitutive of altruism, professional duty, or both 14. Ensuring that disaster work is recognized and fairly compensated 15. Colleagues who cover shifts for peers deployed to distant disaster sites could share in the recognition usually given only to frontline responders 16. Determining how volunteers are certified as trained, up to date, culturally and technically competent, and how they should remain accountable 17. Establishing the circumstances under which hospital and other healthcare leaders can compel personnel to report to work 18. Acceptance of more humble job assignments and duties is challenging in the absence of clear compensation, insurance, authority, or control

Provider–Society (Macro) Level 1. Determining the duties and the limits of responding to disasters, be they local, domestic, foreign, or global in nature 2. Developing organizational codes of conduct vs. unfettered laissez-faire preparedness and response ethics 3. Organizational willingness/duty to respond altruistically to disasters on a corporate level vs. duties to dues-paying members’ rights and

individual interests (e.g., AMA/ACEP/IFEM/WMA, NGOs) 4. Maintaining integrity amid opportunities for self-enrichment and promotion by leveraging public ignorance, fear, and paranoia 5. Ensuring justice/fairness and minimizing conflicts of interest in setting priorities for allocating resources for disaster preparedness and response 6. Duty to support/subscribe to valid preparedness exercises, disaster drills, vaccination programs, and volunteer corps 7. Prudent stewardship, e.g., cost/benefit of stockpiling drugs, new vaccine development, and widespread purchasing of personal protective

equipment amid other legitimate and competing needs for resources 8. Resisting unethical reporting polices, ethnic profiling, and vilification of specific religious groups or nationalities 9. Duty to honest/careful communication of risk to federal, state and local policymakers, the media, and the populace

10. Proactive vs. retroactive promotion of evaluation and waiver of consent policies for research on disaster populations 11. Appropriating prudent economic and political support of disaster exercises, evaluation, and research (e.g., funding to competent investigators

vs. funding to politically powerful) 12. Establishing transparent protocols for ethical triage and activation/maintenance/termination of disaster plans 13. Scope of practice transgressions/expertise issues (e.g., healthcare provided by nonphysicians or untrained personnel) 14. Enduring economic, health, and legal risk in the absence of reciprocity, disability, or Good Samaritan protections 15. Working domestically or abroad with limited resources while being held to a nondisaster standard of care 16. Upholding quarantine, reporting, and other public health powers legislation 17. Accountability for preventable losses and preventable health consequences of disasters 18. Attempting needed assistance amid domestic or foreign government disinterest or hostility to outside help 19. Resisting corporate opportunities to exploit victims, provider groups, governments, NGOs, and philanthropists

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Table 5.3: The Three Core Principles for the Doctor–Patient Relationship

1. Respect for patient autonomy 2. Nonmaleficence (avoiding harm) 3. Beneficence (doing good)

further developed the idea of maximizing social benefits in his book On Liberty.9 The underlying essence of this utility prin- ciple is central to the lifeboat challenges of disaster planning and response. Under an ethic of utility, consequences weigh more heavily than Pollyanna-like pronouncements of treating “all patients equally.” Resources are parsed to obtain maximal benefit for the most people.

Disaster triage (see Chapter 12) is grounded in principles of utility and equality, suggesting that one person’s survival is no greater than another person’s survival. This, however, is not always the case; to maximize societal outcome, one person may be more useful to save (e.g., the President) than another. The application of utility during disasters does not suggest that human rights can be violated or that rules of human decency are not important; for example, fresh organs cannot be har- vested from one unwilling but healthy patient to save five others. Triage and rationing must proceed according to the goal of help- ing the most people when resources are severely limited. Hence, expectant patients are provided comfort care, but allowed to die; ambulatory wounded patients wait longer than nonambula- tory patients; the sickest salvageable patients (given the resource- constrained environment) are top priority, all other things being equal. It may be difficult to determine reasonably which patients are salvageable in a specific dynamic disaster environment (i.e., more resources may or may not arrive, patient conditions may change, and more patients may or may not present). Priorities are established by need and by social utility. Prejudice based entirely on creed, color, age, and sex is unethical. However, it is not wrong that patients who contribute more transpar- ently to the functioning of society may be prioritized. Within a given strata of priority, however, time elements also matter, and a “first-come, first-served” system may be the only reasonable option in the context of contingent resources and unpredictable demand.

Maximizing benefits for the larger population of victims is a primary concern. In pandemic situations, using nonpharma- cological interventions such as quarantine prioritize population health over individual liberty. As a pediatric example, late sec- ond trimester newborns are resuscitatable under optimal cir- cumstances; however, saving 23-week premature infants in the throes of a resource-poor disaster situation may result in a lack of supplies for many other infants, children, and adults. Trying to save all when all cannot be saved is neither good policy nor good practice. Furthermore, just because someone can be saved does not mean that person always should be saved. In a nonvi- talistic sense, there are some outcomes worse than death. When electricity, clean water, beds, and medicine are in short supply, utilitarian ideals necessarily inform many of the rationing deci- sions that must be made on the spot. Even under nondisaster conditions, resources may be inadequate. In a multiple casu- alty disaster situation, the justification and need for utility-based rationing is even more transparent and the cost in human and emotional terms for providers and healers who may be put in a situation where patients cannot be saved is significant.

