An Overview of Public Health Ethics in Emergency Preparedness and Response
Abstract and Keywords
In recent decades, a wide range of abrupt and unpredictable events—including bioterrorism, natural disasters, industrial disasters, and infectious disease outbreaks—have endangered population health and challenged even the most advanced public health and health care systems. Affected populations may face imminent risk to life or health; scarce medical resources; lack of food, water, and shelter; electrical power outages; and interrupted communication. The urgent need to mitigate harms to population health may necessitate rapid decision-making, with incomplete or imperfect information, against a backdrop of political, economic, and social instability. These defining characteristics of public health emergencies are morally significant, not only because they present normatively complex questions about what constitutes an ethical emergency response, but also because they highlight the vital importance of incorporating ethics into public health emergency preparedness.
Since the beginning of the twenty-first century, a growing number of large-scale events have endangered population health and challenged even the most advanced public health and health care systems. These events—whether classified as bioterrorism, such as the 2001 anthrax attacks; natural disasters, such as the 2004 Indian Ocean tsunami; industrial disasters, such as the 2010 BP Deepwater Horizon oil spill; or infectious disease outbreaks, such as Zika virus—collectively highlight human vulnerability to abrupt, unpredictable, and often uncontrollable threats. Affected populations may face imminent risk to life or health; scarce medical resources; lack of food, water, and shelter; electrical power outages; and interrupted communication networks. The urgent need to mitigate harms to population health may necessitate rapid decision-making, with incomplete or imperfect information, against a backdrop of political, economic, and social instability. These defining characteristics of public health emergencies are morally significant, not only because they reinforce the vital importance of emergency preparedness and response, but also because they present normatively complex questions about what constitutes an ethical public health emergency response (Viens and Selgelid, 2016).
(p. 768) Public Health Emergency Preparedness and Response Activities
Governments, institutions, and communities have prepared for and responded to public health emergencies for hundreds of years (Clements and Casani, 2016). The field of public health emergency preparedness and response, however, is relatively young (Rose et al., 2017), and efforts to address the ethical complexities arising from its practice are developing in real time (Ellis et al., 2016). Nevertheless, there is broad consensus about what public health emergency preparedness and response entails, and growing attention to the tragic choices that communities, health care providers, emergency managers, and others must confront in the emergency context.
Public health emergency preparedness and response involves taking the steps “necessary to maximize the ability” of public health and health care systems to “prevent, respond to, and recover from major events, including efforts that result in the capability to render an appropriate public health and medical response that will mitigate the effects of illness and injury, limit morbidity and mortality to the maximum extent possible, and sustain societal, economic, and political infrastructure” (DHS, 2007, sec. (2)(f)). As its definition suggests, preparedness and response is a multisector, multistep endeavor. It requires the participation, cooperation, and coordination not only of public health and health care systems, but also of other sectors, including national security agencies, humanitarian aid organizations, industries, economists, engineers, and members of the community. Each group brings important knowledge to the process, as well as particular priorities, interests, and values.
Because of the wide range of potential large-scale public health emergencies, preparedness and response activities generally follow an “all-hazards” approach (DHS, 2003; World Health Assembly, 2011). Instead of engaging in specific planning for each type of emergency, an all-hazards approach assumes that certain core functions and capacities will be required in any emergency. The process of emergency preparedness and response unfolds in four phases: mitigation, preparedness, response, and recovery. Mitigation takes place before an emergency event and involves assessing potential threats and present vulnerabilities in an effort to prevent either the occurrence or the impact of a large-scale public health emergency. An example of mitigation is enacting and enforcing building codes to limit structural damage during natural disasters. Preparedness attempts to improve the capacity of governments, institutions, and communities to respond to public health emergencies once they are underway. Establishing a strategic national stockpile of essential medicines is a form of preparedness. Response describes the actions taken during an emergency event to protect people, property, infrastructure, and the environment. The decision to quarantine individuals to limit the spread of an infectious disease is one type of response. Recovery, the final phase, describes actions that aim to return populations to normalcy as soon as possible. Reopening hospitals, restoring electricity and potable water, and offering mental health services are examples of recovery activities.
(p. 769) Ethical dilemmas can arise during any phase of public health emergency preparedness and response. Mitigation strategies may raise questions, for example, about the use of societal resources. How much of its budget should a city allocate to strengthening its infrastructure (e.g., buildings) against unknown and unquantifiable future natural disasters? Recognizing that emergencies often exacerbate existing patterns of social injustice, should the city focus its initial efforts on improving infrastructure in poor communities? What if better-off communities have larger populations in equal need of those improvements? Ethics does not offer quick or discrete answers to morally challenging questions that arise in the context of emergency preparedness and response. Ethical awareness and analysis can, however, illuminate the values at stake in those decisions and provide the moral language to describe and resolve situations in which values conflict.
