Ethics and Public Health
How Public Health Reacts
Ethically in a Disaster
South Central Public Health
Advanced Crisis Leadership Institute
March 11-14, 2007
New Orleans, Louisiana
By John R. Wible, General Counsel
Alabama Department of Public Health
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Outline
► Setup
and Introduction
► Action Principles
► A Quick Ethical Problem
► Sources of Personal Ethics
► Professional Ethical Principles
► The Eye of the Storm – Application
► An Ethical Exercise
► Epilogue
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Dire Ethical Straits
► Hurricane
Katrina
 the people have left the building
► Pandemic
Influenza
 the “new and improved disaster”
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Question from CDC
► What
objectives and principles should be
considered in pandemic vaccine prioritization?
► What is the relative importance of the CDC goals?
► Which population should have vaccine priority?
► What is the rationale?
► How can fairness, equity, efficiency and related
principles be reflected in the determination of
priority groupings?
► Who
should determine the answers?
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An Ethical Person
► Are
you and ethical person?
► From where or whom did you learn your
ethical principles?
 Hint: “Yo Mama”
► “All
I Ever Needed to Know,
I learned in Kindergarten”
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Our Purpose
The purpose of this presentation is to ask you
a lot of questions and help you discover the
answers from within yourself so that
ultimately, you will be able to make
decisions that will allow you to go about
living outside yourself.
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The Pareto Principle
► The
“80-20 Rule” revisited
 10% basically ethical
 10% basically unethical or “aethical”
 80% wandering somewhere in the
middle
► The
ethical job of the manager
 Differentiate the animals
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A Personal Aside - You
► Who
helped shape your ethical principles
and how?
► What did he or she teach you?
► What do you think is the most important
ethical principle of them all and why?
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Group Ethical Questions
► What
are some universally accepted ethical
concepts?
► Where did they come from and how do we
learn them as individuals?
► How does each of us develop his own set of
ethical principles?
► Do we view those as static or sliding?
► What is the price of each of us? (For how
much would you sell out?)
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John’s Five Action Principles
► The
“No Delta Principle”
► To tell the truth, the whole
truth and nothing but the
truth
► “We’ll Sing in the Sunshine”
► Be a Square
► It’s not about me.
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An Ethical Problem at St. Elsewhere
► Multitudes
presenting with flu-like
symptoms
► Resources and staff exhausted
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The Characters
 Annie Cavanero - graduate
 Cathy Martin, RN
 Ben Samuels – autistic boy
 Wayne Fiscus - policeman
 Unknown homeless man
 Peter White - janitor
 Helen Rosenthal – survivor
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Ethics Questions Presented
► Triage:
 How to sort patients to determine priority for
treatment?
 What criteria will be used?
 Who will develop those criteria?
► Staff
Participation:
 Are healthcare workers obligated to work during
an influenza pandemic?
 What can be done to increase staff participation
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Sources of Personal Ethical Principles
► Religious





teachings
Hindu
Buddhism
Judaism
Christianity
Islam
► Cultural
teachings
-American Historical Documents
 Declaration of Independence
 United States Constitution
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Religious Teachings - Hindu
► Oldest
practiced religion
► Dharma – the “right way of living”
or “proper conduct” for each societal
segment
► To live in accord with the principles is to move
more quickly to personal liberation
► Hindu writing
 Acara – daily caste-centered rituals
 Vyavahara – rules about doubt and substantive law
 Prayascitta – penance for rules violations
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Yogic Teachings from the Hindu
Yamas
Moral Restraints
Niyamas
Moral observances
Ahimsa
- do no harm
Saucha
- cleanliness
Satya
- do not lie
Samtosha - contentedness
Asteya
- do not steal
Tapas
- perserverance
Brahmacharya - moderation
Svahhyaya - self-study
Aparigraha
Ishvara pranidhan
-do not hoard
- surrender to the higher being
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Buddhism
“Any person who has awakened from the
‘sleep of ignorance’ by directly realizing the
true nature of reality is called a buddha
Siddhartha Gautama, the Buddha, was the
most notable
Life is full of pain, the ultimate goal is to
break the cycle, become ‘enlightened’ and
reach Nirvana.
