1 University of South Alabama University of South Alabama November 5, 2011 November 5, 2011 Mobile, Alabama Mobile, Alabama By John R. Wible, General Counsel, Retired By John R. Wible, General Counsel, Retired Alabama Department of Public Health Alabama Department of Public Health Ethics and Health Care: Ethics and Health Care: How EMTS and Other How EMTS and Other Health Care Providers Health Care Providers May React Ethically in a May React Ethically in a Disaster Disaster ADPH, 2011 ADPH, 2011
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University of South Alabama University of South Alabama November 5, 2011November 5, 2011Mobile, AlabamaMobile, Alabama
By John R. Wible, General Counsel, RetiredBy John R. Wible, General Counsel, RetiredAlabama Department of Public HealthAlabama Department of Public Health
Ethics and Health Care:Ethics and Health Care:How EMTS and Other How EMTS and Other Health Care Providers Health Care Providers
May React Ethically in a May React Ethically in a DisasterDisaster
ADPH, 2011ADPH, 2011
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OutlineOutline►Setup and IntroductionSetup and Introduction►Action PrinciplesAction Principles►A Quick Ethical ProblemA Quick Ethical Problem►Sources of Personal EthicsSources of Personal Ethics►Professional Ethical PrinciplesProfessional Ethical Principles► InterludeInterlude►The Eye of the Storm – ApplicationThe Eye of the Storm – Application►An Ethical ExerciseAn Ethical Exercise►EpilogueEpilogue
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Dire Ethical StraitsDire Ethical Straits
►Hurricane Katrina Hurricane Katrina the people have left the buildingthe people have left the building
►Pandemic Influenza Pandemic Influenza the “new and improved disaster”the “new and improved disaster”
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Question from CDCQuestion from CDC
► What objectives and principles should be What objectives and principles should be considered in pandemic vaccine prioritization?considered in pandemic vaccine prioritization?
► What is the relative importance of the CDC What is the relative importance of the CDC goals?goals?
► Which population should have vaccine priority? Which population should have vaccine priority? ► What is the rationale?What is the rationale?► How can fairness, equity, efficiency and related How can fairness, equity, efficiency and related
principles be reflected in the determination of principles be reflected in the determination of priority groupings?priority groupings?
►Who should determine the answers?Who should determine the answers?ADPH, 2011
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An Ethical PersonAn Ethical Person
►Are you and ethical person?Are you and ethical person?►From where or whom did you learn From where or whom did you learn
your ethical principles? your ethical principles? Hint: “Yo Mama”Hint: “Yo Mama”
►““All I Ever Needed to Know, All I Ever Needed to Know, I learned in Kindergarten I learned in Kindergarten””
►Role of the supervisor as an exampleRole of the supervisor as an example
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Our PurposeOur Purpose
► The purpose of this presentation is to The purpose of this presentation is to help you discover the answers from help you discover the answers from within yourselfwithin yourself so that you will be able so that you will be able to make decisions that will allow you to to make decisions that will allow you to go about go about living outside yourselfliving outside yourself..
► Look for the “Secret in the sauce.”Look for the “Secret in the sauce.”
Whistlestop Café, Irondale, ALADPH, 2011
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The Pareto PrincipleThe Pareto Principle
► The “80-20 Rule” revisitedThe “80-20 Rule” revisited 10% basically ethical10% basically ethical 10% basically unethical or “aethical”10% basically unethical or “aethical” 80% wandering somewhere in the 80% wandering somewhere in the
middlemiddle
► The ethical job of the manager – The ethical job of the manager – Like a good shepherd:Like a good shepherd: Differentiate the animalsDifferentiate the animals Lead the sheepLead the sheep
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A Personal Aside - A Personal Aside - YouYou
►Who helped shape your ethical Who helped shape your ethical principles and how? principles and how?
►What did he or she teach you?What did he or she teach you?►What do you think is the most important What do you think is the most important
ethical principle of them all and why?ethical principle of them all and why?
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Group Ethical QuestionsGroup Ethical Questions
►What are some universally accepted What are some universally accepted ethical concepts?ethical concepts?
►Where did they come from and how do Where did they come from and how do we learn them as individuals? we learn them as individuals?
►How does each of us develop his own How does each of us develop his own set of ethical principles? set of ethical principles?
►Do we view those as static or sliding? Do we view those as static or sliding? ►What is the price of each of us? (For What is the price of each of us? (For
how much would you sell out?)how much would you sell out?)ADPH, 2011
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John’s Five Action Principles
►To tell the truth, the whole To tell the truth, the whole truth and nothing but the truth and nothing but the truthtruth
►““We’ll Sing in the Sunshine”We’ll Sing in the Sunshine”►Casper the Friendly GhostCasper the Friendly Ghost► It’s not about meIt’s not about me►The “Nike Principle.”The “Nike Principle.”
