Disaster ethics: What are the ground rules?
3 cases can help you make appropriate decisions when priorities suddenly change.
In general, patients were not given benzodiazepines for acute anxiety or acute stress disorder. Evacuees who presented to the clinic were educated about normal responses to trauma, received supportive care, and were referred to on-site social service agencies for help finding housing and lost family members.
CASE 2: Urgent care for chronic illness?
Ms. J, age 46, presented to the mental health clinic for evaluation and treatment of chronic depression and anxiety. When asked how she was coping with the storm, she replied, “I wasn’t in the storm. I live in Houston, and I’ve been waiting 6 months to see doctors at the public hospital. I decided to come here and see everyone I needed to see.”
Because of news coverage, Houston residents were well-informed about the hurricane and the Astrodome clinics. Ms. J was resourceful in seeking needed treatment.
The Astrodome clinics were intended to provide acute care to evacuees who lacked alternate resources. Ms. J had chronic mental health problems, but her symptoms could have been exacerbated by graphic media reports of the storm’s devastation.
A challenge in treating chronic health problems in an acute setting is the inability to provide follow-up and continuity of care. An “emergency” clinic is meant to serve as a bridge to later care providers.
Four principles guide ethical decision-making: respect for autonomy, beneficence, nonmaleficence, and justice (Table 1). Would it be an injustice to allocate scarce resources—number of personnel, physician time, space, and medication—to a patient with chronic rather than acute needs?
One could argue that a patient-physician relationship and duty to treat began when Ms. J presented herself as a patient in need and began a dialogue with a physician. The treating physician felt Ms. J’s interest would be served best by continuing the evaluation and acutely managing her symptoms while trying to help her obtain treatment in a more stable setting.
The staff correctly anticipated that this case was unique; no other patients who were not evacuees are known to have requested treatment at the Astrodome clinic.
Table 1
Ethical principles that guide disaster psychiatry
| Principle | Definition | Example |
|---|---|---|
| Respect for autonomy | Promotion of and respect for the patient with capacity to make informed, voluntary decisions about his or her healthcare | A competent patient must provide voluntary informed consent to be admitted to an inpatient psychiatric facility |
| Beneficence | The commitment to act in a manner that brings about benefit or a good outcome | During an emergency, a physician overrides a patient’s confidentiality to inform his mother of his location |
| Nonmaleficence | An obligation to avoid doing harm | Physician refuses to prescribe potentially harmful medication to a patient with an addiction |
| Justice | “Fair” distribution of healthcare resources | Each patient receives care according to need or as resources are available |
| Source: Adapted from reference 11 | ||
CASE 3: Compassion vs confidentiality
Mrs. C, age 67, came to the mental health clinic in tears because she had been separated from her son when she boarded a bus to evacuate from New Orleans. Her son has schizophrenia, and she asked if we had seen him at our clinic. In fact, he had visited our clinic shortly before she arrived.
As healthcare professionals, we value compassion but also are bound by tenets of the physician-patient relationship—in this case, maintaining confidentiality. Physicians are ethically and legally obligated to refrain from disclosing information obtained from a patient without the patient’s permission.11
“Health care providers can share patient information as necessary to provide treatment. Health care providers can share patient information as necessary to identify, locate, and notify family members, guardians, or anyone else responsible for the individual’s care of the individual’s location, general condition, or death.”12
Based on these arguments, the treatment team believed that working with Mrs. C and, if necessary, informing her of her son’s location outweighed the conflicting need to maintain his right to confidentiality.
Therapeutic resources
Catastrophes evoke powerful emotions that can blur responders’ therapeutic boundaries and interfere with how we care for individuals in need (Table 2).13 Some Web-based resources to help you prepare for disasters are available from:
