Ethics in mass-casualty occurs when a medical practitioner is forced to make decisions whom to treat first due to a shortage in information, personnel, and time. Apart from the utilization of professional tools and skills, physicians on site are required to put into consideration moral principles. Even imanaging n the face of disaster, medical practitioners are expected to practice ethics and other principles related to managing the disaster. The issue here is whom to give attention and twho to deny the same. Additionally, there us the issue of right and wrong and the impact of the physician’s decision to the victim, their families and the society.
Ethics in Mass Casualty Incidents
In this case, health specialists lack the ability and opportunity to attend to all injured victims temporarily. Many ethical dilemmas and conflicts tend to arise in such situations. While making moral decisions in mas-casualty situations, four critical qualities are compassion, discernment, integrity, and trustworthiness. Most physicians in these positions rely on the principle of “doing the greatest good for the greatest numbers”. In every life situation, proper decision-making is based on four significant principles. These include non-maleficence, beneficence, justice, and autonomy. Beneficence in this scenario is acting for the benefit of patients based on the situation and information shared by patients. Non-maleficence requires maintenance of the physician’s integrity and trust of patients. Only qualified and skilled emergency doctors are allowed to treat the wounded. Independence requires involvement of patients in the decision-making process regarding their health. In case of casualty-situations, a surrogate decision maker can make decisions on behalf of a patient. It is only acceptable in case of an emergency that requires immediate intervention. Justice ensures physicians provide care to affected victims regardless of their race, gender, nationality, or color. It also involves distribution of medical benefits and resources in an equitable manner (Christian, Farmer, & Young, 2009).
Because of the urgency of the state, it is essential for health institutions to develop a consensus on ethical guidelines for doctors who care for victims at the time of disasters. The ethical approach must be based on virtues and still be practical when it comes to extreme conditions. A curriculum explaining these situations is central to prepare physicians for a future occurrence. Having this ethical knowledge in advance should be a part of the medical profession to help in solving issues relating to prioritization and triage, equity and justice, ethical and moral responsibilities (Lee, 2010). Thus, physicians follow the triage process, which involves assigning of patients into different categories based on their ability to survive. The triage system determines who will receive treatment and who will have their treatment delayed. The color-coded tagging system for categorizing disaster victims is as illustrated below:
a. Red Triage Tag represents patients in danger requiring immediate treatment,
b. Yellow Triage Tag represents patients with a not so immediate danger requiring urgent treatment,
c. Green Triage Tag symbolizes patients with minor injuries who are required to get treatment eventually,
d. Black Triage Tag represents patients who cannot be saved in the situation.
Three main ethical challenges faced by physicians are restrictions, rationing, and responsibilities. Rationing involves allocation of resources, especially in case everyone requires medications. Restrictions encompass quarantine and isolation, which tend to limit liberty and freedom of both patients and physicians. Most emergencies have a strong relation with public health ethics as compared to medical ethics. The same way disasters vary; ethical considerations and actions vary as well (Lee, 2010).
Disaster in ethics is addressed in three stages, which are:
a. Pre-disaster or preventive phase: there is the development of a preventive ethics approach to help reduce any forms of conflicts during crisis,
b. Disaster and early response phase: this phase explains four main principles of maleficence, non-maleficence, autonomy, and justice as discussed. It also encompasses the triage stage and limited distribution of medical resources.
c. Post-disaster or rehabilitation: this is for survivors and their respective families.
Mass Casualty Response Plan
The plan provides operations and specific procedures that are unique to Mass Casualty responses. The document consists of management tools, procedures, and techniques that have been used in the earlier disaster incidences, thus proving to be successful. It defines patient evaluation, treatment, and care based on the type of disaster experienced (Christian, Farmer, & Young, 2009). It provides clear guidelines on behavior of physicians during the three calamity stages. It also describes roles and responsibilities of each individual when it comes to mitigation, preparation, response, and management of different forms of disasters (King, 2014). When developing this plan, five ethical decision-making theories are important as discussed in the next section. These approaches stem from teleological and deontological categories of ethics.
a) Utilitarian Approach
This approach focuses on the principle of the greatest good for the greatest number. Back in the 19th century, it was developed by Jeremy and John to establish which laws were good, hence morally explaining that all ethical actions had to provide a balance between good and evil. It also emphasizes the result while trying to create the greatest good at the same time. This method became popular in the 1900s (Lee, 2010). The approach begins with identification of available courses of action together with their pros and cons and ends with the choice of an appropriate action. In the mass casualty situation, most affected victims can get treatment and attention as long as the situation can be handled. The primary intention here is maximization of survival of casualties. In terms of its advantage, it proves that physicians will achieve the highest efficiency using available resources. It is best suited for evidence-based and outcome-driven medical settings. The problem with this approach is that physicians are unable to provide acute care when it comes to the need for life-saving procedures with the aim of maximizing medical resources in the society. While it might save a few, those with severe conditions may only last long enough based on the medication administered.
b) Rights Approach
This approach was developed by Immanuel Kant in the 18th century. The methodology involves the right of individuals to choose for themselves. In case of a mass casualty incidence, victims are allowed to make their choices based on resources available. The main concern here is whether the course of action to be undertaken respects moral rights of affected victims. In the casualty setting, every individual has the right to leave and acquire medical treatment. Triage, on the contrary, requires restriction, isolation, and responsibility, which tend to be in conflict with the approach (Lee, 2010). From a positive perspective, every affected victim can gain medical attention as stated in the rights despite the level of injuries. The real thing is that lives can be saved and survival rate of patients can be improved. On the negative side, the approach favors less the individuals who require immediate treatment (King, 2014).
