© 2011
The Ethics of Disasters Policy and Practice
Sarah Clark and Albert Weale
Author contact:
Sarah Clark
Department of Political Science
School of Public Policy
University College London
29/30 Tavistock Square
London
WC1H 9QU
This material was written as part of a programme of work for an ESRC research project entitled
‘Social Contract, Deliberative Democracy and Public Policy’ (RES-051-27-0264). This support
is warmly acknowledged.
Workshop on ‘The Ethics of Disasters Policy and Practice’
Thursday, 26 January 2012; 9.30-14.30
Venue: Mary Ward House,
5/7 Tavistock Place London WC1H 9SN
Organisers: Albert Weale and Sarah Clark, UCL School of Public Policy
Contact: Sarah Clark
Email s.l.clark@ucl.ac.uk; Tel. 07981130302
Pre-Workshop Pack
Contents
1. Aims of the workshop
2. Outline programme
3. Ethical dilemmas: issues, examples and questions
A.
Issues of priority setting: dilemmas of equal treatment
B.
Issues of quality I: dilemmas of compromising standards in emergency
situations
C.
Issues of quality II: dilemmas of standards and cultural difference
D.
Issues of responsibility: dilemmas of action and non-action
4. Delegate list
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1. Aims of the workshop
The ethical issues around disasters are numerous: this is a very large and varied field with
challenging ethical problems occurring at many different levels and in multiple types of
scenarios.
The primary purpose of this workshop is to provide an opportunity to hear participants’
views and experiences of the issues and to promote discussion, with the aim of better
understanding the relevant ethical dilemmas from the perspective of practitioners.
As you will no doubt be aware, there are a number of sets of ethical guidelines which
apply to this area, for example the Sphere Standards. However, the approach we would
like to take is bottom-up. We think that progress is likely to be made by reflections on
the experience that people have had in facing hard ethical questions.
We do not aim to resolve the issues! However, we hope that by building up a ‘casebook’ of interesting and important problems, and bringing ethical analysis to bear on
them, we can improve understanding of the problems, and feed that understanding in to
improving ethics and governance around disasters work.
Our idea is that good governance in this area should be substantially informed by practice
and genuinely responsive to the issues faced by practitioners. We hope that learning from
the workshop can be instrumental in this, and we would greatly value suggestions as to
practical ways in which the work might be carried forward, in particular by creating a
research resource that would help improve practice.
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2. Outline Programme
09.30
Arrivals and coffee
10.00 - 10.30
Start
Introductions, background and aims for the workshop
10.30 - 11.15
Discussion of ethical dilemmas: Issues of priority-setting
11.15 - 11.30
Coffee
11.30 - 12.45
Discussion of ethical dilemmas: Issues of quality and responsibility
12.45 - 13.15
Lunch
13.15 - 13.45
Discussion of ethical dilemmas: Issues of responsibility (continued)
13.45 - 14.30
Round up of themes and discussion of ways forward
14.30
Tea
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3. Ethical dilemmas: issues, examples and questions
The following material is largely drawn from thoughts and comments kindly contributed
by participants at the workshop, and based on their experiences of issues of policy and
practice in the context of disasters. It is by no means exhaustive, and does not seek to set
a specific agenda, but rather just to stimulate thought and to provide a starting point for
discussion.
Material has been edited with every attempt to remain faithful to contributors’ meanings,
but naturally we take responsibility for any mistakes or misinterpretations.
A) Issues of priority-setting: dilemmas of ‘equal treatment’
In the context of providing help to people in disaster situations, humanitarian principles
suggest that all people in need are equal and that assistance must be provided according
to need without discrimination on grounds of, for example, race, religion, politics or age.
By implication, priorities should be set strictly by need alone and, in doing this, they
should take into account particular vulnerabilities which contribute to need. However, in
practice, personnel in extreme conditions face acutely challenging decisions about who
receives what kind of help, and the following situations can arise:
i)
Strictly equal treatment sometimes does not lead to equal benefit - that is, to needs
being met equally.
For example, in a context where the disaster area is also one of conflict, one
contributor asked ‘do you "run with the devil"?’: if the UN has an agreement that
humanitarian aid will be distributed equally between warring factions, but one side
has significantly greater needs than the other, do you comply with the UN
requirement for equal treatment, given the possibility that not doing so may
exacerbate conflict? The contributor commented ‘When I didn't (comply) and tried
to take it all (the aid) to the most needy, the other side took the lot at gunpoint’.
ii)
The young are often prioritized over the elderly.
