Terrorism and the ethics of emergency medical care

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.

Full text

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
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646 ANNALS OF EMERGENCY MEDICINE 37:6 JUNE 2001
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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.