Limits of Utilitarianism

Utilitarianism has limitations. For example, although maximiz- ing benefits for the majority may appeal to a sense of democracy and fairness, legitimate minority concerns are easily marginal- ized in a utilitarian schema. In addition, some goods are more worthy of pursuing than others and some goods require a more long-term calculation of consequences. In WW II London, for example, water was a scarce resource; however, when civil ser- vants asked Winston Churchill (1874–1965) whether a fire at St. Paul’s Cathedral should be extinguished or allowed to burn in deference to needy Londoners, Mr. Churchill was clear: He opined that England could afford to lose a few of its citizenry, but if they lost St. Paul’s, they would lose the will to win, and hence the war itself.10

Another challenge with utilitarianism is the need to weigh biases, minority interests, and competing definitions of the good to be maximized. In wartime, heads of state are responsible for millions of lives; they may need special “very important person” [VIP] treatment, despite their minority status. Similarly, health- care workers in the frontline of a pandemic may need added pro- tection as an especially valuable and scarce resource warranting preferential vaccination, prophylaxis, and even compensation to ensure their optimal function in guarding the health of others. A person’s VIP status and social worth become material to the utilitarian sum of goods in a disaster, whereas such preferential treatment would be unethical in normal circumstances. Some- times a rule-utilitarian would subordinate VIP interests to the short-term interests of the majority. Whether to allow a mayor to receive treatment ahead of people who have been waiting for a longer time is one such example. Utilitarianism is sometimes applied as a rule and sometimes applied according to anticipated consequences; in either case it does not always provide clear and consistent guidance. The interests of rank and file individuals may give way to the functioning of society and the overall inter- ests of the greater population.

Another problem with unbridled utilitarianism is its appli- cation to the disabled and chronically ill. When two or more persons may be saved for the same resources needed to save a severely disabled person who will continue to consume a dis- proportionate share of scarce goods and services, principles of utility may lead to a total disregard of the disabled, seemingly making difficult decisions easier. Such harsh biases are inconsis- tent with notions of fairness and a healthcare provider’s natural desire to protect first the vulnerable and those with the greatest medical needs. Utilitarian extremism can be a slippery slope and may hearken back to the horrors of Nazi Germany or ancient Sparta, in which disabled adults and infants were systematically discarded. Hence, utilitarianism can favor some groups while penalizing others. Although utility is useful for guiding disaster triage, resource rationing, quarantine, and distribution dilem- mas, it has many shortcomings. Like justice, it does not provide a comprehensive solution to all ethical dilemmas before, during, or after disasters. At an operational level, advance preparation, policy, character, and Codes of Ethics can provide more guidance than theories of ethics.

Code of Ethics and Disaster Response

Optimal moral action in a disaster requires more than an under- standing of utility, rationing, and triage. Beyond standard bioeth- ical principles, codes of ethics and/or codes of conduct can help

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Table 5.4: ICRC 10 Principles of Conduct

1. The humanitarian imperative comes first 2. Aid is given regardless of the race, creed, or nationality of the recipients and without adverse distinction of

any kind; aid priorities are calculated on the basis of need alone 3. Aid will not be used to further a particular political or religious standpoint 4. We shall endeavor not to act as instruments of government foreign policy 5. We shall respect culture and custom 6. We shall attempt to build disaster response on local capacities 7. Ways shall be found to involve program beneficiaries in the management of relief aid 8. Relief aid must strive to reduce future vulnerabilities to disaster as well as meeting basic needs 9. We hold ourselves accountable to both those we seek to assist and those from whom we accept resources

10. In our information, publicity, and advertising activities, we shall recognize disaster victims as dignified humans, not hopeless objects

provide a moral framework that addresses at least some of the many micro-, meso-, and macro-level disaster challenges. Orga- nizational codes of conduct are useful for disaster preparedness and planning at the meso level. Many national and local disas- ter response organizations, such as Disaster Medical Assistance Teams, Medical Reserve Corps, the Centers for Disease Con- trol and Prevention, and other governmental organizations and NGOs within the U.S., lack Codes of Ethics or Conduct that guide their organizational response to disasters. Conversely, some international organizations, notably the International Commit- tee of the Red Cross (ICRC), do promulgate ethical guidelines (Table 5.4).11

The ICRC Code of Conduct includes the following “Prin- ciples of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Response Pro- grammes.”11

1) The Humanitarian imperative comes first. The right to receive humanitarian assistance, and to offer

it, is a fundamental humanitarian principle which should be enjoyed by all citizens of all countries. As members of the international community, we recognize our obligation to provide humanitarian assistance wherever it is needed. Hence the need for unimpeded access to affected populations, is of fundamental importance in exercising that responsibility. The prime motivation of our response to disasters is to alle- viate human suffering amongst those least able to withstand the stress caused by disaster. When we give humanitarian aid it is not a partisan or political act and should not be viewed as such.

2) Aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind. Aid priorities are calculated on the basis of need alone.

Wherever possible, we will base the provision of relief aid upon a thorough assessment of the needs of the disaster victims and the local capacities already in place to meet those needs. Within the entirety of our programmes, we will reflect considerations of proportionality. Human suffering must be alleviated whenever it is found; life is as precious in one part of a country as another. Thus, our provision of aid will reflect the degree of suffering it seeks to alleviate. In implementing this approach, we recognize the crucial role played by women in disaster-prone communities and will ensure that this role is supported, not diminished, by our aid programmes. The implementation of such a universal, impartial and independent policy, can only be effective if we

and our partners have access to the necessary resources to provide for such equitable relief, and have equal access to all disaster victims.

3) Aid will not be used to further a particular political or religious standpoint.

Humanitarian aid will be given according to the need of individuals, families and communities. Not withstand- ing the right of Non Governmental Humanitarian Agencies (NGHAs) to espouse particular political or religious opin- ions, we affirm that assistance will not be dependent on the adherence of the recipients to those opinions. We will not tie the promise, delivery or distribution of assistance to the embracing or acceptance of a particular political or religious creed.

4) We shall endeavour not to act as instruments of government foreign policy.

NGHAs are agencies which act independently from gov- ernments. We therefore formulate our own policies and implementation strategies and do not seek to implement the policy of any government, except in so far as it coincides with our own independent policy. We will never knowingly – or through negligence – allow ourselves, or our employees, to be used to gather information of a political, military or eco- nomically sensitive nature for governments or other bodies that may serve purposes other than those which are strictly humanitarian, nor will we act as instruments of foreign pol- icy of donor governments. We will use the assistance we receive to respond to needs and this assistance should not be driven by the need to dispose of donor commodity sur- pluses, nor by the political interest of any particular donor. We value and promote the voluntary giving of labour and finances by concerned individuals to support our work and recognize the independence of action promoted by such vol- untary motivation. In order to protect our independence we will seek to avoid dependence upon a single funding source.

