The AMA's Council on Ethical and Judicial Affairs' position statement on “Disaster Preparedness and Response” is a welcome discussion of an important issue: the extent to which physicians have a responsibility to treat people affected by disasters in which the nature, source, and cause of the harm is unclear and where the risk is largely unknown.
The AMA paper considers historical accounts of physician behavior in response to epidemics and disease outbreaks. It reflects on findings from a national survey in which 80% of physicians claimed they would continue to care for people in the event of an outbreak of “an unknown but potentially deadly illness,” whereas fewer (55%) accepted that there is an obligation to do so.1
Alexander GC, Wynia MK. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Affairs 2003;22:189–97.
The position statement concludes that physicians have an obligation to render aid and, although this obligation is not absolute, it increases with the degree of need, the proximity of those harmed, the capacity to treat, and the lack of other sources of assistance.
Although the AMA position statement is a contribution to the debate, we believe the approach to be too narrow, both in its treatment of disaster and in the range of responses put forward. We propose a broader framing for this issue and a wider ethical basis for analysis.
Framing the Issue(s): Broadening the Notion of Disaster
The AMA paper focuses on individuals responding to unknown or dangerous infectious diseases and to bioterrorism. This perspective is too narrow. Within this last year we have seen terrorist attacks on public transport systems, devastating earthquakes, tsunamis, hurricanes and floods, and famine resulting from protracted violent political conflict. In all these cases, adequate responses have depended on many individuals acting in concert. Lack of preparedness, such as in New Orleans before and after Hurricane Katrina, delays humanitarian relief and exacerbates the misery. For all these reasons we suggest that the understanding of “disaster” and suggestions for adequate preparedness to respond be framed more broadly.
The AMA paper is limited to local and national events and recognizes “proximity” as a key factor in an “obligation” to respond. Hurricane Katrina underscored this moral obligation by exposing local, state, and federal governments to severe criticism for their lack of adequate preparation and response to a predicted disaster at home. We suggest, however, that not only is there an obligation to respond nationally, but also to respond to crises beyond local and national boundaries.2
Singer P. One World: The Ethics of Globalization. New Haven, Conn.: Yale University Press; 2002.
Nussbaum argues that cultivating humanity in the contemporary world requires that we see ourselves as “not simply citizens of some local region or group but also, and above all, as human beings bound to all other human beings by ties of recognition and concern.”3
Nussbaum M. Liberal education and global citizenship. 2004 Academic Convocation Address, Virginia Military Institute, Aug 31, 2004. Available at: http://www.vmi.edu/media/dean/nussbaumaddress.pdf (accessed Jul 14, 2005).
Most developed countries have the capacity to mount a response and be on the ground almost anywhere in the world within 24 hours. The issue in any major disaster, both at home and abroad, is preparation and the ability to render timely and effective assistance to those experiencing significant adversity. In New Orleans, there was no adequate response for several days. Conversely, following the December 26 tsunami, there was an influx of foreign medical and other personnel on short-term “relief missions” to places such as Aceh and Sri Lanka. However, many were poorly prepared. Their motivation to assist was gratefully acknowledged, but there has been criticism of a lack of awareness and sensitivity to local capacities and processes. This highlights a need for those coming from outside the affected populations to work respectfully with local communities and agencies. Both of these situations—Hurricane Katrina and the December 26 Tsunami—highlight a need for prior training, planning, and development of the capacity of agencies to coordinate willing volunteers. This is a practical issue and quite different from a moral argument that responsibility is greater when disaster confronts us at home rather than in distant lands.
In confining itself to a notion of acute disaster, the AMA provides some guidance to the individual physician challenged by single events, such as isolated threats or potential occurrences of bioterrorism or terrorist attacks on a small scale. However, the most significant challenges to humankind are chronic and complex humanitarian disasters characterized by structural inequalities, poverty, and state and intergroup violence. O'Neill also stresses the importance of looking beyond narrow borders and keeping in mind the relationship between the developed and developing worlds:
In failing to look beyond boundaries we fail to take into account the fact that boundaries are now multiply porous. Health problems travel across boundaries not only because diseases travel, but because the mirror image of a global configuration of social and economic power is a global configuration of poverty and ill health.4
O'Neill O. Public health or clinical ethics: Thinking beyond borders. Ethics and International Affairs 2002;16:35–45.
Developed countries are not innocent bystanders in relation to crises that are caused or exacerbated by poverty5
Pogge T. World Poverty and Human Rights: Cosmopolitan Responsibilities and Reforms. Cambridge, UK: Polity Press; 2002.
The AMA paper prompts the physician to consider her position in relation to individuals requiring medical treatment. The ethical questions that arise at a population level—concerns about public health and health promotion responsibilities—remain largely unanswered. Moreover, an adequate external response to any disaster, whether acute or on-going, necessarily involves concerted and coordinated responses by individuals acting together as members of governmental or nongovernmental, local or international, public or private organizations.
Ethical Basis for Analysis
The AMA paper relies on a Kantian (duty-based) approach to ethics. Kant conceived of ethics in terms of duty or obligation, defined in rational terms. Although duty to treat is one element of a doctor's response, it is not the only, or even the strongest, motivation for going to the aid of another person. Questions also arise in relation to imposing an obligation to treat on health professionals when they may themselves be exposed to risk of extreme harm.
What is significant about human beings is their willingness to respond to others in crises even in the face of personal risk. Although not true of all, it is remarkable how many volunteer in such circumstances. We suggest that a more ethical and effective stance is to rely on, and build on, a deep humanitarian impulse to care for others. Van Hooft describes this as “a primordial motivational field” that he calls “deep caring.”6
Van Hooft S. Caring: An Essay in the Philosophy of Ethics. Boulder: University of Colorado Press; 1995.
Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New York: Oxford University Press; 1993; see also note 6, van Hooft 1995.
The responses to Ebola virus, SARS, and avian influenza outbreaks, as well as the early response to HIV/AIDS, demonstrate this. Such “deep caring” has not, however, been manifest in the response to pressing and compounding crises and disasters in distant places such as Darfur in West Sudan, where militia have terrorized and displaced millions of people, or in Niger, where we have been shamed to act to avert further catastrophe. Clearly, a better understanding of the conditions leading to an effective humanitarian response is required. It may be that the most significant factors are an understanding of ourselves as “human beings bound to all other human beings by ties of recognition and concern,”8
See note 3, Nussbaum 2004.
There are some situations, such as in Louisiana, where governments have a duty to respond and should, if necessary, have personnel conscripted to fulfill this duty. There are other situations, however, where it may be more appropriate to rely on volunteers. We need not impose a duty when a different approach, such as an ethics of care, would recognize and support a freely given response. A multifaceted response to disaster would reinforce a qualified professional duty and obligation to go to the assistance of those harmed in disasters. However, in other situations, for example, where there is danger to those rendering assistance, it may be more ethical and effective to rely on caring and humane responses of individuals, nongovernmental agencies, and governmental bodies acting in concert. Making sure this happens requires prior training of individual healthcare professionals, coordinating organizations and nurturing the conditions for effective humanitarian responsiveness.