c) Fairness or Justice Approach
Aristotle, a Greek philosopher of the ancient times, was the first to mention this approach (Lee, 2010). The main issue here is the level of fair-mindedness of the action to human nature. It requires everyone to be treated equally and fairly without any form of discrimination or bias. While bias gives burdens to a selected number of people with no justification, discrimination involves imposition of burdens on people (Christian, Farmer, & Young, 2009). In mass casualty cases, ‘the first come, the first served’ approach is rampant. One of the benefits of the approach is the ease of application and the balance it brings to different situations. The negative part of the approach is the fact that no attention is given to victims who require immediate or urgent attention. In most cases, the first victims to get to hospital are the less injured who may decide to seek treatment later on. When physicians choose to use objectivity and justice, then all resources would be used on the less damaged, leaving behind those with grave conditions, thus improving wellness of the whole society. Most individuals find this system unfair as it follows ‘the end justifies the means’ principle. This approach is not morally correct as it promotes keeping of those who can be saved. In essence, all victims deserve to be protected unlike saving more as the approach suggests (Lee, 2010).
d) Common-Good Approach
The central issue in this approach is common good, which tends to bind community members. The assumption here is that the whole society consists of individuals whose good is also useful to the society. Under the approach, procedures and processes involved in mass casualty incidences are beneficial for everyone affected (King, 2014). It requires victims and their families to discover the common goal of getting medical attention to everyone else. In these scenarios, those with acute injuries are expected to allow those with minor injuries to get treatment and vice versa. The problem here is that not everyone works for the common good of the society.
e) Virtues Approach
This approach follows the assumption that everyone strives to uphold particular ideals in different situations of human life that ensure individual and personality development. The key qualities are integrity and trustworthiness among others. The problem with this approach is that not everyone is as virtuous as expected. It only works for those individuals who value this idea. From the discussion, it is clear that no ethical approach is effective when it comes to making triage decisions (Lee, 2010). Most incident plans today decide to adopt all the five approaches by putting their focus on the neediest patients with a chance for survival. In case when needs of patients are equal, ‘the first come, the first served’ method is the most common approach.
Degree of Ethical Duty to Citizens
In case of mass casualty incidences, it is the duty of nurses and physicians to report to their different workstations in the event of a disaster. As explained in their code of conduct, they are expected to address life and health of patients above any other considerations. They are required to attend to victims and be at tragedy sites even in cases when their lives are in danger. At the scene of disasters, physicians must provide quality and competent care without any form of favoritism and discrimination based on ethnicity, disease, or affliction. Being in this profession, a physician is expected to recognize responsibilities to patients (first and foremost), society, and other professionals. Apart from medical practitioners, health institutions also have an obligation that involves providing safe environments for both patients and physicians. Patients, in turn, need to appreciate the effort of physicians, medical centers, and societies by making it easy for them to function at the time of emergency or medical administration. Without them, many individuals would have lost their lives (King, 2014).
Needs of the Socially Vulnerable
Socially susceptible individuals and those who lack the ability to withstand severe impacts and situations in life should be accounted for from natural, social, political, and economic perspectives. These groups consist of the young, the elderly, the marginalized, and the poor. Most emergencies and disasters have effects on all individuals regardless of their status or background, but with no equal individual effect. For vulnerable people, there is the need to prepare for disasters by providing them with necessary requirements for handling disasters. Such individuals face the risk of death and potential harm during disasters and other emergency cases because of the failure to plan for specific needs (Lee, 2010). They are more at risk during most disasters than the rest because they lack the ability to avoid them and are further affected by them. When this happens, such individuals fail to cope with injuries, resulting in further damages. Apart from this, there are employees who work in dangerous and hazardous regions such as factories. Some needs of these individuals include support from family members, society, and government. For the homeless and the poor, it is required to satisfy basic needs such as shelter, clothing, and food together with access of medical facilities. They also need training on different forms of survival together with their management practices. In summary, socially vulnerable individuals need good and quality homes, good nutrition standards, occupational safety, and health. Because of this, there is the need for policy makers, emergency planners, and community to come together to formulate and deliver better disaster responses, recovery, and relief measures.
When these needs are addressed appropriately, severity of the situation also reduces. When such individuals get quality and good homes, it is possible to reduce risks brought about by natural hazards and other accidents (Christian, Farmer, & Young, 2009). With proper health care, vulnerable people in the society can obtain appropriate medical care in any situation they face. Policies and procedures set up by the community and other involved parties provide guidelines on disaster recovery and management.
In the medical field, morals will remain a core clinical practice of ensuring quality services. This section provides recommendations when it comes to efficient management of mass casualty incidences. All sectors dealing with such situations must begin with getting an understanding of different incidences, as well as needs and requirements of vulnerable communities. After this, there is a need for effective planning to ensure all policies discussed are being implemented. It is important for every participant to take part in the delivery of effective emergency responses, recovery, and relief that are specific to those who need it. Thus, there is a need for effective and targeted communication to every member of the society, including the government. The ethical approaches discussed above are important when it comes to preparation of a mass casualty plan. While all approaches have their benefits, disadvantages are also present. Today, no country adopts any pure form of the ethical approaches when it comes to casualty management. Instead, many systems are adopting two or three of the approaches to reap more benefits as opposed to those that come with one. Ethics in casualty incidences is a sensitive topic that requires proper decision-making. While physicians may desire to treat all casualty victims equally, it is not possible due to the lack of adequate resources, time, and varying situations. The most important decision would be to give priority to those who require immediate or urgent attention in order to save lives. It is possible to make other victims understand the urgency, thus adopting either of the ethical approaches.