Topic Collection Cover Page

Ethics
Topic Collection
December 12, 2018

Topic Collection: Ethics

Healthcare providers have an obligation to deliver care and services consistent with professional ethics standards. In the event of a catastrophic natural or human-caused disaster, these obligations can become complicated under crisis standards of care when difficult decisions may need to be made about allocation of resources. Consistency, fairness, effectiveness, and transparency-which are all part of medical disaster planning— are best achieved by engagement with stakeholder communities so that planning incorporates  the values,  The resources in this Topic Collection include lessons learned from recent disasters, educational and training materials, and plans, tools, and templates that can help healthcare professionals, planners, and communities identify, plan for, and address ethical challenges they may face before, during, and after a disaster. (Please note: ASPR TRACIE also developed a comprehensive Topic Collection on Crisis Standards of Care, which focuses on systems and processes including clinical aspects of crisis care. The “Ethics” category of the Ebola/VHF Topic Collection contains topic-specific resources.)

Note that in some cases, specific ethical frameworks or conclusions differ from other authors’ approaches/experiences. There is broad acceptance of the foundations of disaster ethics, but sometimes differing opinions about how the details are applied or the systems implemented – particularly evident between the ethics community and the clinical community. Readers are encouraged to look at a variety of sources when developing plans.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

Must Reads


Baker, M. (2015). Ebola Response in West Africa: My Experience. Alabama Department of Public Health.
The speaker for this one-hour, 23 minute video discusses his experience working in West Africa during the 2014-2015 outbreak. He is a pediatric physician, and discusses his experiences, including ethical challenges he experienced in the care of children with Ebola.
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Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
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Connerton, P. (2013). Ethical Guidelines for the Development of Emergency Plans. American Health Care Association.
This guidance can help disaster planners incorporate ethical considerations into their documents, exercises, and other preparedness activities. The author provides a concise summary of disaster ethics principles and linkages to long-term care.
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Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
This report was designed to help authorities operationalize the concepts first developed in the 2009 Institute of Medicine (now known as the National Academy of Medicine) document titled, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.” Volume 1, Section 3 provides an overview of legal and liability issues in catastrophic disasters. Legal and regulatory issues are a frequently discussed point in other areas of the document as well.
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Hick, J.L., Hanfling, D., and Cantrill, S.V. (2012). Allocating Scarce Resources in Disasters: Emergency Department Principles. Annals of Emergency Medicine. 59(3): 177-187.
The authors summarize key elements contained in the Institute of Medicine work on crisis standards of care. Written for the emergency medicine community, this paper is intended to be a useful adjunct to support discussions related to the planning for large-scale disaster events.
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This report was written for the CDC to provide an ethical framework for public health providers to use when planning for or responding to a public health emergency or other disaster.
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This guidance document is divided into five sections on ethical preparedness and response in a healthcare system: 1) an overview of ethical challenges; 2) workforce capacity and responsibility; 3) resource allocation; 4) hospice and palliative care; and 5) limiting personal liberty to preserve public health. The document also includes a checklist for implementing the plan guidance.
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Singer, P., Benatar, S., Bernstein, M., et al. (2003). Ethics and SARS: Lessons from Toronto. British Medical Journal. 327(7427): 1342-1344.
The authors formed a working group and developed a list of SARS-related ethical issues and values by a consensus process. They also developed a framework for looking at the ethical implications of the SARS outbreak, including 10 key ethical values, and five major ethical issues faced by medical decision makers.
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Thompson, A. (2006). Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.
In this presentation, the author shares a 15-point ethical guide for pandemic planning based in part on experiences with and study of the 2003 severe acute respiratory syndrome outbreak.
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The authors contrast the principles underlying everyday triage with those underlying disaster triage. They note that a “lack of standards and distinct guidelines” could cause distress for nurses, who are expected to act against their normal standards and inclinations when caring for patients during a disaster.
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Duty to Care