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An Ethical Problem at An Ethical Problem at St. Elsewhere St. Elsewhere
►Multitudes presenting with flu-like Multitudes presenting with flu-like symptomssymptoms
►Resources and staff exhaustedResources and staff exhausted
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The CharactersThe Characters
Annie Cavanero - graduateAnnie Cavanero - graduate Cathy Martin, RN Cathy Martin, RN Ben Samuels – autistic boyBen Samuels – autistic boy Wayne Fiscus - policemanWayne Fiscus - policeman Unknown homeless manUnknown homeless man Peter White - janitorPeter White - janitor Helen Rosenthal – survivorHelen Rosenthal – survivor
► Cultural teachings Cultural teachings -American Historical Documents -American Historical Documents Declaration of Independence Declaration of Independence United States ConstitutionUnited States Constitution
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The Ancient Greeks -The Ancient Greeks -The “Seven Sages”The “Seven Sages”
opportunity”opportunity”► Periander – “forethought in all Periander – “forethought in all
things”things”
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Mosaic of Socrates and the Seven SagesSurrounding the Muse, Calliope
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Socrates, Plato and Socrates, Plato and AristotleAristotle
►Socrates – “know thyself”Socrates – “know thyself”►Plato – human well-being, the highest Plato – human well-being, the highest
aim of moral thought and conductaim of moral thought and conduct►Aristotle – apply what we know in Aristotle – apply what we know in
social settingssocial settings16
L:Plato and Aristotle by RaphaelR:Raphael’s Socrates
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Religious Teachings - Religious Teachings - HinduHindu
► Oldest practiced religionOldest practiced religion► Dharma – the “right way of living” Dharma – the “right way of living”
or “proper conduct” for each societal or “proper conduct” for each societal segmentsegment
► To live in accord with the principles is to To live in accord with the principles is to move more quickly to personal liberationmove more quickly to personal liberation
► Hindu writingHindu writing Acara – daily caste-centered ritualsAcara – daily caste-centered rituals Vyavahara – rules about doubt and substantive Vyavahara – rules about doubt and substantive
lawlaw Prayascitta – penance for rules violationsPrayascitta – penance for rules violations
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Yogic Teachings from the Yogic Teachings from the HinduHindu
- surrender to the higher - surrender to the higher
beingbeing
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BuddhismBuddhism
““Any person who has awakened from Any person who has awakened from the ‘sleep of ignorance’ by directly the ‘sleep of ignorance’ by directly realizing the true nature of reality is realizing the true nature of reality is called a buddhacalled a buddhaSiddhartha Gautama, the Buddha, was Siddhartha Gautama, the Buddha, was the most notable the most notable Life is full of pain, the ultimate goal is to Life is full of pain, the ultimate goal is to break the cycle, become ‘enlightened’ break the cycle, become ‘enlightened’ and reach Nirvanaand reach NirvanaThus, one lives a holy life Thus, one lives a holy life
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Buddhism- Four Noble Buddhism- Four Noble TruthsTruths
The nature, cause and cessation of sufferingThe nature, cause and cessation of suffering
The way to cessation of suffering is the The way to cessation of suffering is the “The Eightfold Path,” foundation of ethics “The Eightfold Path,” foundation of ethics found in three divisions: bodily actions, found in three divisions: bodily actions, conscious thoughts and unconscious thoughtsconscious thoughts and unconscious thoughts
Right speech, actions and livelihood (do no Right speech, actions and livelihood (do no harm) harm)
Right effort/exercise to improveRight effort/exercise to improve
Right mindfulness/awareness – seeing clearlyRight mindfulness/awareness – seeing clearly
Right concentration -thoughts and understandingRight concentration -thoughts and understanding
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JudaismJudaism
Ten CommandmentsTen Commandments11
You shall have no other gods before MeYou shall not make for yourself an idolYou shall not make wrongful use of the name of your GodRemember the Sabbath and keep it holyHonor your parentsHonor your parentsYou shall not murderYou shall not murderYou shall not commit adulteryYou shall not commit adulteryYou shall not stealYou shall not stealYou shall not bear false witnessYou shall not bear false witnessYou shall not covet your neighbor's wifeYou shall not covet your neighbor's wifeYou shall not covet your neighbor's house...You shall not covet your neighbor's house...
11 Note: The Torah counts 613 “Commandments” Note: The Torah counts 613 “Commandments”ADPH, 2011
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ChristianityChristianity
Jesus said, “ I came not to abolish Jesus said, “ I came not to abolish the Law, but to fulfill it,” thus the Law, but to fulfill it,” thus reaffirming the right conduct of the reaffirming the right conduct of the Decalogue.Decalogue.
Jesus says “righteousness” must be internal, Jesus says “righteousness” must be internal, not external; conduct is more than negative, not external; conduct is more than negative, it places affirmative duties to actively do it places affirmative duties to actively do good even to those who harm you. good even to those who harm you.
The “Golden Rule” – “The “Golden Rule” – “Do unto others as you Do unto others as you would have them do unto you” or ”love thy would have them do unto you” or ”love thy neighbor as thyself.”neighbor as thyself.”
Summary: “Love God and love man.”Summary: “Love God and love man.”ADPH, 2011
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Christianity- per St. PaulChristianity- per St. Paul
The Apostle Paul says, to reach God, The Apostle Paul says, to reach God, one must be righteous, but man is not one must be righteous, but man is not righteous by nature, thus a spiritual righteous by nature, thus a spiritual dilemmadilemma
Paul tells us that it is by taking on the Paul tells us that it is by taking on the “mind of Christ” that we can be made “mind of Christ” that we can be made righteous and thus be “bridged” to righteous and thus be “bridged” to God.God.
