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Terrorism and the ethics of emergency medical care

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Abstract

The threat of domestic and international terrorism involving weapons of mass destruction-terrorism (WMD-T) has become an increasing public health concern for US citizens. WMD-T events may have a major effect on many societal sectors but particularly on the health care delivery system. Anticipated medical problems might include the need for large quantities of medical equipment and supplies, as well as capable and unaffected health care providers. In the setting of WMD-T, triage may bear little resemblance to the standard approach to civilian triage. To address these issues to the maximum benefit of our patients, we must first develop collective forethought and a broad-based consensus that these decisions must reach beyond the hospital emergency department. Critical decisions like these should not be made on an individual case-by-case basis. Physicians should never be placed in a position of individually deciding to deny treatment to patients without the guidance of a policy or protocol. Emergency physicians, however, may easily find themselves in a situation in which the demand for resources clearly exceeds supply. It is for this reason that emergency care providers, personnel, hospital administrators, religious leaders, and medical ethics committees need to engage in bioethical decision making before an acute bioterrorist event.
642 ANNALS OF EMERGENCY MEDICINE 37:6 JUNE 2001
CONCEPTS
Nicki Pesik, MD
*
Mark E. Keim, MD
*‡
Kenneth V. Iserson, MD
§
From the Department of Emergency
Medicine, Emory University, Atlanta,
GA
*
; Emergency and Disaster Public
Health Sciences, Centers for Disease
Control and Prevention, Atlanta,
GA
; and Arizona Bioethics Program,
University of Arizona College of
Medicine, Tucson, AZ.
§
Received for publication
June 22, 2000. Revision received
September 21, 2000. Accepted for
publication October 17, 2000.
Address for reprints: Mark Keim,
MD, Emergency and Disaster Public
Health Sciences, National Center for
Environmental Health, Centers for
Disease Control and Prevention, 4770
Buford Highway, MS-F38, Atlanta,
GA 30341-3724.
Copyright © 2001 by the American
College of Emergency Physicians.
0196-0644/2001/$35.00 + 0
47/1/114316
doi:10.1067/mem.2001.114316
See related article, p. 535.
The threat of domestic and international terrorism involving
weapons of mass destruction–terrorism (WMD-T) has become
an increasing public health concern for US citizens. WMD-T
events may have a major effect on many societal sectors but
particularly on the health care delivery system. Anticipated
medical problems might include the need for large quantities of
medical equipment and supplies, as well as capable and
unaffected health care providers. In the setting of WMD-T,
triage may bear little resemblance to the standard approach to
civilian triage. To address these issues to the maximum benefit
of our patients, we must first develop collective forethought
and a broad-based consensus that these decisions must reach
beyond the hospital emergency department. Critical decisions
like these should not be made on an individual case-by-case
basis. Physicians should never be placed in a position of
individually deciding to deny treatment to patients without the
guidance of a policy or protocol. Emergency physicians,
however, may easily find themselves in a situation in which the
demand for resources clearly exceeds supply. It is for this
reason that emergency care providers, personnel, hospital
administrators, religious leaders, and medical ethics
committees need to engage in bioethical decisionmaking
before an acute bioterrorist event.
[Pesik N, Keim ME, Iserson KV. Terrorism and the ethics of
emergency medical care. Ann Emerg Med. June 2001;37:642-646.]
BACKGROUND: THE THREAT
The threat of domestic and international terrorism in-
volving weapons of mass destruction–terrorism (WMD-T)
has become an increasing public health concern for US cit-
izens.
1
Increasing concern over the potential for WMD-T
has led numerous federal, state, and local agencies to
address the response to such an event. Some of these efforts
Terrorism and the Ethics of Emergency
Medical Care
TERRORISM AND ETHICS
Pesik, Keim & Iserson
JUNE 2001 37:6 ANNALS OF EMERGENCY MEDICINE 643
include the following: (1) comprehensive planning that
focuses on local preparedness and response
2
; (2) increas-
ing public health infrastructure and capacity
2
; (3)
increasing education for health care providers
3-5
; (4)
bridging communication between agencies and institu-
tions
6
; and (5) consequence management and develop-
ment of medical stockpiles.
7
A major effect on the health care delivery system by a
WMD-T event will be the anticipated medical need for
large quantities of medical supplies, such as antidotes,
antibiotics, antitoxins, critical care supplies, and ventila-
tors, as well as unaffected health care providers (hereafter
referred to as resources). Individual hospitals have been
encouraged to incorporate a means to procure needed
medical supplies into their own disaster plans.
8,9
In the
face of a WMD-T act (or threat), hospitals may face both
overwhelming numbers of real casualties and multiple
patients presenting with psychogenic symptoms.
10
They
may also experience demands for preventive or prophy-
lactic treatment from those who fear that sufficient re-
sources for their treatment may not later be available.
Although public panic is uncharacteristic after disasters,
significant changes in social behavior have been proposed
as unique to the setting of WMD-T.
11,12
THE CHALLENGE OF RESOURCE ALLOCATION
After a WMD-T event, hospitals and emergency depart-
ments may have only enough resources available for
patients that present relatively early after an event.
Resource-allocation decisions will need to be made until
additional resources become available. This means that
some patients will receive treatment and others will not.
The only option is to make hard resource-allocation deci-
sions. The ethical decisions inherent in triage decisions
should not be first considered during a real event. Rather,
they should be rehearsed and discussed long before they
are needed.
13
UNIQUE CHALLENGES INVOLVING TRIAGE OF
WMD CASUALTIES
Patients presenting to EDs after a WMD-T event may pose
a unique set of challenges for clinicians. These challenges
may include diagnostic, therapeutic, and occupational
health issues.
In some cases, the diagnostic challenge of WMD-T may
be much more difficult compared with that for other
causes of mass casualties. Patients exposed to biologic
agents, unlike most chemical agents, may experience a
latency period during which they remain free of symp-
toms. In addition, large numbers of nonexposed, asymp-
tomatic patients (ie, “the walking worried”) may present
for evaluation after an event of WMD-T.
14
It has also been
postulated that WMD-T may create psychogenic illness
among populations.
10,11
Consider an event involving
radiologic, biologic, or chemical contamination of a pub-
lic area. One may expect that a significant number of peo-
ple who may or may not have recently visited the area will
present as patients with requests to rule out hazardous
exposure. Such would not likely be the case after an
explosion, flood, or high wind condition within the same
area. However, even in the absence of obvious physical
injury, these patients have the potential to consume
scarce human and material resources. During these situa-
tions, even patients who constitute the routine cases of
ED care will need to fit into the triage protocol.
There may also be a therapeutic challenge that is
unique to WMD-T events. In the case of some WMD
agents, treatment is most efficacious when given very
early in the course of illness, even before the onset of
symptoms. However, currently held concepts now apply
triage according to acutely obvious conditions. In addi-
tion, emergency care may also come under the rule of a
higher forum for decisionmaking that will allocate re-
sources according to a regional or national plan.
15
Care
providers must then be capable of integrating with com-
munity and national assets.
WMD-T also offer an additional challenge to include
occupational health concerns for care providers in the
event of secondary exposure to threat agents. Resource
allocations may then need to take into consideration the
need for prophylaxis, personal protection, and/or immu-
nization of clinical staff to preserve the multiplier effect of
their ongoing ability to provide care.
ETHICAL CONSIDERATIONS OF TRIAGE AFTER
WMD-T EVENTS
Although the term “triage” is commonly used for the prior-
itization of patients on the basis of their medical condition
in normal emergency medicine practice, this triage differs
markedly from that on battlefields or during civilian dis-
asters. Under routine circumstances, ED triage takes the
most urgent cases first and the less urgent on a first-come,
first-served basis. Everyone receives necessary treatment,
although the less ill must wait longer.
There are 3 potential triage models. These models
include those that are based on the following: (1) first-
TERRORISM AND ETHICS
Pesik, Keim & Iserson
644 ANNALS OF EMERGENCY MEDICINE 37:6 JUNE 2001
use of these resources? There are certain factors that should
and should not be taken into consideration when making
the decision for resource allocation. These factors are
summarized in the Table.
20
In the setting of a WMD-T event, the likelihood of ben-
efit using minimal resources takes precedence to maxi-
mize the efficient use of scarce medical supplies. The
problem with likelihood of benefit is in predicting medi-
cal outcomes of individual patients. In certain situations,
the treatment will be equally effective for all patients if
given early. For instance, if appropriate antibiotics are
given before the onset of respiratory symptoms of inhala-
tional anthrax or pneumonic plague, survival is markedly
increased. Theoretically, symptomatic patients are less
likely to benefit from treatment. Thus, the likelihood of
benefit may be equal between patients when presenting
early on in course of the disease, yet there may not be
enough of the available resource. Ideally, treatment would
be started before the onset of any symptoms. Because this
may not be possible with limited resources, objective
signs, such as fever, may be required before initiating
treatment.
Resource allocation is always made on a utilitarian
basis; those who will have the best chance of benefiting
the most from the available resources get those resources
first. In situations with limited resources, the decision
algorithm changes. Practitioners must prioritize inter-
vention to those who will benefit most from the fewest
resources. This widens the scope of patients for whom
medical intervention is deemed futile.
Should age be a triage factor in these cases? Not in
itself, although the complexity of comorbid conditions in
the elderly may make their treatment more resource
intensive, limiting treatment options for some patients.
For those without comorbid conditions, triage personnel
come, first-served; (2) patient’s best prognosis; and (3)
patient’s social worth.
All social systems for allocating scarce resources suffer
from the presence of natural and social lotteries. Natural
lotteries are the wide range of talents, abilities, disabili-
ties, deformities, and illnesses among individuals. Social
lotteries indicate the disparity in how individuals are cho-
sen to be the recipients of attention, jobs, love, care, or
other benefits.