It is a common implicit assumption in disaster (and non-disaster) situations that
priority should be given to children. Some suggest this is on grounds that they have
simply had fewer years of life than older people and therefore fairness indicates that
they should take priority in order that they can have similar opportunities to people
who have already enjoyed long lives.
However, one contributor commented, ‘older people are rarely, if ever, given
specific consideration… we see this as discrimination and contrary to humanitarian
principles, but the instinctive feeling that children are more important is deeply
ingrained in humanitarians (and people in general) so how can we square this with
our other principles that everyone has a right to life and humanitarian assistance?’
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iii) Some people may be not only difficult and time-consuming to treat, but also less
likely to survive than others.
If the aim is to maximize the benefits that can be provided to all of those affected,
spending a great deal of time and resources on a small number of people may seem
ill-advised. However, if all needs are to be met equally, then needs which demand
intensive effort and resource must be given equal priority with needs which can be
more easily met, even if that means fewer needs are met overall.
For example, issues have been raised about the discriminatory nature of some
disaster triage systems in relation to people with disabilities: the US Sequential
Organ Failure Assessment (SOFA) protocol evaluates patient health status and
suggests that patients below a certain SOFA score are not eligible for ventilator
support in times of scarcity, and that the duration of the period of care on a ventilator
must be limited in order to meet the needs of as many people as possible. This
arguably discriminates against those with disabilities involving breathing difficulties
- some have commented that ‘natural disasters are realized disproportionately as
human disasters for disabled people’ (Wolf and Hensel, 2011). But if ventilators are
in short supply, how should their use be allocated?
iv)
To what extent should people on the ground obey rules set down by, for example,
the UN, if those rules seem to rule out meeting legitimate need appropriately?
For example, one contributor commented about being involved in medical
evacuation but having concerns about the UN approach of deciding which conditions
qualified for evacuation and which did not, rather than setting priorities but allowing
for flexibility on the ground.
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B. Issues of quality I: dilemmas of compromising standards in emergency situations
Achieving the standards of quality and excellence to which professionals work in nondisaster circumstances may be very difficult in extreme conditions. The reality may be
that delivering services or care that is clinically excellent by ‘normal’ standards means
that very few people would be assisted in the context of a disaster. There are practical
issues of professional competence, of variability of practice across foreign teams and of
accountability here. However, some particularly difficult ethical issues arise around the
following:
i)
How far it is acceptable to compromise quality standards in an emergency
response situation, if we are to reach as many people as possible?
If there has to be a compromise in standards, how do we decide what is acceptable or
justifiable practice and what is not? Is practice that would be considered substandard in ‘normal’ circumstances acceptable in the context of disasters, given the
exceptional challenges? For example:
ii)
•
There has been a debate in emergency nutrition between those who say that
clinical excellence is best achieved by taking mothers and infants into
therapeutic feeding centres where high quality care can be provided, and those
who advocate a community therapeutic care approach based on home-feeding,
where the quality of nutrition is lower but where many more people are reached.
•
Rehabilitation for amputees would be routinely provided in the UK, but there
may not be capacity to do it when all resources are focused on emergencies:
providing rehabilitation may dramatically improve amputees’ quality of life, but
it may reduce capacity for meeting short term need.
•
Similarly, in ‘ordinary’ circumstances, patient follow up is considered to be a
vital part of care, but in emergency situations, doing this means less time for
seeing patients who have not yet been treated. Is it ever acceptable for
rehabilitation work or patient follow-up not to be carried out in a disaster
scenario?
•
Is it acceptable for medical personnel to work beyond their abilities - for
example, performing procedures of which they have no experience and for
which they are not qualified - if they are the only people available?
How should the balance be struck between values of quality and efficiency on the
one hand, and capacity building and/or sustainability on the other?
For example, should speed and efficiency dictate that locally sourced medicines be
used even if they may be of lower quality? Should agencies always use local
building materials (better from the perspective of capacity building) even if it is
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slower and less efficient to obtain them in an emergency situation, and if they are of
lower quality and therefore less sustainable in the long term?
Conversely, should high-tech, highly effective equipment be installed to provide
short-term benefits, even if there are negative effects in the long term? For example,
air conditioning units have been shown to provide a strong protective effect during
extreme heatwaves, but their use is environmentally unsustainable and creates a
negative feedback loop: they raise carbon emissions and potentially add to global
warming, thereby increasing the risk of future extreme heat events.
iii) Is it acceptable to opt for the short-term easiest option if it will help more people,
more quickly, even if it leaves problems in the long term?
As one contributor put it, is it acceptable to ‘do what you can do (and do it now),
rather than wait and do what you should do?’