Perdido Pass BridgeADPH, 2011
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IslamIslam
Mohammed saw a society on a Mohammed saw a society on a “slippery slope” to destruction with the “slippery slope” to destruction with the loss of traditional valuesloss of traditional values
Doctrine is based on four sources:Doctrine is based on four sources: the Qur'an, the Qur'an, the the sunnahsunnah (“traditions”) (“traditions”) ijma'ijma' (“consensus”) (“consensus”) ijtihadijtihad (“individual thought”) (“individual thought”)
Its chief goal is the establishment of a Its chief goal is the establishment of a “faithful” society by following the “faithful” society by following the “Straight Path”“Straight Path”
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Values Sought in the Values Sought in the Quer’anQuer’an
Values SoughtValues Sought Brotherhood in place of Brotherhood in place of
blood relationshipsblood relationships Fidelity and chastity in Fidelity and chastity in
place of indecencyplace of indecency HumilityHumility Charity towards widows, orphans and Charity towards widows, orphans and
poorpoor Justice to neighborsJustice to neighbors
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American Historical American Historical DocumentsDocuments
►Declaration of IndependenceDeclaration of Independence►United States ConstitutionUnited States Constitution
1776ADPH, 2011
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Declaration of Declaration of IndependenceIndependence
Mr. Jefferson’s Declaration:Mr. Jefferson’s Declaration:► Set forth the “self evident truth” Set forth the “self evident truth”
such as “equality”such as “equality”► Established an ethical basis for Established an ethical basis for
independenceindependence► What Locke applied to individuals, What Locke applied to individuals,
Jefferson applied to a Jefferson applied to a people – John people – John AdamsAdams
► Did not condemn the British Did not condemn the British peoplepeople
► Did Did not not address address African address address African slaveryslavery
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““Self-Evident” TruthsSelf-Evident” Truths
►““All men are created equal” (All men are created equal” (Really?)Really?)►Endowed by their CreatorEndowed by their Creator
LifeLife LibertyLiberty Pursuit of happinessPursuit of happiness
►Modern ComparisonsModern Comparisons Life becomes “human dignity’ in UN Life becomes “human dignity’ in UN
CharterCharter Life becomes “personal autonomy” in Life becomes “personal autonomy” in
Belmont ReportBelmont ReportADPH, 2011
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The Declaration’s The Declaration’s Purpose for GovernmentPurpose for Government
►““. . . To . . . To secure these rightssecure these rights, , governments are instituted among governments are instituted among men . . . men . . .
deriving their power from the deriving their power from the consentconsent of the governed . . .of the governed . . .
to effect their to effect their safety and happiness.”safety and happiness.”►As an institution of government, public As an institution of government, public
health has a role in health has a role in securing securing these these rightsrights
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United States United States ConstitutionConstitution
““We the People of the United States, in We the People of the United States, in Order to form a more perfect Union, Order to form a more perfect Union, establish Justice, insure domestic establish Justice, insure domestic Tranquility, provide for the common Tranquility, provide for the common Defense, promote the general Welfare , Defense, promote the general Welfare , and secure the Blessings of Liberty to and secure the Blessings of Liberty to ourselves and our posterity, do ordain ourselves and our posterity, do ordain and establish this Constitution for the and establish this Constitution for the United States of America.”United States of America.”
►““We, the People” – social contract theory We, the People” – social contract theory of government based in personal of government based in personal autonomyautonomy
►““Insure Domestic Tranquility” – peaceInsure Domestic Tranquility” – peace►““Promote the General Welfare” Promote the General Welfare”
– the sum of it all – the sum of it allADPH, 2011
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Summary of Personal Summary of Personal EthicsEthics
Right livingRight livingDo no harmDo no harmDo not lieDo not lieDo not stealDo not stealDo not hoardDo not hoardModerationModerationCleanlinessCleanlinessContentednesContentednesssPerseverancePerseveranceSelf-studySelf-studyHigher BeingHigher Being
Right SpeechRight SpeechRight ActionsRight ActionsRight livelihoodRight livelihoodRight effortRight effortEffort to ImprovementEffort to ImprovementRight mindfulnessRight mindfulnessAwarenessAwarenessRight Mental thoughtRight Mental thoughtNo gods/idols/swearingNo gods/idols/swearingSabbath keepingSabbath keepingHonor parentsHonor parentsDo not murderDo not murderDo not commit adulteryDo not commit adulteryDo not stealDo not stealDo not lieDo not lieDo not covet Do not covet
► The Hippocratic Oath and Medical EthicsThe Hippocratic Oath and Medical Ethics► Augustine’s “Just War”Augustine’s “Just War”► Nursing Ethics Nursing Ethics ► Ethics and EMSEthics and EMS► Ethics and PharmacistsEthics and Pharmacists► The Belmont Report and Institutional Review The Belmont Report and Institutional Review
BoardsBoards► The Public Health Code of EthicsThe Public Health Code of Ethics► Public Officer and Employee Ethics LawsPublic Officer and Employee Ethics Laws
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The Concept of DeathThe Concept of Death
Is the causing or allowing of Is the causing or allowing of death death always always ethically bad?ethically bad? Cain and AbelCain and Abel Instructions to wipe out the Instructions to wipe out the
people of Canaanpeople of Canaan Lex talionis, Lex talionis, cities of refugecities of refuge and and
the “Avenger of Blood”the “Avenger of Blood”
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Common Law Justifications Common Law Justifications for Causing Death for Causing Death
► State Sanctioned ExecutionState Sanctioned Execution► Defense of Self or AnotherDefense of Self or Another► Augustine’s “Just War”Augustine’s “Just War”
Lawful authorityLawful authority Defensive in natureDefensive in nature Proper motiveProper motive Carried out by legitimate governmentCarried out by legitimate government proportionalproportional
► Modern Rules of Warfare Modern Rules of Warfare – Geneva Conventions – Geneva Conventions
“Gitmo”ADPH, 2011
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Oath of Hippocrates – Oath of Hippocrates – Medical EthicsMedical Ethics
►““Primum non nocere” – first do no harmPrimum non nocere” – first do no harm►Always Always look to the good of the patientlook to the good of the patient►Place a high value on human lifePlace a high value on human life►Perform only within one’s training and skillPerform only within one’s training and skill►Refrain from improper relations with patientRefrain from improper relations with patient►Maintain patient’s secrets inviolateMaintain patient’s secrets inviolate►Do not violate community laws or moralsDo not violate community laws or morals
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Medical Ethics in a Medical Ethics in a DisasterDisaster
AMA Policy Statement E-9.067AMA Policy Statement E-9.067► There is a duty to provide urgent careThere is a duty to provide urgent care► The physician workforce is not unlimitedThe physician workforce is not unlimited► Therefore, balance is requiredTherefore, balance is required
Live to fight another dayLive to fight another day Are physicians required Are physicians required merely merely stay and not run stay and not run
awayaway Or to volunteer to come back in and help?Or to volunteer to come back in and help?