Thus, one lives a holy life
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Buddhism- Four Noble Truths
The nature, cause and cessation of suffering
The way to cessation of suffering is the
“The Eightfold Path,” foundation of ethics found in
three divisions: bodily actions, conscious thoughts
and unconscious thoughts
Right speech, actions and livelihood (do no harm)
Right effort/exercise to improve
Right mindfulness/awareness – seeing clearly
Right concentration -thoughts and understanding
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Judaism
Ten Commandments1
You shall have no other gods before Me
You shall not make for yourself an idol
You shall not make wrongful use of the name of
your God
Remember the Sabbath and keep it holy
Honor your parents
You shall not murder
You shall not commit adultery
You shall not steal
You shall not bear false witness
You shall not covet your neighbor's wife
You shall not covet your neighbor's house...
1
Note: The Torah counts 613 “Commandments”
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Christianity
Jesus said, “ I came not to abolish
the Law, but to fulfill it,” thus
reaffirming the right conduct of the Decalogue.
 Jesus says “righteousness” must be internal, not
external; conduct is more than negative, it places
affirmative duties to actively do good even to
those who harm you.
 The “Golden Rule” – “Do unto others as you would

have them do unto you” or ”love thy neighbor as
thyself.”

Summary: “Love God and love man.”
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Christianity
The Apostle Paul says, to reach God, one
must be righteous, but man is not righteous
by nature, thus a spiritual dilemma
 Paul tells us that it is by taking on the “mind
of Christ” that we can be made righteous
and thus reach God.

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Islam
Mohammed saw a society on a “slippery
slope” to destruction with the loss of
traditional values
 Doctrine is based on four sources:

the Qur'an,
the sunnah (“traditions”)
 ijma' (“consensus”)
 ijtihad (“individual thought”)

Its chief goal is the establishment of a
“faithful” society by following the
“Straight Path”
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Values Sought in the Quer’an
Values Sought
 Brotherhood in place of
blood relationships
 Fidelity and chastity in
place of indecency
 Humility
 Charity towards widows, orphans and poor
 Justice to neighbors
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American Historical Documents
► Declaration
of Independence
► United States Constitution
1776
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Declaration of Independence
► Jefferson’s





sources:
John Locke
Algernon Sydney
Other Continental writers
Thomas Ludwell Lee
Benjamin Franklin
► Edited
by the Committee
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What it Did and Didn’t Do
► Set
forth the “self evident truth” such as
“equality”
► Established an ethical basis for
independence
► What Locke applied to individuals, Jefferson
applied to a people – John Adams
► Did not condemn the British people
► Did not address address African slavery
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“Self-Evident” Truths
men are created equal” (Really?)
► Endowed by their Creator
► “All
 Life
 Liberty
 Pursuit of happiness
► Modern
Comparisons
 Life becomes “human dignity’ in UN Charter
 Life becomes “personal autonomy” in Belmont
Report
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The Declaration’s
Purpose for Government
. . To secure these rights, governments
are instituted among men . . .
deriving their power from the consent of
the governed . . .
to effect their safety and happiness.”
► As an institution of government, public
health has a role in securing these rights
► “.
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United States Constitution
“We the People of the United States, in Order
to form a more perfect Union, establish
Justice, insure domestic Tranquility, provide
for the common Defense, promote the
general Welfare , and secure the Blessings
of Liberty to ourselves and our posterity, do
ordain and establish this Constitution for the
United States of America.”