American College of Emergency Physicians. (2017). Code of Ethics for Emergency Physicians.
This policy statement focuses on ethics in emergency medicine. Section D (“The Emergency Physician’s Relationships with Society”) covers resource allocation, promoting resource stewardship, disaster response, and public health promotion.
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This factsheet highlights the concerns nurses may have related to ethical and legal issues during a public health emergency or other disaster. Links to other resources are also provided.
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This article begins with a description of nurse-involved scenarios that could occur during a public health emergency. It explains the “duty of care” concept, and highlights how obligations (to family, self, to anticipate and prepare for emergencies) may be considered by nurses prior to an emergency to help with planning and reporting to work.
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* Draper, H., Sorell,T., Ives,J. et al. (2010). Non-Professional Healthcare Workers and Ethical Obligations to Work during Pandemic Influenza. Public Health Ethics. 3(1):23-34.
This paper (which provides perspective from the UK National Health Service with potential relevance to U.S. health settings) considers whether non-professional healthcare professionals have an obligation to work during a pandemic, and, if so, whether professional obligations outweigh others they may have (e.g., to their families). The authors explore if workers should be compelled to work, and propose that any compulsion involve, “a larger pool of people with the relevant skills and abilities” as that is a more equitable approach.
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Iserson, K.V., Heine, C.E., Larkin, G.L., et al. (2008). Fight or Flight: The Ethics of Emergency Physician Disaster Response. (Abstract only.) Annals of Emergency Medicine. 51(4): 345-353.
The authors highlight the factors that influence healthcare workers' decisions in disaster situations relative to the amount of danger they actually faced. They share information related to guidelines from medical professional organizations about duty to provide care despite risk, moral reasoning behind providing care during disasters, and the effect of fear on behavior. The importance of effective risk communication and its ability to enable informed decision making is also emphasized.
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Malm, H., May, T., Francis, L.P., et al. (2008). Ethics, Pandemics, and the Duty to Treat. (Abstract only.) The American Journal of Bioethics. 8(8): 4-19.
The authors examine reasoning for and against healthcare workers’ duty to treat, especially in light of an infectious disease pandemic. They also include practical recommendations for consideration.
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Nova Scotia College of Pharmacists. (n.d.). A Pharmacist’s Duty During a Pandemic: An Ethical Framework. (Accessed 10/9/18.)
This document discusses the values that pharmacists should use to inform decision-making during large-scale public health emergencies, such as influenza pandemics.
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Ruderman, C., Tracy, S., Bensimon, C., et al. (2006). On Pandemics and the Duty to Care: Whose Duty? Who Cares? BMC Medical Ethics. 7(1).
The Severe Acute Respiratory Syndrome outbreak challenged the notions of the extent of duty to care and resulted in changes to selected codes of healthcare provider ethics. The authors examine the concept of duty of care and associated risks and obligations providers have during a public health emergency.
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Education and Training


* Beaton, R., Reyes, G., and Call, J.A. (2007). Disaster Research Ethics: Gaps, Challenges, and Team Sustainability. (Requires free registration.) Northwest Center for Public Health Practice.
Speakers in this two-part webinar provide tips and explain ethical considerations associated with conducting disaster mental health research with children and families.
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* Hamilton, L. (2007). Ethical Issues in Disaster Response. (Requires free registration.) University of North Carolina, Gillings School of Global Public Health, Center for Public Health Preparedness.
The speakers in this webinar provide an overview of ethical issues and highlight those that may “impact the effective response to disaster by mental health professionals.”
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* Hick, J., Witte, C., Hanfling, D., and Raheem, M. (2018). Crisis Standards of Care-Panel Presentation.
The speakers provide a definition and legal overview of crisis standards of care (CSC), illustrate how the principles of CSC apply to disaster medical care, and share how to apply CSC into emergency planning. An overview of ethics and disaster response is also included, as are lessons learned from recent incidents (e.g., Hurricane Maria, the 2014 Ebola outbreak, and the earthquake that struck Haiti in 2010).
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Jewell, S. (2008). Ethics and Public Health in the Age of Terrorism. (Requires free registration.) University at Albany, State University of New York, School of Public Health and Health Professions, Center for Public Health Preparedness.
This course is comprised of ten modules which illustrate the role of public health in addressing the ethical issues that may arise after a terrorist attack.
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Kayman, H. (2008). Ethical Decision Making in Times of Public Health Catastrophe. (Requires free registration.) University of Washington, Northwest Center for Public Health Practice.
The speaker provides an overview of ethical decision-making during public health emergencies and teaches participants how to make decisions with local partners during a disaster. Links to the slides and the actual recording are provided.
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Orenstein, D. (2014). Crisis Standards of Care: Public Health Ethics in Light of Evolving Mandates. (Free video software download necessary to view video.) The Network for Public Health Law.
The presenter highlights the intersections between public health law and public health ethics, with a focus on public health emergency ethics.
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Presidential Commission for the Study of Bioethical Issues. (2016). Community Engagement in Ethics and Ebola: Public Health Planning and Response.
This 18-page learning module discusses the importance of community engagement as it relates to public health emergency planning and response efforts; ways in which community engagement can facilitate ethical public health planning and response; and different ways to engage communities in public health decision making both domestically and internationally.
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* Region IV Public Health Training Center. (2014). Pandemic Influenza: A Justice Case Study (Public Health Ethics, Module 5). (Free registration required.)
This online training “provides an overview of the various concepts of justice that can be applied to anticipated responses to an influenza pandemic.”
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Training and Education Collaborative System - Preparedness and Emergency Response Learning Center. (2015). Ethics in Public Health Emergencies. (Requires free registration.)
This course highlights the ethical challenges that accompany public health disasters (e.g., resource allocation, evacuation, restriction of individual rights).
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University of California, Berkeley, School of Public Health. (2011). Ethics and Public Health in an Age of Catastrophe: Public Health 253E - Spring 2010. DNATube.
This set of 14 lectures, delivered by Harvey Kayman and other instructors, covers a variety of issues related to ethics and disasters.
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World Association for Disaster and Emergency Medicine (2017). Tragic Choices: Ethical Uncertainty and Least-Worst Options in Humanitarian Healthcare.
This one-hour, 42-minute webinar discusses how all choices healthcare professionals must make in the delivery of care in humanitarian settings are problematic. The presentation focuses on dilemmas of competency, and dilemmas of patient selection, and ways to address those dilemmas.
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General Guidance on Disaster Ethics