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Some Canadian Some Canadian ThoughtThought
► The ability of physicians and health care The ability of physicians and health care workers to provide care is greater than that of workers to provide care is greater than that of the public, thus increasing their obligation to the public, thus increasing their obligation to provide careprovide care
► By freely choosing a profession devoted to care By freely choosing a profession devoted to care for th ill, they assume risksfor th ill, they assume risks
► The profession has a social contract that calls on The profession has a social contract that calls on members to be available in times of emergencymembers to be available in times of emergency
► Equated with police officers and fire fightersEquated with police officers and fire fighters Note: They largely work in publicly supported systems Note: They largely work in publicly supported systems
in many countries (remember these are Canadians in many countries (remember these are Canadians writing this report.)writing this report.)
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Nurse’s Ethics in Providing Nurse’s Ethics in Providing CareCare
►Provide care in a Provide care in a “non-discriminatory manner“non-discriminatory manner
►There are limits to the amount There are limits to the amount of personal harm required to risk of personal harm required to risk
►Cannot abandon a patientCannot abandon a patient►Personal risk may depend on the Personal risk may depend on the
individual condition of the nurseindividual condition of the nurse►A “sacred duty”A “sacred duty”
American Nursing Association – December American Nursing Association – December 19941994
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Nurses Criteria for LimitsNurses Criteria for Limits
►The client is in significant risk of The client is in significant risk of harm . . . if the nurse does not assistharm . . . if the nurse does not assist
►The nurse’s intervention is directly The nurse’s intervention is directly relevant to prevent harm relevant to prevent harm
►The nurse’s care will probably prevent The nurse’s care will probably prevent harm. . . harm. . .
►The benefit the client will gain The benefit the client will gain outweighs any harm the nurse might outweighs any harm the nurse might incur and does not present more than incur and does not present more than an acceptable risk to the nursean acceptable risk to the nurse
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Ethics and EMSEthics and EMS
►EMS began about 1928 when Julien Stanley EMS began about 1928 when Julien Stanley Wise implemented the first rescue squad Wise implemented the first rescue squad (Roanoke Life Saving Crew) in Roanoke, VA. (Roanoke Life Saving Crew) in Roanoke, VA.
►Pre- WW II, hospital ambulancesPre- WW II, hospital ambulances►During WW II city ambulances run During WW II city ambulances run
by fire departmentby fire department►1969 - The Miami, FL Fire Department 1969 - The Miami, FL Fire Department
started the nation's first paramedic programstarted the nation's first paramedic program
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Then “EMERGENCY!” Then “EMERGENCY!” DebutedDebuted
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EMS Ethical PrinciplesEMS Ethical Principles► Fundamental responsibility-conserve life, Fundamental responsibility-conserve life,
alleviate suffering, promote health, do not alleviate suffering, promote health, do not harmharm
► Respect human dignity w/o regard to statusRespect human dignity w/o regard to status► Never harm the public well beingNever harm the public well being► Be a good citizen and work well with othersBe a good citizen and work well with others► Assume responsibility for individual actionsAssume responsibility for individual actions► Maintain confidencesMaintain confidences► Do not delegate to a less qualified personDo not delegate to a less qualified person► Expose incompetence of others ethicallyExpose incompetence of others ethically► Advertise ethicallyAdvertise ethically
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Researchers EthicsResearchers Ethics
► The Tuskegee Experiment – “Bad Blood” The Tuskegee Experiment – “Bad Blood” ► Tuskegee by the numbers:Tuskegee by the numbers:
600 men in the study600 men in the study 399 infected with syphilis and untreated399 infected with syphilis and untreated 201 without syphilis201 without syphilis 100 dead of causes “related to” syphilis100 dead of causes “related to” syphilis 74 men survived74 men survived 40 wives contracted syphilis40 wives contracted syphilis 19 children born with congenital syphilis19 children born with congenital syphilis 9,000,000 dollars paid out in direct damages9,000,000 dollars paid out in direct damages 1 good result – The Belmont Commission1 good result – The Belmont Commission
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The Belmont Commission The Belmont Commission Studied:Studied:
► The boundaries between biomedical and The boundaries between biomedical and behavioral research and the accepted and behavioral research and the accepted and routine practice of medicine, routine practice of medicine,
► The role of assessment of risk-benefit criteria The role of assessment of risk-benefit criteria in the determination of the appropriateness in the determination of the appropriateness of research involving human subjects, of research involving human subjects,
► Appropriate guidelines for the selection of Appropriate guidelines for the selection of human subjects for participation in such human subjects for participation in such research and research and
► The nature and definition of informed The nature and definition of informed consent in various research settings consent in various research settings
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Other International WorksOther International Works► Nuremberg Code – Nuremberg Code – ex post facto ex post facto guidance to guidance to
