On Bioethics: Ben Rich | The transvaluation of values – ethics in public health emergencies
Since Sept. 11, 2001, the United States and other nations have experienced a series of unrelated tragic events that have demonstrated our individual and collective vulnerability to terrorism and natural disasters. The anthrax attacks of late 2001, the SARS epidemic of 2003, the Katrina disaster of 2005, and the recent H1N1 pandemic are prominent examples justifying a greatly increased focus on disaster preparedness and public health emergency-response readiness. California is among the vanguard of jurisdictions seeking to organize and systematize the response to circumstances that threaten to overwhelm existing resources. The contingency planning that has taken place and the professional literature that has informed and responded to these initiatives have identified ethical implications that are profound and, in some instances, troubling.
The nature of public health ethics
The German philosopher Friedrich Nietzsche invoked the phrase "transvaluation of values" in several of his (perennially controversial) works on moral philosophy. A transvaluation process takes place as we move from the traditional ethics of patient care in ordinary circumstances to the public health ethics that prevail in response to mass casualty emergency events.
Health-care professionals have not been trained or acculturated to focus on populations rather than individual patients. The Hippocratic Oath and corpus, and the legion of professional codes that have followed, admonish the physician to make the individual patient's interests the primary consideration. The basic presupposition of public health and disaster planning approaches is sharply divergent, endorsing allocation of scarce medical resources in order to maximize the number of patients likely to survive.
Crisis standards of care
Also referred to as "altered standards of care for mass casualty events," guidelines for patient care during crises are developed by interdisciplinary groups of experts. In 2005, the Agency for Healthcare Research and Quality (AHRQ) issued such altered standards of care, which stated, "Rather than doing everything possible to save every life, it will be necessary to allocate scarce resources in a different manner to save as many lives as possible."
A transvaluation process takes place as we move from the traditional ethics of patient care in ordinary circumstances to the public health ethics that prevail in response to mass casualty emergency events.
A particularly thorny ethical dimension of these standards is the provision that the "needs of current patients, such as those recovering from surgery or in critical or intensive-care units, and the resources they use, will become part of overall resource allocation. In addition, certain lifesaving efforts may have to be discontinued."
In contrast, the Institute of Medicine (IOM) published a report in September 2009 titled "Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations," which endorsed adherence to ethical norms during crises. The IOM report states, "Conditions of overwhelming scarcity limit autonomous choices for both patients and practitioners regarding the allocation of scarce health-care resources, but do not permit actions that violate ethical norms." This admonition echoes that of the American College of Physicians Ethics Manual, which states that "denial of appropriate care to a class of patients for any reason, including disease state, is unethical."
Reasonable minds may differ as to whether, in a public health emergency, adherence to crisis standards of care would violate that provision. A decision to shift to crisis standards of care under questionable circumstances could provoke charges of ethical violations. Lest anyone be sanguine about the uncertainties and potential for second-guessing, recall the criminal charges and civil suits leveled against Dr. Ann Pou for her management of certain seriously ill patients stranded at Memorial Medical Center after Hurricane Katrina struck New Orleans.
Rationing patient care at the bedside has been universally disfavored. Particularly troubling, therefore, is the prospect of decision makers with no relationship to the patient issuing edicts to the patient's physician about withholding or withdrawing therapeutic or life-sustaining measures under crisis standards of care. The dedicated physician with a primary relationship to the patient likely would resist a request to discontinue these measures or step aside so that others may take control, and possibly withdraw care.
The duty to provide care in a crisis
Another unresolved issue is the amount of personal sacrifice that can reasonably be demanded of physicians in a crisis. Only slightly more than half of 1,000 physicians who in 2002 took part in a random survey of American Medical Association (AMA) members believed they were under a duty to treat in the event of an outbreak of a potentially deadly illness. While the original AMA Code of Ethics (1847) recognized the physician's duty to care for patients "when pestilence prevails even at jeopardy of one's own life," the provision had been deleted altogether by the late 20th century.
The current version of the AMA code contains only a provision within the general Declaration of Professional Responsibility that "physicians should apply their knowledge and skills when needed, though doing so may place them at risk." California law specifies a clear role for health-care professionals in response to public health emergencies, but contains no related discussion of the state's authority to require individual health-care professionals to provide services or impose punitive measures for declining to respond as requested.
A final caveat
None of this discussion should be interpreted as a challenge to the ethical propriety of crisis standards of care. Imposition of such standards is essential in many potential situations in order to minimize morbidity and mortality. The physicians within UC Davis Health System and elsewhere who have been involved in this form of strategic planning understand and appreciate what is at stake. Health-care professionals and most of the general public who are unfamiliar with the planning process will need to become acquainted with its underlying public health concept and acclimate to the full range of implications. It is not a question of whether this transvaluation of medical values will ever be necessary, but only when and where.
Spring / Summer 2010
UC Davis Health System is proud to be home to medical, nursing, family nurse practitioner / physician assistant, public health and health informatics students and to also be the internship site for pharmacy, nutrition and other programs. Improving the health of our communities requires that we bring together these perspectives, and UC Davis is well positioned to do so.