Childress, J.F., Faden, R.R., Gaare, R.D., et al. (2002). Public Health Ethics: Mapping the Terrain. (First page only.) The Journal of Law, Medicine & Ethics, 30: 170–178.
The authors attempt to “map” public health ethics by defining the field and highlighting ethics-related features.
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* Delaware Public Health and Medical Advisory Board. (n.d.). Prioritization of Ethical Values. (Accessed 10/25/2018.)
This graphic illustrates the prioritized list of ethical values and examples created as a guide for the Delaware Public Health and Medical Advisory Board as recommendations to the Division of Public Health.
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The authors examine the concept of social justice and how it can be applied to public health emergencies.
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* Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
This report was designed to help authorities operationalize the concepts first developed in the 2009 Institute of Medicine (now known as the National Academy of Medicine) document titled, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.” Volume 1, Section 3 provides an overview of legal and liability issues in catastrophic disasters. Legal and regulatory issues are a frequently discussed point in other areas of the document as well.
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This report was written for the CDC to provide an ethical framework for public health providers to use when planning for or responding to a public health emergency or other disaster.
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Jennings, B., Arras, J., Barrett, D., and Ellis, B. (eds.). (2016). Emergency Ethics-Public Health Preparedness and Response. (Book available for purchase.) Oxford University Press.
This book discusses, “ethical aspects of preparedness and response with specific application to public health policy and practice.”
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Matzo, M., Powell, T., Surbeck, J., and Erickson-Hurt, C. (2012). Palliative Care in Disasters.
This presentation was given at the Integrated Medical, Public Health, and Response Training Summit. The speakers: shared an overview of palliative care; explained how it fits into Crisis Standards of Care research (and highlighted related ethical considerations during disasters); described a model of palliative care and how it was used in an exercise; and discussed firsthand experience in providing palliative care after disasters struck Haiti and Indonesia.
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O’Mathúna, D. (2016). Ideal and Nonideal Moral Theory for Disaster Bioethics. Human Affairs. 26(1): 8-17.
This paper discusses nonideal moral theory and its application to bioethics in disaster situations. This approach “views moral dilemmas as situations where no choice is ideal and every option involves some element of unavoidable wrongdoing.”
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Presidential Commission for the Study of Bioethical Issues. (2015). Presidential Commission for the Study of Bioethical Issues: Meeting Twenty: Feb. 5-6, 2015, Washington, D.C. U.S. Department of Health and Human Services.
This website includes links to the agenda, webcast, transcript, and more from the 2015 Commission meeting, which focused on research during disaster and issues related to Ebola.
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Singer, P., Benatar, S., Bernstein, M., et al. (2003). Ethics and SARS: Lessons from Toronto. British Medical Journal. 327(7427): 1342-1344.
The authors formed a working group and developed a list of SARS-related ethical issues and values by a consensus process. They also developed a framework for looking at the ethical implications of the SARS outbreak, including 10 key ethical values, and five major ethical issues faced by medical decision makers.
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The Center for Health Policy, Columbia University School of Nursing. (2008). Adapting Standards of Care under Extreme Conditions: Guidance for Professionals during Disasters, Pandemics, and Other Extreme Emergencies. American Nurses Association.
This policy paper is intended for professionals in a care giver or service provider role. It includes guidance on ethical principles in emergency care, meeting usual care expectations, and recommendations for emergency event care.
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Upshur, R.E.G. (2002). Principles for the Justification of Public Health Intervention. (Free registration required.) Canadian Journal of Public Health. 93(2):101-3.
The author describes a set of four principles (based on a literature review) that can be used in the analysis of ethical issues in public health practice and may be helpful for analyzing potential emergency interventions.
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The author presents the case for prioritization to maximize health benefits and save the highest number of lives, but notes that "basic moral principles allow consideration of certain other priorities."
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Part 2 of this training manual includes materials on patient care, including triage, standards of care and the professional duties of health care workers in emergencies.
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This document was created to help policy-makers, health care providers, researchers, and others prepare for the ethical issues anticipated to arise during infectious disease outbreaks.
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World Medical Association, Inc. (2017). WMA Statement on Medical Ethics in the Event of Disasters.
This World Medical Association statement includes a definition of "disaster" (with a focus on the medical aspects). The rest of the statement covers the following ethical principles and procedures: triage, relations with the patients, aftermath of disaster, media and other third parties, duties of pharmaceutical personnel, training, and responsibility.
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Wynia, M., Powell, T., Gable, L., et al. (2011). Ethics in Public Health Emergencies: Developing an Arizona Code of Public Health Emergency Ethics. Arizona State University.
The resources available on this website include presentations from a 2011 focus group meeting on the State of Arizona's code of public health emergency ethics. Information can be customized by public health emergency planners from other states.
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Haiti Earthquake and Ethics