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Constitutional Principles
► “We,
the People” – social contract theory of
government based in personal autonomy
► “Establish justice” –
 Equity
 Equality
 Fair process
► “Insure
Domestic Tranquility” – peace
► “Promote the General Welfare”
– the sum of it all
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Summary of Personal Ethics
Right living
Do no harm
Do not lie
Do not steal
Do not hoard
Moderation
Cleanliness
Contentedness
Perseverance
Self-study
Higher Being
Right Speech
Right Actions
Right livelihood
Right effort
Effort to Improvement
Right mindfulness
Awareness
Right Mental thought
No gods/idols/swearing
Sabbath keeping
Honor parents
Do not murder
Do not commit adultery
Do not steal
Do not lie
Do not covet
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†Golden Rule
†Love God/Love man
‫ﺶ‬Brotherhood
‫ﺶ‬Fidelity/chastity
‫ﺶ‬Humility
‫ﺶ‬Charity
‫ﺶ‬Justice
Equality
Life
Liberty
Happiness
Government
Social contract
Equity
Fair process
Peace
General welfare
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Professional Ethics
► The
Hippocratic Oath and Medical Ethics
► Augustine’s “Just War”
► Nursing Ethics
► The Belmont Report and Institutional
Review Boards
► The Public Health Code of Ethics
► Public Officer and Employee Ethics Laws
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The Concept of Death
Is the causing or allowing of death
always ethically bad?
 Cain and Abel
 Instructions to wipe out the people
of Canaan
 Lex talionis, cities of refuge and the
“Avenger of Blood”
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Common Law Justifications
for Causing Death
► State
Sanctioned Execution
► Defense of Self or Another
► Augustine’s “Just War”





Lawful authority
Defensive in nature
Proper motive
Carried out by legitimate government
proportional
► Modern
Rules of Warfare
– Geneva Conventions
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Oath of Hippocrates – Medical Ethics
► “Primum
non nocere” – first do no harm
► Always look to the good of the patient
► Place a high value on human life
► Perform only within one’s training and skill
► Refrain from improper relations with patient
► Maintain patient’s secrets inviolate
► Do not violate community laws or morals
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Summary of Medical Ethics
• Non-maleficence, doing no harm;
• Beneficence, doing what is best for
the patient;
• Autonomy, allowing the patient the
informed right to choose
• Justice, treating everyone alike
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Medical Ethics in a Disaster
AMA Policy Statement E-9.067
► There is a duty to provide urgent care
► The physician workforce is not unlimited
► Therefore, balance is required
 Live to fight another day
 Are physicians required merely stay and not run away
 Or to volunteer to come back in and help?
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Some Canadian Thought
► The
ability of physicians and health care workers
to provide care is greater than that of the public,
thus increasing their obligation to provide care
► By freely choosing a profession devoted to care for
th ill, they assume risks
► The profession has a social contract that calls on
members to be available in times of emergency
► Equated with police officers and fire fighters
 Note: They largely work in publicly supported systems
in many countries (remember these are Canadians
writing this report.)
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Nurse’s Ethics in Providing Care
► Provide
care in a
“non-discriminatory manner
► There are limits to the amount
of personal harm required to risk
► Cannot abandon a patient
► Personal risk may depend on the individual
condition of the nurse
► A “sacred duty”
 American Nursing Association – December 1994
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Nurses Criteria for Limits
► The
client is in significant risk of harm . . .
if the nurse does not assist
► The nurse’s intervention is directly relevant
to prevent harm
► The nurse’s care will probably prevent harm.
..