5) We shall respect culture and custom. We will endeavour to respect the culture, structures and

customs of the communities and countries we are working in.

6) We shall attempt to build disaster response on local capac- ities

All people and communities – even in disaster – possess capacities as well as vulnerabilities. Where possible, we will strengthen these capacities by employing local staff, purchas- ing local materials and trading with local companies. Where

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possible, we will work through local NGHAs as partners in planning and implementation, and co-operate with local government structures where appropriate. We will place a high priority on the proper co-ordination of our emergency responses. This is best done within the countries concerned by those most directly involved in the relief operations, and should include representatives of the relevant United Nations (UN) bodies.

7) Ways shall be found to involve programme beneficiaries in the management of relief aid.

Disaster response assistance should never be imposed upon the beneficiaries. Effective relief and lasting rehabilita- tion can best be achieved where the intended beneficiaries are involved in the design, management and implementa- tion of the assistance programme. We will strive to achieve full community participation in our relief and rehabilitation programmes.

8) Relief aid must strive to reduce future vulnerabilities to disaster as well as meeting basic needs.

All relief actions affect the prospects for long term devel- opment, either in a positive or a negative fashion. Recogniz- ing this, we will strive to implement relief programmes which actively reduce the beneficiaries’ vulnerability to future dis- asters and help create sustainable lifestyles. We will pay par- ticular attention to environmental concerns in the design and management of relief programmes. We will also endeav- our to minimize the negative impact of humanitarian assis- tance, seeking to avoid long-term beneficiary dependence upon external aid.

9) We hold ourselves accountable to both those we seek to assist and those from whom we accept resources.

We often act as an institutional link in the partnership between those who wish to assist and those who need assis- tance during disasters. We therefore hold ourselves account- able to both constituencies. All our dealings with donors and beneficiaries shall reflect an attitude of openness and transparency. We recognize the need to report on our activi- ties, both from a financial perspective and the perspective of effectiveness. We recognize the obligation to ensure appropri- ate monitoring of aid distributions and to carry out regular assessments of the impact of disaster assistance. We will also seek to report, in an open fashion, upon the impact of our work, and the factors limiting or enhancing that impact. Our programmes will be based upon high standards of profes- sionalism and expertise in order to minimize the wasting of valuable resources.

10) In our information, publicity and advertising activities, we shall recognize disaster victims as dignified humans, not hopeless objects.

Respect for the disaster victim as an equal partner in action should never be lost. In our public information we shall portray an objective image of the disaster situation where the capacities and aspirations of disaster victims are highlighted, and not just their vulnerabilities and fears. While we will cooperate with the media in order to enhance public response, we will not allow external or internal demands for publicity to take precedence over the principle of maximizing overall relief assistance. We will avoid competing with other disaster response agencies for media coverage in situations where such coverage may be to the detriment of the service provided to the beneficiaries or to the security of our staff or the beneficiaries.11

The organizational model provided by the 10 Principles in the ICRC Code of Conduct addresses the critical need for objec- tive, apolitical, culturally competent, dignified, humane, and sus- tainable disaster responses at both the macro and meso levels. Although the ICRC suggests an important corporate ethical pos- ture, it does not address basic micro-level issues around disaster response, per se. For example, individual providers are often con- fronted with the fundamental questions: “Should I respond to this disaster by going to the scene, near or far?” “Should I stay home with my family where I am also needed?” Alternatively, the dilemma may be one in which providers’ hospitals are in the eye of the storm itself, and they must decide whether to stay and work or evacuate to a safer location. For an answer to this basic “stay or go?” question, more specific ethical guidance is required.

Codes of Medical Ethics

Although the ICRC Code of Conduct may apply to NGOs and the ICRC itself, other guidance is needed for individuals serving as healthcare workers in unaffiliated organizations or working as individuals. Organized medicine has provided general ethical guidance to physicians that may be extrapolated to disaster situa- tions. Although each disaster has its own set of moral challenges, physicians, like other professionals, operate under extant codes of conduct, both within medicine as a whole and within emer- gency and disaster medicine, in particular. These more general ethical principles and professional duties may provide specific guidance for disaster planning and response.

American Medical Association Code of Ethics

Inspired by John Gregory (1724–1773) in 18th-century Scot- land,12 Thomas Percival (1740–1804) penned the first mod- ern Code of Western Medical Ethics in 19th-century England.13

Across the Atlantic, the American Medical Association (AMA) followed suit with a similar Code of Medical Ethics, first pub- lished in 1847.14 These codes were visionary in addressing issues of personal risk in rendering service during epidemics. In fact, the AMA Code was the first to suggest that

When pestilence prevails, it is [physicians’] duty to face the danger, and continue their labors for the alleviation of suffering, even at the jeopardy of their own lives.

Such strong statements as this were largely unprecedented and, according to Zuger and Miles, helped formalize a sense of duty that was sustained though the following century.15 As the threats of smallpox, polio, and related epidemics were dissolving in the 1950s and 60s, so too were heroic statements vanishing from the AMA Code.16

Decades later, the human immunodeficiency virus threat motivated changes in the Code that were less inspired, suggest- ing in 1986 that treating patients with human immunodeficiency virus was only required if the physician was “emotionally able to do so.”17 This self-serving stance was ridiculed and short-lived; within 6 months a revised statement was issued.

A physician may not ethically refuse to treat a patient whose condition is within the physicians’ current realm of competence solely because the patient is seropositive.16

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More recently, the events of September 11, 2001 and the ensuing anthrax attacks in the United States ushered in a new “Social Con- tract with Humanity” adopted by the AMA House of Delegates in December 2001.18 Within the Social Contract is a Declaration of Professional Responsibility which, like an oath, begins with a general promise followed by nine duties; the fourth obligation is reminiscent of the personal risk declaration in the 1847 AMA Code of Medical Ethics.