Daniel, M. (2012). Resource Stewardship in Disasters: A Provider's Dilemma Practicing in an Ethical Gap. (Registration required.) Journal of Clinical Ethics. 23(4):331-5.
The author shares a provider's experience allocating an oxygen tank in the intensive care unit at a hospital in Port-au-Prince, Haiti after the 2010 earthquake and lists the factors that influenced her allocation decision. (It is important to note that her decisions were consistent with frameworks developed by the Institute of Medicine and others; see also Ytzhak, A., Sagi, R., Bader, T., et al. [2012] in this topic collection).
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Etienne, M., Powell, C., and Amundson, D. (2010). Healthcare Ethics: The Experience after the Haitian Earthquake. American Journal of Disaster Medicine. 5(3):141-7.
The authors describe the multidisciplinary Healthcare Ethics Committee set up aboard the USNS Comfort after the 2010 earthquake that devastated Haiti. The principles and some of the processes the authors illustrate in the article can be applied to future disaster medical relief efforts.
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Eyal, N., Firth, P., and MGH Disaster Relief Ethics Group. (2012). Repeat Triage in Disaster Relief: Questions from Haiti. PLOS Currents Disasters. 22(4).
Medical responders to the earthquake that struck Haiti in 2010 identify and explain five considerations they took into account when treating repeat patients. They concluded that “responders can permissibly give a degree of priority to existing patients over newcomers” after a disaster.
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* Hick, J., Witte, C., Hanfling, D., and Raheem, M. (2018). Crisis Standards of Care-Panel Presentation.
The speakers provide a definition and legal overview of crisis standards of care (CSC), illustrate how the principles of CSC apply to disaster medical care, and share how to apply CSC into emergency planning. An overview of ethics and disaster response is also included, as are lessons learned from recent incidents (e.g., Hurricane Maria, the 2014 Ebola outbreak, and the earthquake that struck Haiti in 2010).
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Merin, O., Nachman, A., Levy, G., et al. (2010). The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response. The New England Journal of Medicine. 362(e38).
The authors share experiences with field hospital issues in an austere environment and how healthcare practitioners addressed resource dilemmas. They describe their triage protocols and how they managed ethical dilemmas.
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Wake Forest University Center for Bioethics, Health & Society in conjunction with the Wake Forest University Documentary Film Program. (n.d.). In the Wake of Tragedy: Medical Ethics and the Haiti Earthquake. (Accessed 10/15/2018.)
The project team had to make challenging ethical decisions about whom to treat and how to do so with scarce resource during their response in Haiti. Medical providers tried to answer, “How should these decisions be made? Who should make them? And how should medical aid workers deal with a limited supply of resources?” This webpage includes links to videos and a discussion guide.
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* Ytzhak, A., Sagi, R., Bader, T., et al. (2012). Pediatric Ventilation in a Disaster: Clinical and Ethical Decision Making. (Abstract only.) Critical Care Medicine. 40(2).
After the 2010 earthquake that struck Haiti, medical staff from the Israeli Defense Forces Medical Corps field hospital responded and was the only facility that had the capability to ventilate children and neonates during the first week after the disaster. The authors provide an overview of five case studies and the decision-making processes they went through using a tool developed for ventilator allocation during an influenza pandemic.
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Mental and Behavioral Health


* Beaton, R., Reyes, G., and Call, J.A. (2007). Disaster Research Ethics: Gaps, Challenges, and Team Sustainability. (Requires free registration.) Northwest Center for Public Health Practice.
Speakers in this two-part webinar provide tips and explain ethical considerations associated with conducting disaster mental health research with children and families.
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* Hamilton, L. (2007). Ethical Issues in Disaster Response. (Requires free registration.) University of North Carolina, Gillings School of Global Public Health, Center for Public Health Preparedness.
The speakers in this webinar provide an overview of ethical issues and highlight those that may “impact the effective response to disaster by mental health professionals.”
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Pandemic Influenza and Ethics