► The benefit the client will gain outweighs
any harm the nurse might incur and does
not present more than an acceptable risk to
the nurse
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Researchers Ethics
► The Tuskegee Experiment –
► Tuskegee by the numbers:









“Bad Blood”
600 men in the study
399 infected with syphilis and untreated
201 without syphilis
100 dead of causes “related to” syphilis
74 men survived
40 wives contracted syphilis
19 children born with congenital syphilis
9,000,000 dollars paid out in direct damages
1 good result – The Belmont Commission
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The Belmont Commission Studied:
► The
boundaries between biomedical and
behavioral research and the accepted and routine
practice of medicine,
► The role of assessment of risk-benefit criteria in
the determination of the appropriateness of
research involving human subjects,
► Appropriate guidelines for the selection of human
subjects for participation in such research and
► The nature and definition of informed consent in
various research settings
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Other International Works
Code – ex post facto guidance to
judge WWII Nazi war criminals
► Nuremberg
 Boundaries between research
and practice
 Ethical research
 Ethical practice
► Declaration
of Helsinki (1964)
 Informed consent as the ethical standard
 “Surrogate” consent defined and allowed
 Research should only be performed when “necessary to
promote the health of the population represented”
 Laid the foundation for the establishment of IRBs
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The “Common Rule”
(Based on the Belmont Report)
► Established
boundaries between research
and practice
► Defined ethical practice based on three
principles to include:
 Respect for persons
 Beneficence
 Justice
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Respect for Persons
► People
are treated as autonomous agents
► Protection for those of diminished capacity
► Informed consent defined
► Period reviews of status of subjects required
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Beneficence
► Look
out for the “broader good” of the
subject
► Do no harm
► Balance the risks against the benefits
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Justice
► Applies
the allocation of risk or
burden to benefit to the subject
and to the proposed benefited population
 Are these welfare patients,
 from a particular socio-economic or ethic background,
 confined populations such as prisoners
► Formulations
for distributing benefits and burdens:
 to each person
 to each person
 to each person
and future
 to each person
an equal share,
according to his or her need,
according to societal contributions past
according to (perceived) merit
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Application
► Informed,
knowing consent
► Detailed risk analysis with varied elements





physical,
psychological,
legal,
social
economic
► Detailed
and fair subject selection criteria
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Special or Confined Populations
Are they really “volunteers?”
► Soldiers or service people
► Prisoners
What issues would this raise?
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Public Health Code of Ethics (2002)
► Health:
“a state of complete physical,
mental, and social well-being, and not
merely the absence of disease or infirmity.”
 Preamble to the Constitution of the World
Health Organization as adopted by the
International Health Conference, New York, 1922 June 1946, and entered into force on 7 April
1948.
 As affirmed by the Code
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The Code’s Twelve Principles
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Addresses fundamental causes of disease,
aiming at prevention.
Respects the rights of individuals in the community.
Utilizes community input to develop policies, programs, and
priorities.
Advocates “empowerment” of disenfranchised community members.
Seeks the information needed before acting.
Provides the community with information to make decisions.
Acts in a timely manner on the information.
A variety of approaches anticipate and respect diversity.
Programs and policies to enhance the physical & social environment.
Confidentiality - Exceptions must be justified.
Professional competence.
Work collaboratively to build the public's trust.
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Public Health Values
►
Reaffirms the Declaration of Human Rights
 Everyone has the right to a standard of living adequate for the
health and well-being of himself and his family
Humans are inherently social and interdependent,
thus the principle of “community
► Community is perpetually balanced as against the rights of
the individual
► Public trust and transparency
► People and their environment are interdependent
► Upheld by the science of prevention
► Appropriate gathering, use and dispersion of knowledge
► The Code requires action
►
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Public Officer and Employee
Ethics laws
No public official or public employee shall use or cause to be
used his or her official position or office to obtain personal
gain for himself or herself, or family member of the public
employee or family member of the public official, or any
business with which the person is associated unless the
use and gain are otherwise specifically authorized by law.
Personal gain is achieved when the public official, public
employee, or a family member thereof receives, obtains,
exerts control over, or otherwise converts to personal use
the object constituting such personal gain
 Code of Ala.1975, § 36-25-5
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Nature and Scope
of Public Ethics Laws
► Very
narrowly constructed
and construed
► Contrasted
with the broad
sweep of professional codes
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Summary – Professional Ethics
►
Death
acceptable
Do no harm
Patient first
Value on life
Proper relations
Confidentiality
Follow law &
morals
Duty to care
Balance
Not discriminate
Not abandon
“Sacred duty”
►Respect person
►Beneficence
►Justice
Individual rights
Community
Empowerment
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Use Information
Timeliness
Diversity
Confidentiality
Collaboration
Competence
Public trust
Interdependence
Not abuse public
position
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-The Eye of the Storm-
What Really Happens in a Disaster
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So, what really happens?
