- FROM BIOETHICS BRIEFINGS
Disaster Planning and Public Health
Framing the Issue
Disasters happen. Coping with them and recovering and rebuilding afterward are nothing new. Systematic, evidence-based advance planning and preparedness are more novel, however, and seeing disasters as fundamental matters of public health, in addition to matters of public safety, is a recent development with important ethical challenges and implications.
In the United States, emergency or disaster preparedness took on a special urgency in the wake of the attacks on September 11, 2001, and the attacks using weaponized anthrax a short time later. From an initial focus on bioterrorism, emergency preparedness soon shifted to an “all-hazards” approach in recognition that contemporary populations were vulnerable to many different types of insults that cause severe social disruption and threaten human life and health on a large scale. Since then, there have been many occasions around the world to call upon public health emergency preparedness and response and to face the ethical dilemmas that accompany it—such as the hard lessons learned in the devastating earthquake in Haiti in 2010, the flooding and damage to Fukushima Daiichi nuclear reactor in Japan in 2011 that resulted in severe radiation, Hurricane Sandy in the New York city metropolitan area in 2013, and the serious Ebola 2014 outbreak in West Africa in 2014.
Additional public health challenges loom on the horizon, including new strains of pandemic influenza and other infectious diseases and the prospect of long-term climate change with its multiple threats to public health and well-being—including fatal heat waves; intensifying violent storms and flooding, sea level rise and the contamination of fresh water supplies, drought, malnutrition, the spread of zoonotic disease, aggravation of chronic conditions such as allergies and pulmonary disease, and large-scale human migration with attendant sanitation and epidemic side-effects.
The Learning Curve of Emergency Preparedness and Response
A public health emergency exists when the ordinary health service capabilities of a community are overwhelmed by an extreme situation or event. Emergency preparedness is that aspect of public health designed to ensure sustained public health and medical readiness in the event of an emergency, minimize the impact of emergencies on affected communities, and foster safe and healthful environments before, during, and after an emergency.
In 2006 Congress enacted the Pandemic and All-Hazards Preparedness Act (PAHPA) and it was reauthorized in 2013. In general it attempted to coordinate and streamline emergency response at the federal level and to work effectively to support emergency planning and preparedness at state and local levels. It also sought to enhance the capacity of the health care system to respond quickly and effectively. Reflected in that legislation was the expanding and evolving understanding of the challenge of public health generally and both the virtual inevitability of disaster and emergency events and the necessity of building resilient health care and social systems to endure and recover from them.
Emergency preparedness encompasses more than adequate equipment, deployment of health professionals, training, and supplies. It also involves community engagement and participation from the outset of the pre-emergency planning process. Emergency plans drawn up behind closed doors are not sufficient. A much more elaborate and ongoing process of community asset and needs assessment, stakeholder participation, and public awareness and engagement is required. Public trust and confidence are essential in emergency preparedness, and public health decision-making will be most effective generally when it is transparent and has direct links to the communities it serves.
An additional point of consensus in the field today is that emergency preparedness should not be separated unduly from the nonemergency concerns of public health policy and capacity. A well-prepared community is a community in which the population is medically well-served, a strong public health infrastructure is in place, and community-based public health services are robust and well- integrated into everyday life.
Ethical Questions Posed by Public Health Emergencies
Emergency preparedness requires ethical analysis at several different levels. It clearly involves a clinical component and thus professional health care ethics with its emphasis on patients’ rights and well-being and professional fiduciary obligations. In addition, this area involves public health and the intersection between the health and safety of populations and of individuals.
There are several core ethical problems in the domain of emergency preparedness. For example, since it involves state action to control individual behavior, one key issue is the problem of justifying limitations on the liberty of individuals and groups. The complex ethical and social values invoked when coercive measures are included in an emergency plan should be examined before such measures are implemented.
In addition, since emergencies often involve scarce personnel and resources, another issue concerns distributive justice, the allocation of scarce resources, rationing, and triage. Examples are the allocation of vaccines and medications during an influenza pandemic and of mechanical ventilators during an outbreak of acute respiratory disease. Several studies have proposed ethical frameworks and principles to address the triage and allocation of scarce resources issues.
A third major issue concerns accommodating people with special needs and vulnerabilities. Public officials and emergency planners should attempt to identify in advance the potential burdens of emergency preparedness and response measures and take steps to mitigate undue burdens on particular segments of the population through, for example, the provision of special resources and compensation.
Finally, there are a number of ethical issues that pertain to the planning, communication, and coordination process of emergency preparedness. These process and policy issues contain many ethical assumptions that are often implicit, and many consequences that are of ethical concern, both to the types of issue listed above and to the question of legitimacy and trust in democratic societies under stress due to extraordinary circumstances. They include: 1) the relationship between experts, leadership, and elected representatives on one hand, and the diverse body of citizens and ordinary members of society, on the other; 2) the role of the press and other forms of mass communication in mediating this relationship during emergencies; 3) the obligations and duties of individuals who play important roles in the emergency preparedness process, particularly health professionals, whose professional obligations may conflict with their personal and family obligations; and 4) the sense of responsibility and cooperation on the part of private citizens that will facilitate effective and ethically sound preparation, response, and recovery in a community.