Arras, J., Benjamin, G., Gamble, V.N., et al. (2007). Stockpiling Antivirals for Pandemic Influenza: The Key Ethical Principles. Centers for Disease Control and Prevention.
This document can help decision makers charged with purchasing and storing antiviral drugs address the ethical principles that will likely arise during an influenza pandemic.
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* Ball, R. and Schneider, P. (2009). South Carolina Prepares for Pandemic Influenza: An Ethical Perspective. South Carolina Department of Health and Environmental Control.
The authors share ethical principles and planning goals associated with pandemic influenza planning. Several templates are included as appendices.
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* Belmont, E., Abelman, D., Lax, J., et al. (2014). Pan-Flu Preparedness: Key Legal Issues.
This guidebook reviews legal and ethical issues for healthcare providers and community leaders to consider when preparing for and responding to a pandemic or other large-scale outbreak.
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* Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
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Biddison, L.D., Berkowitz, K.A., Courtney, B., et al. (2014). Ethical Considerations: Care of the Critically Ill and Injured during Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4 Suppl):e145S-55S.
The authors worked together to come up with ethical domains regarding caring for critically ill and injured patients. They developed 24 questions, conducted related literature reviews, and presented suggestions on five domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns.
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This document was created to provide an ethical framework for pandemic influenza preparedness, response, and recovery planning for the healthcare sector in Canada.
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* Draper, H., Sorell,T., Ives,J. et al. (2010). Non-Professional Healthcare Workers and Ethical Obligations to Work during Pandemic Influenza. Public Health Ethics. 3(1):23-34.
This paper (which provides perspective from the UK National Health Service with potential relevance to U.S. health settings) considers whether non-professional healthcare professionals have an obligation to work during a pandemic, and, if so, whether professional obligations outweigh others they may have (e.g., to their families). The authors explore if workers should be compelled to work, and propose that any compulsion involve, “a larger pool of people with the relevant skills and abilities” as that is a more equitable approach.
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Emanuel, E.J., and Wertheimer, A. (2006). Public Health. Who Should Get Influenza Vaccine When Not All Can? Science. 312(5775): 854-5.
The authors discuss the ethical reasoning behind vaccine prioritization and include a table that illustrates tiers and rankings (as of 2006).
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Florida Department of Health, Pandemic Influenza Technical Advisory Committee. (2011). Pandemic Influenza: Triage and Scarce Resource Allocation Guidelines.
The Florida Department of Health prepared this guidance document to help medical and healthcare entities statewide prepare for scarce resource allocation in the event of a pandemic influenza. While the triage criteria is slightly dated, the roles and responsibilities are outlined well within a replicable framework.
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Kinlaw, K. and Levine, R. (2007). Ethical Guidelines in Pandemic Influenza. Centers for Disease Control and Prevention.
The Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention proposed the guidance in this document to assist with decision making in preparing for and responding to pandemic influenza.
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Lemon, S., Hamburg, M., Sperling, F., Choffnes, E., and Mack, A. (2007). Ethical and Legal Considerations in Mitigating Pandemic Disease. (Free download available; book also available for purchase.) Microbial Threats Workshop Summary, Institute of Medicine of the National Academies.
This workshop summary defines the critical legal and ethical issues involved in the implementation of plans. A historical lessons-learned approach is discussed based on prior pandemics and biological outbreaks. The political and legal issues associated with medical and non-medical approaches to disease containment include positive health outcomes as well as adverse effects and unintended consequences.
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This document summarizes the recommendations of the Pandemic Influenza Medical Ethics Work Group, with regard to the following topics: Vaccine Allocation and Distribution; Antiviral Medication Allocation and Distribution; Medical Surge Resource Allocation and Distribution; and Ventilator Allocation and Distribution.
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The author shares results from a public engagement study on resource prioritization and allocation during a severe pandemic. The panels included demographically diverse people who took their “role seriously and [were] willing to reconsider their previously held beliefs and engage in authentic deliberation in the interest of making better decisions for the community at large.”
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* Li-Vollmer, M., Beebe, A., Kite, H., et al. (2009). Public Engagement Project on Medical Service Prioritization during an Influenza Pandemic. Public Health-Seattle & King County.
Public Health-Seattle & King County hosted four public engagement forums to discuss the rationing of scarce resources during a severe pandemic influenza. This report summarizes themes that emerged from the forums.
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The author proposes a policy for scarce vaccine allocation that prioritizes those at risk of contracting the disease in the course of health-related work, and then provides an equal chance for all other citizens to receive vaccination.
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Meslin, E., Alyea, J., and Helft, P. (2007). Pandemic Flu Preparedness: Ethical Issues and Recommendations to the Indiana State Department of Health. Indiana University, Center for Bioethics.
Authors from the Indiana University Center for Bioethics provide recommendations on four specific areas of ethical concern: management of the healthcare workforce; resource allocation; changes to the standard of care provided by healthcare professionals; and allocating scarce vaccines and antiviral medications.
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* Powell, T., Christ, K.C., and Birkhead, G.S. (2008). Allocation of Ventilators in a Public Health Disaster. Disaster Medicine and Public Health Preparedness. 2(01): 20-26.
This paper details one of the first efforts intended to identify a statewide approach to allocating mechanical ventilators in the setting of a large-scale respiratory emergency event. The authors highlight the ethical principles that govern such decision making, with an emphasis on the “duty to plan,” the “duty to care,” and the “duty to steward resources.”
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* Public Engagement Pilot Project on Pandemic Influenza (PEPPPI). (2005). Citizen Voices on Pandemic Flu Choices: A Report of the Public Engagement Pilot Project on Pandemic Influenza. University of Nebraska Public Policy Center.
This report describes the Public Engagement Pilot Project on Pandemic Influenza, the objectives of which were twofold: 1) to discuss and rank goals for a pandemic influenza vaccination program and 2) to pilot test a model for engaging citizens in vaccine-related policy decisions.
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* Region IV Public Health Training Center. (2014). Pandemic Influenza: A Justice Case Study (Public Health Ethics, Module 5). (Free registration required.)
This online training “provides an overview of the various concepts of justice that can be applied to anticipated responses to an influenza pandemic.”
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This guidance document is divided into five sections on ethical preparedness and response in a healthcare system: 1) an overview of ethical challenges; 2) workforce capacity and responsibility; 3) resource allocation; 4) hospice and palliative care; and 5) limiting personal liberty to preserve public health. The document also includes a checklist for implementing the plan guidance.
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Tabery, J. and Mackett, C.W. (2008). Ethics of Triage in the Event of an Influenza Pandemic. (Free registration required.) Disaster Medicine and Public Health Preparedness. 2:114-118.
The authors propose a conceptual framework for the ethical issues raised by the need to perform triage during an influenza pandemic.
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Thompson, A. (2006). Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.
In this presentation, the author shares a 15-point ethical guide for pandemic planning based in part on experiences with and study of the 2003 severe acute respiratory syndrome outbreak.
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Thompson, A.K., Faith, K., Gibson, J.L., and Upshur, R.E.G. (2006). Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making. British Medical College of Medical Ethics.
The authors share an ethical framework for pandemic influenza planning, which includes substantive and procedural elements.
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* U.S. Department of Veterans Affairs. (2010). Meeting the Ethical Challenges of a Severe Pandemic Influenza: VA (Veterans Affairs) Fact Sheet for Health Care Staff. U.S. Department of Veterans Affairs.
This factsheet describes how healthcare providers can plan for and address the ethical challenges that may accompany a severe pandemic influenza.
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* United Kingdom Pandemic Influenza Preparedness Team, The Department of Health. (2007). Responding to Pandemic Influenza: The Ethical Framework for Policy and Planning.
This ethical framework is designed to assist planners and strategic policy makers with ethical aspects of decisions they face before, during and after an influenza pandemic. It may also help clinicians and other health and social care professionals with decisions they need to make in the same context.
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* University of Nebraska Public Policy Center. (n.d.). Public Engagement Pilot Project on Pandemic Influenza Evaluation. (Accessed 10/18/2018.)
This webpage provides links to publications that resulted from public engagement sessions on pandemic influenza vaccination prioritization.
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Vancouver Coastal Health. (n.d.). Ethical Framework for Decision Making. (Accessed 10/19/18.)
This slide presentation provides a succinct overview of the ethical principles that can guide decision-making during an influenza pandemic that is based on the earlier work of the Joint Centre for Bioethics at University of Toronto (Stand on Guard for Thee). Ethical processes and values are reviewed.
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Vawter, D.E., Garrett, E.J., Gervais, K.G., et al. (2010). For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic. Minnesota Center for Health Care Ethics and the University of Minnesota Center for Bioethics.
This report—developed for the state of Minnesota—contains and describes the reasoning behind the creation of ethical frameworks for rationing antiviral medications, N95 respirators, surgical masks, vaccines and mechanical ventilators during a pandemic that met nine specific assumptions. The guidelines can be adopted and tailored by other states.
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This resource includes discussion of: general ethical considerations; priority setting and equitable access to therapeutic and prophylactic measures; isolation, quarantine, border control and social-distancing measures; and the role and obligations of health-care workers during an outbreak of pandemic influenza.
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Pediatric Issues