judge WWII Nazi war criminalsjudge WWII Nazi war criminals Boundaries between research Boundaries between research
and practiceand practice Ethical researchEthical research Ethical practiceEthical practice
► Declaration of Helsinki (1964)Declaration of Helsinki (1964) Informed consent as the ethical standard Informed consent as the ethical standard ““Surrogate” consent defined and allowedSurrogate” consent defined and allowed Research should only be performed when “necessary Research should only be performed when “necessary
to promote the health of the population represented” to promote the health of the population represented” Laid the foundation for the establishment of IRBs Laid the foundation for the establishment of IRBs
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The “Common Rule” The “Common Rule” (Based on the Belmont (Based on the Belmont
Report)Report)►Established boundaries between Established boundaries between
research and practiceresearch and practice►Defined ethical practice based on Defined ethical practice based on
three principles to include:three principles to include: Respect for personsRespect for persons BeneficenceBeneficence JusticeJustice
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Respect for PersonsRespect for Persons
►People are treated as autonomous People are treated as autonomous agentsagents
►Protection for those of diminished Protection for those of diminished capacitycapacity
► Informed consent definedInformed consent defined►Period reviews of status of subjects Period reviews of status of subjects
requiredrequired
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BeneficenceBeneficence
►Look out for the “broader good” Look out for the “broader good” of the subject of the subject
►Do no harmDo no harm►Does it actually do some good?Does it actually do some good?►Balance the risks against the benefitsBalance the risks against the benefits
“Beneficence” – Ball State University
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JusticeJustice► Applies the allocation of risk or Applies the allocation of risk or
burden to benefit to the subject burden to benefit to the subject and to the proposed benefited populationand to the proposed benefited population Are these welfare patients, Are these welfare patients, from a particular socio-economic or ethic background, from a particular socio-economic or ethic background, confined populations such as prisoners confined populations such as prisoners
► Formulations for distributing benefits and Formulations for distributing benefits and burdens: burdens: to each person an equal share, to each person an equal share, to each person according to his or her need, to each person according to his or her need, to each person according to societal contributions to each person according to societal contributions
past and future past and future to each person according to (perceived) merit to each person according to (perceived) merit
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ApplicationApplication
► Informed, knowing consentInformed, knowing consent►Detailed risk analysis with varied Detailed risk analysis with varied
elementselements physical, physical, psychological, psychological, legal, legal, social social economiceconomic
►Detailed and fair subject selection criteriaDetailed and fair subject selection criteriaADPH, 2011
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Public Officer and Employee Public Officer and Employee Ethics lawsEthics laws
No public official or public employee shall use or No public official or public employee shall use or cause to be used his or her official position or office cause to be used his or her official position or office to obtain personal gain for himself or herself, or to obtain personal gain for himself or herself, or family member of the public employee or family family member of the public employee or family member of the public official, or any business with member of the public official, or any business with which the person is associated unless the use and which the person is associated unless the use and gain are otherwise specifically authorized by law. gain are otherwise specifically authorized by law. Personal gain is achieved when the public official, Personal gain is achieved when the public official, public employee, or a family member thereof public employee, or a family member thereof receives, obtains, exerts control over, or otherwise receives, obtains, exerts control over, or otherwise converts to personal use the object constituting converts to personal use the object constituting such personal gainsuch personal gain Code of Ala.1975Code of Ala.1975, § 36-25-5 , § 36-25-5
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Nature and Scope Nature and Scope of Public Ethics Lawsof Public Ethics Laws
►Very narrowly Very narrowly constructed constructed and construedand construed
►Contrasted with the Contrasted with the broad sweep of broad sweep of professional codesprofessional codes
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Summary – Professional Summary – Professional EthicsEthics
► Death Death acceptableacceptableDo no harmDo no harmPatient firstPatient firstValue on lifeValue on lifeProper Proper relationsrelationsConfidentialityConfidentialityFollow law & Follow law & moralsmoralsDuty to careDuty to careBalanceBalance
Use Use InformationInformationTimelinessTimelinessDiversityDiversityConfidentialityConfidentialityCollaborationCollaborationCompetenceCompetencePublic trustPublic trustInterdependenInterdependen
ceceNot abuse Not abuse
public positionpublic position
Not Not discriminatediscriminateNot abandonNot abandon““Sacred duty”Sacred duty”
-The Eye of the Storm--The Eye of the Storm-What Really Happens in a What Really Happens in a
DisasterDisaster
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So, what really happens?So, what really happens?