We, the members of the world community of physicians, solemnly commit ourselves to:

4. Apply our knowledge and skills when needed, though doing so may put us at risk.19

This promise or oath is not forsworn by all physicians and many may rely instead on the AMA’s enforcement of profes- sional autonomy, found in Principle VI of the AMA Code.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the envi- ronment in which to provide medical care.20

This emphasis on professional autonomy led the American Col- lege of Emergency Physicians to develop a separate Code of Ethics in 1996; this code is especially important because emer- gency physicians in particular do not choose “whom to serve” and are committed to open access to all who seek their services in both disaster and nondisaster situations.

The first two, and arguably, the most important Principles of Ethics for Emergency Physicians within the Code, are the most instructive.

“Emergency Physicians Shall:

1) Embrace patient welfare as their primary professional responsibility.

2) Respond promptly and expertly, without prejudice or par- tiality, to the need for emergency medical care.”21,22

These guideposts underscore the need to put patients first, and to treat all patients promptly, regardless of their particular prob- lems, contagions, viruses, or other illnesses.

Such principles from organized Emergency Medicine have, in turn, inspired more recent versions of the AMA Code to con- sider more seriously the notion of patient centeredness; the 2001 Preamble to the AMA Code states

A physician must recognize responsibility to patients first and foremost, as well as to society, to other health pro- fessionals, and to self.23

Responding physicians understand the need to be there when others are unwilling or unable to care for victims of a disaster. Some healthcare workers, such as emergency personnel, have special training and skills that may buttress their obligations to treat those disaster victims who are acutely ill, vulnerable, and lack other sources of medical care. Although some patients may have severe acute respiratory syndrome (SARS), influenza during a pandemic, or Ebola virus, a certain level of risk taking has always been constitutive of emergency medical practice, and part of the idealized expectation of emergency medicine is to be

ready, willing, and able to treat anyone and everyone who enters as a patient into the hospital emergency department.24

Duty to Respond: Social Contract

Public expectations of emergency- and disaster-trained profes- sionals transcend extant Codes of Conduct, Principles of Ethics, and professional oaths, into the realm of social contracts, profes- sional responsibility, and reciprocity. Under the social contract arrangement, physicians enjoy the status, respect, honor, and income of an autonomous profession. As a profession, physi- cians are accorded the rights to self-police and set the standards and rules that govern emergency and disaster medical practice. As quid pro quo, physicians are then expected by society to fulfill a certain duty or role to help those in need of their services. Emer- gency physicians in particular have special abilities to provide initial care to the acutely ill and injured. In some cases, public funding sources supported the development of these skills. Duties of reciprocity and solidarity suggest that physicians should give back to society by fulfilling their expected roles to treat the sick and injured, regardless of the disaster or their personal risks.

As a professional, there is a duty to report to work, includ- ing during times of disaster, unless other arrangements have been made with the employer. Despite modern trends toward unionization within nursing and medicine, physicians constitute a trusted profession that enjoys economic and status advantages that compel service in disasters; this is especially true when they comprise an explicit part of a disaster plan wherein there is a fiduciary duty to show up for work as part of an agreed insti- tutional arrangement. Need, proximity, capability, and the lack of other responders create an obligation and duty of care that cannot be ignored; yet this obligation must be counterbalanced with the duty to future patients, coworkers, and to family and self when faced with a particularly dangerous exposure or situa- tion. There is no duty to disaster martyrdom, or even to being a Good Samaritan, but personnel who deploy as part of organized disaster response teams have a clear duty to disaster patients, irrespective of their race, sex, religion, or underlying medical conditions. Physicians themselves benefit from this kantian duty and the reciprocal social contract as both providers and potential patients who may themselves need to depend on the willingness of other doctors to assume personal risk should they become ill or injured in the next disaster.

Although considerations of duty, principles, utility, and codes of ethics are illuminating, a more overarching ethical theory is needed that is immune to many of the variables and contingen- cies inherent in principlism, utilitarianism, contracts, and codes of ethics. Each specific context may defy an overly simplistic algorithm that can be applied like a cookie cutter to the melt- down of every Three Mile Island or Chernobyl. Something more than knowledge of principles, contracts, or codes is required to determine moral valence and ethical action in real-time disas- ter practice. That something more goes beyond ethical ideology and considers the characteristics of the doctors and other health- care workers that make transparent, real-time, disaster decisions. That something more is virtue.

VIRTUE: A Transcendent and Timeless Ethic

Ethike, Greek for character, is the etymological basis on which much of classic western ethics is built. The earliest recorded

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depictions of character (ethike) or virtue (ârete) are found in Homer’s Iliad;25 here the heroes of the Trojan War, Hector and Achilles, are animated with an overarching quest for virtue. Homer used the Greek word ârete to describe not only virtue, but excellence of every kind.

A son excels his father in every kind of ârete – as athlete, as soldier and in mind. (Iliad 20.411)

Arete has been described as those excellences or virtues that enable individuals to do properly what their roles require. Hence, the extension of ârete from soldiers on the ancient battlefield of Troy to an embattled disaster relief team working amid the rubble of a modern earthquake is a fitting extrapolation.

This notion of moral excellence, or virtue, was central to the ancient conception of ethics developed by Aristotle approx- imately 330 bce. Under his genius, virtues became the basis of ethics for the next 2,000 years. In his famous Nicomachean Ethics, Aristotle asserts that the exercise of virtues is necessary to live a good and happy life.26 Virtues are dispositions to be good, and include not only good actions, but good thoughts and feelings as well. Aristotle further described virtue or character as the golden mean between deficiency and excess; courage, for example, was described as the mean between foolhardiness and cowardice. Like Socrates and Plato before him, Aristotle also recognized that virtue must be practiced and cultivated to become a regular habit of moral behavior.

