Are we doing the right thing in the face of disaster?
Sandy. Haiti. Katrina. Fukushima. Earthquake. Tsunami. We are familiar with the names and terms that describe natural disasters and their fallout around the globe. Meanwhile, news pours in of deaths and casualties in areas of conflict.
But how much do we know about the bioethics of humanitarian responses to such crises? What are the ethical dilemmas around deciding to treat some people and not others as the resources allow? How can we address cultural and planning practices that could put people at higher risk of death in a disaster? And how does a team dealing with the pressures of an acute disaster consider the long-term impact on survivors?
Those are some of the ethical issues to be explored by a new European project led by Dublin City University, which is setting up a global network to inform research and training.
“The overall aim is to improve ethical decision making for healthcare, medical relief workers and those doing research around disasters,” says Dr Dónal O’Mathúna, a senior lecturer in ethics in DCU’s school of nursing and human sciences and an affiliated scholar at DCU’s Institute of Ethics.
He’s leading an initiative on disaster bioethics that’s being funded through the European Union’s Cost programme. It is already drawing together bioethicists and medical relief personnel from 19 countries and has had contact with major global health and humanitarian organisations.
The project will gather information about the kinds of ethical issues that people experience on the ground when dealing with disaster relief, but some are already known, according to O’Mathúna.
“One of the big issues is that people go out into dangerous, unstable areas and they usually have a lot fewer resources than they are used to, or they just don’t have materials on the ground,” he says.
“That means they frequently have to make what would be called triage decisions, where they decide who they can treat and who they can’t.”
No ideal answer
In essence, they have gone to provide care but find that in some cases they can’t, and they sometimes lack the training to deal with that, he explains.
“They may have to decide who gets to avail of whatever medicine they have, who gets surgery at a field hospital and who gets left with little or no care and maybe even no pain relief. Those decisions are extremely psychologically wearing,” says O’Mathúna.
“Part of the problem is that so much of western ethics training is about finding the ideal solution and then implementing it. But in a lot of disaster settings there is no ideal answer – it’s choosing the lesser of two or several evils.
“So one of our aims is to develop training materials that would help to at least prepare people for some of these decisions they are going to have to make.”
Lack of evidence
The decisions taken during acute disaster relief can also have long-term consequences for survivors, he adds, citing the amputation of injured limbs as an example.
“In some cultures someone with an amputation is going to be shunned or regarded as somebody not to be cared for. So sometimes even though the acute injury may seem to be better taken care of with an amputation, in the long term it might be better to leave the person with the limb even though it is not as functional. But there is a lack of evidence to know exactly what is best.”
There are also questions around who needs to go to disaster zones. If the region already has a relatively good medical infrastructure, sending people and medicines could be a waste of resources rather than a help, notes Dr O’Mathúna.
“Just because we want to do good and feel a lot of compassion for people, it doesn’t necessary mean they need what we want to send them,” he says.
“That’s where it gets into the planning end of things, and some of these decisions are ethical or cultural ones.”
Culture could also play a role in some cases where women are more likely to die as a result of a disaster, and it’s a complex consideration, he adds.
“In some cultures, women are not supposed to leave the house unless they get permission from their husbands, so they may sit there and then it is too difficult for them to get away from floodwaters. There is a very difficult challenge there as to how you would make a change in those sorts of practices.”
O’Mathúna admits there are no easy answers when it comes to disaster bioethics, but the four-year project hopes to listen to people who have gone to disaster zones and to survivors to hear about their experiences.
The group will also look at current reports and guidelines and carry out deeper academic analysis on certain topics, such as triage.
“There are numerous different guidelines on how to make triage decisions,” says O’Mathúna.
“We want to see is there a way that these could be combined into one overall guideline, so there isn’t conflict when people from different countries or different organisations go into regions and have different approaches to making triage decisions.”
The project will also feed into training people who are heading to provide relief and help to inform researchers looking at disaster planning and responses.
“The need for more research is huge, and the need to do that research ethically is vital,” says O’Mathúna. “There are many challenges with this project, but it’s a real privilege to be involved with many others in a project like this.