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Resource Allocation After a Nuclear Detonation Incident: Unaltered Standards of Ethical Decision Making

  • J. Jaime Caro, Evan G. DeRenzo, C. Norman Coleman, David M. Weinstock and Ann R. Knebel...

Abstract

This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as “the most lives saved,” needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.

(Disaster Med Public Health Preparedness. 2011;5:S46-S53)

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Copyright

Corresponding author

Correspondence: Address correspondence and reprint requests to Dr J. Jaime Caro, United Biosource Corp, 430 Bedford St, Suite 300, Lexington, MA 02420 (e-mail: jaime.caro@mcgill.ca).

References

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1.Brock, DEthical issues in recipient selection for organ transplantation.In: Mathieu D, ed. Organ Substitution Technology: Ethical, Legal, and Public Policy Issues. Boulder, CO: Westview Press; 1988.
2.Burkle, FM JrMass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am. 2002;20 (2):409436.
3.Devereaux, A, Christian, MD, Dichter, JR, Geiling, JA, Rubinson, LTask Force for Mass Critical Care. Summary of suggestions from the task force for mass critical care summit, January 26-27, 2007. Chest. 2008;133 5(Suppl)1S7S.
4.Fink, SThe deadly choices at memorial. New York Times Magazine; August 30, 2009; 28-46.
5.Gostin, LO, Sapsin, JW, Teret, SP.The Model State Emergency Health Powers Act: planning for and response to bioterrorism and naturally occurring infectious diseases. JAMA. 2002;288 (5):622628.
6.Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. http://www.iom.edu/Reports/2009/DisasterCareStandards.aspx. Published 2009. Accessed April 2, 2010.
7.Kraus, CK, Levy, F, Kelen, GD.Lifeboat ethics: considerations in the discharge of inpatients for the creation of hospital surge capacity. Disaster Med Public Health Prep. 2007;1 (1):5156.
8.Merin, O, Ash, N, Levy, G, Schwaber, MJ, Kreiss, Y.The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362 (11):e3820200362.
9.Pesik, N, Keim, ME, Iserson, KV.Terrorism and the ethics of emergency medical care. Ann Emerg Med. 2001;37 (6):642646.
10.Rubinson, L, Nuzzo, JB, Talmor, DS, O’Toole, T, Kramer, BR, Inglesby, TV.Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care. Crit Care Med. 2005;33 (10):23932403.
11.Stroud, C, Altevogt, BM, Nadig, LCrisis Standards of Care: Summary of a Workshop Series, Forum on Medical and Public Health Preparedness for Catastrophic Events. http://iom.edu/Reports/2009/Crisis-Standards-of-Care-Summary-of-a-Workshop-Series.aspx. Published September 2009. Accessed February 5, 2011.
12.Thompson, AK, Faith, K, Gibson, JL, Upshur, RE.Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7:E1217144926.
13.Ventilator Guidance Workgroup for the Ethics Subcommittee, Centers for Disease Control and Prevention. Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators During a Severe Influenza Pandemic [draft guidance]. http://s3.amazonaws.com/propublica/assets/docs/Vent_Guidance_.draftoc2008pdf.pdf. Published October 30, 2009. Accessed February 5, 2011.
14.Powell, T, Christ, KC, Birkhead, GS.Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2008;2 (1):2026.
15.Knebel, AR, Coleman, CN, Cliffer, KD.Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5(Suppl 1)S20S31.
16.Casagrande, R, Wills, N, Kramer, E.Using the model of resource and time-based triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S98S110.
17.Coleman, CN, Knebel, AR, Hick, JL.Scarce resources for nuclear detonation: project overview and challenges. Disaster Med Public Health Prep. 2011;5(Suppl 1)S13S19.
18.Dodgen, D, Norwood, AE, Becker, SM.Social, psychological and behavioral responses to a nuclear detonation in a US city: implications for health care planning and delivery. Disaster Med Public Health Prep. 2011;5(Suppl 1)S54S64.
19.Hick, JL, Weinstock, DM, Coleman, CN.Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S73S88.
20.Murrain-Hill, P, Coleman, CN, Hick, JL.Medical response to a nuclear detonation: creating a playbook for state and local planners and responders. Disaster Med Public Health Prep. 2011;5(Suppl 1)S89S97.
21.Sherman, SE.Legal considerations in a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S65S72.
22.Coleman, CN, Weinstock, DM, Casagrande, R.Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S98S110.
23.DiCarlo, AL, Maher, C, Hick, JL.Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S32S44.
24.Coleman, CN, Hrdina, C, Bader, JL.Medical response to a radiologic/nuclear event: integrated plan from the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services. Ann Emerg Med. 2009;53 (2):213222.