Virtue is the most ancient branch of ethics, reaching its apex 1,500 years after Aristotle’s death under the teaching of St. Thomas Aquinas (1225–1274). Aquinas taught the importance of the four primary virtues (prudence, temperance, courage, and justice); he also added the theological virtues of faith, hope, and charity. To this revised list of seven cardinal virtues, St. Thomas contrasted the seven deadly sins or vices (gluttony, envy, wrath, sloth, greed, lust, and pride).27

Since Aquinas and the advent of modern science, medieval virtue was successively challenged in the west by Machiavelli, Hobbes, Nietzsche, Ayn Rand, and others.28–31 Only recently, since the publication of Alasdair MacIntyre’s (1929–) After Virtue in 1981, has there been any consideration given to reversing this trend.32 The medical ethicists Edmund Pellegrino and David Thomasma, apostles of MacIntyre, have argued that health- care has become too steeped in the tradition of following rules, laws, Hippocratic codes, and utilitarian practice guidelines.32,33

Although following rules and guidelines can be useful, the clas- sic notions of character and virtue, while often neglected, are of central importance in ensuring that healthcare professionals can fulfill their roles in promoting the interests of patients and the greater community of which they are a part.24

VIRTUE AND DISASTER

Asserting virtue as an essential element to the practice of disaster medicine requires accepting as a starting premise that there is an ideal toward which emergency and disaster healthcare professionals should strive. Aristotle discussed this ideal way of being as telos, or natural end; this telos is integral to the social fabric and not only individual morality.26 Some experts assert that the telos or goal of the disaster professional is not merely to support legal dicta, Hippocratic principles, and disaster plans; it is also to become a good, moral, and honorable professional who

genuinely cares for and about disaster victims and the societies in which disasters occur.24

Virtue provides an ideal model of behavior in the quest for professional excellence. Virtue is also its own intrinsic good and promises a stronger possibility for fulfillment, thereby enriching the satisfaction that healthcare providers as both profession- als and members of a community, obtain from the practice of medicine. Strictly following rules, algorithms, and the status quo, by contrast, threatens to diminish autonomy and create adver- sarial relationships with patients, legalistic restrictions, and a morally impotent and inflexible disaster response system. Virtue can provide a dynamic solution that supports provider strengths in ways that are good for patients, professionals, and society, regardless of context.

Having trustworthy and available healthcare workers with a basic integrity and goodness of character is a moral prerequi- site and central to any preparedness plan or disaster response that is both reliable and responsive to changing circumstances. Proactively selecting for “the right stuff” is an important con- sideration as time exigencies in the wake of mass casualty events do not allow for protracted moral reflection and ethical delib- eration; thus preventive measures and a priori policies that amplify virtue and clarify expectations for ethical practice are warranted. Disaster preparedness training and related exercises must include opportunities for character and team building as well as provide guidance on optimal and ethical distribution of scarce medical resources. Fostering virtue proactively may be thought of as a kind of moral vaccination against the eth- ical pitfalls inherent in emergency medical services provision. Manifest virtue gives frightened, anonymous, and vulnerable victims and the sometimes mentally exhausted disaster team members something in which to believe when they need it the most.

CARDINAL VIRTUES FOR DISASTER

PREPAREDNESS AND RESPONSE

Eight virtues that express the qualities, dispositions, and uniqueness of the ideal disaster response team volunteer are: pru- dence, courage, justice, vigilance, stewardship, resilience, com- munication, and self-effacing charity (Table 5.5).

These virtues, detailed later, are not intended to be all- inclusive. Equally important virtues such as humility are beyond the scope of this chapter. As both Plato and Aristotle noticed, there is considerable overlap between many of the virtues, reflect- ing both the compatibility and interdependence of virtues on each other.26,34 It would be difficult to have only one virtue and

Table 5.5: The Cardinal Virtues of Disaster Response

1. Prudence 2. Courage 3. Justice 4. Stewardship 5. Vigilance 6. Resilience 7. Self-effacing Charity 8. Communication

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not possess at least some of the others. Timeless insight can be gleaned from the classic virtues of antiquity, and three such virtues are examined first: prudence, courage, and justice.

PRUDENCE

Prudence was first defined by the Greeks as phronesis, or practical wisdom. This virtue connotes discernment, perspicac- ity, judiciousness, and proper discrimination. Phronesis was con- sidered by Aristotle to be the prerequisite basis of all other virtues because it was needed to properly weigh between justice, temper- ance, and all the other virtues and vices. Prudence, or practical judgment, was necessary to “do the right thing in the right place at the right time in the right way and the right amount.”26 Unlike rigid Hippocratic rule-following, prudence or sound judgment is central to the dynamic functioning of the healthcare team in a disaster situation. Prudence connotes practical wisdom or a basic common sense, which is indispensable to the proper application of technical and moral facts in any particular crisis. In disaster medicine there are no quick formulas for the determination of right action and right emotion because each patient and each situation is unique. Balancing burdens and benefits, determin- ing a triage category, choosing when to refer, knowing when to withhold advance life support interventions, when to vaccinate for smallpox, and what to tell the mass media and when to tell them – cannot be found in textbooks, but are all manifestations of prudence. All clinical judgment involves some measure of prudence. This is particularly critical in disaster medicine when uncertainty and urgency are rampant. The exercise of prudence reflects professional competency and is, therefore, essential to the development of leadership, trust, and respect within the disaster response team. Because prudence promotes safety, its opposite is recklessness. Persons lacking prudence are vectors of danger and collateral damage and must be removed from leadership when disaster strikes.

COURAGE

Virtue is bold, and goodness never fearful.35

Tisn’t life that matters! Tis the courage we bring to it.36

Moral courage is a type of fortitude that is especially important when preparing for and responding to disasters or multiple casu- alty events. Courage is often exemplified by being steadfast, for example, advocating for public health needs when nonmedical influences convince policymakers to support directing resources to smallpox preparedness in the absence of a highly credible threat. Courage may also be shown at the micro level by advocat- ing for patients when utilization review nurses and managed-care gatekeepers deny medical services or when consultants, families, or employers fail to act in patients’ best interests. It is also mani- fest in the determination required to put aside fear when treating the violent, psychologically agitated, or criminal (even terrorist) patients. Unlike machismo, courage sometimes means accom- modation or “turning the other cheek” when, for example, an angry patient makes threatening statements, delivers insults, or spits. The words of Austrian poet Rainier Maria Rilke (1875– 1926) offer insight into this higher form of courage.

