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BY: CARL MIDDLETON, DMin, MDiv, MA, MRE

Over the past several years natural disasters have been both expensive and deadly. In addition to natural disasters there have been acts of domestic terrorism in schools, churches, synagogues and mosques. In recognition of the significant and increasing effect that disasters can have on hospital care in the United States as well as on Catholic missions overseas, Catholic Health Association members gathered in the summer of 2018 for "When Disasters Strike: A Special Convening for International and Domestic Response," a forum for sharing insights and lessons learned. Participants and panelists with vast and varied experience discussed the numerous effects that Catholic health care should anticipate in a disaster.

Participants described a resounding sense of religious and moral obligation to help during a disaster, a commitment shared across individuals and their organizations. This discussion led to a conversation regarding a discernment process and ethical framework to assist health care and aid organizations when making decisions related to natural disaster response.

As a theologian and ethicist, I have continued to think about the subject since that gathering. In my role at both the local and national levels, I have served on disaster planning committees, served on the incident command team during Hurricane Harvey, have completed the Incident Command System Training and the FEMA Healthcare Leadership for Mass Casualty course. These experiences have enabled me to suggest an ethical framework for the disaster planning discernment and identify the key ethical values and questions that pertain to disaster decision-making.

Disasters often require some combination of triaging, allocating and rationing of resources because the demand is far greater than the supply. Recent disasters that have involved Catholic health facilities and systems reinforce the importance of preparedness for all types of disasters. A discernment process and ethical framework are needed to provide guidance in decision-making for a wide variety of disasters.

DISCERNMENT PROCESS
Catholic health care systems have their own discernment processes that can be used as a model for disasters/humanitarian crises. A discernment process from a faith-based perspective would typically include clinical, organizational and public health ethics. A disaster planning committee can use a discernment process as a way to organize their work.

Prior to implementing the discernment process and ethical framework, they would need to go through a selection process to identify a team of people with appropriate expertise and experience who will be involved in disaster planning discernment. It is important to include a mission leader and an ethicist in the planning process and to serve on the Incident Command Team.

Though the terminology might change, these are the typical elements of a discernment process: an analysis phase, a resolution phase and an evaluation. After describing the steps of each phase, I will suggest elements of an ethical framework for disaster planning discernment.

ETHICAL GOALS
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. A disaster planning committee can evaluate their disaster plan in light of these seven goals.

• 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 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, safe communities. Emergency preparedness activities should strive toward 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 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.¹

Decision-makers should assess who among the staff is willing to: serve during a crisis; work collaboratively with stakeholders and professional staff in advance to establish practice guidelines; work collaboratively to develop fair and accountable processes to resolve disputes; and provide support to ease the moral burden of those with the duty to care.

ETHICAL DILEMMAS
Catastrophic events raise the potential for many serious ethical dilemmas and quandaries. FEMA's instructor manual for Catastrophe Readiness and Response provides examples of some issues where ethics are relevant for a disaster planning committee:

• How do we ethically determine allocation and distribution of benefits and burdens before, during and following a catastrophic event?
• How do we resolve or determine the fairness of unintended consequences?
• How much participation by the public or [by] affected individuals in the planning and preparing for catastrophic events is required [in order for it] to be "ethical"?
• How do we determine roles of responsibility and duty in catastrophe response? Who is responsible for responding? What types of responses are required? Who pays for response?
• What is the nature and extent of professional duties and responsibilities during catastrophe response? Must emergency responders put themselves in danger? Is there an ethical duty to attempt a rescue even when doing so might put the first responder's own life in danger?
• How do private responsibilities relate to public duties? Is government "ethically" required to be proactive? More or less active than individuals and families?
• How do we determine to whom a duty is owed (our "moral community")? Is assistance provided on a purely first-come, first-served basis? How do we deal with especially vulnerable populations? Do the elderly and infirm receive additional resources or fewer? What about the poor? Immigrants? Prisoners? (Author's note: See Part One of the Ethical and Religious Directives for Catholic Care Health Services.)
• How do we ethically set policy and enforce limitations on individual rights, for example, curfew, quarantine, confinement, mandatory evacuation? Does autonomy trump public safety, or vice versa?
• In emergency conditions can due process be suspended or modified? Might other constitutional rights be suspended?
  • Can the government impose limitations on personal and family movement (e.g., can families be prevented from returning to their homes and neighborhoods, from exercising their property rights, when conditions are rendered unsafe?)
  • How do we deal with residents who refuse to follow an order to evacuate? What is the ethical responsibility to them? Legal ramifications? How does this impact the concerns for first responder safety?
• What duty is owed the public in terms of messaging and communication about impending catastrophic events? How is this balanced with the need to avoid "panic" or "overreaction" on the part of the public? What role does the mass media play in communicating warnings and other information to the public? What role should it play (i.e., what is the ethical thing for the media to do?)²

ETHICS ALGORITHM
The FEMA training manual's section on ethics states: "There are no simple, formulaic schemes for making ethical choices, particularly in the catastrophe setting. There are, however, ways of thinking about key values, ethical principles and theories that can help preparedness planners devise strategies for emergency response. These involve a systematic approach to applying basic ethical principles and theories to any particular situation. One can create an ethics algorithm that, if consistently applied to planning for any particular kind of emergency, at least can provide reasonable confidence that ethical issues raised by an emergency are well-considered."³ The ethics algorithm might be constructed as follows:

1. Who are all the possible interested parties? Think broadly — include not only persons and categories of persons but institutions/organizations/professions/communities.
2. What is the full range of duties and obligations of each potentially interested party, or at least the primary interested parties? Think of parties as not only individuals but also institutions and groups.
3. How might various duties and obligations of each of the various parties' clash/conflict?
4. What might be short-term and long-term consequences, both good and bad of each possible course of action? How confident are you of your predictive accuracy?
5. What ethical principles are at stake? (Possible ethical principles include respect for persons, beneficence, non-malfeasance, justice, truth telling, liberty, opportunity and reciprocity). Which ones are in tension?
6. What might be the intentions of the various players? Evaluate the praiseworthiness or lack thereof, of the motives of the people, organizations and/or institutions involved.
7. What appears to be the full range of possible courses of action?
8. Weed out those possible courses of action that appear not to be justifiable based on potentially bad consequences, inability to meet duties and obligations, and/or the ethical soundness, or lack thereof, of intentions.⁴
9. Another important resource is the World Medical Association's set of ethical principles and procedures with regard to triage outlined in its Statement of Medical Ethics in the Event of Disasters.⁵

Values Analysis: What Values Are Affirmed, in Conflict or Negated
Some of the values to be considered for values analysis in a Catholic Healthcare Disaster Plan might include the following:

• Reasonableness: Decisions should be based on reasons (including evidence, principles, values) that stakeholders can agree are relevant to meeting health needs during a disaster.
• Responsiveness: Leaders should revisit and revise decisions as new information emerges throughout the crisis.
• Duty to provide care: The duty to provide care and to respond to suffering is inherent to all health care professionals' codes of ethics.
• Equity: During a crisis, tough decisions will need to be made when resources are limited.
• Individual liberty: Restrictions to individual liberty may be necessary to protect the public from serious harm.
• Privacy: In a crisis it may be necessary to override this right to protect the public from serious harm.
• Proportionality: Requires restrictions to individual liberty and measures taken to protect the public from harm.
• Do no harm: A foundational principle of ethics is the obligation to protect the public from serious harm.
• Common good: During a crisis, people, especially those most vulnerable, need to have the basic necessities, food, shelter, water, clothing, etc.
• Reciprocity: Requires that society supports those who face a disproportionate burden in protecting the public good and takes steps to minimize its impact.
• Solidarity: A disaster requires collaboration between local, regional, national and global partners.
• Stewardship: Trust, ethical behavior and good decision-making are utilized in allocation and rationing decisions.
• Trust: Early engagement and transparent communication with stakeholders.⁶

EVALUATION PHASE

• Evaluate whether the solution addressed the defined problem.
• Determine if your actions produced the desired outcomes.
• Document and use lessons learned for future planning and response.

In evaluating a disaster plan, the Army's after-action review is arguably one of the most successful organizational learning methods yet devised for evaluation and performance improvement, especially in light of disaster planning. The process involves all persons involved regardless of title or role to share and learn in order to have continuous improvement. I suggest that an after-action review be conducted at the end of each day of the disaster by the incident command team. The assessment allows both employees and leaders to discover and learn what happened and why. Don Clark's "After Action Review" article outlines the steps.⁷

CONCLUSION
For hospitals and health systems that have discernment processes, the disaster planning process needs to be evaluated through a collaborative effort by Incident Command Team, the ethics committee and the disaster preparedness committee. They should make sure the process is relevant to making decisions, especially triage and allocation decisions that have to be made during a disaster or crisis. As James Childress writes: "Yet we need rules such as a capacity triage plan, established in advance of emergencies, so that everyone will know how to respond…Although rules of triage must be formulated with the best medical information available, they are not merely medical in nature. They also reflect important moral values."⁸

CARL MIDDLETON is a retired health care executive, theologian/ethicist and senior mission leader with 45 years of ministry experience in Catholic health care.

NOTES

1. Bruce Jennings et al., eds., Emergency Ethics: Public Health Preparedness and Response, (Oxford: Oxford University Press, 2016).
2. Anna Schwab and Timothy Beatley, Catastrophe Readiness and Response, FEMA Initial Ethics Training, Session 4 (2019): 16.
3. Anna Schwab, Catastrophe Readiness, 12.
4. Schwab, Catastrophe Readiness, 12.
5. "WMA Statement on Medical Ethics in the Event of Disasters," World Medical Association website, Revised October 2017, https://www.wma.net/policies-post/wma-statement-on-medical-ethics-in-the-event-of-disasters/.
6. Alison K. Thompson et al., "Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making," BMC Medical Ethics 7, no. 12 (Dec. 4, 2006), https://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-7-12.
7. "After Action Review," Donald Clark, Big Dog and Little Dog's Performance Juxtaposition website, May 1, 1997, http://www.nwlink.com/~donclark/leader/leadaar.html.
8. James F. Childress, "Disaster Triage," American Medical Association Journal of Ethics 6, no. 5 (May 2004), https://journalofethics.ama-assn.org/article/disaster-triage/2004-05.