25.Casagrande, R, MacKinney, J, Bader, J.Federal nuclear preparedness and response measures reflect new modeling paradigms. Homeland Secur Aff. 2010;6:17.
26.Buddemeier, BR, Dillion, MKey Response Planning Factors for the Aftermath of a Nuclear Detonation.LLNL-TR-410067.: http://www.remm.nlm.gov/IND_ResponsePlanning_LLNL-TR-410067.pdf. Published August 2009. Accessed June 28, 2010.
27.Sandel, MJustice: What's the Right Thing to Do?.New York: Farrar, Straus and Giroux; 2009.
28.Fink, SL.Worst case: rethinking tertiary triage protocols in pandemics and other health emergencies. Crit Care. 2010;14 (1):10320122291.
29.Guest, T, Tantam, G, Donlin, N, Tantam, K, McMillan, H, Tillyard, A.An observational cohort study of triage for critical care provision during pandemic influenza: ‘clipboard physicians’ or ‘evidenced based medicine’? Anaesthesia. 2009;64 (11):11991206.
30.Khan, Z, Hulme, J, Sherwood, N.An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic. Anaesthesia. 2009;64 (12):12831288.
31.Gebbie, KM, Peterson, CA, Subbarao, I, White, KM.Adapting standards of care under extreme conditions. Disaster Med Public Health Prep. 2009;3 (2):111116.
32.Christian, MD, Hawryluck, L, Wax, RS.Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175 (11):13771381.
33.Gostin, LO.Medical countermeasures for pandemic influenza: ethics and the law. JAMA. 2006;295 (5):554556.
34.Tabery, J, Mackett, CW IIIUniversity of Pittsburgh Medical Center Pandemic Influenza Task Force's Triage Review Board. Ethics of triage in the event of an influenza pandemic. Disaster Med Public Health Prep. 2008;2 (2):114118.
35.Soanes, C, Stevenson, AConcise Oxford English Dictionary.11th ed. New York: Oxford University Press; 2009.
36.Kramer, MSSection 7. 5.1 efficacy vs effectiveness.In: Kramer MS, ed. Clinical Epidemiology and Biostatistics: A Primer for Clinical Investigators and Decision-Makers. New York: Springer-Verlag; 1988.
37.Hick, JL, Koenig, KL, Barbisch, D, Bey, TA.Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment. Disaster Med Public Health Prep. 2008;2(Suppl 1)S51S57.
38.Kaji, A, Koenig, KL, Bey, T.Surge capacity for healthcare systems: a conceptual framework. Acad Emerg Med. 2006;13 (11):11571159.
39.Dolan, P, Shaw, R, Tsuchiya, A, Williams, A.QALY maximisation and people's preferences: a methodological review of the literature. Health Econ. 2005;14 (2):197208.
40.Garoon, JP, Duggan, PS.Discourses of disease, discourses of disadvantage: a critical analysis of National Pandemic Influenza Preparedness Plans. Soc Sci Med. 2008;67 (7):11331142.
41.Williams, A.Intergenerational equity: an exploration of the ‘fair innings’ argument. Health Econ. 1997;6 (2):117132.
42.Johri, M, Damschroder, LJ, Zikmund-Fisher, BJ, Ubel, PA.The importance of age in allocating health care resources: does intervention-type matter? Health Econ. 2005;14 (7):669678.
43.Kanter, RK, Cooper, A.Mass critical care: pediatric considerations in extending and rationing care in public health emergencies. Disaster Med Public Health Prep. 2009;3(Suppl 2)S166S171.
44.Public Engagement Project on Medical Service Prioritization During an Influenza Pandemic.Seattle: Public Health-Seattle & King County; 2009.
45.US Department of Veterans Affairs. Meeting the Challenge of Pandemic Influenza: Ethical Guidelines for Leaders and Health Care Professionals in the Veterans Health Administration. http://www.ethics.va.gov/activities/pandemic_influenza_preparedness.asp. Published July 2010. Accessed November 15, 2010.
46.Levin, D, Cadigan, RO, Biddinger, PD, Condon, S, Koh, HKJoint Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group. Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep. 2009;3(Suppl 2)S132S140.
47.Beekley, AC, Starnes, BW, Sebesta, JA.Lessons learned from modern military surgery. Surg Clin North Am. 2007;87 (1):157184, vii.
48.Brook, RH.Health policy and public trust. JAMA. 2008;300 (2):211213.
49.Rogers, DE.On trust: a basic building block for healing doctor-patient interactions. J R Soc Med. 1994;87(Suppl 22)25.
50.Groopman, JEHow Doctors Think.Boston: Houghton Mifflin; 2007.
51.Kass, NE, Otto, J, O’Brien, D, Minson, M.Ethics and severe pandemic influenza: maintaining essential functions through a fair and considered response. Biosecur Bioterror. 2008;6 (3):227236.
52.Agency for Healthcare Research and Quality. Mass Medical Care With Scarce Resources: A Community Planning Guide. http://www.ahrq.gov/research/mce. February 2007. Accessed February 4, 2011.
53.Holt, GR.Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139 (2):181186.
54.Repine, TB, Lisagor, P, Cohen, DJ.The dynamics and ethics of triage: rationing care in hard times. Mil Med. 2005;170 (6):505509.

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