Perhaps all the dragons in our lives are princesses who are only waiting to see us act, just once, with beauty

and courage. Perhaps everything that frightens us is, in its deepest essence, something helpless that wants our love.37

Courage is manifest in other ways, for example, by acting deci- sively when information is lacking. Fortitude is also needed to abide by reporting statutes or to enforce quarantine provisions during a bioterrorism event or other public health emergency like SARS. As mentioned previously, courage can be seen as an Aris- totelian mean between cowardice and foolhardiness. Although refusing to treat a monkeypox patient can be considered cow- ardice, expressing pus from an anthrax-laden abscess with bare hands simply shows poor judgement. Courage is entirely differ- ent. Courage is embracing the duty to care for victims of disaster without undue concern for malpractice exposure, infectious dis- ease risk, or economic reimbursement.

A measure of bravery is also required to report incompetence, impairment, or academic fraud, at the times when it occurs in the disaster preparedness industry. It takes courage to say “no” to the temptations of wealth and notoriety when it is being dis- tributed widely to any who would hold themselves out to be an expert in the area of disaster preparedness. Healthcare providers must have the courage and integrity to take responsibility for any shortcomings of the medical profession. Self-discipline and monitoring are important rather than blaming others, e.g., soci- ety, attorneys, bureaucrats, and insurers, when moral problems arise. In summary, courage is having the moral resolve to do the right thing even when it is difficult, inconvenient, risky, or unpopular to do so.

JUSTICE

As mentioned previously, justice is one of the four core prin- ciples of western medical ethics (along with beneficence, non- maleficence, and respect for autonomy). It is also a key virtue in disaster circumstances. Justice is a quality that helps disaster workers and planners shepherd resources, employ therapeutic parsimony, and administrate well. Justice requires that practi- tioners be fair and resist selfish passions. Justice was the prin- ciple theme of Plato’s Republic;34 today, in some countries it is the ordering principle of healthcare reform and discussions of rationing, access, and runaway costs. Although establishing dis- tributive and social justice policy seem like a more appropriate task for the electorate, disaster workers must assume this duty as well. Specifically, they must steward resources by prioritiz- ing disaster needs fairly in relation to other programs. At the micro level, a just provider defers or denies marginally beneficial care to some victims and patients (e.g., expectant or non-critical ambulatory wounded) whereas guaranteeing a basic level of care for others. Disaster physicians and other medical volunteers and disaster practitioners must resist public, legislative, or institu- tional policies that are unfair or unjust. The ethical and virtuous disaster professional must also act to ensure that disaster aid is accessible and available to all who need it, especially the most vulnerable. Justice would enjoin practitioners to adhere to the World Medical Association’s Declaration of Geneva’s entreaty to treat all patients regardless of “age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sex- ual orientation or social standing.”38 Such justice is a lofty goal and may contradict the political will of government, for example, to care for soldiers ahead of civilians or for politicians ahead of

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members of the lay public. Providers may also be challenged by the demands of VIPs, families, and friends that do not support the greater good of humanity. Justice, as with prudence, is essen- tial to the development of mutual trust, especially between team members in administrative roles.

Having discussed three of the cardinal virtues of antiquity and their role in the modern practice of disaster medicine, addi- tional virtues that help disaster workers realize their true ideal will now be explored. The following virtues express some of the community of values unique to the practice of emergency and disaster medicine, which disaster responders need but Aris- totle could not have foreseen. Specifically, these are: steward- ship, vigilance, resilience, self-effacement/charity, and communi- cation.

STEWARDSHIP

The American Heritage Dictionary defines a steward as “one who manages another’s property, finances, or other affairs.”39

Stewardship, like justice, is a quality that helps disaster workers shepherd resources, use therapeutic parsimony, and adminis- trate with temperance and self-control. Preparing for disasters requires objectivity and a steadfast refusal to be swayed by mar- keting, vendors, or even government when money and resources are being dissipated or squandered. Corporate and individual greed are antithetical to the good of society. Rationing at the micro, meso, and macro levels is required in times of auster- ity. Emergency providers are often trained to guard resources by encouraging them to withhold marginally beneficial care to some victims and patients, while guaranteeing a basic level of care for others. The duty of stewardship has been previously recognized in the “Principles of Ethics for Emergency Physicians” adopted by the Board of Directors of the American College of Emergency Physicians in 1997 and reaffirmed in 2001.21 Principle 9 of this document states, “Emergency physicians shall act as responsible stewards of the health care resources entrusted to them.”21 The duty of stewardship thus enjoins emergency physicians to make effective use of the healthcare resources at their disposal.22 In times of plenty, this is less challenging, but in times of disaster, austerity may require limiting the provision of beneficial care, or outright rationing. Rationing may raise the ire of clinicians and the distrust of patients, but it is sometimes a necessary com- ponent of stewardship in the wake of a mass casualty incident. Although it would be challenging to provide comprehensive pro- tocols that address all of the allocation and triage decisions that providers must make in austere situations, the ethical and pru- dent steward will maximize outcomes and minimize harm in the overall population being served. This utilitarian approach to stewardship demands a careful consideration of the likelihood, magnitude, and duration of benefits to patients and populations, the urgency of the situation, and the cost of burdens of alloca- tion and triage strategies to patients, payers, government, and society.

VIGILANCE

Vigilance is both a defining and essential virtue to the enter- prise of disaster preparedness and response. Vigilance is nearly synonymous with preparedness. In few venues other than dis- asters are physicians or other disaster responders called on to be ready, willing, and able to assist patients, paramedics, and

colleagues, immediately, competently, and compassionately, 24 hours a day. This around-the-clock and watchful guardianship does not weaken during weekends, holidays, or nights; in fact, disaster care is often provided during nontraditional work hours. In the wake of a tsunami, earthquake, terrorist or other type of disaster, demands are often unpredictable and uncontrol- lable, evolving over time, and rarely defined by an individual patient’s needs. Yet utmost alertness, stamina, and preparedness are required, despite the circadian disharmony that threatens personal wellness. Expectations of excellence demand participa- tion in preparedness exercises so that no matter what the illness or injury, no matter what the crisis, some emergency or disaster responder is available to provide assistance. This is what it is to be vigilant in times of trauma, disaster, terrorism, or life-threatening illness.

