Legal and Ethical Issues in Crisis Intervention
As the workshops showed, work on standards of care in crisis has a strong focus on consistency, in part because consistency and equity are integral to any ethical system. IOM`s 2009 information report outlines seven ethical considerations critical to the development of crisis ethical standards for care protocols: fairness, due diligence, obligation to manage resources, transparency, proportionality and accountability (IOM, 2009). However, the application of the ethical framework is difficult because these are difficult questions for which there are rarely obvious and singular “good” “good”. Many workshop participants emphasized the importance of community values and the need to involve communities in the ethical planning process before a crisis occurs. In all cases, ethical requirements come first and must be integrated from the outset. On the other hand, Powell noted, many people take risks. This includes non-physicians inside and outside the hospital, such as nurses, nurses, ventilation technicians, paramedics and more. “You include all these people, and if your crisis is bad enough, I think you just ran out of ventilators and nobody in your community has any, just the health workers.” In addition, Powell said, if a ventilation triage program is structured around employment, children are excluded. But the ethical questions that these questions raise are fundamental for other reasons. They are fundamental because if we do not act in accordance with our ethical principles, the impact on individuals and society will be enormous in retrospect. They are fundamental because our ethical principles form the basis of our laws.
They are fundamental because people will only act and make sacrifices if they believe that they are acting in an ethical system and that individuals are treated fairly and transparently in full view of the law. Moreover, frankly, they are fundamental because many of the decisions considered are made with imperfect information – these will be the best guesses. These assumptions must be made on the basis of a common ethical construct in the absence of clear evidence. Fortunately, as the workshops showed, there is a huge body of research that can be leveraged on ethical issues surrounding standards of crisis care, including the work of Powell and many others (DeBruin et al., 2009; IOM, 2009; Powell et al., 2008; VHA, 2009a). Online tools, guides, and planning systems can help communities move forward in developing ethical standards of crisis care (New Jersey Hospital Association, 2008; VHA, 2008b). One tool that several users highlighted was the built-in ethics tool available on the VHA`s National Center for Ethics in Health Care (VHA, 2009b) website. Developed by leading experts in the field and tested in a range of scenarios, it has been highly recommended as a good starting point for communities. Powell of the Montefiore-Einstein Center presented his committee`s work to create an ethical framework for ventilator assignment in public health emergencies in New York City (Powell et al., 2008).
One question that immediately arose during the discussions was whether health workers would have priority access to ventilators in an emergency. “You have to be able to give your workers at least one correct answer,” Powell said. “It`s true that there`s not just one right answer, but you don`t want to get them to do the wrong thing.” Much remains to be done in terms of resource allocation, personnel issues, community involvement and coherence. But this work must be done before disasters occur. In the heat of the moment, there will be no time to raise community awareness or reflect on the ethical implications of each response. This can put caregivers in impossible situations with extraordinary potential impacts. Ethical issues in situations where resources and crisis norms are scarce and fundamental at the same time. They are difficult, as one workshop participant said, because they contradict many of the values we hold dear, such as providing the best possible care for each patient. 2600 South First Street, Springfield, IL 62704, United States The case for such a policy is clear: health workers take additional risks in public health emergencies, especially in infectious situations such as an influenza pandemic. If they do not have priority access to care, some may not report to work.
If health workers do not show up for work, fewer people are treated. This is a logical and reasoned argument for giving priority access to these workers. A recurring question is that of priority, Powell added. Too often, she suggested, the people who write the priority access rules are at the top of the list. She cited a case where the rules were developed by a legislative body and elected officials were at the top of the list. The problem, of course, is that arguments can be made for many different constituencies. Typically, if the people who create the prioritization list end up at the top, the community is unlikely to buy into the program. For the New York standard, Powell`s group decided that access to ventilators would be based solely on medical assessments. Instead of giving priority access to health care workers, New York decided to do more to protect them from the disease. It is important to note that Powell did not necessarily position the New York decision as “the right one.” But it was “right” because it reflected the considered values of the community.