For example in Haiti, cities of temporary shelters were built with little planning and
in some cases on disaster-prone land. Possible reasons for this are that NGO
agencies had the skills and donor funding to build temporary shelters rather than
permanent structures, and because it was a way around inadequate land tenure
documents and avoided the risk of conflict with local authorities. Is it ethical to take
this kind of quick and easy option in the short term, when in the medium and long
term it may be worse than doing nothing for as long as it takes to work out how to
achieve a more sustainable and development-orientated intervention?
iv) How justifiable is it in disaster situations to spend time and resources on activities
related to data gathering and research which may improve the quality of future
practice and outcomes but impinge on the ability to relieve suffering in the
present?
For example, many think it essential that the experiences, lessons and successes of
disaster preparedness and response are written up and published so that future
policies and practices can be improved. Documenting these experiences accurately
may mean gathering data in the immediate aftermath of a disaster. There have been
conflicts between medical practitioners in the field about this: some believe that all
efforts should be put into responding in the aftermath of a disaster, and that research
activities are not a priority.
In another example, photographs and film footage are very valuable for record
keeping. However, in certain situations the relationship between patients and health
workers could be made more difficult by taking photos, since some authorities
regard photography as a way of publicising their failings. This can negatively
impact on the relationship between humanitarian responders and the host country and therefore ultimately on patients. Furthermore, it can be difficult to obtain the
kind of consent for taking photographs of patients that would be required in the UK:
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is the potential harm of showing disrespect to patients and ignoring confidentiality a
price worth paying if it leads to better documentation from which learning can be
taken and future practice improved?
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3. Issues of quality II: dilemmas of standards and cultural difference
Standards of practice in many areas relevant to disasters, for example medicine and
construction, may vary widely across different countries. Some local cultural practices
may also conflict with ‘liberal’ approaches to fairness and equality. To what extent
should interventions be adapted to fit local circumstances and preferences? For example:
i)
How far should foreign medical personnel adapt their practice to local practice?
For example, in the UK sedation and pain relief would always be given to children
for painful procedures including dressing changes, but in other countries this is not
always common practice. The use of opiates in particular, and pain relief in general
does not always cross cultural boundaries and patients may be expected to suffer a
level of pain that would be considered unacceptable in the UK.
What should be done in a situation where a foreign team is managing local medical
staff who do not work to the standards of the foreign team, but rather to the
standards of local practice? Should the local medical staff be required to work to,
for example, UK standards in their own country?
ii)
How far should foreign development agencies impose their standards for following
official protocols in disaster zones, against the practices and preferences of local
populations?
For example, following official government processes in seeking planning
permission in creating disaster-resilient infrastructures, may not only significantly
slow the process of development, but also go against the practice and preferences of
local people who do not follow official processes, perhaps regarding the relevant
authorities as corrupt, discriminatory or autonomy-limiting. On one hand it could be
thought important from the perspective of government capacity building for agencies
to engage in official processes. However, on the other hand, it could earn distrust
from local people, and even empower politicians complicit in making their
populations vulnerable to the effects of disasters.
iii) Should liberal standards of fairness and equality be imposed in order to meet all
needs equally, even if that runs against (reasonable) local cultural practices?
Some have noted a disconnect between external and local definitions of vulnerability
and therefore disparities about who - if anyone - is thought to deserve targeted
assistance. This can lead, for example, to widespread sharing of targeted food or
medical assistance such that everyone gets something even if that means no-one gets
very much, or so that men receive most of the aid because they are seen as central to
the survival of families (Jaspars and Maxwell, 2008). To what extent should these
community/communitarian practices be accepted and/or facilitated by the policies
and practices of ‘western liberal’ organizations?
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4. Issues of responsibility: dilemmas of action and non-action
Whilst it seems obvious that we need to act in response to disasters, there are nonetheless
very important questions around issues of responsibility for action and non-action. Within
this, there are commonly thought to be a range of ‘duties’ which recommend or limit
action, for example duties to assist those in need, duties to ‘do no harm’, and duties to
protect the vulnerable. However, the need to determine who is responsible for what
precedes any action or performance of a ‘duty’. Some questions that arise in connection
with issues of responsibility are as follows:
i)
Who is responsible and where is the locus of responsibility for different types of
action? How wide do the limits of responsibility stretch?
How do we assign obligations to act, given the vastly different and complex levels
and areas of responsibility, and the number of actors - local, regional, global involved in disasters planning, policy and practice? One recent report uses the
phrase ‘common but differentiated responsibility’ referring to the need for shared
overall responsibility but where specific actions are clearly assigned to different
agents (Cox and Max, 2011).