RESILIENCE

In a disaster setting, amid human suffering, flooding, and destruction, an overstressed staff requires a certain elasticity and optimism to stave off physical and emotional fatigue, cynicism, resignation, disillusionment, and professional burnout. This type of diverting optimism that allows one to sustain competence under the stress of disaster is called resilience. Resilience enables disaster workers to recharge emotional stores so that, for example, when a frightened and lost child comes to the command center after the parent is pronounced dead, they are able to provide compassion and comfort the child.

Resilience greatly facilitates the ability to recover undaunted from trauma, change, or misfortune. This self-preserving virtue does not, however, imply that compassion, empathic listening, and sensitivity are to be abandoned. To the contrary, a resilient disaster worker is “all things to all people,” giving both victims and coworkers exactly what they need without becoming dis- tracted from the overarching job at hand. A resilient responder is sensitive and compassionate, but keeps the balance between apathetic indifference and over-identification with the victims, thereby avoiding the paralysis of either extreme.

True excellence in emergency and disaster medicine requires transcendent flexibility, adaptability, and a cooperative nature, thereby allowing a responder to work well with patients and team members of all types. It is also manifest in an ability to resist taking criticism too seriously from angry patients, families, and coworkers. Resilient persons are hardy, curious, purpose- ful, expectant and acceptant of change, and trust in their own power to influence the course of events. Maintaining flexibility and coping with the typical circadian rhythm disruptions of the disaster recovery worker is difficult, but aikido-like resilience is facilitated through the psychosocial support of the healthcare team. An appropriate sense of humor and wittiness coupled with an optimistic outlook can keep the team spirit afloat even in the harshest environment. Resilience is thus another essential virtue needed for disaster workers to remain functional amid the turmoil of catastrophe.

SELF-EFFACING CHARITY

Effacement of self-interest, temperance, humility, altruism, and charity are perhaps the highest levels of human virtue. Char- ity goes beyond ethical principles of nonmaleficence and mere beneficence. Charity denotes the volunteer who willingly stays

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late to help cover for a colleague in quarantine. An altruist is willing to attend to a coworker’s concerns beyond the work rela- tionship despite real or imagined interprofessional boundaries. Examples of benevolent charity would include: canceling a vaca- tion to volunteer to help hurricane victims in Haiti; taking care of SARS patients without concern for combat pay; and working for a pregnant colleague during a nuclear disaster.

A fictitious example of charity in times of plague is provided by Mark Twain in his work, A Connecticut Yankee in King Arthur’s Court. Here, King Arthur risks death to assist a woman dying of plague.40

Aquinas first introduced charity as one of the cardinal virtues in the Middle Ages, but the reason that it has never fallen out of fashion and remains noble in secular society today is its rarity and beauty.27 Like diamonds or gold, charity’s supererogation, self-sacrifice and generosity is precious, and transcends the white coat duties that are merely expected by the social contract of a medical professional with society. Charitable providers take liter- ally the opening eloquence from the World Medical Association’s Declaration of Geneva.

I solemnly pledge to consecrate myself to the service of humanity.38

To be truly charitable, a responder must be humble and allow other members of the team to receive praise. Also, true charity is nonjudgmental and understanding when coping with self- involved or narcissistic coworkers. Charity is critical to the team effort in delivering disaster care as Aristotle’s golden mean between the extremes of obsequiousness and self-centeredness. Charity helps disaster practitioners cope with uncooperative coworkers or clientele. Generosity to patients and colleagues may be manifest in many ways. Beyond simple diplomacy, being charitable to others includes being a willing team player who is both forgiving and magnanimous. Even with a trend in some locales for diminishing professional autonomy and height- ened entrepreneurism, charity remains the pinnacle of all virtue because, at bottom, it is about core values, destiny, and the calling to genuine caring and selfless giving. The poet Rilke describes charity as the ultimate task.37

For one human being to love another human being: that is perhaps the most difficult task that has been entrusted to us, the ultimate task, the final test and proof, the work for which all other work is merely preparation.

(Rainier Maria Rilke 1875–1926)37

COMMUNICATION

Communication skills are key elements necessary for crowd control, media interactions, debriefings, and incident command center functions. Of all the virtues of emergency and disas- ter teamwork, communication is most essential. Almost every obstacle to successful disaster team interaction may be over- come through good communication. “Good communication” within the incident command structure consists of four inte- gral characteristics: empathy, shared power and control, self- disclosure/ventilation, and confirmation.41,42

Empathy Empathy refers to observing the world from another per-

son’s point of view. To communicate empathetically healthcare

providers must be consciously aware of the behavior, moods, and feelings of others, the influence of their own communicative style and the responses, both spoken and unspoken. Entering another person’s world enables the empathetic listener to inter- pret more accurately the intended message. Thus empathy helps professionals build interpersonal relationships with one another and with patients – an almost universally desired goal of the successful disaster management team. Such relationships may ease tensions among team members and thwart occasions for conflict.

Shared Power and Control Sharing control is a sensitive issue especially in “life and

death” or disaster situations. Under these conditions, healthcare professionals may believe they require total control so that the environment in which they attempt to save lives becomes maxi- mally efficient and predictable. Although there is often a named “incident commander” during disaster operations, healthcare professionals must depend on one another if they are to function with optimal effectiveness. Through sharing control, interdepen- dence can be achieved without any individual losing control. In addition to these factors, the obstacle of professional hubris, pro- voked by interprofessional ignorance, must be mitigated through education and the virtues of self-effacement and trustworthiness. Colleagues and other professionals are coequal as far as morals are concerned, and they are due respect accordingly.