Events like Hurricane Katrina and the West African Ebola epidemic have graphically demonstrated that during public health emergencies, it is just as important to have policies and practices on ethics (e.g., on how to distribute scarce resources, when individual liberties can be restricted, and the scope of professional duties) as it is to have policies to minimize public health impact. Addressing those ethics issues—sometimes referred to as the three R’s: rationing, restrictions, and responsibility (Wynia, 2006)—should be part of any all-hazards approach. Deliberation among diverse stakeholders about these challenges can reveal a community’s values and goals, which in turn can guide decision-makers in additional, unexpected emergency situations.
Determining how to allocate scarce, life-saving resources is one of the most difficult and ethically fraught aspects of emergency preparedness and response. Regardless of whether the limited resources are medical (e.g., drugs, vaccines, ventilators, and hospital beds), structural (e.g., electricity and evacuation routes), or human (e.g., medical personnel), decisions about their distribution require prioritizing some members of the affected population over others. In confronting issues of distributive justice, decision-makers should strive for policies that are fair, steward scarce resources, and address the needs of special and at-risk populations. Fairness requires that if one group receives a more favorable distribution than others, the difference be justified by morally relevant factors, such as the priority group’s importance to community survival (e.g., first responders) (IOM, 2012). Allocation schemes that treat groups differently based on morally irrelevant factors like gender or religion are, therefore, presumptively unethical. Decision-makers should also ensure that allocation policies manage limited resources prudently. Allocation criteria like “first come, first served” and random lotteries, which would provide care to some patients who are likely to die regardless of treatment, while denying care to others who might survive with treatment, fail to appropriately steward scarce resources. Lastly, every allocation policy should account for the needs of populations, which, because of (p. 770) social, economic, cultural, and biological factors, are especially vulnerable to harms or injustices during emergencies. Because groups that are disadvantaged or marginalized before a public health emergency are more likely to suffer poor outcomes during an emergency, planning for their needs is critical.
Several allocation schemes, each reflecting particular values, have been proposed to address the emergency distribution of scarce health care resources. One frequently articulated strategy, grounded in utilitarianism, aims to maximize net benefits, which are specified, for example, as the number of people who survive to hospital discharge (Powell, Christ, and Birkhead, 2008) or the number of adjusted life years saved (White et al., 2009). A different allocation scheme, driven by “narrow social utility” (CDC, 2011), prioritizes individuals, such as health care providers, who carry out functions essential to others’ survival (HHS, 2005). Another alternative, the “fair innings” or “life cycle” approach (Emanuel and Wertheimer, 2006), takes the view that each individual ought to have equal opportunity to live through all of life’s stages, and therefore prioritizes younger people to receive scarce resources. Because choosing an allocation scheme involves value-based determinations that people may disagree about, it is important that the decision-making process is itself ethical. In an emergency, resource allocation is more likely to be effective and perceived as legitimate when the planning process is transparent, inclusive, and involves open public engagement (Jennings and Arras, 2016; Daniels and Sabin, 2008).
The second ethical challenge that emergency planners should prepare for involves the tensions that can arise between protecting population health and individual liberty. The United States has a long-standing and deep tradition of protecting individual autonomy from public interference, but liberty is “not . . . an absolute right . . . at all times and in all circumstances” (Jacobson v. Massachusetts, 197 U.S. 11 , 206). In some situations, it may be ethically justified to limit one person’s liberty to prevent harm to others (Mill,  1978). In the context of an infectious disease outbreak, for example, public health interventions such as social distancing, travel restrictions, contact tracing, isolation, and quarantine, may stem the tide of new infections, but at the cost of infringing on individual liberty. Targeted individuals may also face additional burdens, including loss of privacy, stigmatization, discrimination, lost wages, and psychological stress (Wynia, 2007a). For these reasons, and because liberty-restricting interventions have historically targeted marginalized groups (e.g., the 2014 Ebola-related quarantine of the impoverished neighborhood of West Point, Liberia; see Klibanoff, 2014), there is wide consensus that decision-makers should utilize the least restrictive measure that is compatible with protecting the public’s health (Presidential Commission, 2015). Whenever possible, such measures should be voluntary, but in all cases they should be implemented with due process protections, such as reasonable notice and the right to appeal.