In terms of the limits of responsibility, for example, there are issues about UK
medical staff being released from the NHS for short term deployments in disaster
zones. Currently, staff must take annual leave to do this. Should the NHS as an
institution be willing to release some of its staff to assist in disasters on a nonannual leave basis? That is, what responsibility do relevant UK institutions have,
and is it such that they should bear some cost in performing those responsibilities?
ii)
When is it justifiable to assign culpability to people who performed their
responsibilities, but did so ineffectively or with bad consequences?
For example, the geophysicists who failed to predict the L’Aquila earthquake in
Italy were prosecuted as a result. Japanese geophysicists seriously underestimated
the magnitude of the Tohoku earthquake and tsunami in their hazard assessments,
which meant that people were evacuated to areas which were devastated by the
tsunami. Should the Japanese geophysicists be prosecuted too?
In a different context, should development agencies who build structures from
poor quality local materials be held responsible if those structures fail to hold up
well in another disaster, even though, from another perspective, buying local
materials could be seen as acting ethically by supporting local markets?
iii)
When is it right not to act?
In some professional codes of conduct the first principle is ‘do no harm’. This
implicitly recognizes that benefits and harms are not of the same value, hence it is
always better to avoid a harm than to gain a benefit of the same value (Cox and
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Max, 2011). The precautionary principle in some ways ‘backs up’ the injunction
to do no harm, but where decisions have to be made quickly and in highly nonideal circumstances with inadequate information, weighing up the severity and
likelihood of risk (the two elements of the precautionary principle) may be very
challenging.
Our choice may be between two apparent harms, rather than a clear harm and a
benefit: how should we judge the lesser harm, especially in circumstances of
uncertainty? For example:
•
If foreign agencies intervene with food aid to ameliorate malnutrition in a
post-disaster area where the government has the capacity but is failing to
act, does the agency effectively alleviate the government from its rightful
responsibilities, therefore fostering a ‘harm’ in the shape of ineffective
government whilst working to avoid the harm of malnutrition amongst its
population?
•
Similarly, in conflict situations, one contributor asks ‘do external ‘neutral’
forces effectively relieve warring factions of the responsibility to deal with
the consequences of their actions, and so prolong the war?’
•
Another contributor offers the following example: ‘I was running an
emergency field hospital for an IDP camp housing 350,000 people in a
post conflict situation. The monsoon rains created regular flooding and we
had limited access to patients due to strict military control. We had a
Memorandum of Understanding with the Government that stipulated we
could not contact international press about what was happening: if we
breached these rules we would be asked to leave the country. We were one
of only a handful of organisations that had permission to work in this
camp. We faced a difficult decision about the risks of communicating
what was happening to the international community on the one hand, and
maintaining a presence, continuing health care and not jeopardising the
safety, health and security of both our staff and patients on the other.’
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4. Delegate List
Name
Organisation
Role
Ayesha Ahmad
Tutor
Mark Bulpitt
University College London
Medical School
World Vision
Katie Carmichael
Health Protection Agency
Kate Crawford
Sarah Clark
Carolyn Johnston
University College London
Kings College London
Justine Lowe
Imperial College Hospital
Niddhi Mittal
Save the Children
Virginia Murray
Linda O’Halloran
Marcus Oxley
Christopher Potter
Anthony Redmond
Health Protection Agency
Thinking Development
(UCL)
Medicins Sans Frontier
Disaster Bioethics project at
Dublin City University
School of Nursing and
Human Sciences
Disasters Network
NHS Wales
University of Manchester
Mark Salter
Health Protection Agency
Peter Sammonds
Emily Speers-Mears
UCL Institute for Risk and
Disaster Reduction
Save the Children
Frances Stevenson
Jo Wells
Dan Walden
HelpAge International
HelpAge International
Save the Children
Albert Weale
University College London
Simon Heuberger
Dónal O’Mathúna
Head of humanitarian emergency
affairs
Environmental Public Health
Scientist
Independent Consultant
Research Associate
Advisor in Medical Law and
Ethics
Consultant Anaesthetist and
RCOA College Tutor
Climate Change Adaptation
Advisor
Head of Extreme Events
Founder of ‘Thinking
Development’
MSF Association Co-ordinator
Head of Disaster Bioethics
Project
Director
Director of Public Health
Professor of International
Emergency Medicine; Deputy
Director
Humanitarian and Conflict
Response Institute
Consultant in Communicable
Disease Control
Director
Senior Conflict and Fragile States
Advisor
Head of Emergencies
Humanitarian Policy Manager
Disaster Risk Reduction Policy
Advisor
Professor of Political Theory
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