► How do people’s relationships change? How do people’s relationships change? ► Do people think and react differently?Do people think and react differently?► Are the consequences the same as if you Are the consequences the same as if you
had reacted “in the sunshine?”had reacted “in the sunshine?”► The “Outback Steakhouse Question,” are The “Outback Steakhouse Question,” are
there really “no rules?”there really “no rules?”► How can you “rank” people in order or How can you “rank” people in order or
precedence to receive vaccine, ventilators precedence to receive vaccine, ventilators or treatment according to ethical principles?or treatment according to ethical principles?
► Can you invoke “altered standards of care?Can you invoke “altered standards of care?► What are the rights of staff to desert?What are the rights of staff to desert?
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Effects on Victims Effects on Victims and and StaffStaff
Psychological, physiological and physiological Psychological, physiological and physiological Symptoms: Symptoms:
► Irritability or anger, blaming or denial, mood swings, Irritability or anger, blaming or denial, mood swings, fear of recurrence, hyperactivity, feeling stunned, fear of recurrence, hyperactivity, feeling stunned, helpless, numb, or overwhelmed; helpless, numb, or overwhelmed;
► Loss of appetite and energy, headaches, chest pain, Loss of appetite and energy, headaches, chest pain, and fatigue; and fatigue;
► Increase in alcohol or drug consumption; Increase in alcohol or drug consumption; ► Nightmares and inability to sleep; Nightmares and inability to sleep; ► Concentration and memory problems; Concentration and memory problems; ► Sadness, depression and grief; Sadness, depression and grief; All leading to BAD CHOICESAll leading to BAD CHOICES
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Are there Really No RulesAre there Really No Rules
?
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EuthanasiaEuthanasia
► Is euthanasia Is euthanasia everever an option for an option for suffering victims?suffering victims?
►What is it?What is it?►Assuming the answer is “yes,” How Assuming the answer is “yes,” How
would would you you justify it?justify it?► Is it a fair balance between individual Is it a fair balance between individual
rights and the rights of society?rights and the rights of society?
Dr. Kevorkian
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A Seminal Case – A Seminal Case – Jacobson v. Jacobson v.
Massachusetts Massachusetts ►FactsFacts
Rev. Jacobson refused to be vaccinated Rev. Jacobson refused to be vaccinated against smallpox in Cambridge, MA.against smallpox in Cambridge, MA.
Fined $5.00 and appealed to the United Fined $5.00 and appealed to the United States Supreme Court.States Supreme Court.
►Question presented for review:Question presented for review: What are the limits of how far the state What are the limits of how far the state
can go to protect the public health?can go to protect the public health?
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Summary of the HoldingSummary of the Holding
The Court found this a The Court found this a legitimate use of legitimate use of state powers and state powers and established a floor of established a floor of constitutional constitutional protections that protections that consists of four consists of four standards: standards:
Are the secured rights Are the secured rights “fundamental?”“fundamental?”►If “no,” the state If “no,” the state may impose limits may impose limits “reasonably related to “reasonably related to a legitimate state a legitimate state interest”interest”►If “yes,” the rights If “yes,” the rights cannot legally be cannot legally be violatedviolated
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This brings up the question of This brings up the question of “No”“No”
Authorities, citing the experience at Authorities, citing the experience at Memorial Hospital in New Orleans – short Memorial Hospital in New Orleans – short of a pandemic – your worst case scenario of a pandemic – your worst case scenario and Supreme Court authority . . .and Supreme Court authority . . .
►Advises that in the question of whether Advises that in the question of whether euthanasia is an option, the answer is euthanasia is an option, the answer is “no,”“no,”
►Euthanasia is Euthanasia is nevernever an option an option
((Unless it is the end of the world as we know Unless it is the end of the world as we know
it and it doesn’t matter it and it doesn’t matter))“The Big Bang”ADPH, 2011
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Let’s Just Let them Eat Cake*Let’s Just Let them Eat Cake*
OK, so we can’t “depopulate” the OK, so we can’t “depopulate” the victims, can we just let them die – a victims, can we just let them die – a philosophical interlude: Utilitarianism philosophical interlude: Utilitarianism vs. Egalitarianismvs. Egalitarianism
* * Quote from Marie Antoinette Quote from Marie Antoinette some time before her executionsome time before her execution..
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Utilitarianism vs. Utilitarianism vs. EgalitarianismEgalitarianism
► Jeremy Bentham’s theory of Jeremy Bentham’s theory of utilitarianism what is right or utilitarianism what is right or good based on whether the good based on whether the consequences will be goodconsequences will be good
► Immanuel Kant’s egalitarianism Immanuel Kant’s egalitarianism theory focuses on non-theory focuses on non-consequentially based notions of consequentially based notions of good - deciding what is right or good - deciding what is right or good is based on meeting duties good is based on meeting duties and obligationsand obligations
► These contradistinguished ideas These contradistinguished ideas will clash over and overwill clash over and over
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History of TriageHistory of Triage
► TriageTriage, (, (to sort out) , to sort out) , a French military medical a French military medical term based on the utilitarian principles term based on the utilitarian principles the most good for the most people the most good for the most people
► Adapted to modern military Adapted to modern military and civilian and civilian medicinemedicine► Originally, triage grouped casualties into four Originally, triage grouped casualties into four
groups based on care needed: immediate, minimal, groups based on care needed: immediate, minimal, delayed, expectant. delayed, expectant.