The third moral dilemma that emergency planners should address, ideally in cooperation with professional associations, is the scope of health care workers’ obligation to provide care during emergencies. Society generally expects health professionals to provide assistance as a matter of social contract or professional duty (Wynia, 2007b), and there is broad ethical agreement that providers’ responsibility increases with patients’ needs, providers’ proximity and capability, and lack of other providers (Larkin, 2010). (p. 771) Nevertheless, providers have “no duty to disaster martyrdom” (Larkin, 2010, 68), and their duty to care should be balanced against the personal risks associated with any given emergency. As the SARS and Ebola outbreaks demonstrated, health care workers exposed to infectious diseases may acquire the infection, cross-contaminate their families, and even become victims of the outbreak themselves. In addition to assuming “greater-than-ordinary” health risks (Capron, 2007, 163), providing care during emergencies may expose health care workers to legal risks, particularly when confronted with tragic choices that depart from the standard of care (Fink, 2009). For those reasons, it is essential to have an explicit agreement between emergency planners and health care workers regarding the scope of providers’ responsibility. At the same time, planners should consider what society owes providers who assume personal risks to advance population health. Policies such as preferential access to countermeasures, immunity from liability under certain circumstances, and hazard pay demonstrate that emergency response is a collective undertaking.
The chapters in the Emergency Preparedness and Response section of The Oxford Handbook of Public Health Ethics introduce and consider the ethical challenges associated with planning for and responding to three types of public health emergencies: biosecurity threats, natural and industrial disasters, and pandemic disease. “Biosecurity and Public Health Ethics Issues Raised by Biological Threats,” by Nicholas Evans and Thomas Inglesby, examines the ethical issues associated with government efforts to prevent and mitigate serious biological threats. As a primer to biosecurity, the authors explore the moral distinction between deliberate biological attacks, which are the primary focus of the chapter, and other biological threats, such as pandemics. Because biological attacks have implications for public health and national security, ethical norms from both fields are critical in assessing government actions aimed at preventing and responding to such attacks. To account for the range of values at stake, Evans and Inglesby propose a pluralistic framework that emphasizes utility, fairness, and liberty, as well as the security of those fundamental values. They then illustrate the various ways in which those values are challenged at three critical times: before a crisis, during a crisis, and after a crisis. In the process, the authors consider circumstances, such as the allocation of scarce resources, in which two or more values are in conflict, and they suggest avenues for addressing such situations.
“Natural and Industrial Disaster Events, Public Health, and Ethics,” by Elizabeth Fenton and Dan Hanfling, highlights the human vulnerability at the crux of large-scale disasters. While everyone is vulnerable to disaster events, certain subpopulations are disproportionately at risk of adverse outcomes, such as people with cognitive and physical disabilities who depend on others. Focusing on natural disasters (e.g., storms, flooding, droughts, and earthquakes) and industrial disasters (e.g., human-made or technological hazards like toxic waste and nuclear radiation), Fenton and Hanfling draw (p. 772) attention to “geographic vulnerability.” They employ this term to describe the special vulnerability to physical hazards that people of low socioeconomic status experience as a consequence of where they live and work, as is the case for those living near a hazardous waste facility. The authors contend that those involved in emergency preparedness and response have an ethical obligation—grounded not only in the principles of social justice, equity, and reciprocity, but also as a matter of civic practice—to include all vulnerable populations in the planning process, ensure their safety during a response, and establish sufficient public health capacity to reduce systematic health disparities over the long term.
“Pandemic Disease, Public Health, and Ethics,” by Maxwell Smith and Ross Upshur, discusses ethical challenges involved in planning for and responding to pandemics. Although every pandemic is different, the authors note that most pandemics pose a common set of moral dilemmas related to resource allocation, public health interventions, the scope of health care workers’ duty to care, conducting research during pandemics, and global governance. Smith and Upshur examine the ethical issues that arise in each of these contexts, and consider prominent ethical frameworks developed to address these issues. Drawing on recent pandemic responses, however, they observe that the global health community remains ill-prepared for future pandemics. People living in countries with inadequate public health and health care infrastructure, for example, are especially vulnerable to pandemics. Smith and Upshur therefore urge global actors to not only strengthen outbreak capacity, but also to invest in health care systems in the worst-off countries.
Together, these chapters suggest that, in the context of public health emergencies, ethical preparedness is as important as scientific or technical preparedness. Advance planning, as Alexander Capron (2007, 174) has remarked, is “the key to an ethically responsible and appropriate” response.
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