► How do people’s relationships change?
► Do people think and react differently?
► Are the consequences the same as if you
had
reacted “in the sunshine?”
► The “Outback Steakhouse Question,” are there
really “no rules?”
► How can you “rank” people in order or precedence
to receive vaccine, ventilators or treatment
according to ethical principles?
► Can you invoke “altered standards of care?
► What are the rights of staff to desert?
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Effects on Victims and Staff
Psychological, physiological and physiological Symptoms:
► Irritability or anger, blaming or denial, mood swings, fear of
recurrence, hyperactivity, feeling stunned, helpless, numb,
or overwhelmed;
► Loss of appetite and energy, headaches, chest pain, and
fatigue;
► Isolation, withdrawal, diarrhea, stomach pain, nausea;
► Increase in alcohol or drug consumption;
► Nightmares and inability to sleep;
► Concentration and memory problems;
► Sadness, depression and grief;
All leading to BAD CHOICES
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Are there Really No Rules
?
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Euthanasia
euthanasia ever an option for suffering
victims?
► What is it?
► Assuming the answer is “yes,” How would
you justify it?
► Is it a fair balance between individual rights
and the rights of society?
► Is
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A Seminal Case –
Jacobson v. Massachusetts
► Facts
 Rev. Jacobson refused to be vaccinated against
smallpox in Cambridge, MA.
 Fined $5.00 and appealed to the United States
Supreme Court.
► Question
presented for review:
 What are the limits of how far the state can go
to protect the public health?
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Jacobson Court held:
“The police power of state must be held to embrace, at least, such
reasonable regulations established directly be legislative enactment as
will protect the public health and safety. . . .The mode or manner in
which those results are to be accomplished is within discretion of the
state, subject, of course, that . . . no rule . . . or regulation . . . shall
contravene the Constitution of the United States, or with any right
which that instrument gives or secures.”
“The liberty secured by the Constitution of the United States to
every person within its jurisdiction does not import an absolute right in
each person to be, at all times and in all circumstances, wholly freed
from restraint. There are manifold restraints to which every person is
necessarily subject for the common good.”
Real liberty for all could not exist if each individual can use his
own, whether in respect of his person or property, regardless of the
injury that may be done to others. . . . Upon the principle of self
defense, of paramount necessity, a community has the right to
protect itself against an epidemic of disease which threatens
the safety of its members.”
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Summary of the Holding
The Court found this a
legitimate use of state
powers and established
a floor of constitutional
protections that
consists of four
standards:
► Necessity
► reasonable means
► Proportionality
► harm avoidance.
Are the secured rights
“fundamental?”
►If “no,” the state may
impose limits “reasonably
related to a legitimate
state interest”
►If “yes,” the rights
cannot legally be violated
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This brings up the question of “No”
Authorities, citing the experience at Memorial
Hospital in New Orleans – short of a
pandemic – your worst case scenario and
Supreme Court authority . . .
► Advises that in the question of whether
euthanasia is an option, the answer is “no,”
► Euthanasia is never an option
► (Unless it is the end of the world as we know it and it
doesn’t matter)
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Let’s Just Let them Eat Cake*
OK, so we can’t “depopulate” the victims, can
we just let them die – a philosophical
interlude: Utilitarianism vs. Egalitarianism
* Quote from Marie Antoinette
some time before her execution.
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Utilitarianism vs. Egalitarianism
►
►
►
Jeremy Bentham’s theory of
utilitarianism (consequentialist ethics)
assesses what is right or good based
on whether the consequences of the
actions to be taken will be good
Immanuel Kant’s deontology theory
(principlism or egalitarianism) focuses
on non-consequentially based notions
of good - deciding what is right or
good is based on meeting duties and
obligations
These contradistinguished ideas will
clash over and over
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History of Triage
►
►
►
►
►
The term, Triage, (to sort out) was a French
military medical term based on the Benthamite
utilitarian principles or trying to achieve the most
good for the most people
It has been adapted to modern military and civilian
medicine
Originally, triage grouped casualties into four groups based
on care needed and typically in this order: immediate,
minimal, delayed and expectant.