► Use must be done without regard to rank, age, Use must be done without regard to rank, age, race, social worth or income or such distinctionrace, social worth or income or such distinction
► Not based on the social worth of individual, Not based on the social worth of individual, but on societal need but on societal need
Baron Larrey, Father of Triage
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Modern Disaster TriageModern Disaster Triage
► In disasters there is a switch In disasters there is a switch from standard medical ethics from standard medical ethics with the primary focus on with the primary focus on Individual autonomyIndividual autonomy to an ethics of to an ethics of public health with a primary focus on public health with a primary focus on the the health of the communityhealth of the community
►The overarching goal is to The overarching goal is to minimize minimize morbidity and mortality during the morbidity and mortality during the pandemicpandemic (according to CDC) (according to CDC)
►Will it be Will it be most goodmost good or or greatest needgreatest need??ADPH, 2011
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Utilitarianism Says:Utilitarianism Says:
►The goal is to help those for whom you The goal is to help those for whom you can do the can do the most most good following the long-good following the long-established standard in military medicine established standard in military medicine
►Advantages: follows a clear, simple, Advantages: follows a clear, simple, community-recognized goal in a community-recognized goal in a potentially chaotic environmentpotentially chaotic environment
►Disadvantages: situations will arise with Disadvantages: situations will arise with no clear utility-based answer that may no clear utility-based answer that may lead to “unintended, insidious lead to “unintended, insidious discrimination” discrimination”
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Egalitarianism Says:Egalitarianism Says:
►Goal: to help those in Goal: to help those in greatest greatest needneed
►Ranks patients based on severity Ranks patients based on severity of illness, with patients in the most of illness, with patients in the most severe condition receiving the severe condition receiving the medical attentionmedical attention
►The ultimate goal such as limiting The ultimate goal such as limiting morbidity and mortality during the morbidity and mortality during the pandemic is pandemic is de-prioritizedde-prioritized in order in order to preserve the egalitarian to preserve the egalitarian principles principles “It’s all about the process” –
Saban, 2008 Coach of the Year
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Hybrid TriageHybrid Triage
►Uses both conceptsUses both concepts Utilitarian approachUtilitarian approach Egalitarian methodsEgalitarian methods
►Requires sorting out into 3-4 groupsRequires sorting out into 3-4 groups►Treat those in the group before going Treat those in the group before going
to the next lower groupto the next lower group
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Examples of MethodsExamples of Methods
► CERT training advises four groupsCERT training advises four groups► SOFA’s four level sorting is based on organ SOFA’s four level sorting is based on organ
failurefailure► Current EMS (START) model has four levelsCurrent EMS (START) model has four levels► Hospital Emergency Department – five levelsHospital Emergency Department – five levels► Canadian and Alabama Method – four levelsCanadian and Alabama Method – four levels
►Engage the public in the discussionEngage the public in the discussion►An experienced triage officerAn experienced triage officer
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Altered Standards of CareAltered Standards of Care
When it permissible from an ethical and When it permissible from an ethical and legal standpoint to provide less than legal standpoint to provide less than the care normally pr traditionally the care normally pr traditionally expected or held to be what is referred expected or held to be what is referred to in both the medical and legal to in both the medical and legal professions as the “standard of care”?professions as the “standard of care”?
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Goals of Altered Goals of Altered StandardsStandards
►Maximize the number of lives saved. Maximize the number of lives saved. ►Changes necessary to allocate resources Changes necessary to allocate resources ►Basis for allocation - fair and clinically Basis for allocation - fair and clinically
sound sound ►Process for decisions - transparent and Process for decisions - transparent and
fair fair ►Protocols flexible and “scalable”Protocols flexible and “scalable”►Staff concerns addressed pre-event Staff concerns addressed pre-event
Goal!
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Focus Change in Altered Focus Change in Altered StandardsStandards
►Critical : Critical : Focus Changes from Focus Changes from doing to best for each patient doing to best for each patient to maximizing the most lives saved to maximizing the most lives saved
►The The systemsystem becomes the pt. becomes the pt.►Affect current patients already in hospital Affect current patients already in hospital ►The scope of practice changesThe scope of practice changes►Equipment, meds and supplies rationedEquipment, meds and supplies rationed►Record-keeping changes Record-keeping changes
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Ethical ConsiderationsEthical Considerations
► KeepKeep the health care system functioning the health care system functioning and and deliver “acceptable” quality of care to deliver “acceptable” quality of care to preserve as many lives as possiblepreserve as many lives as possible
► The plan must be community wideThe plan must be community wide► There must be an adequate legal framework There must be an adequate legal framework
to allow for the altered standards of careto allow for the altered standards of care► The rights of individuals must be protected The rights of individuals must be protected
to the extent possible and reasonable under to the extent possible and reasonable under the circumstancesthe circumstances
► The public must be informed on planning The public must be informed on planning and decision making pre, during and post and decision making pre, during and post event event
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Legal Concerns of Altered Legal Concerns of Altered StandardsStandards
How to make it legal:How to make it legal:►Change the laws at federal Change the laws at federal
and state levels directlyand state levels directly►Change laws to allow for regulatory Change laws to allow for regulatory
