- FROM BIOETHICS BRIEFINGS
Disaster Planning and Public HealthDownload as PDF
Framing the Issue
September 11th, Hurricane Katrina, avian flu, global climate change—a list such as this serves as a stark reminder of society’s vulnerability to a public health disaster and the need for emergency preparedness planning. Today, concerted attention is being paid to public health preparedness both at the federal level and in virtually every state and county in the country. Priority setting, rationing, and triage are being contemplated; coercive measures that will override individual liberty and property rights are being orchestrated. And yet little, if any, explicit attention is being paid to the complex ethical and social values that are involved in such planning and in the aftermath of a crisis. A recent review of federal and state influenza pandemic plans by James C. Thomas, Nabarun Dasgupta, and Amanda Martinot showed that with few exceptions, there is no explicit reference to ethical issues and concepts in these documents.
Emergency Planning Comes to the Fore
The threat of sudden disruption in the health care system and serious danger to life and health on a large scale seized the attention of the public health community (and the nation) in the 1990s due to the threat of terrorism, spurred by the bombings in a parking garage at the World Trade Center and at the federal office building in Oklahoma City and a poison gas release in the Tokyo subway system. Congress responded by passing legislation that established a domestic preparedness program and broadened the mandate of the Federal Emergency Management Agency (FEMA) to include attacks by weapons of mass destruction as well as natural disasters. In 1998, the Centers for Disease Control and Prevention (CDC) established the Bioterrorism Preparedness and Response Program, which improved laboratory, surveillance, and emergency response communication capabilities. In addition, in this same year, CDC was authorized by Congress to establish a national stockpile of pharmaceuticals and vaccines. Nonetheless, in 2000 and early 2001, simulation exercises revealed many remaining shortcomings in emergency preparedness and the ability to respond, including poor interagency and intergovernmental communication and coordination, a lack of local planning, and inadequate surge capacity—that is, the ability of medical services and facilities to respond to a large, sudden influx of patients.
Needless to say, such concerns increased exponentially in the aftermath of the terrorist attacks of September 11, 2001, and the use of anthrax as a means of bioterrorism shortly thereafter. After Hurricane Katrina and the flooding of New Orleans and other areas of the Gulf Coast, and amid concerns about pandemic influenza and other infectious diseases, public health preparedness has shifted from bioterrorism to an all-hazards approach and orientation. This approach is now recognized as being central to the public health mission and has been a focal point of a massive infusion of funding, manpower, training, and other resources during the last several years at the federal, state, and local levels.
The Elements of Public Health Emergency Preparedness
Public health emergency preparedness and response has been defined by Christopher Nelson and others (see box, “Resources”) as “the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.” Public health preparedness planning is a multidisciplinary endeavor that draws on traditional public health expertise as well as the experience and skills of the social and behavioral sciences, risk communication, architecture and planning, environmental science, engineering, and public safety.
Public health planners must work together with those responsible for disaster management who come from other fields—such as law enforcement and the military—and must negotiate a complicated web of jurisdictional, bureaucratic, and organizational interests and boundaries. Emergency planning and response must recognize the legal implications of its functions, and it must work effectively with policymakers, elected officials, the business community, civic leaders. and the press. It must operate in such a way as to maintain the confidence and trust of the public. Public health preparedness activities include:
- regulating environmental conditions and food and water safety to minimize disease threats
- planning for emergency medical and public health response capabilities
- detecting a disease outbreak
- conducting epidemiological investigations to ascertain the nature of a disease epidemic
- performing laboratory analyses to support surveillance and epidemiology
- pursuing public health interventions to limit the spread of disease
- assuring the provision of emergency medical treatment and prophylaxis
- remediating environmental conditions
- presenting secondary public health emergencies following
The Ethics Behind Public Health Emergencies
Emergency planning and response requires ethical analysis at several levels. First, public health preparedness clearly has fundamentally important ethical goals, including protecting life and health, respecting human rights, promoting social justice, and building civic capacity so that communities will be resilient in their response and recovery from disasters (see box, “Ethical Goals of Public Health Emergency Preparedness”). These goals must be clearly articulated and understood, both because widespread public recognition and acceptance is important to the practical success of any preparedness effort and because these goals are difficult to prioritize in a systematic way and may give rise to practical ethical dilemmas when they conflict.
Moreover, emergency preparedness planning requires ethical analysis and scrutiny because it is an activity conducted under the auspices of the state that involves the use of power, and potentially the use of coercion. It has an impact, not only on the health and safety of individuals, but also on their liberty, autonomy, civil and human rights, property, and other fundamental interests. In addition to using power, emergency preparedness planning is inherently prone to paternalism, since one of its basic missions is to tell people how to behave during an emergency so as to promote their own best interests.
Our culture generally—and the field of bioethics in particular—has strongly antipaternalistic currents within it. Americans value individual freedom of choice and self-reliance. They are suspicious of authority, not deferential to it or cowed by it. Within the last generation, the American public has come to the point where they no longer believe that “father knows best,” much less that doctor knows best, and even less that health commissioner knows best. Many Americans question the competency or efficiency of any enterprise associated with government.
Nonetheless, when their community is threatened, even people in our privacy-oriented and individualistic culture will volunteer, feel a sense of solidarity, and make sacrifices for the common good. This was the experience of the World War II generation, and it was demonstrated again for a time after 9/11. Public engagement activities dealing with community mitigation interventions—such as so-called social distancing plans that call for people to remain in their own homes, for school closures, and for the prohibition of mass gatherings—have indicated that there is a willingness at the grassroots level to forgo or temporarily suspend some ordinary civil liberties and freedoms in the face of a pandemic.
However, our culture’s individualism—reinforced by ethical systems that stress autonomy, rights, and civil liberties—will have an impact both on the planning phase of public health preparedness and on the recovery phase. In the planning phase, inherently paternalistic directives must be fully explained and justified. Indeed, if the planning and its directives are deliberative, transparent, and publicly justified, emergency preparedness can actually turn into a kind of social contract to which the citizens have given free informed consent. That notion suggests an important theme—namely, that the ethical acceptability of an emergency plan is a function both of its substantive content (what it tells people to do and what the consequences of that are) and of the process through which that content is discussed, formulated, argued about, and ultimately agreed to.
In the aftermath of an emergency or disaster event, experience shows that solidarity and self-sacrifice often give way to disillusionment, recrimination, and even litigation. To mitigate this, it is important to take a “who watches the guardians” approach through ongoing monitoring of the use of authority and power during the implementation of emergency plans. This is to ensure that power and authority are not abused and that paternalistic or coercive measures are justified under the circumstances. This can be accomplished in several ways: by having multiple authorities involved in the emergency response (including federal, state, and local public health officials, law enforcement officials, and elected officials), through the continued role of the press, and through recourse to the courts for relief if government officials exceed or abuse their authority. It is also important to have ongoing and ex–post facto evaluation and assessment to gauge the effectiveness of emergency plans, to learn from mistakes, and to make improvements for the future.
Ethical Goals of Public Health Emergency Preparedness and Response
Hastings Center Fellows John Arras and Bruce Jennings are currently at work on a study of ethical issues in public health emergency preparedness and response. They have formulated seven ethical goals designed to inform both the content of preparedness plans and the process by which they are devised, updated, and implemented in an emergency situation and its aftermath.
- Harm reduction and benefit promotion that protect public safety, health, and well-being. Public health emergency preparedness planning and response activities should protect public safety, health, and well-being. They should minimize the extent of death, injury, disease, disability, and suffering during and after an emergency.
- Equal liberty and human rights. Preparedness and response activities should be designed so as to respect the equal liberty, autonomy, and dignity of all persons.
- Distributive justice. Preparedness and response activities should be conducted so as to ensure that the benefits and burdens imposed on the population by the emergency and by the need to cope with its effects are shared uniformly and fairly.
- Public accountability. Preparedness and response activities should be based on and incorporate decision-making processes that are inclusive and transparent and that sustain public trust.
- Development of strong as well as safe communities. Preparedness and response activities should strive as a long-term goal to develop hazard-resistant and resilient communities. These are communities with robust internal support systems and networks of mutual assistance and solidarity. They are also communities that maintain sustainable and risk mitigating relationships with their local ecosystems and their natural environment.
Public health professionalism. Preparedness and response activities should recognize the special obligations of some public health professionals and promote their competency, as well as coordination among them.
Responsible civic response. Preparedness and response activities should promote a sense of personal responsibility and citizenship.
The Next Generation of Preparedness Planning
Ethical analysis in public health preparedness planning—by its very nature an ongoing activity—will help engage the public when hard decisions must be made. Emergency plans and mitigation activities should have clearly defined, widely understood, and realistic goals that are reached by consensus. These goals should be pursued and implemented as effectively as possible given existing resources and information. Ineffective, unduly burdensome, and wasteful policies and practices are not ethically justified.
Officials and planners should attempt to identify in advance the known or potential burdens of the mitigation activity and the segments of the population upon whom those burdens are likely to fall. Moreover, planners and policymakers should attempt to minimize these burdens. They should consider alternative approaches to achieve the same goals, and they should avoid imposing undue burden on groups unfairly or inequitably.
Fairness should be a feature not only of the outcome of any mitigation activity but also of the way in which it is conducted. Planners should attempt to balance the public health benefits of the mitigation activity with the accompanying social, economic, and personal burdens it causes.
Finally, public trust is key to the success of any emergency planning, and public engagement is one important way to secure and sustain public trust. Planning processes should be transparent, and multiple venues for deliberative citizen participation should be provided. Meaningful two-way communication is essential, from the bottom up as well as from the top down. Deliberative planning that is broadly inclusive and participatory is not only the most effective means for creating well-informed and successful emergency plans, it will also strengthen the ethical fabric of the very open, pluralistic society we seek to protect.
Bruce Jennings, MA, a Hastings Center Fellow, directs the Center for Humans and Nature.
Bruce Jennings, “Disaster Planning and Public Health,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008), 41-44.