The use of triage must be done without regard to rank,
age, race, social worth or income or such distinction
It is thus based not on the social worth of the individual,
but on societal need
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Modern Disaster Triage
► In
disasters there is a switch
from standard medical ethics
with the primary focus on
Individual autonomy to an ethics of public
health with a primary focus on the health of
the community
► The
overarching goal is to minimize
morbidity and mortality during the
pandemic (according to CDC)
► Will it be most good or greatest need?
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Utilitarianism Says:
► The
goal is to help those for whom you can
do the most good following the longestablished standard in military medicine
► Advantages: follows a clear, simple,
community-recognized goal in a potentially
chaotic environment
► Disadvantages: situations will arise with no
clear utility-based answer that may lead to
“unintended, insidious discrimination”
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Egalitarianism
to help those in greatest need
► Ranks patients based on severity of illness,
with patients in the most severe condition
receiving the medical attention
► The ultimate goal such as limiting morbidity
and mortality during the pandemic is deprioritized in order to preserve the
egalitarian principles
► Goal:
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Hybrid Triage
► Uses
both concepts
 Utilitarian approach
 Egalitarian methods
► Requires
sorting out into 3-4 groups
► Treat those in the group before going to the
next lower group
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Examples of Methods
► CERT
training advises 3 groups: immediate,
delayed and dead
► SOFA’s four color sorting is based on organ
failure
► Current EMS (START) model has four colors
Delayed
urgent
immediate
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Current Hospital ED-Based Methods
►
►
►
►
►
Category 1: Need for resuscitation - patients seen
immediately, critically ill.
Category 2: Emergency - patients seen within 10
minutes. Critical illness or very severe pain.
Category 3: Urgent - patients seen within 30 minutes.
Severe illnesses, head injuries but conscious, and people
with major bleeding, persistent vomiting or dehydration.
Category 4: Semi-urgent - patients seen within 60
minutes. less severe symptoms or injuries.
Category 5: Non-urgent - patients seen within 120
minutes. Minor illnesses or symptoms.
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SERV Method for PI
► Current
methods do not address exposure,
duration or infectivity
► Do not address control of disease
transmission
► SERV method seeks a broad-based
“population control” method tied to the CDC
Pandemic Influenza phases
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Canadian Method
► Uses
components from several triage methods
► Uses a severity scoring system
► Includes four components:
 inclusion criteria – persons who may benefit
 exclusion criteria – those who won’t based on:
► Poor
prognosis
► Excess demand on resources
► Underlying advanced medical condition
 minimum qualifications for survival – limits resources
 color-coded prioritization system
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Ethical Responsibilities in Triage
► Plan
NOW! See “Bryant’s Rule”
► Establish a Triage Review Committee
 Plan
 Oversee
 Evaluate post-event
► Engage
the public in the discussion
► An experienced triage officer
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Altered Standards of Care
When it permissible from an ethical and legal
standpoint to provide less than the care
normally pr traditionally expected or held to
be what is referred to in both the medical
and legal professions as the “standard of
care”?
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Goals of Altered Standards
► To
maximize the number of lives saved.
► Changes will be necessary to allocate scarce
resources
► The basis for allocating health and medical
resources must be fair and clinically sound
► The process for making these decisions should be
transparent and judged by the public to be fair
► Protocols flexible and enough to change as the
size of a mass casualty event grows
► Staff concerns must be addressed pre-event
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Focus Change in Altered Standards
► Changes
from doing to best for each patient
to maximizing the most lives saved
► This will affect current patients already in
the hospital
► The scope of practice changes
► Equipment, meds and supplies rationed
► Record-keeping changes
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Ethical Considerations
aim is to keep the health care system
functioning and to deliver an “acceptable” quality
of care to preserve as many lives as possible
► The plan must be community wide
► There must be an adequate legal framework to
allow for the altered standards of care
► The rights of individuals must be protected to the
extent possible and reasonable under the
circumstances
► The public must be informed on planning and
decision making pre, during and post event
► The
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Legal Concerns of Altered Standards
How to make it legal:
► Change the laws at federal
and
state levels directly
► Change laws to allow for regulatory changes
► Consider pre-drafting emergency orders for
the Governor to sign in an event invoking
the altered standards of care
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CDC’s Plan for Rationing Vaccine
► CDC
scares us with their predictions
► The system of manufacturing vaccine is old
and tired
► CDC has devised priority groups with
subgroups
 Health care workers
 Public service workers
 High risk populations
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Ethical Look at the CDC Plan
►A
hybrid system
 Utilitarian goal
 Egalitarian execution
► Allows
for local input should the locals want
input
► Buck-passing and the failure to plan will be
a catastrophic ethical failure
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Rationing Ventilators
► The
American Association of Respiratory
Care has a recommended plan. Consider
one state’s draft plan to recommend to
hospitals
► Triggered by declarations by government
edit, activation of National PI Plan or local
hospital HEICS
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Ventilators -the Gist of the Plan
► Four
tiers based on respiratory failure
 Withhold ventilators starting with Tier 1
 Withdraw ventilators starting with Tiers 3 and 4
► What
would St. Augustine say?
► The same discussion applies to all such
allocations of medicines, supplies or
equipment
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More Help from Canada An Ethical Guide
Based on Toronto’s SARS experience, “Stand On
Guard for Thee” offers an Ethical guide in mass
events dealing with issues:
►Reciprocity
►Individual
liberty
►Protection of the public
►Proportionality
►Privacy
►Duty to Provide Care
►Equity
►Trust
►Solidarity
►Stewardship
What historical ethical principles do you see in each?
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Legal Issues
► What
is legal may not necessarily
be what is ethical and what is
ethical may not necessarily be what is legal
► Legal Issues will be criminal, civil and regulatory
and administrative law issues
► Changes to the laws and legal precedents made
per se, to allow rules to be changed or by
executive directive such as PDD
► Change will require consensus or at least
consultation with all stake-holders
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The Right to Desertion –
“When is it time to go to the house”
► Practical
dilemmas faced personally – what
are my obligations to me and my family?
► Professional dilemmas – conflicting ethical
principles
 Autonomy vs. non-maleficence
 Autonomy vs. beneficence
 Autonomy vs. justice
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Professor Tabery Says:
If you don’t come to work, the problem
doesn’t go away. In fact, the problem only
gets worse. In a disaster situation or a
pandemic, every employee will make a
difference by contributing his or her part to
providing care. All employees must ask
themselves, ‘If I don’t work in times of
crisis, then who will?’
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A Suggestion
► Take
a deep breath
► Look for the balance
► Remember John’s principle of
living outside yourself based on the truth
within yourself
 (This assumes you know the truth)
► Planners
and facility administrators must
“think outside the box” – but do it now
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Exercise - The Kobayashi Maru
In the Star Trek fictional universe,
the Kobayashi Maru is a starship
that serves as the subject of a
graded training exercise at
Starfleet Academy.
The term Kobayashi Maru is a
shorthand for no-win scenarios.
Questions presented by the exercise:
►Given the scare resources, who gets what
resources?
►Who decides who gets what resources?
►What is your rationale for your decision?
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SummaryJohn’s Five Action Principles
► The
“No Delta Principle”
► To tell the truth, the whole
truth and nothing but the
truth
► “We’ll Sing in the Sunshine”
► Be a Square
► It’s not about me.
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Epilogue
The Eagle soars above the din,
of mankind's rushing out and in,
And lesser creatures left to spin,
The Eagle soars from deep within.
His course is true as gaffer's pike,
His keen eye pierces like a spike,
His quest surrounds him like a dike,
The Eagle soars, but phantomlike.
Those who on the Earth have stood,
Thinking that they never could,
Nor many even perhaps should ... but,
The Eagle soars because he would.
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- John R. Wible, 1981
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The Eagle has Landed
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