for the Governor to sign in an event for the Governor to sign in an event invoking the altered standards of careinvoking the altered standards of care
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CDC’s Plan for Rationing CDC’s Plan for Rationing VaccineVaccine
►CDC scares us with their predictionsCDC scares us with their predictions►The system of manufacturing vaccine The system of manufacturing vaccine
is old and tiredis old and tired►CDC has devised priority groups with CDC has devised priority groups with
subgroupssubgroups Health care workersHealth care workers Public service workersPublic service workers High risk populationsHigh risk populations
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Ethical Look at the CDC Plan Ethical Look at the CDC Plan
►A hybrid systemA hybrid system Utilitarian goalUtilitarian goal Egalitarian executionEgalitarian execution
►Allows local input should they Allows local input should they wantwant inputinput
►Buck-passing and the failure to plan will Buck-passing and the failure to plan will be a catastrophic ethical failurebe a catastrophic ethical failure
►Ethical Issues: fairness and equity, Ethical Issues: fairness and equity, reciprocity and flexibilityreciprocity and flexibility
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Rationing VentilatorsRationing Ventilators
► Alabama plan to be triggered by Alabama plan to be triggered by declarations by government or activation of declarations by government or activation of the National PI Plan the National PI Plan
► Three tiers based on respiratory failureThree tiers based on respiratory failure Withhold ventilators starting with Tier 1Withhold ventilators starting with Tier 1 WithdrawWithdraw ventilators starting with Tiers 2 and 3 ventilators starting with Tiers 2 and 3
► What would St. Augustine say?What would St. Augustine say?► The same discussion applies to all such The same discussion applies to all such
allocations of medicines, supplies or allocations of medicines, supplies or equipmentequipment
► Plan written at State level, our Plan written at State level, our “day job”“day job”
► Partnership with Hospital Partnership with Hospital AssociationAssociation
► Added to the State EOP Added to the State EOP ► Invoked by Governor’s orderInvoked by Governor’s order► Grants immunity to Grants immunity to
professionalsprofessionals► Legislation would be “surer” – Legislation would be “surer” –
New York New York
1971 Triumph Spitfire –Top Down
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More Help from Canada -More Help from Canada -An Ethical GuideAn Ethical Guide
Based on Toronto’s SARS experience, “Stand Based on Toronto’s SARS experience, “Stand On Guard for Thee” offers an Ethical guide On Guard for Thee” offers an Ethical guide in mass events dealing with issues:in mass events dealing with issues:
►Individual liberty Individual liberty ►Protection of the publicProtection of the public►ProportionalityProportionality►PrivacyPrivacy►Duty to Provide CareDuty to Provide Care
what are my obligations to me and my what are my obligations to me and my family?family?
►Professional dilemmas – conflicting Professional dilemmas – conflicting ethical principlesethical principles Autonomy vs. non-maleficenceAutonomy vs. non-maleficence Autonomy vs. beneficenceAutonomy vs. beneficence Autonomy vs. justiceAutonomy vs. justice
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The Problem Won’t Go The Problem Won’t Go AwayAway
► If you don’t come to work, If you don’t come to work, the problem doesn’t go away the problem doesn’t go away
► In fact, the problem only gets worse In fact, the problem only gets worse ►Every employee will make a difference Every employee will make a difference
by contributing his or her part by contributing his or her part ►All employees must ask themselves, ‘If All employees must ask themselves, ‘If
I don’t work in times of crisis, then I don’t work in times of crisis, then who will?’who will?’
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A SuggestionA Suggestion
►Take a deep breathTake a deep breath►Look for the balanceLook for the balance►Remember John’s principle of Remember John’s principle of
living outside yourself based on the living outside yourself based on the truth within yourselftruth within yourself (This assumes you (This assumes you know know the truth) the truth)
►Planners and facility administrators Planners and facility administrators must “think outside the box” – but must “think outside the box” – but do it do it nownow
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Exercise - Exercise - The Kobayashi The Kobayashi MaruMaru
In the Star Trek fictional universe, In the Star Trek fictional universe, the the Kobayashi MaruKobayashi Maru is a starship is a starship that serves as the subject of a that serves as the subject of a graded training exercise at graded training exercise at Starfleet Academy. Starfleet Academy.
The term The term Kobayashi MaruKobayashi Maru is a is a
shorthand for no-win scenarios.shorthand for no-win scenarios.
Questions presented by the exercise:Questions presented by the exercise:►Given the scare resources, who gets Given the scare resources, who gets what resources?what resources?►Who decides who gets what resources?Who decides who gets what resources?►What is your rationale for your decision?What is your rationale for your decision?
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John’s Five Action Principles
►To tell the truth, the whole To tell the truth, the whole truth and nothing but the truth and nothing but the truthtruth
►““We’ll Sing in the Sunshine”We’ll Sing in the Sunshine”►Casper the Friendly GhostCasper the Friendly Ghost► It’s not about meIt’s not about me►The “Nike Principle.”The “Nike Principle.”
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EpilogueEpilogueThe Eagle soars above the din, The Eagle soars above the din, of mankind's rushing out and in,of mankind's rushing out and in,And lesser creatures left to spin,And lesser creatures left to spin,The Eagle soars from deep within.The Eagle soars from deep within. His course is true as gaffer's pike, His course is true as gaffer's pike, His keen eye pierces like a spike,His keen eye pierces like a spike,His quest surrounds him like a dike,His quest surrounds him like a dike,The Eagle soars, but phantomlike.The Eagle soars, but phantomlike. Those who on the Earth have stood, Those who on the Earth have stood, Thinking that they never could,Thinking that they never could,Nor many even perhaps should ... but,Nor many even perhaps should ... but, The Eagle soars because he would. The Eagle soars because he would. - John R. Wible, 1981- John R. Wible, 1981