Antommaria, A., Powell, T., Miller, J, Christian, M., and Task Force for Pediatric EMCC. (2011). Ethical Issues in Pediatric Emergency Mass Critical Care. Pediatric Critical Care Medicine. 12(6):S163-168.
This article details the recommendations of the Pediatric Emergency Mass Critical Care Task Force (36 experts from diverse medical, public health, and disaster response fields). The authors highlight recommendations agreed upon by the task force and note those recommendations upon which the group was unable to reach consensus.
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Baker, M. (2015). Ebola Response in West Africa: My Experience. Alabama Department of Public Health.
The speaker for this one-hour, 23 minute video discusses his experience working in West Africa during the 2014-2015 outbreak. He is a pediatric physician, and discusses his experiences, including ethical challenges he experienced in the care of children with Ebola.
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Botkin, J., O'Lonergan, T., Wilfond, B., et al. (2013). Pediatric Ethics Subcommittee Meeting of the Pediatric Advisory Committee Meeting: September 9-10, 2013. U.S. Food and Drug Administration.
This meeting transcript from September 9, 2013 includes a discussion of the Ethical Framework of 21 CFR Subpart D (which provides for the ethical protection of children in research), and pediatric-specific risk considerations related to countermeasure research.
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Cooper, A. (n.d.). Ethical Issues in Response Pertaining to Pediatrics. (Accessed 10/19/2018.) American Academy of Pediatrics.
This extensively referenced slide presentation reviews: the history of ethics, bioethics basics, and relevance to moral quandaries in pediatric mass casualty events (MCEs); approaches to healthcare resource allocation in pediatric MCEs; contingency and crisis standards of care in MCEs advocated by the Institute of Medicine (IOM); and expected competencies in disaster ethics advocated by the World Health Organization (WHO).
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Presidential Commission for the Study of Bioethical Issues. (2013). Safeguarding Children: Pediatric Medical Countermeasure Research.
This report is centered on Pediatric Medical Countermeasures research (testing interventions with children that will be used before, during, or in response to a bioterrorist attack). The Bioethics Commission also explained additional conditions that must be met before such pediatric research is ethically considered.
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Wizemann, T., Reeve, M., and Altevogt, B. (2015). Preparedness, Response, and Recovery Considerations for Children and Families. Workshop Summary. Institute of Medicine of the National Academies.
This report is a summary of presentations and discussions by expert medical and public health panelists and participants during a workshop on disasters and the needs of children and families, including children with special healthcare needs.
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* Ytzhak, A., Sagi, R., Bader, T., et al. (2012). Pediatric Ventilation in a Disaster: Clinical and Ethical Decision Making. (Abstract only.) Critical Care Medicine. 40(2).
After the 2010 earthquake that struck Haiti, medical staff from the Israeli Defense Forces Medical Corps field hospital responded and was the only facility that had the capability to ventilate children and neonates during the first week after the disaster. The authors provide an overview of five case studies and the decision-making processes they went through using a tool developed for ventilator allocation during an influenza pandemic.
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Plans, Tools, and Templates