Self-Disclosure Self-disclosure may appear at first to be of primary concern

to the physician–patient relationship but it is just as important to the intimate and interpersonal relationships among members of a disaster response team. A close relationship with teammates affords the opportunity to share feelings, concerns, and frustra- tions, fostering the mutual comfort and trust necessary to cope with difficult situations. This sharing, then, reciprocates in the self-disclosure of other team members. Emotions are commu- nicated across professional boundaries, yielding greater inter- professional understanding and empathy, cultivating more inti- mate interpersonal relationships, and nurturing unity of team spirit.

Confirmation Confirmation is a method to communicate interpersonal

acknowledgment and acceptance of others. Praising a team mem- ber’s accomplishments, acknowledging another’s frustrations, and simply listening openly to patients’ worries exemplifies con- firming communication. Confirmation and the virtues of empa- thy and compassion require one to recognize the need of health professionals to feel accepted and worthwhile. Although rarely spoken, most healthcare workers have compelling needs to be viewed as important to the functioning of the team. Feeling included provides a sense of purpose transcending simple team membership.

Confirming communication can be difficult especially when angry patients and teammates generate negative responses to attempts at compassionate and empathic speech. Despite this, confirmation is reciprocal in nature and, if practiced, influences others to communicate similarly over time. Communicating in a confirming manner is essential in showing respect for peoples’ hopes, abilities, and concerns. Disaster team members should

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enhance their teamwork and communication skills by engag- ing in team building activities before they are required to work together during a critical incident.

Team Leaders: Models and Mentors of Virtue

U.S. President Abraham Lincoln once said, “It has been my expe- rience that folks who have no vices have very few virtues.”43

Sometimes in disaster situations, a vice can become a virtue. Physicians who are hypomanic may be able to work long hours without sleeping. Narcissistic responders may be better able to interact with the media and function as leaders. Self-confidence is often better than extreme humility in effecting optimal disas- ter teamwork. Highly sensitive individuals may not perform well when confronted with body parts or human debris.

Given the many ethical pitfalls in disaster settings, persons with strong moral character must be actively recruited as leaders to help teach, model, and grow virtue in other team members. Excellent communicators, for example, foster team-based virtues and individual traits of prudence, justice, self-effacement, char- ity, compassion, and resilience in others. Strong leaders and loyal staff learn from each other because they are neither dependent nor independent of each other; rather they are interdependent.44

Effective and ethical disaster managers, chairpersons, chief exec- utive officers, policymakers, and other leaders understand this interdependence and empower their coworkers first and fore- most with strong moral support and a virtuous example. In the aftermath of September 11, 2001, New York City Mayor Rudy Giuliani understood the importance of both support and example, visibly working hard in and around New York City’s five boroughs to keep morale at a high level. His leadership secret? “Attend every funeral.”45 Giuliani attended many New York police and firefighter personnel’s funerals, wakes, memo- rial services, and other functions. At a critical time in history, his behavior was virtuous and his physical presence was deeply appreciated. Strong leaders inspire others. Similarly, both respon- ders and adult learners in preparedness exercises learn better to adopt optimal virtues when real-life models are visibly present. Although intrinsic character cannot be easily measured, virtu- ous behaviors can be evaluated objectively. For example, role- play can be used during disaster preparedness exercises with video review and feedback to formatively teach optimal crisis and emergency risk communication skills to peers, patients, and the media. The more closely teachers and leaders exemplify a virtuous ideal, the more successful they will be in developing useful, skilled, and truly excellent disaster medicine teams that measurably improve the quality of care for patients, enrich the environment and relationships in which disaster response teams operate, and bring honor and integrity to the forefront of disaster service.46

RECOMMENDATIONS FOR FURTHER RESEARCH

This chapter presents important ethical principles, codes of con- duct, and cardinal virtues gleaned from history that may assist emergency managers and disaster response personnel who are confronted by ethical dilemmas encountered in disaster pre- paredness and response. Future work should focus on more explicit and transparent policies that can be developed both locally and globally, incorporating the principles of utility and justice into more concrete operational guidelines. Traditional

individualistic principles of bioethics are insufficient when the functioning and viability of civil society is at stake. Realistic dis- aster triage protocols must be refined and tested to show that they improve outcomes. Furthermore, studies are urgently needed to determine fair and equitable allocation of scarce resources dur- ing a catastrophic disaster.47,48 Leaders must inform the public of the need to embrace the difficult issues of social worth and prior- itization within disease and illness strata; a policy of “first come, first served” without consideration of the overall circumstances is insufficient as a moral rule.

Beyond the application of public health ethics, disaster situ- ations create a parallel need for a host of virtues not commonly required in daily medical practice, including vigilance, courage, stewardship, prudence, resilience, justice, and self-effacing char- ity. Ongoing research suggests that such traits form a cadre of core competencies, “the right stuff,” from which the ideal dis- aster worker is made. Future work should evaluate the ability of such virtues to act as a polyvalent counterpoint to the vices of apathy, cowardice, profligacy, recklessness, inflexibility, and narcissism. Outcome data may validate virtues that empower providers at all levels to integrate vertically principles of safety, public health, utility, and medical ethics at the micro, meso, and macro levels. Longitudinal and prospective studies should explore if, over time, virtuous behavior can be modeled, men- tored, practiced, and institutionalized to become a useful vaccine against the vast array of moral threats inherent in disaster pre- paredness and response.

Future empiric research in the field should help discern the feasibility of screening for, selecting, teaching, and modeling the cardinal virtues among provider candidates in advance of a disaster or multiple casualty incident. Multisite studies must also be conducted that validate the ability to measure and imbue core values of fairness, utility, and virtue in a multicultural context. Future codes of conduct must also incorporate practical aspects of provider discretion, the importance of good intent, and the challenge of dynamic decision making amid changing disaster circumstances. Mass media must help engage the populace and leaders alike into dialogue to discern in advance how best to help the disabled, the incarcerated, noncitizens, and the poor and disenfranchised. Future work must determine how best to prioritize and weigh the long-term goals of civil society and public health over the short-term liberty and health interests of individual citizens during a catastrophic event.

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