While the use of coercion, such as mandatory evacuation, or deliberately withholding information from the public should be avoided if possible and as a general rule, such measures cannot be ruled out categorically. The ethical justification of coercion in particular instances will be a matter of context and circumstance. Mandatory evacuation or quarantine may be unavoidable and ethically justified under extreme circumstances. Withholding information from the public may be necessary in order to prevent large-scale panic. It is precisely because measures may be taken in emergencies that would be unacceptable in normal times that public health planners should not wait for disaster to strike before trying to work out a viable scheme of carefully orchestrated decision-making. The role of ethics in the planning phase before a crisis and in the recovery phase afterward is to define reasonably just, humane, and responsible parameters for action and decision-making.
The bioethics of emergency preparedness studies norms and values that are pertinent to how emergency preparedness should be conducted in a generic sense and in regard to specific types of hazard or emergencies. It is common to find the articulation of various frameworks of principles or rules, and in this regard discussions of emergency preparedness emulate and derive from more general works in bioethics and public health ethics. The purpose of such analyses is to provide general principles that can guide particular decisions- made concerning emergency preparedness policies and practical activities. In this approach, the object of analysis tends to be specific actions, choices, and decisions by particular individuals or groups. The actions and agents are critically assessed in light of general ethical norms, and recommendations are made concerning training and procedural or institutional reforms that may lead to improved compliance with these general norms or principles in the future.
Public health ethicist Nancy Kass has identified six questions that should be asked in an ethical evaluation of public health policy and practice: What are the public health goals of the proposed program? How effective is the program in achieving its stated goals? What are the known or potential burdens of the program? Can the burdens be minimized, for example, with alternative approaches? Is the program being implemented fairly? How can the benefits and burdens of a program be fairly balanced?
Ethical goal setting has also been an important aspect of work on emergency preparedness. (See “Ethical Goals of Emergency Preparedness and Response.”) The ethical goals proposed are generally based on the notion that the emergency preparedness process ought to be guided by values that are accessible and reasonable to the community as a whole, even as they are subject to an ongoing reinterpretation, clarification, and discussion. These values are the compass points of a general orientation and a mode of thinking designed to increase the likelihood that public health emergency preparedness will be both effective and trustworthy.
In addition to goals, Kass focuses on effectiveness and fairness as ethical benchmarks. Emergency preparedness planning requires accountability in terms of effectiveness and fairness because it is an activity, resting on the legal authority of the state, that involves the use of power. In other words, emergency preparedness and response 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.
For example, public health measures during emergencies—such as so-called “social distancing” plans that call for people to remain in their own homes, close schools, and prohibit mass gatherings—require individuals to forgo or temporarily suspend some ordinary civil liberties and freedoms for the sake of the public good and the health of others. Therefore, in the planning phase prior to the onset of an emergency, proposed paternalistic restrictions 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 a disaster, experience shows that solidarity and self-sacrifice often give way to disillusionment, recrimination, and even litigation. To mitigate these reactions, it is important to take a “who watches the guardians” approach: there should be 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 oversight 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 press coverage, 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.
Ongoing Ethical Engagement in a Dangerous World
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 identify the segments of the population upon whom those burdens are likely to fall. Moreover, planners and policymakers should attempt to minimize the burdens of the mitigation activity. They should consider alternative approaches to achieve the same goals. 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 and carried out. Planners should attempt to make the public health benefits and the accompanying social, economic, and personal burdens balanced and proportionate.
Finally, public trust is key to the success of any emergency planning, and public engagement is one important key to securing and sustaining public trust. Planning processes should be transparent and multiple venues for deliberative citizen participation should be provided for. Meaningful two-way communication, bottom up communication as well as top down communication, is essential. 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.
Ethical Goals of Public Health Emergency Preparedness and Response
In their book, Emergency Ethics: Public Health Preparedness and Response, Hastings Center Fellows Bruce Jennings and the late John Arras 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. Emergency preparedness 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. Emergency preparedness activities should be designed so as to respect the equal liberty, autonomy and dignity of all persons.
- Distributive justice. Emergency preparedness 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 equitably and fairly.
- Public accountability and transparency. Emergency preparedness activities should be based on and incorporate decision-making processes that are inclusive, transparent, and sustain public trust.
- Community resilience and empowerment. A principal goal of emergency preparedness should be to develop resilient, as well as safe communities. Emergency preparedness activities should strive towards the long-term goal of developing community resources that will make them more hazard-resistant and allow them to recover appropriately and effectively after emergencies.
- Public health professionalism. Emergency preparedness activities should recognize the special obligations of certain public health professionals, and promote competency of and coordination among these professionals.
- Responsible civic response. Emergency preparedness activities should promote a sense of personal responsibility and citizenship.
Bruce Jennings, MA, is a senior advisor to The Hastings Center and a Hastings Center Fellow, and an adjunct associate professor at Vanderbilt University’s Center for Biomedical Ethics.
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