* Ball, R. and Schneider, P. (2009). South Carolina Prepares for Pandemic Influenza: An Ethical Perspective. South Carolina Department of Health and Environmental Control.
The authors share ethical principles and planning goals associated with pandemic influenza planning. Several templates are included as appendices.
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* Belmont, E., Abelman, D., Lax, J., et al. (2014). Pan-Flu Preparedness: Key Legal Issues.
This guidebook reviews legal and ethical issues for healthcare providers and community leaders to consider when preparing for and responding to a pandemic or other large-scale outbreak.
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This document was created to provide an ethical framework for pandemic influenza preparedness, response, and recovery planning for the healthcare sector in Canada.
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The authors highlight several real-life cases involving ethical issues encountered by humanitarian aid workers and propose an ethical framework to assist with the decision-making process. The framework includes a ten-step process modelled on tools used in the clinical setting that promotes a transparent decision-making process, and the authors make organizational recommendations that will help healthcare facilities and disaster aid providers implement the framework.
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Connerton, P. (2013). Ethical Guidelines for the Development of Emergency Plans. American Health Care Association.
This guidance can help disaster planners incorporate ethical considerations into their documents, exercises, and other preparedness activities. The author provides a concise summary of disaster ethics principles and linkages to long-term care.
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* Delaware Public Health and Medical Advisory Board. (n.d.). Prioritization of Ethical Values. (Accessed 10/25/2018.)
This graphic illustrates the prioritized list of ethical values and examples created as a guide for the Delaware Public Health and Medical Advisory Board as recommendations to the Division of Public Health.
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This document summarizes the recommendations of the Pandemic Influenza Medical Ethics Work Group, with regard to the following topics: Vaccine Allocation and Distribution; Antiviral Medication Allocation and Distribution; Medical Surge Resource Allocation and Distribution; and Ventilator Allocation and Distribution.
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Minnesota Department of Health, Office of Emergency Preparednes. (2018). Crisis Standards of Care.
This website includes links to several critical crisis standards of care (CSC) resources and tools including the MN CSC Framework (released in November 2018) which provides an overview of the actions the state will take in response to a CSC situation. The framework also includes operational annexes for Ethics, Legal, EMS, Hospitals, and Public Engagement. The site also contains other resources including a summary report on community engagement, pandemic, and other resources.
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This document reviews key literature related to scarce resource allocation developed by 2009; discusses relevant ethical and legal considerations; and provides detailed recommendations for the implementation of a plan development process in support of scarce resource allocation during a public health emergency.
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This guidance document is divided into five sections on ethical preparedness and response in a healthcare system: 1) an overview of ethical challenges; 2) workforce capacity and responsibility; 3) resource allocation; 4) hospice and palliative care; and 5) limiting personal liberty to preserve public health. The document also includes a checklist for implementing the plan guidance.
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* The Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. (2011). Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency. Centers for Disease Control and Prevention.
This document, developed by an expert workgroup, provides a conceptual framework for planning efforts related to allocation of mechanical ventilators during a severe influenza pandemic. It supplements a document released by CDC in 2007, Ethical Guidelines in Pandemic Influenza. The document outlines key assumptions, describes routine versus emergency practice, and discusses principles guiding ventilator allocation, who should make allocation decisions, and other considerations.
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* U.S. Department of Veterans Affairs. (2010). Meeting the Ethical Challenges of a Severe Pandemic Influenza: VA (Veterans Affairs) Fact Sheet for Health Care Staff. U.S. Department of Veterans Affairs.
This factsheet describes how healthcare providers can plan for and address the ethical challenges that may accompany a severe pandemic influenza.
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* United Kingdom Pandemic Influenza Preparedness Team, The Department of Health. (2007). Responding to Pandemic Influenza: The Ethical Framework for Policy and Planning.
This ethical framework is designed to assist planners and strategic policy makers with ethical aspects of decisions they face before, during and after an influenza pandemic. It may also help clinicians and other health and social care professionals with decisions they need to make in the same context.
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* Vawter, D.E., Garrett, J.E., Gervais, K.G., et al. (2011). Attending to Social Vulnerability When Rationing Pandemic Resources. (Abstract only.) Journal of Clinical Ethics.
The authors provide an overview of the Minnesota Pandemic Ethics Project, an effort focused on rationing scarce health resources during a severe influenza pandemic. The authors list seven recommendations that can help vulnerable populations (and those who serve and treat them) before, during, and after an influenza pandemic.
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Public Engagement


* Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
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Garrett, J.E., Vawter, D.E., Gervais, K.G., et al. (2011). The Minnesota Pandemic Ethics Project: Sequenced, Robust Public Engagement Processes. Journal of Participatory Medicine. Volume 3.
The Minnesota Pandemic Ethics Project developed ethical frameworks for allocating scarce medical resources during a severe influenza pandemic and gathered a community-based panel to facilitate related exchanges. This article describes the types and timing of public engagement methods, the strengths and challenges, and how the methods fit together.
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* Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
This report was designed to help authorities operationalize the concepts first developed in the 2009 Institute of Medicine (now known as the National Academy of Medicine) document titled, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.” Volume 1, Section 3 provides an overview of legal and liability issues in catastrophic disasters. Legal and regulatory issues are a frequently discussed point in other areas of the document as well.
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The purpose of this study was to explore how lay people, general practitioners, medical students and other health professionals evaluate the fairness of ten allocation principles for scarce medical resources. The authors found differences among the groups regarding what each considered to be “fair,” and advise “decision makers” to determine if ethicists, health professionals, and the general public should have equal input into scarce resource allocation protocols.
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* Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009). Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(SUPPL.2):S132-S140.
This paper discusses a series of stakeholder workgroups (comprising ethicists, lawyers, clinicians, and local and state public health officials, as well as community members) conducted by the Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group in 2006 to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. The planning process and principles for equitable allocation of resources identified by the project may be helpful to other organizations/jurisdictions developing altered standards of care plans.
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* Li-Vollmer, M., Beebe, A., Kite, H., et al. (2009). Public Engagement Project on Medical Service Prioritization during an Influenza Pandemic. Public Health-Seattle & King County.
Public Health-Seattle & King County hosted four public engagement forums to discuss the rationing of scarce resources during a severe pandemic influenza. This report summarizes themes that emerged from the forums.
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* Persad, G. (2017). Public Preferences About Fairness and the Ethics of Allocating Scarce Medical Interventions. Interdisciplinary Perspectives on Fairness, Equity, and Justice, DOI 10.1007/978-3-319-58993-0_4.
In this book chapter, the author provides: an overview of different approaches to the ethics of allocating scarce medical interventions; a brief recap of social scientific research on the allocation of scarce medical resources; an examination of different ways in which public preferences could matter to the ethics of allocation; ways in which social scientists could learn from ethics as they conduct research into public preferences regarding the allocation of scarce medical resources.
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* