THE JOURNAL OF CLINICAL ETHICS Clinical Ethics in Catastrophic Situations: Mapping a Standard of Care—Imagining the Unthinkable Jeffery T. Berger, Guest Editor 3 Bedside Ethics and Health System 55 Legal Briefings: Crisis Standards of Care Catastrophe: Imagine If You Will . and Legal Protection during Disasters and Jeffrey T. Berger, Guest Editor Emergencies Thaddeus Mason Pope and 6 A Possible Application of Care-Based Mitchell F. Palazzo Ethics to People with Disabilities during a Pandemic 65 Imagining the Unthinkable, Illuminating Edmund G. Howe the Present Jeffrey T. Berger, Guest Editor 15 Family Participation in the Care of Patients in Public Health Disasters 68 How Can Careproviders Most Help Tia Powell Patients during a Disaster? Edmund G. Howe 21 Sufficiency of Care in Disasters: Ventilation, Ventilator Triage, and the 82 An Ethical Framework for the Responsible Misconception of Guideline-Driven Management of Pregnant Patients in a Treatment Medical Disaster Griffin Trotter Frank A. Chervenak and Laurence B. McCullough 35 Pandemic Preparedness Planning: Will Provisions for Involuntary Termination of 87 Non-Pharmaceutical Interventions to Life Support Invite Active Euthanasia? Limit the Transmission of a Pandemic Jeffrey T. Berger Virus: The Need for Complementary Programs to Address Children’s Diverse 39 Should Palliative Care Be a Necessity or a Needs Luxury during an Overwhelming Health Armand H. Matheny Antommaria and Catastrophe? Emily A. Thorell Philip M. Rosoff 95 Attending to Social Vulnerability 48 Taking Seriously the “What Then?” When Rationing Pandemic Resources Question: An Ethical Framework for the Dorothy E. Vawter, J. Eline Garrett, Responsible Management of Medical Karen G. Gervais, Angela Witt Prehn, and Disasters Debra A. DeBruin Laurence B. McCullough Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. 2 The JournalThe of Clinical Journal Ethics of Clinical Ethics 2020—Special Publication 6 West Washington Street, Suite 302, Hagerstown, Maryland 21740 USA 240-420-8850; fax 240-420-0037 [email protected] www.clinicalethics.com EDITOR IN CHIEF Edmund G. Howe, MD, JD Professor of Psychiatry, Director of Programs in Medical Ethics, Uniformed Services University of the Health Sciences EXECUTIVE EDITOR AND PUBLISHER Norman Quist MANAGING EDITOR Leslie LeBlanc ASSOCIATE EDITORS Arthur Caplan, PhD Charles MacKay, PhD University of Pennsylvania National Institutes of Health Christine K. Cassel, MD Alan Meisel, JD American Board of Internal Medicine University of Pittsburgh Jeffrey T. Berger, MD Christine I. Mitchell, RN, MS Winthrop Hospital Children’s Hospital of Boston T. Forcht Dagi, MD, MPH Jonathan D. Moreno, PhD Kennedy Institute of Ethics University of Pennsylvania Dena S. Davis, JD, PhD James Lindemann Nelson, PhD Cleveland State University Michigan State University Arthur R. Derse, MD, JD Robert Pearlman, MD, MPH Medical College of Wisconsin Seattle VA Medical Center Ezekiel J. Emanuel, MD, PhD Edmund D. Pellegrino, MD National Institutes of Health Georgetown University Sally Gadow, PhD Lainie Friedman Ross, MD, PhD University of Colorado University of Chicago Jodi Halpern, MD, PhD James E. Sabin, MD University of California, Berkeley Harvard Pilgrim Health Care and Harvard Medical School Albert J. Jonsen, PhD Mark Siegler, MD University of Washington University of Chicago John La Puma, MD Peter Singer, MD, MPH, FRCPC Santa Barbara Institute for Medical Nutrition and Healthy Weight University of Toronto Robert J. Levine, MD Robert Truog, MD Yale University Harvard Medical School Childrens Hospital Erich H. Loewy, MD Harry Yeide, Jr., PhD University of California, Davis George Washington University Laurie Zoloth, PhD Northwestern University The Journal of Clinical Ethics, ISSN 1046-7890, print and electronic versions. The Journal of Clinical Ethics is a peer-reviewed, refereed journal, indexed in PubMed, Research Alert, and Cumulative Index to Nursing & Allied Health Literature. Photocopying: All rights reserved. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any other information storage and retrieval system without the prior written permission of The Journal of Clinical Ethics. Note: The Journal of Clinical Ethics does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in The Journal of Clinical Ethics reflect the views of the authors. This journal is published as an information and research tool only. The publisher is not rendering legal or medical advice nor is the publisher to be held liable for the accuracy of the information contained herein. © 2020 by The Journal of Clinical Ethics. Please contact Mary Gesford at 240-420-8850 or [email protected] for assistance with subscriptions. Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. 2020—Special Publication The Journal of Clinical Ethics 3 Citation for the original article: Jeffrey T. Berger, “Bedside Ethics and Health System Catastrophe: Imagine If You Will . ” The Journal of Clinical Ethics 21, no. 4 (Winter 2010): 285-87. Bedside Ethics and Health System Catastrophe: Imagine If You Will . Jeffrey T. Berger, Guest Editor In view of recent public health challenges, The Journal of Clinical Ethics has collected articles that were originally published as “Clinical Ethics in Catastrophic Situations: Mapping a Standard of Care,” written after Hurricane Katrina, Guest Edited by Jeffrey T. Berger, MD, FACP, FAAHPM, Professor of Medicine, NYU Long Island School of Medicine and Chief, Division of Palliative Medicine and Bioethics, Department of Medicine, NYU Winthrop Hospital. We thought it would be helpful to make these articles available to policy makers and practitioners, as the challenges remain salient. ABSTRACT “Imagine if you will . .” followed by an imagi- nation-bending scenario with weighty moral Preparations for large-scale disasters have tended to overtones. If he were writing this introduction, focus on triage schema, stockpiling of materials, and other he might lay down this challenge: “Imagine if logistical concerns. Less attention has been given to the you will, a world suddenly gone mad. A world myriad of distressing and almost unthinkable ethically in which ordinary expectations for health and charged dilemmas that will emerge at the bedside during a safety are hijacked; a world in which established catastrophe, and how they may be best managed. Yet, it is norms of morality are upended; a world in these bedside issues that may limit or thwart the effective- which your very survival is no longer assured. ness of disaster planning, and, therefore, they ought to be You have entered the world of health system carefully considered. collapse, you have entered The Twilight Zone.” The dual phenomena of high population Rod Serling, the creator and narrator of the densities, and the increasingly technologic na- 1960s television program The Twilight Zone, ture of basic services and medical care, create often introduced its episodes with the words, an enormous vulnerability for the public’s health and profound challenges for health prac- Jeffrey T. Berger, MD, is an Associate Professor of Medi- titioners in times of catastrophe. Large-scale cri- cine at S.U.NY Stony Brook School of Medicine and is Di- ses may be caused by natural phenomena such rector of Clinical Ethics, Chief, Section of Hospice and Pal- as hurricanes (Katrina, 2005), tsunamis (Indian liative Medicine, Department of Medicine at Winthrop Uni- Ocean, 2004), cyclones (Myanmar, 2008), earth- versity Hospital in Mineola, New York, [email protected]. quakes (China, 2008), and pandemics (influ- ©2010 by The Journal of Clinical Ethics. All rights reserved. enza, 1918); and by industrial accidents (Bho- Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. 4 The Journal of Clinical Ethics 2020—Special Publication pal 1984, Chernobyl, 1986). The specter of ter- tonomy, justice, and utility. The rapidity of this rorists’ use of conventional, biological, and shift may mirror the nature of the disaster. Will nuclear agents also raises the threat of health authorities prepare clinicians to accommodate catastrophes. These events can immediately a revised ethical calculus prior to a calamity? If transform large portions of a society by disabling so, how? How will they be briefed and coached electrical grids, communications systems, wa- during a catastrophe, and by whom? How will ter utilities and sewerage systems, and by dis- compliance be assured? Will some clinicians rupting fuel supplies, transportation, and sani- invoke conscientious objection to “martial eth- tation, in addition to directly causing illness. ics”? Will some passively object and others ac- The delivery of healthcare services would likely tively protest? Will such objection add to chaos collapse just when hospitals would be faced and cause harms in addition to ones directly with a large spike in patient volume. caused by the catastrophe? How will these pro- The health system may collapse from a large