16
Those who normally suffer in these lot-
teries include patients with multiple diseases, drug or
alcohol abuse, or antisocial or aggressive behaviors and
the homeless. Under normal circumstances, these patients
should not receive a lower priority and access to scarce
resources.
17
In catastrophic triage situations, however,
they may also do poorly because the necessary additional
time and normal medical resources may not be available
to meet their needs.
Nondisaster triage systems work, in part, on a statisti-
cal lottery or first-come, first-served basis. Natural and
social lotteries continue to operate in catastrophic situa-
tions. The statistical lottery may appear to have a lessor
potential for bias; however, it does not achieve an equi-
table or utilitarian resource distribution in catastrophic
situations.
18
Furthermore, a statistical lottery may favor a
segment of the population that has access to media, trans-
portation, or health care, while discriminating against
those with physical and mental disabilities or financial
hardships.
Triage according to the medical model of best progno-
sis is widely accepted and may be the most favorable
model in the setting of WMD-T events. Under this model,
rationing decisions must be made on the basis of patient
survivability or best prognosis. The ethics involved in this
type of triage follow from the idea that “ought” implies
“can.” If something cannot be accomplished (eg, saving
all lives with the limited available resources), then there is
no ethical obligation to do so. Rather, those responsible
for triage in these circumstances must use their clinical
skills to provide maximum benefit to the most people.
Unaccustomed as they are to it, “the general public in
Western society may find the consequences of triage in
their own environment hard to accept.”
19
TRIAGE FACTORS
The ethical issues involving medical resource allocation
during a mass casualty event are complex. What issues
should emergency physicians consider in deciding to
whom and how we distribute and use scarce resources?
What criteria could help us determine the most ethical
Table.
Factors involved in the allocation of scarce resources.
Should Consider Should Not Consider
Likelihood of benefit Age, ethnicity, or sex
Effect on improving quality of life Talents, abilities, disabilities, or deformities
Duration of benefit Socioeconomic status, social worth, or
Urgency of the patient’s condition political position
Direct multiplier effect among Coexistent conditions that do not affect short-
emergency caregivers term prognosis
Amount of resources required for Drug or alcohol abuse
successful treatment Antisocial or aggressive behaviors
TERRORISM AND ETHICS
Pesik, Keim & Iserson
JUNE 2001 37:6 ANNALS OF EMERGENCY MEDICINE 645
will not be able to predict individual life expectancies,
and therefore, the elderly should be considered in the
same triage pool as all others.
TRIAGING EMERGENCY PROVIDERS
Should emergency health care workers get priority treat-
ment and prophylaxis? This is a question of individual
social worth. When triage involves questions of social
worth, these criteria need to be carefully examined be-
cause it could feasibly be used to discriminate against vir-
tually any group in society and should generally not be
factored into the allocation of scarce resources.
20,21
Yet
this does not address the idea of those that put themselves
at risk and are immediately valuable because of their abil-
ity to help others (ie, the multiplier effect).
The threat of terrorism has created a situation in which
both patients and caregivers are potentially vulnerable.
Health care providers, for example, may face personal
risk if they provide aid during some disasters, such as
WMD-T events. A well-established ethical principle is
that health care providers should first look to their own
safety, then their team’s, and finally the patient’s.
22
In fact,
many key care providers would be expected to continue
to function regardless of personal danger, even beyond
the threshold of what may be considered accepted profes-
sional risk. However, if not given priority for treatment or
prophylaxis, these health care and emergency responders
would likely also become casualties, and this critical
resource for emergency public health would cease to
exist.
23
In this regard, these individuals should undergo
triage according to a principle for preservation of a mis-
sion-critical resource.
Fortunately, only a few of the biologic warfare agents
(smallpox/monkeypox, pneumonic plague, viral hemor-
rhagic fever viruses, ie, Ebola, Marburg) are considered
contagious, thus necessitating prophylactic measures.
Exposure to chemical agents often requires specific anti-
dotes or treatment. The problem arises when a scarcity of
appropriate resources occurs during a WMD-T event.
With this in mind, the use of prophylactic antibiotics or
vaccination should be based on strict guidelines. On both
ethical and administrative levels, these guidelines should
be planned and coordinated to provide the best protec-
tion for mission-critical providers while ensuring the
maximal possible provisions of health care to the popu-
lace. This means, in part, ensuring that providers will be
cared for. In addition, these guidelines should also pre-
vent health care providers from preferentially treating
themselves, family members, or friends.
Terrorist event involving
weapons of mass destruction
Patients present to ED
AsymptomaticSymptomatic
Person vital to
save others
(multiplier effect)
OthersRequires more
resources than are
reasonable
or
less
than reasonable
chance to save
life
or
improve
condition
Minimal resources
required to
help patient
No treatment unless
resources become
available
Supportive care
Treatment if
resources
available
Prophylactic
measures and
treatment when
indicated
No treatment
Observe and
educate
Figure.
Algorithm for triage after a WMD-T event.
TERRORISM AND ETHICS
Pesik, Keim & Iserson
646 ANNALS OF EMERGENCY MEDICINE 37:6 JUNE 2001
REFERENCES
1. Sidel VW. Weapons of mass destruction: the greatest threat to public health. JAMA.
1989;262:680-682.
2. Hamburg MA. Addressing bioterrorist threats: where do we go from here? Emerg Infect Dis.
1999;5:564-565.
3. Pesik N, Keim ME, Sampson TR. Do US emergency medicine residency programs provide
adequate training for bioterrorism? Ann Emerg Med. 1999;34:173-176.
4. Eitzen EM Jr. Education is the key to defense against bioterrorism [editorial]. Ann Emerg
Med. 1999;34:221-223.
5. Keim ME, Kaufmann AF. Principles of emergency response to bioterrorism. Ann Emerg
Med. 1999;34:177-182.
6. Garshnek V, Burkle FM. Telecommunications systems in support of disaster medicine: appli-
cation of basic information pathways. Ann Emerg Med. 1999;34:213-218.
7. Tucker JB. National health and medical response to incidents of chemical and biological
terrorism. JAMA. 1997;278:362-372.
8. Richards CF, Burnstein JL, Wackerle JF, et al. Emergency physicians and biological terror-
ism. Ann Emerg Med. 1999;34:183-190.
9. English JF, Cundiff MY, Malone JD, et al. Bioterrorism Readiness Plan: A Template for
Health Care Facilities. Atlanta, GA: Centers for Disease Control and Prevention; 1999.
10. Wessely S. Responding to mass psychogenic illness. N Engl J Med. 2000;342:129-130.
11. Holloway HC, Norwood AE, Fullerton CS, et al. The threat of biological weapons: prophy-
laxis and mitigation of psychological and social consequences. JAMA. 1997;278:425-427.
12. Quarantelli EL. Organizational Behaviors in Disasters and Implications for Disaster Planning.
Newark, DE: Disaster Research Center, University of Delaware; 1985.
13. Iserson KV, Sanders AB, Mathieu D. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ:
Galen Press, Ltd; 1995.
14. Olsen KB. Aum Shrinrikyo: once and future threat. Emerg Infect Dis. 1999;5:513-516.
15. Advisory Panel to Assess Domestic Response Capabilities for Terrorism involving Weapons
of Mass Destruction. First Annual Report to the President and the Congress: Assessing the
Threat. Washington, DC: Rand Corporation; 1999.
16. Englehardt HT, Rie MA. Intensive care units, scarce resources, and conflicting principles of
justice. JAMA. 1986;255:1159-1164.
17. Childress J. Who shall live when not all can live? Soundings. 1970;53:340-350.
18. McIntyre KM, Benfari RC, Battin MP. Two cardiac arrests, one medical team. Hastings Cent
Rep. 1982;12:24-25.
19. Department of the Army. NATO Handbook on the Medical Aspects of NBC Defensive
Operations. Washington, DC: AMED P-6; 1987. Draft No. 1986-87:17-19.
20. American Medical Association Council on Ethical and Judicial Affairs. Ethical considera-
tions in the allocation of organs and scarce medical resources among patients. Arch Intern Med.
1995;5:29-39.
21. Diekma DS. The preferential treatment of VIPs in the emergency department. Am J Emerg
Med. 1996;14:226-229.
22. Iserson KV. Threatening situations. In: Iserson KV, Sanders AB, Mathieu D, eds. Ethics in
Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press, Ltd; 1995:383-386.
23. Leaning J. Physicians, triage and nuclear war. Lancet. 1988;2:269-270.
24. Milo RD. Physician calls re: do-not-resuscitate orders. In: Iserson KV, Sanders AB, Mathieu
D, eds. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press, Ltd; 1995:371-377.
AN ALGORITHM
One method to analyze a practical and ethical response
to triage after a WMD-T event is to use an algorithm
(Figure). It follows utilitarian principles: the limited
resources will be used to benefit the most people possi-
ble. The difference is that it also provides for prophy-
laxis of those individuals who, because of their position,
need to have physical protection to greatly assist others
(ie, the multiplier effect). To receive treatment, patients
would exhibit early objective signs of illness. Asympto-
matic patients would not initially receive treatment
because it would be difficult to distinguish potential
casualties, regardless of exposure history, from the wor-
ried well.
In summary, with many ethical decisions that arise in
emergency medicine, those during mass-casualty situa-
tions require immediate decisions with little time for col-
lective deliberation. Failing to act because of moral un-
certainty is unacceptable because inaction is often the
worst of the available options.
24
When faced with this situation, emergency physicians
must do the best they can with the available resources.
Simultaneously, they should use every possible means to
acquire additional resources. Available resources must be
used to provide the most good to the most people. The
definition of what may be a reasonable use of resources
will also be extremely situation dependent and may vary
according to the facility, the natural history of the event,
the offending WMD agent, and the community standard
of care.
Emergency physicians must be willing to make diffi-
cult triage decisions, knowing that some of their deci-
sions, made without adequate information or the time for
reflection, may not be perfect. Guidelines for decision-
making should be developed in advance of an event in
association with emergency medical personnel, hospital
administrators, religious leaders, and medical ethics
committees. As WMD-T readiness plans are developed,
bioethics committees should be asked to work with
health care providers to develop a plan to address the
unique moral and ethical dilemmas that arise. Such plans
should provide resource-allocation guidelines that are
flexible enough to cover a myriad of scenarios with a con-
sistency that allows equitable treatment for all patients
and potential patients. Emergency physicians should
now move to initiate the process of ethical consensus as
leaders in the field of disaster medicine and emergency
care.
... Iako je krajnje kontroverzan, moglo bi se reći da utilitaristički pristup trijaže, u pokušaju da se maksimizira preživljavanje iznad svega ostalog, treba da diskriminiše godine starosti. Moglo bi se tvrditi da na preživljavanje ne utiče starost direktno, već indirektno, preko komorbiditeta koji su povezani sa većim brojem godina starosti (Pesik, 2001;Tan et al., 2004). Jasno je da se ishodi traume pogoršavaju sa godinama, a zapravo je starost kriterijum u određivanju potrebe za evaluacijom. ...
... Kipnis, 2003;Iserson & Pesik, 2003b;Kilner, 1981;Pesik et al., 2001). Stoga bi utilitaristički argument bio da bi dopuštanje ovim pojedincima da se zbrinu "preko reda" zapravo služilo većem društvenom dobru na duge staze i da bi to bio etički pravedan izbor. ...
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Poštovana/poštovani, imamo izuzetnu čast i zadovoljstvo da vam predstavimo Zbornik radova, „PRAVNI I BEZBEDNOSNI ASPEKTI UPRAVLJANJA RIZICIMA OD PRIRODNIH I ANTROPOGENIH KATASTROFA“, koji zajedno izdaju Pravni fakultet, Univerzitet u Novom Sadu, Naučno-stručno društvo za upravljanje rizicima u vanrednim situacijama i Međunarodni institut za istraživanje katastrofa iz Beograda. Glavni i odgovorni urednik zbornika je doc. dr Vladimir M. Cvetković, Univerzitet u Beogradu, Fakultet bezbednosti. Poštovani čitaoci, pred vama se nalazi tematski zbornik radova pod naslovom Pravni i bezbednosni aspekti upravljanja rizicima od prirodnih i antropogenih katastrofa. Zbornik je nastao kao rezultat samostalno istraživačkih aktivnosti profesora i istraživača njime je obuhvaćeno dvadeset dva relevantna naučna rada u kojima se na vrlo vešt i interesantan način elaboriraju različiti pravni i bezbednosni aspekti upravljanja prirodnim i antropogenim katastrofama. Radove je recenzirao veći broj recenzenata, dok je naučni i programski odbor činilo više od deset profesora sa različitih Univerziteta i Fakulteta. Tematske jedinice zbornika su bile vrlo različite imajući u vidu dosadašnji trend razvoja studija katastrofa: a) Pravni aspekti upravljanja rizicima od prirodnih katastrofa - pravni aspekti upravljanja rizicima u litosferskim katastrofama (zemljotres, klizišta i odroni, vulkanske erupcije); pravni aspekti upravljanja rizicima u hidrosferskim katastrofama (poplave i bujice, lavine); pravni aspekti upravljanja rizicima u atmosferskim katastrofama (olujno gradonosne pojave, suše, ekstremno niske i visoke temperature); pravni aspekti upravljanja rizicima u biosferskim katastrofama (epidemije, epizotije i epifitonoze, šumski požari); b) Pravni aspekti upravljanja rizicima od antro-pogenih katastrofa - pravni aspekti upravljanja rizicima u nuklearnim i radio-loškim katastrofama; pravni aspekti upravljanja rizicima u industrijskim katastrofama; pravni aspekti upravljanja rizicima u transportnim i infrastruk-turnim katastrofama; pravni aspekti upravljanja rizicima u katastrofama izazvanim opasnim materijama; pravni aspekti upravljanja rizicima u katastro-fama izazvanim ratnim razaranjima; pravni aspekti upravljanja rizicima u katastrofama izazvanim požarima; pravni aspekti upravljanja rizicima u katastrofama izazvanim upotrebom oružja za masovno uništavanje (hemijski, biološki, nuklearni i radiološki terorizam); c) Bezbednosni aspekti upravljanja rizicima od prirodnih katastrofa – bezbednosni aspekti upravljanja rizicima u litosferskim katastrofama (zemljotres, klizišta i odroni, vulkanske erupcije) i bezbednosni aspekti upravljanja rizicima u hidrosferskim katastrofama (poplave i bujice, lavine);bezbednosni aspekti upravljanja rizicima u atmosfer-skim katastrofama (olujno gradonosne pojave, suše, ekstremno niske i visoke temperature); bezbednosni aspekti upravljanja rizicima u biosferskim katas-trofama (epidemije, epizotije i epifitonoze, šumski požari) i d) Bezbednosni aspekti upravljanja rizicima od antropogenih katastrofa – bezbednosni aspekti upravljanja rizicima u nuklearnim i radiološkim katastrofama; bezbednosni aspekti upravljanja rizicima u industrijskim katastrofama; bezbednosni aspekti upravljanja rizicima u transportnim i infrastrukturnim katastrofama; bezbed-nosni aspekti upravljanja rizicima u katastrofama izazvanim opasnim materi-jama; bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim ratnim razaranjima; bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim požarima; bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim upotrebom oružja za masovno uništavanje (hemijski, biološki, nuklearni i radiološki terorizam). Zbornik radova je namenjen svima onima koji imaju želju za dodatnim usavršavanjem u oblasti studija katastrofa kako bi unapredili svoju akadem-sku delatnost. Imajuću u vidu nedostatak stručne literature u oblasti upravlja-nja rizicima od prirodnih i antropogenih katastrofa, naučni i društveni značaj zbornika je nesumnjivo veliki. U okviru prvog rada ,,Normativni okvir kriznog menadžmenta i nadležnosti gradova i opština u Srbiji (1948-2021)“, čiji je autor Jasmina Tanasić, analizira se razvoj lokalne samouprave i razvoj kriznog menadžmenta u Srbiji je tekao od kraja 40-ih godina XX veka naovamo na sličan način: od rastuće decentra-lizacije, koja je dostigla vrhunac od sredine 70-ih i trajala do 1990. godine. Devedesete godine karakteriše naglo sprovedena centralizacija i gubitak nadležnosti opština u kriznom menadžmentu ali i u ostalim javnim politikama. Od 2000. naovamo, ponovo se uspostavlja decentralizacija u nadležnostima lokalne samouprave u oblasti kriznog menadžmenta. Novija zakonska rešenja upravlјanja u kriznim i vanrednim situacijama na lokalnom nivou u Srbiji slede savremene prakse razvijenih zemalja, ali je upitno koliko su sprovedena i uz postojeći nivo podrške lokalnim samoupravama, ostvariva na lokalnom nivou. U drugom radu pod nazivom ,,Pravno uređenje bezbednosti informacione kritične infrastrukture“ autori Tatjana Bugarski i Milan Pisarić zaključuju da mrežni i informacioni sistemi i usluge, kao informaciona kritična infrastruktu-ra, imaju značajnu ulogu u savremenom društvu, pa je njihova pouzdanost i bezbednost od važnosti za ključne društvene i ekonomske aktivnosti. Ipak, njihovom postojanju i pravilnom funkcionisanju prete određeni bezbednosni rizici u sajber prostoru, koji su sve većih razmera, učestalosti i uticaja. Tako ovi sistemi mogu postati meta sajber napada, odnosno nedozvoljenih radnji koje se preduzimaju sa namerom prouzrokovanja štete i/ili prekida njihovog rada. Ovakvi incidenti mogu ugroziti društvene i ekonomske aktivnosti, koji zavise od informacione kritične infrastrukture. Zbog toga je neophodno posvetiti pažnju sajber bezbednosti. Pri tome, upravljanje rizicima u sajber prostoru mora biti takvo da se ne ugrozi pravna sigurnost. U tom smislu od izuzetne važnosti je način na koji se propisuju smernice za procenu rizika po sajber bezbednost. Dobar primer regulative predstavlja Direktiva Evropske unije o bezbednosti mrežnih i informacionih sistema. Direktiva predviđa da se određene organizacije obavežu da preduzmu odgovarajuće i proporcionalne mere bezbednosti, te da uoče, procene i uzmu u obzir rizike po sajber bez-bednost sa kojima se suočavaju, kako bi se smetnje po pružanje usluga sprečile i svele na minimum. Cilj Direktive je da se propisivanjem takvih obaveza obezbedi da informaciona kritična infrastruktura bude zaštićena od prekida koji bi mogli biti od uticaja po ključne ekonomske i društvene aktivnosti. Predmet rada je analiza obaveze zaštite i informisanja koje Direk-tiva o bezbednosti mrežnih i informacionih sistema propisuje za pružaoce digitalnih usluga. Rad ,,Odluke lokalnih štabova za vanredne situacije usmerene ka suzbijanju epidemije zarazne bolesti COVID-19: kazneni aspekt“ autor Ivan Milić temelji na ispitivanju odluke da u pojedinim lokalnim samoupravama važe posebna pravila ponašanja koja su uvedena iz razloga suzbijanja epidemije zarazne bolesti COVID-19. Odlukama lokalnih štabova za vanredne situacije uvode se određene obaveze za sva ili pojedina fizička i pravna lica ali i za preduzetnike. Tim odlukama se na primer skraćuje radno vreme ugostitelјskih objekata, propisuje obavezno nošenje zaštitne maske, ograničava sloboda kretanja, i dr. Pojedinim odlukama se propisuju i prekršaji ukoliko se prekrši određeni član te iste odluke lokalnog štaba za vanredne situacije. Međutim, važno pitanje o kojem će biti reči u radu tiče se „kaznenih posledica“ ukoliko neko lice postupi suprotno odluci lokalnog štaba za vanredne situacije. U radu ,,Upravno ograničavanje prava svojine u slučaju elementarnih nepo-goda“ autor Ratko Radošević ističe da elementarne nepogode mogu da dovedu do različitih vidova ograničavanja prava svojine građana na nepo-kretnim i pokretnim stvarima. Cilj rada je da se utvrdi pravni režim ograniča-vanja prava svojine u ovim vanrednim okolnostima i da se izdvoje one mere koje imaju upravni karakter – koje se vrše uz upotrebu upravnih ovlašćenja. U pitanju su mere koje bi, uslovno, mogle da se podvedu pod eksproprijaciju i rekviziciju, kao klasične vidove upravnog ograničavanja prava svojine. U okviru rada ,,Teorijsko i normativno-pravno određenјe civilne odbrane i civilne zaštite“, čiji je autor Vladimir Jakovljević, kao osnovni cilј i namena izdvaja se upoznavanje šire čitalačke, naučne i stručne javnosti sa pojmom i suštinom civilne odbrane i civilne zaštite, različitim teorijskim i pravnim pristupima i elaboracijama (užim i širim) koje idu u prilog jasnog definisanja ovih termina i ukazivanje na razlike jednog od drugog, kao i različitost od drugih sličnih termina kao što su, civilna bezbednost, civilno planiranje za vanredne situacije i slično. U teorijskim analizama i elaboracijama koja se tiču civilne odbrane sadržaj i obim te sintagme nije još uvek precizno i jasno razgraničen od ostalih sličnih pojmova. Mogu se uočiti težnje za korišćenje mnogobrojnih pojmova kao što su, civilna zaštita, civilna bezbednost, pri-vredna odbrana, odbrana civila, pasivna zaštita, nacionalna ili alternativna odbrana, civilno planiranje za vanredne situacije. Ovakav specifičan izbor reči i pojmova obično nije slučajan. On ne samo da govori ono što autori misle i žele da kažu, nego vrlo često govori o stanju i shvatanjima društvenih grupa koje se tim terminima služe, pa čak i o društvu unutar koga su termini u opticaju. U okviru rada ,,Prevare u kontekstu upravljanja vanrednim situacijama“ autori Snežana Knežević, Stefan Milojević, Miljan Adamović i Jovan Travica potvrđuju da je prevarna radnja (prevara) reč koja ima značajnu težinu. Da bi se sprečio nastanak prevara, neophodno je identifikovati šta su uzroci prevare i napraviti plan za njihovo sprečavanje. Različiti su mogući uzroci koji podsti-ču ljude da izvrše prevaru. Nezavisno od razlike u kulturi, tradiciji, običajima, sve kulture prevaru, mito i korupciju tretiraju kao radnje koje su zabranjene i neetičke. Vanredne situacije se dešavaju nepredvidivo i dovode do toga da pojedinci i organizacije odmah prebace svoj fokus i pažnju na rešavanje situacije. Tokom pandemije ili velikih prirodnih katastrofa, dolazi do ograni-čenja u mogućnosti upravljanja rizicima od nastanka prevarnih radni, koje mogu imati razne oblike i izazvati velike ekonomske i druge posledice. U ovom radu se diskutuje o uzrocima i problemima vezanim za pojavu prevara koje su specifične za vanredne situacije. Biće ukazano i na razne kontrolne aktivnosti koje se mogu preduzeti tokom vanredne situacije da bi se rizik od nastanka prevarnih radnji sveo na najmanji mogući nivo. U radu ,,Prevare u slučaju katastrofe: finansijski aspekti“ autori Snežana Knežević, Mrako Špiler, Aleksandra Mitrović i Marko Milašinović ukazuju da smo svi iskusili, posebno u novije vreme, kako katastrofe uništavanju ljudske živote i imovinu širom sveta. Ovaj članak opisuje specifičan problem koji se javlja uglavnom u slučaju katastrofe i oporavku od nje. Oporavak od katastrofa podrazumeva zadovoljenje finansijskih potreba, dugoročno ili kratkoročno posmatrano. Obim prevara i kriminalnih aktivnosti se povećava tokom katastrofa. Problem se odnosi na razmatranje pitanja vezanih za katastrofe, a koje mogu „otvoriti puteve“ za podršku pranju novca ili mogu da iniciraju utaju poreza. Dalje, posebno će biti istaknuta uloga koju imaju finansijski forenzičari. U radu ,,Uloga privatnog obezbeđenja u upravljanju rizicima od katastrofa“ autor Nenad Radivojević ističe da sve brojnije i destruktivnije pojave poput masovnih i učestalih elementarnih nepogoda, terorističkih napada na kritičnu infrastrukturu, havarija, tehničko-tehnoloških akcidenata i sličnih događaja često dovode do proglašenja vanrednih situacija. To je uticalo na to da države reorganizuju svoje elemente sisteme nacionalne bezbednosti, a pose-bno sisteme smanjenja rizika od katastrofa i upravljanja vanrednim situacija-ma, kako bi blagovremeno i adekvatno odgovorile na navedene oblike ugrožavanja. Okosnicu te reorganizacije čini i aktivnosti na donošenju pravnog okvira kojim se proširuje krug subjekta zaštite i spasavanja. Jedan od tih subjekta u društvu jesu i subjekta iz oblasti privatnog obezbeđenja. Predmet ovog rada jeste analiza pozitivnopravne regulative koja uređuje oblast privatnog obezbeđenja, zaštite kritične infrastrukture i oblast smanjenja rizika od katastrofa i upravljanja vanrednim situacijama u R. Srbiji, a cilj je sagledavanje aktuelne i moguće uloge privatnog obezbeđenja u upravljanju rizicima od katastrofa. U radu ,,Bezbednosni rizici od požara u ustanovama za izvršenje krivičnih sankcija” autor Dejan Novaković elaborira da se obezbeđenje određenih objekata od nastanka požara u ovom slučaju kazneno-popravnih zavoda kao ustanova za izvršenje krivičnih sankcija, zasniva na bezbednosnoj proceni ugroženosti tih objekata, koja predstavlja osnov za određivanje ciljeva, zadataka i nosilaca zaštite. Da bi se mogla sagledati mogućnost unapređenja procene ugroženosti kazneno-popravnih zavoda u ovom istraživanju prikaza-će se aktuelno stanje i način procenjivanja njihove ugroženosti u odnosu na rizike od požara. U cilju izrade naučne monografije i prikupljanja podataka za planirano empirijsko istraživanje, sačinjen je upitnik kako bi se sagledalo aktuelno stanje u oblasti organizacije sistema zaštite od požara u ustanovama za izvršenje krivičnih sankcija u Republici Srbiji. Anketa je bila anonimna, podaci su se isključivo koristili u istraživačke svrhe. Posebna pažnja bila je posvećena metodologiji procenjivanja rizika od požara i preduzimanju mera usmerenih na eliminisanje uzroka nastanka ili minimizaciji efekata rizičnog događaja, kao i mera za obezbeđenje minimalnih gubitaka i otklanjanja posledica ukoliko dođe do realizacije rizičnih događaja, što sve zajedno predstavlja osnov upravljanja rizikom od požara. U radu ,,Deljenje podataka u vanrednim situacijama“ autori Miljan Adamo-vić, Stefan Milojević, Marko Špiler i Jovan Travica ističu da deljenje podata-ka u vanrednim situacijama predviđa da se ono obavlja na rutinskoj osnovi, što podrazumeva mogućnost da se planira unapred. Međutim, to možda nije uvek slučaj, jer može doći do vanrednih situacija koje nisu mogle da se predvide. Tako, kriza koja je nastala usled pandemije koronavirusa, ilustruje potrebu za zajedničkim odgovorima javnih službi gde je brzo deljenje poda-taka od ogromnog uticaja na javno zdravlje i bezbednost. Prirodne katastrofe punog obima mogu opustošiti zemlje i naškoditi hiljadama ljudi. U vanrednim situacijama, aktivnosti koje spasavaju živote i ograničavaju uticaj zbog opasnosti, su ključne, i tada je važno brzo donositi odluke. U tom slučaju, posebno kompleksno pitanje za razne državne agencije i organizacije je koliko je moguće reagovati na pravi način, te doneti odluku o (ne)deljenju informa-cija. Predmet ovog rada jeste razmatranje šireg konteksta vezanog za deljenje informacija u vanrednim situacijama. U radu ,,Fenomenološke i etiološke dimenzije katastrofa izazvanih zemljo-tresom“ autori Jelena Planić i Vladimir Cvetković zaključuju da su prirodne katastrofe postale deo svakodnevnog života savremenog čoveka, i njihove pojave su sve učestalije i intenzivnije zbog klimatskih promena. Zemljotresi zbog svoje nepredvidivosti predstavljaju jednu od najstrašnijih i najskupljih prirodnih katastrofa. Autori u ovom radu, koristeći pregled literature, pred-stavljaju osnovne karakteristike zemljotresa kao prirodnih katastrofa, kao i značaj pripremljenosti u odgovoru na prirodne katastrofe. Prikazani su osnovni elementi zemljotresa, klasifikacija, skale za merenje jačine zemljotre-sa i posledice koje izazivaju zemljotresi. S obzirom na to da pripremljenost za katastrofe na nivou pojedinca, zajednice i društva predstavlja efikasno oruđe u smanjenju rizika od katastrofa i ublažavanju njihovih posledica, u radu je posebna pažnja posvećena načinima poboljšanja pripremljenosti. Korišćenjem brojnih naučnih radova, prikazana su iskustva mnogih država čije primere je potrebno pratiti kako bi se na pravilan način osmislile i implementirale strate-gije ublažavanja posledica prirodnih katastrofa, i programi edukacije građana. Rad ,,Mogućnosti upravljanja rizicima od šumskih požara pomoću geograf-skih informacionih sistema“ autor Saša Ljubojević temelji na opisivanju mogućnosti primene geografskih informacionih sistema u upravljanju rizicima od šumskih požara, sa osvrtom na prikupljanje podataka, analizom prikuplje-nih podataka, te predviđanjem bezbednosno rizičnih područja. Biće prikazano na koji način se može ostvariti sveobuhvatniji pregled ugroženih područja, objekata i stanovništva, na osnovu čega se mogu donositi adekvatne i pravo-vremene odluke. Pored navedenog, biće opisano i koliki bezbednosni aspekt prestavlja navedena baza podataka i na koji način je potrebno upravljati istom, te ko i kada može koristiti podatke. Podaci u toj bazi će jasno pokazati najrazličitija područja, te na koji način je moguće namerno izazvati štetu ogromnih razmera. Iako kreiranje jedne takve sveobuhvatne baze podataka, iz bezbednosnih razloga, predstavlja i bezbednosni rizik sam po sebi, potreba za zaštitom od požara prevazilazi takav rizik, ali zahteva strogo kontrolisano upravljanje rizicima. U radu ,,Ekonomske posledice prirodnih katastrofa“ autori Goran Milošević i Luka Čaušić ispituju prirodne katastrofe (poplave, suše, ekstremne tempera-ture, požari, zemlјotresi) koje direktno i indirektno utiču na nivo rizika i stanje bezbednosti lјudi, životinja, materijalnih i kulturnih dobara i životne sredine. Pored tragičnih gubitaka ljudskih života, svoje negativne efekte katastrofe ispolјavaju u uništavanju materijalnih dobara i životne sredine u lokalnoj, regionalnoj i nacionalno zajednici. Posledice prirodnih katastrofa - faktori uticaja na percepciju građana Srbije. Zavisno od intenziteta delovanja prirod-ne katastrofe mogu izazvati negativne ciklične oscilacije u okviru ekonom-skog sistema zemlje i to: na tržište rada, finansijsko tržište, tržište kapitala, odnosno na sve aspekte života i rada jednog društva. To može značiti eko-nomsku neravnotežu ne samo u okviru mikroekonomskog područja gde se dogodio neželјeni događaj, već i na nivou makroekonomskog prostora. U radu ,,Integrisano upravljanje otpadom u sistemu smanjenja rizika od katastrofa“ autor Jovana Martinović polazi od činjenice da u Republici Srbiji i širom sveta, nenaučno upravlјanje čvrstim otpadom i dalјe predstavlja složen i ozbilјan ekološki problem. Porast urbanizacije, industrijalizacije i eskponen-cijalnog rasta svetskog stanovništva odgovorni su za generisanje velikih količina otpadnih materijala, koji su direktno povezani sa zagađenjem zemljiš-ta, vazduha, vodnih resursa i rizicima po zdravlјe i sigurnost građana. Loše upravlјanje otpadom umnogome podriva uspeh ostvarivanja cilјeva održivog razvoja, čime se naglašava važnost i hitnost prelaska sa tradicionalnih linear-nih na integrisane pristupe upravlјanju otpadom. Polazeći od činjenice da je upravlјanje čvrstim otpadom globalno ekološko pitanje koje sadrži društveno-ekonomske, institucionalne, političke i ekološke aspekte, cilј ove studije je deskripcija i analiza različitih strategija integrisanog upravlјanja otpadom u razvijenim zemlјama i zemlјama u razvoju, sa posebnim fokusom na percepci-ju i učešće javnosti u aktivnostima upravlјanja otpadom, različite izazove i nedostatke sa kojima se suočava upravlјanje čvrstim otpadom i identifikova-nje inovativnih rešenja u ovoj oblasti. Iako je teško pronaći dobar sistem upravlјanja koji bi bio primenlјiv u svim zemlјama, nalazi su ukazali na sledeće karakteristike efikasnih i održivih sistema: prilagođenost lokalnim potrebama, minimalna upotreba toksičnih hemikalija, očuvanje resursa, smanjivanje otpada, korišćenje obnovlјivih izvora, uklјučivanje neformalnog sektora u aktivnosti upravlјanja otpadom (uključujući prikuplјanje, sortiranje i oporavak recikliranog otpada), veća tehnološka sofisticiranost i inovacije u upravlјanju otpadom, kontinuirano sprovođenje istraživanja i jasna zakonska regulativa. Imajući u vidu da nijedan sistem nije dovolјno efikasan u rešava-nju problema otpada usled prekomerne proizvodnje, trošenja i odlaganja, kao i determinisanost stavova i prakse lјudi u upravlјanju otpadom nivoom obrazovanja, starošću i prihodima, neophodno je podizanje svesti i sprovođe-nje kontinuiranih programa i kampanja obrazovanja javnosti o pravilnom upravlјanju otpadom na svim nivoima funkcionisanja društva. Rezultati preglednog rada doprinose unapređenju postojećeg fonda znanja o različitim aspektima integrisanog upravlјanja čvrstim otpadom. U radu ,,Uloga multimedijalnih sadržaja u edukaciji mladih o katastrofama“ autori Ivana Krnjić i Vladimir M. Cvetković ističu da obrazovanje o katastro-fama predstavlja jedan od najznačajnijih preduslova unapređenja pripremlje-nosti društva i građana za blagovremeno i adekvatno reagovanje u takvim situacijama. Iz tih razloga, koriste se različiti tradicionalni i inovativni načini edukacije mladih o katastrofama koji imaju za cilj unapređenje njihove otpornosti na različite prirodne i antropogene katastrofe. Koristeći pregled literature, autori u radu na jedan sistematičan način elaboriraju osnovne karakteristike obrazovanja o katastrofama, ali i karakteristike i načine primene multimedijalnih sadržaja u takvom procesu. Ne zapostavlajući značaj tradici-onalnih obrazovanih metoda, autori u radu predstavljaju osnovne modalitete sticanja znanja o katastrofama kroz školske programe sa osvrtom na njihovu bezbednostu u školskim objektima. Rezultati preglednog rada pokazuju da postoji ozbiljan dostupan društveni i naučno-pragmatični ambijent za osmiš-ljavanje i implementaciju multimedijalnih sadržaja u edukaciji mladih o katastrofama. Potrebno je nastaviti sa sprovođenjem istraživanja u ovoj oblasti u cilju unapređenja razumevanja svih prednosti i nedostataka upotrebe multimedija u obrazovne svrhe. Rad ,,Tačnost informacija i njihovo precizno i nedvosmisleno prenošenje javnosti kao načini upravlјanja rizikom u okolnostima epidemije (Republika Srbija u toku vanrednog stanja 2020. godine)“ autora Dragane Ćorić potvrđu-je da nedovolјno poznavanje materije o kojoj se izveštava javnost, i kompe-tativnost u brzini objavlјivanja informacija, više puta su uznemirili javnost. Brojne edukacije novinara u određenim oblastima o kojima izveštavaju kao i stalno upućivanje istih na striktnu primenu pravila novinarske etike kao da ne postižu svoj cilј. Potreba da neko prvi objavi neku informaciju je ustupila mesto potrebi za istinitim i činjeničnim predstavlјanjem vesti. Ova zamena je bila posebno izražena tokom vanrednog stanja u Republici Srbiji 2020. godine, gde je neprecizno i senzacionalističko prenošenje informacija više puta dovelo do uznemiravanja javnosti i čak i prekršaja od strane građana jer su informacije bile prenete nedovolјno precizno ili netačno. Nakon navođenja nekoliko primera i dobre i loše prakse, rad završavamo sa konstituisanjem jedinstvene formule za stvaranje dobrih, istinitih novinskih tekstova, posebno u situacijama potencijalno velike uznemirenosti javnosti. U radu ,,Bezbednosna zaštita Republike Srbije u uslovima prirodnih katastro-fa“ autori Željko V. Lazić i Martin I. Matijašević identifikuju prirodnu katastrofu kao specifičan bezbednosni fenomen u sebi sadrži različit dijapa-zon pretnji po bezbednost Republike Srbije. U zavisnosti od inteziteta, prostornog rasporeda i trajanja prirodne katastrofe, osim, opasnosti po ljude, materijalna dobra i životnu sredinu, sa sobom nosi pretnje po društveno-politički poredak. Kada državni organi u uslovima prirodnih katastrofa, nastoje da adekvatno organizuju i upravljaju sistemom zaštite i spasavanja, na prostoru koji je pogođen, obavezno dolazi do porasta sociopatoloških pojava, krađa, razbojništava, nasilničkog ponašanja. Predmet istraživanja u radu je zaštita bezbednosti Republike Srbije u uslovima prirodnih katastrofa, zaštite od direktnih posledica prirodnih katastrofa i indirektnih posledica, po posto-jeće društveno-političko uređenje, ekonomsku bezbednost i interese Republi-ke Srbije u regionu. U radu je izvršena tipologizacija bezbednosnih pretnji u uslovima prirodnih katastrofa. U radu ,,Rizik od nastanka litosferskih katastrofa u Braničevskom okrugu“ ,čiji su autori Marija Đurić i Irena Blagajac, predmet istraživanja je analiza rizika od nastanka litosferskih katastrofa u Braničevskom okrugu. Zadatak istraživanja je analizirati intenzitet zemljotresa, kao i zastupljenost klizišta i odrona na proučavanoj teritoriji. Cilj rada je utvrditi stepen rizika nastanka litosferskih katastrofa koje mogu ugroziti život stanovništva i njihove delat-nosti u Okrugu. U radu je kartom prikazana geografska rasprostranjenost klizišta i odrona na teritoriji Braničevskog okruga. Za posmatranu teritoriju prikazane su i karte intenziteta zemljotresa za povratni period od 95 i 975 godina. Analizom su obuhvaćene gustina naseljenosti stanovništva prema naseljima u Okrugu, kao i rasprostranjenost poljoprivrednih, šumskih, naselje-nih, vodnih i industrijskih površina. U radu su kartografski prikazane gustina naseljenosti stanovništva i namena zemljišta. Uporednom analizom navedenih podataka izrađena je sintezna karta koja obuhvata geoprostorno preklapanje istraženih litosferskih nepogoda sa gustinom naseljenosti stanovništva i namenom zemljišta kako bi se dobile zone visokog stepena rizika za stanov-ništvo. Na bazi sintezne karte izrađena je karta visokog, srednjeg i niskog rizika od nastanka litosferskih katastrofa i njihovog uticaja na život stanov-ništva i na njihove delatnosti na teritoriji Braničevskog okruga. Na osnovu istraživanja dati su predlozi mera za prevenciju, pripravnost, odgovor na udes i sanaciju katastrofalnih posledica po stanovništvo, građevinske objekte i privredne delatnosti u Braničevskom okrugu. U radu ,,Bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim šumskim požarima“ autor Milica Stefanović ističe da se u prethodnom periodu javila se značajna opasnost od izbijanja i širenja šumskih požara, kako u svetu tako i kod nas. Pored ljudskog faktora, kao najčešćeg uzročnika, sve veći rizik za pojavu vanrednih situacija ove prirode javlja se usled klimatskih promena. Pod uticajem visokih temperatura, tokom prethodnih meseci došlo je do šumskih požara velikih razmera na području Turske, Grčke, SAD, Srbije. Poseban problem javlja se ukoliko požar nastane pod uticajem ljud-skog faktora, a usled nepovoljnih klimatskih uslova dođe do njegovog nekontrolisanog širenja. Ukoliko se ne saniraju pravovremeno, šumski požari mogu se značajno proširiti i dovesti do uništavanja životne sredine, kao i do ugrožavanja ljudskih života i materijalnih dobara. Prilikom pojave događaja ove prirode, od značaja su vremenski uslovi koji mogu doprineti dodatnom širenju opasnosti (vetar, visoka temperatura, sušno vreme i sl.) Različita istraživanja predviđaju povećanje globalne temperature u narednim decenija-ma. Imajući u vidu da je rešenje za klimatske promene i povećanje globalne temperature proces koji zahteva da prođe određeno vreme, potrebno je raditi na prevenciji i jačanju kapaciteta za odgovor na vanredne i hitne situacije. Takođe, značajno je organizovati obuke i edukativne programe i na taj način uticati da građani izgrade svest o posledicama koje može ostaviti njihovo neodgovorno postupanje, koje može dovesti do izbijanja požara u prirodi. U radu ,,Komunikacija o rizicima od katastrofa“ autori Marko Radovanović i Vladimir M. Cvetković zaključuju da komunikacija rizika od katastrofa predstavlja jedan od temelјa uspešnog upravlјanja u katastrofama koji se ogleda u smanjenju razarajućih uticaja opasnosti od katastrofa na lјudske živote i imovinu, obezbeđenjem pravovremenih kritičnih informacija ugrože-nim zajednicama. Nedovoljno razvijen sistem indetifikacije, analize i deljenja informacija o rizicima od katastrofa dovodi do lošeg upravljanja u svim fazama katastrofa (ublažavanje, pripremljenost, odgovor i oporavak). U svakoj od spomenutih faza upravljanja postoje jasni zahtevi za specifičnim informacijama koje omogućavaju efikasno donošenje ključnih i blagovreme-nih odluka. Razmena informacija o rizicima od katastrofa je pod uticajem velikog broja faktora kao što su stepen naučno-tehnološke razvijenosti, demografskog, sociološkog i psihološkog ambijenta, kao i samih karakteristi-ka prirodnih i antropogenih opasnosti. Polazeći od nesumnjivog značaja informacija o rizicima od katastrofa, autori u preglednom radu identifikuju, analiziraju i sistematizuju relevantne aspekte fenomenoloških dimenzija komunikacije o rizicima od katastrofa. Posebna pažnja posvećena je sveobu-hvatnom sagledavanju izvora, subjekata i sredstava komunikacije, sa osvrtom na inovativna rešenja i strategije komunikacije u odgovoru na rizike od prirodnih i antropogenih katastrofa. U radu ,,Specifični etički aspekti trijaže pružanja prve pomoći u situacijama sa velikim brojem žrtava“ autor Srđan Nikolovski ukazuje da katastrofe koje zahvataju ljudsku populaciju povećavaju rizik od preopterećenja resursa službi prve pomoći po broju žrtava i težini njihovih povreda i drugih hitnih zdravstvenih stanja. U takvim slučajevima, čak i medicinski neobrazovani pojedinci mogu biti u situaciji da pruže neophodnu medicinsku pomoć i pre dolaska ekipa hitne medicinske pomoći. Stalno balansiranje između deonto-logije i utilitarizma je svakodnevna pojava u medicinskoj praksi koja se intenzivira u hitnim medicinskim situacijama i u onim događajima kada spasavanje života dospe na prvo mesto. Iako mogu postojati određene olakšavajuće okolnosti, većina je veoma otežavajuća i one sa zadatkom da obezbede osnovne mere podrške životu stavljaju u stresnu poziciju u kojoj je pribranost od velike važnosti. Predmet ovog rada je ukazivanje na specifične etičke aspekte trijažnog procesa pri pružanju prve pomoći žrtvama katastrofa. U etici je objašnjeno nekoliko situacija koje se odnose na selekciju pacijenata kojima treba pružiti medicinsku pomoć, kao i na mere koje treba primeniti. Najbitniji cilj ovih ilustrativnih situacija jeste da se utvrdi koji od navedenih etičkih pristupa treba primeniti da bi se sačuvalo što više života, a da se nijedna od žrtava istovremeno ne zapostavi. Zbog prisustva vremena kao ograničavajućeg faktora, primena principa trijaže i otklanjanje bilo kakvog oblika konfuzije je najefikasniji način pružanja hitne pomoći svim žrtvama katastrofe kako od strane nemedicinskog tako i od strane medicinskog osoblja. U radu ,,Percepcija građana o primeni inteligentnih informacionih sistema u upravljanju u vanrednim situacijama“ autori Vojkan Nikolić, Predrag Miloše-vić i Nikola Krunić zaključuju da su inteligentni sistemi bitan element ostva-renja ciljeva u različitim oblastima ljudskog rada i ponašanja, pa i u oblasti nacionalne bezbednosti. Korišćenjem računarskih sistema i njihovih aplikacija u operativnim i upravljačkim oblastima rada stvaraju se konkurentske predno-sti, obezbeđuje se razmena informacija zasnovana na znanju. U oblasti upravljanja vanrednim situacijama, brzina reagovanja i odgovora na pretnje je posebno značaja. Zahvaljujući informatičkoj obradi podataka, sistem uprav-ljanja je u mogućnosti da gotovo u svakom trenutku zna gde se pojavljuju problemi i rizici i kakav je nužni odgovor reagovanja na sve izazove i rizike. U ime autora, izražavam zahvalnost onima koji su najviše doprineli objavljivanju zbornika radova kao što su Naučno-stručno društvo za uprav-ljanje rizicima u vanrednim situacijama i Međunarodni institut za istraživanje katastrofa u ulozi izdavača, kao i recenzentima koji su vrlo strpljivo i detaljno proučili i unapredili sve naučne radove. Takođe, izražavam zahvalnost saradnicima Naučno-stručnog društva za upravljanje rizicima u vanrednim situacijama i Međunarodng instituta za istraživanje katastrofaAni Đergović, Tamari Ivković, Tamari Mančić, Martinu Matijaševiću, Stevi Miletiću, Nemanji Miljkoviću, Jeleni Planić, Zoranu Planojeviću, Sofiji Radojković i Milici Stefanović. Beograd, mart 2022. godine Prof. dr Vladimir M. Cvetković Urednici zbornika: prof. dr Branislav Ristivojević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; prof. dr Tatjana Bugarski, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; Prof. dr Goran Milošević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; Prof. dr Bojan Janković, Kriminalističko-policijski univerzitet u Beogradu. Naučni i programski odbor: Prof. dr Branislav Ristivojević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; prof. dr Tatjana Bugarski, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; doc. dr Vladimir M. Cvetković, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Vladimir Jakovljević, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Bojan Janković, Kriminalističko-policijski univerzitet u Beogradu; Prof. dr Srđan Milašinović, Kriminalističko-policijski univerzitet u Beogradu; Prof. dr Slavoljub Dragićević, Univerzitet u Beogradu, Geografski fakultet, Beograd; Prof. dr Želimir Kešetović, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Goran Milošević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; Prof. dr Snežana Knežević, Univerzitet u Beogradu, Fakultet organizacionih nauka, Beograd. Redakcioni odbor: Prof. dr Branislav Ristivojević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; prof. dr Tatjana Bugarski, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; doc. dr Vladimir M. Cvetković, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Vladimir Jakovljević, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Bojan Janković, Kriminalističko-policijski univerzitet u Beogradu; Prof. dr Srđan Milašinović, Kriminalističko-policijski univerzitet u Beogradu; Prof. dr Slavoljub Dragićević, Univerzitet u Beogradu, Geografski fakultet, Beograd; Prof. dr Želimir Kešetović, Univerzitet u Beogradu, Fakultet bezbednosti, Beograd; Prof. dr Goran Milošević, Univerzitet u Novom Sadu, Pravni fakultet, Novi Sad; Prof. dr Snežana Knežević, Univerzitet u Beogradu, Fakultet organizacionih nauka, Beograd. Tematske jedinice su sledeće: Pravni aspekti upravljanja rizicima od prirodnih katastrofa; Pravni aspekti upravljanja rizicima u litosferskim katastrofama (zemljotres, klizišta i odroni, vulkanske erupcije); Pravni aspekti upravljanja rizicima u hidrosferskim katastrofama (poplave i bujice, lavine); Pravni aspekti upravljanja rizicima u atmosferskim katastrofama (olujno gradonosne pojave, suše, ekstremno niske i visoke temperature); Pravni aspekti upravljanja rizicima u biosferskim katastrofama (epidemije, epizootije i epifitonoze, šumski požari); Pravni aspekti upravljanja rizicima od antropogenih katastrofa; Pravni aspekti upravljanja rizicima u nuklearnim i radiološkim katastrofama; Pravni aspekti upravljanja rizicima u industrijskim katastrofama; Pravni aspekti upravljanja rizicima u transportnim i infrastrukturnim katastrofama; Pravni aspekti upravljanja rizicima u katastrofama izazvanim opasnim materijama; Pravni aspekti upravljanja rizicima u katastrofama izazvanim ratnim razaranjima; Pravni aspekti upravljanja rizicima u katastrofama izazvanim požarima Pravni aspekti upravljanja rizicima u katastrofama izazvanim upotrebom oružja za masovno uništavanje (hemijski, biološki, nuklearni i radiološki terorizam). Bezbednosni aspekti upravljanja rizicima od prirodnih katastrofa Bezbednosni aspekti upravljanja rizicima u litosferskim katastrofama (zemljotres, klizišta i odroni, vulkanske erupcije); Bezbednosni aspekti upravljanja rizicima u hidrosferskim katastrofama (poplave i bujice, lavine); Bezbednosni aspekti upravljanja rizicima u atmosferskim katastrofama (olujno gradonosne pojave, suše, ekstremno niske i visoke temperature); Bezbednosni aspekti upravljanja rizicima u biosferskim katastrofama (epidemije, epizootije i epifitonoze, šumski požari). Bezbednosni aspekti upravljanja rizicima od antropogenih katastrofa Bezbednosni aspekti upravljanja rizicima u nuklearnim i radiološkim katastrofama; Bezbednosni aspekti upravljanja rizicima u industrijskim katastrofama; Bezbednosni aspekti upravljanja rizicima u transportnim i infrastrukturnim katastrofama; Bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim opasnim materijama; Bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim ratnim razaranjima; Bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim požarima Bezbednosni aspekti upravljanja rizicima u katastrofama izazvanim upotrebom oružja za masovno uništavanje (hemijski, biološki, nuklearni i radiološki terorizam). Link - https://zbornik.upravljanje-rizicima.edu.rs/index.php/d/issue/view/2
... Iako je krajnje kontroverzan, moglo bi se reći da utilitaristički pristup trijaže, u pokušaju da se maksimizira preživljavanje iznad svega ostalog, treba da diskriminiše godine starosti. Moglo bi se tvrditi da na preživljavanje ne utiče starost direktno, već indirektno, preko komorbiditeta koji su povezani sa većim brojem godina starosti (Pesik, 2001;Tan et al., 2004). Jasno je da se ishodi traume pogoršavaju sa godinama, a zapravo je starost kriterijum u određivanju potrebe za evaluacijom. ...
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Disastrous situations involving human population increase the risk of overwhelming first-responding services re-sources by the number of casualties and the severity of their injuries and other urgent medical conditions. In such cases, even non-medically educated individuals could be placed in a position to provide necessary medical attention even before the arrival of emergency medical service teams. The constant balancing between deontology and utilitarianism is an everyday issue in medical practice which intensifies in emergency medical situati-ons and in those events when saving lives comes into the first place. Although there can be certain facilitating circumstances, most of them are very aggravating and puts those with a task to provide basic life support measures in a stressful position where self-possession is out of paramount importance. The aim of this paper is to discuss specific ethical aspects of triage process in providing first aid to disaster victims. There are several situati-ons explained in ethics dealing with the selection of patients who should receive medical help, as well as measures which should be applied. The most essential goal of the of those illustrative situations is to determine which of the mentioned ethical appro-aches should be implemented in order to save as much lives as possible and not to neglect any of the victims at the same time. Due to the presence of time as a limiting factor, the application of triage principles and the elimination of any form of confusion is the most efficient way in providing emergency assistance to all disaster victims by both non-medical and medical personnel.
... 210 Increasingly EM has been asked to do just that. In the current health care system, emergency departments are routinely placed in the position of solving outpatient and inpatient capacity issues, [211][212][213] triaging disasters and epidemics, 211,214 determining the fair distribution of limited medical resources, 212,215 and acting as the face of American healthcare to millions. 198 As such EM medical education leaders should no longer accept its placement as an elective or noncore component within medical school teaching. ...
Thesis
Objective: The process by which medical students choose a specialization is incompletely understood, especially as related to factors that influence changes in specific career interest during medical school. Women and Underrepresented in Medicine (URiM) students are less likely than their peer to apply for residency in emergency medicine (EM). Identifying whether medical students from these groups have baseline differences in their career interests or if the lower likelihood in planning a career in certain medical specialties develops during medical school. However, comparison to other major medical specialty patterns will provide the first steps toward a general understanding of the mechanisms at play. Hypothesis: First, female and URiM students have lower interest in EM even after controlling for other factors. Second, career interest in EM for both groups would be like other students at medical school onset and that a “cooling out” of interest would occur. Third, that women and URiM physicians would exhibit no difference in EM career persistence. Fourth, female and male students enter medical school with similar interest in fields like internal medicine and surgery and women will have higher odds of an interest in fields with typically more female physicians such as pediatrics and OB/GYN. Fifth, URiM students will have equivalent interests not non-URiM students. Sixth, women will both be “cooled out” and under-recruited. Fourth, URiM medical specialty interest will remain relatively stable from entry of medical school to graduation. Methods: Secondary data analyses was conducted on a cross-section of all residency applicants from 2005-2010. Data sources included: AAMC, NBME, AMA. Binary logistic regression models (BLM) were fitted with the outcomes: a planned career in EM at medical school entry, planned career in EM at graduation, and continued practice in EM. BLMs were also fitted with the outcomes: a planned career in one of four medical specialties (Internal Medicine, Pediatrics, OB/GYN, and General Surgery/Surgical Specialties) at medical school entry and again at graduation. Regression models included demographics, student attitudes, debt, undergraduate GPA and standardized test scores, and, medical school experiences. Results: URiM students expressed less interest in a career in EM when entering medical school and at graduation. No gender differences in interest existed at medical school onset. Women were less likely to enter EM by the time of medical school graduation. After residency, both female and URiM students had similar persistence in EM as all other graduates. Women were less likely to be interested in a career in Internal Medicine and Surgery and more interested in Pediatrics and OB/GYN at the start of medical school while URiM students expressed more interest in OB/GYN and Surgery. At graduation, women were still less likely to enter Internal Medicine and Surgery and more interested in OB/GYN and Surgery. URiM students were more likely to enter in Internal Medicine and less likely Pediatrics. Conclusions: Female and URiM medical students were less likely to enter EM. Women were less likely to develop a career interest in EM. While URiM students were less interested in EM generally, those initially interested in EM had a “cooling out” effect. Women have stable preferences regarding planned medical specialties in other specialties. In contrast, URiM students enter medical school more likely to enter OB/GYN and Surgical careers but at graduation were more likely to plan on Internal Medicine and less likely Pediatrics.
... Pesik et al suggest that the physicians have no ethical obligation to accomplish anything that cannot be achieved due to lack of resources. 17 The ethical obligation to care for a patient also carries a personal risk to MCI responders of being exposed to infectious diseases, radiation, or toxins in cases of pandemics, explosions, and acts of bioterrorism. 18 In a survey involving 744 physicians, Alexander et al found that 80% were willing to work when placed at risk, however, less than 45% felt prepared. ...
Mass casualty incidents, by nature of their scale and unpredictability, can rapidly overwhelm health infrastructure. Preparation is the key to managing these crises with the lowest risk to emergency and health personnel, while providing maximal life saving measures. We present an overview of the multi-tiered planning that should go into forming a well set out emergency response plan and one that is capable of being adapted to a wide range of mass casualty scenarios. We highlight the ethical implications that a healthcare team faces while making challenging decisions rapidly in a high-pressure environment. Radiology trainees should be aware of the response systems in place at their institutions and the role that is expected of them in mass casualty incidents.
Article
Introduction: Mass casualty events (MASCAL) are on the rise globally. Although natural disasters are often unavoidable, the preparation to respond to unique patient demands in MASCAL can be improved. Utilizing telemedicine can allow for a better response to such disasters by providing access to a virtual team member with necessary specialized expertise. The purpose of this study was to examine the positive and/or negative impacts of telemedicine on teamwork in teams responding to MASCAL events. Methods: We introduced a telemedical device (DiMobile Care) to Forward Surgical Teams during a MASCAL simulated training event. We assessed teamwork-related attitudes, behaviors, and cognitions during the MASCAL scenario through pre-post surveys and observations of use. Analyses compare users and nonusers of telemedicine and pre-post training differences in teamwork. Results: We received 50 complete responses to our surveys. Overall, clinicians have positive reactions toward the potential benefits of telemedicine; further, participants report a significant decrease in psychological safety after training, with users rating psychological safety as significantly higher than non-telemedicine users. Neither training nor telemedicine use produced significant changes in cognitive and behavioral-based teamwork. Nonetheless, participants reported perceiving that telemedicine improved leadership and adaptive care plans. Conclusions: Telemedicine shows promise in connecting Forward Surgical Teams with nuanced surgical expertise without harming quality of care metrics (i.e., teamwork). However, we advise future iterations of DiMobile Care and other telemedical devices to consider contextual features of information flow to ensure favorable use by teams in time-intensive, high-stakes environments, such as MASCAL.
Article
Objective The aim of this study was to explore the application of the flipped classroom approach in the training of Mass Casualty Triage (MCT) to medical undergraduate students. Methods In this study, 103 fourth-year medical students were randomly divided into a Flipped Classroom (FC) group (n = 51) and a Traditional Lecture-based Classroom (TLC) group (n = 52). A post-class quiz, simulated field triage (SFT) and feedback questionnaires were performed to assess both groups of students for their learning of the course. Results In the post-quiz, the median (IQR) scores achieved by students from the FC and TLC groups were 42(5) and 39(5.5), respectively. Significant differences were found between the two groups. In the SFT, overall triage accuracy was 67.06% for FC, and 64.23% for TLC students. Over-triage and under-triage errors occurred in 18.43% and 14.50% of the FC group, respectively. The TLC group had a similar pattern of 20.77% over-triage and 15.0% under-triage errors. No significant differences were found regarding overall triage accuracy or triage errors between the two groups. Conclusions The FC approach could enhance course grades reflected in the post-quiz and improve students’ satisfaction with the class. However, there was no significant difference of competency between the two groups demonstrated in the SFT exercise.
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American society has a history of turning to physicians during times of extreme need, from plagues in the past to recent outbreaks of communicable diseases. This public instinct comes from a deep seated trust in physician duty that has been earned over the centuries through dedicated and selfless care, often in the face of personal risks. As dangers facing our communities include terroristic events physicians must be adequately prepared to respond, both medically and ethically. While the ethical principles that govern physician behavior—beneficence, nonmaleficence, autonomy, and social justice—are unchanging, fundamental doctrines must change with the new risks inherent to terroristic events. Responding to mass casualty disasters caused by terrorists, natural calamities, and combat continue to be challenging frontiers in medicine. Preparing physicians to deal with the consequences of a terroristic disease must include understanding the ethical challenges that can occur.
Article
Countries, governments, and cultures must move through each of the behavioral-developmental stages of human development sequentially. It is hypothesized that each behavioral-developmental stage must be achieved, and failure to recognize this may be a major contributing factor to the rise of terrorism and crime in a society. In a war-like situation, an occupying country's attempts to have the conquered country skip behavioral-developmental stages will fail more often than not. This will possibly result in negative sentiment and terrorist behavior among those in the occupied country. Terrorism is an omnipresent condition worldwide. It is common for non-scholarly observers to not know that terrorist attack lethality is now extremely low. Terrorist attacks are often constituted by suicide bombings, which makes them relatively difficult and costly to perform. Remote controlled detonators already exist but they are not used in the Middle East. In the future, terrorists likely have access to not only biological weapons, but also small and easily transportable nuclear weapons which can be smuggled across the world. It is for these reasons that this article was written, to address these problems from an adult developmental perspective. An adult developmental perspective is useful for several reasons. One of the problems is that terrorists are not the same as conventional armies. They do not have a central location so conventional wars against them do not show the same promise. With the Internet and its successors, the difficulty to organize terrorist activities worldwide has decreased drastically. At the moment, many of the attacks are suicidal, but there is no reason to believe that is necessary given remote detonation devices are widely available. This article addresses the larger issue of how to manage and reduce conflict between terrorists and their targets. The approaches for the most part are based on adult behavioral-developmental stage theories. The history of the behavioral-developmental stage theory harks back to Piaget as well as Kohlberg and his students such as Kegan, Selman and Commons. The article provides a systematic framework for viewing many present suggestions that abound in the policy area. What is different is these authors provide a behavioral-developmental-stage diagnostic means for deciding what actions are appropriate for a society and a terrorist group at a given time.
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The microbial world is mysterious, threatening, and frightening to most people. The stressors associated with a biological terrorist attack could create high numbers of acute and potentially chronic psychiatric casualties who must be recognized, diagnosed, and treated to facilitate triage and medical care. Media communications, planning for quarantine and decontamination, and the role of community leaders are important to the mitigation of psychological consequences. Physicians will need to accurately diagnose anxiety, depression, bereavement, and organic brain syndromes to provide treatment, reassurance, and the relief of pain.
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HUMANS often have the aspirations of deities, though never the resources. Intensive care units (ICUs) provide an example of the desire to provide an optimal level of care for all who require it, where "optimal" is taken to mean the highest achievable standard of care. However, recent budgetary retrenchments in the provision of funds for health care show that health care is not always an overriding public policy priority. Consequently, as a matter of morality and public policy, it will be necessary to determine at what point undesirable standards of health care are simply unfortunate, but not unfair in the sense of constituting a claim on further resources. We explore the distribution of health care resources by addressing the problem of allocating ICU beds (1) when further admissions to an ICU will jeopardize the standard of health care for all those in the ICU, (2) when those eligible for admission
Article
Who shall live when not all can live? Although this question has been urgently forced upon us by the dramatic use of artificial internal organs and organ transplantations, it is hardly new. George Bernard Shaw dealt with it in “The Doctor’s Dilemma”: Sir Patrick. Well, Mr. Savior of Lives: which is it to be? That honest decent man Blenkinsop, or that rotten blackguard of an artist, eh? Ridgeon. It’s not an easy case to judge, is it? Blenkinsop’s an honest decent man; but is he any use? Dubedat’s a rotten blackguard; but he’s a genuine source of pretty and pleasant and good things. Sir Patrick. What will he be a source of for that poor innocent wife of his, when she finds him out? Ridgeon. That’s true. Her life will be a hell. Sir Patrick. And tell me this. Suppose you had this choice put before you: either to go through life and find all the pictures bad but all the men and women good, or go through life and find all the pictures good and all the men and women rotten. Which would you choose?1 A significant example of the distribution of scarce medical resources is seen in the use of penicillin shortly after its discovery. Military officers had to determine which soldiers would be treated—those with venereal disease or those wounded in combat.2 In many respects such decisions have become routine in medical circles. Day after day physicians and others make judgments and decisions “about allocations of medical care to various segments of our population, to various types of hospitalized patients, and to specific individuals,”3 for example, whether mental illness or cancer will receive the higher proportion of available funds. Nevertheless, the dramatic forms of “Scarce Life-Saving Medical Resources” (hereafter abbreviated as SLMR) such as hemodialysis and kidney and heart transplants have compelled us to examine the moral questions that have been concealed in many routine decisions. I do not attempt in this paper to show how a resolution of SLMR cases can help us in the more routine ones which do not involve a conflict of life with life. Rather I develop an argument for a particular method of determining who shall live when not all can live. No conclusions are implied about criteria and procedures for determining who shall receive medical resources that are not directly related to the preservation of life (e.g. corneal transplants) or about standards for allocating money and time for studying and treating certain diseases. Just as current SLMR decisions are not totally discontinuous with other medical decisions, so we must ask whether some other cases might, at least by analogy, help us develop the needed criteria and procedures. Some have looked at the principles at work in our responses to abortion, euthanasia, and artificial insemination.4 Usually they have concluded that these cases do not cast light on the selection of patients for artificial and transplanted organs. The reason is evident: in abortion, euthanasia, and artificial insemination, there is no conflict of life with life for limited but indispensable resources (with the possible exception of therapeutic abortion). In current SLMR decisions, such a conflict is inescapable, and it makes them so morally perplexing and fascinating. If analogous cases are to be found, I think that we shall locate them in moral conflict situations. An especially interesting and pertinent one is U.S. v. Holmes.5 In 1841 an American ship, the William Brown, which was near Newfoundland on a trip from Liverpool to Philadelphia, struck an iceberg. The crew and half the passengers were able to escape in the two available vessels. One of these, a longboat, carrying too many passengers and leaking seriously, began to founder in the turbulent sea after about twenty-four hours. In a desperate attempt to keep it from sinking, the crew threw over board fourteen men. Two sisters of one of the men either jumped overboard to join their brother in death or instructed the crew to throw them over. The criteria for determining who should live were “not to part man and wife, and not to throw over any...
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The most painful of all medical care decisions concerns life-preserving measures which, because of limited resources, require certain individuals to be excluded in favor of others. How does one weigh the relative rights of individuals to such care? Whenever possible, decisions to withhold lifesaving therapy should be made in advance. but in the absence of a clear expression that lifesaving care should be withheld, the person in charge must assume that care was intended.
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This report will explore the relationship between organizational behavior in disasters and its implications for disaster planning. There are several new and old features of both disasters and disaster planning to be explained. In recent times a new category of hazards has been added that has altered the effectiveness of disaster planning strategies used in the past.
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"The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all." This 1981 resolution of the World Health Assembly (resolution WHA 34.38) recognizes that the greatest threats to the health of the people of the world lie not in specific forms of acute or chronic disease, not even in poverty, hunger, or homelessness, but rather in the consequences of war. Any war, and even preparation for war,1 can of course lead to poverty, hunger, homelessness, and disease. Indeed, these consequences make even "victory," or the quest for "national security" through massive arms expenditures, seem hollow. Among the dangers of war, the greatest single threat lies in weapons of indiscriminate mass destruction, which The Journal recognizes annually with its Hiroshima anniversary issue.Nuclear Weapons Nuclear weapons remain the most potentially destructive of all these
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KIE Difficult ethical choices imposed by triage, the process of sorting casualties according to severity of illness (need) and priority for treatment (allocation), are discussed in the context of recent disasters such as an Amtrak collision and the Mexico city earthquake. The question of medical response to nuclear war raises issues of professional duty to assist in making plans for morally repugnant events such as mass destruction; the feasibility of triage, as a conscious professional act, during a time of extreme stress and carnage; and fundamental differences among physicians in their beliefs about themselves, their roles, and their moral obligation to the world.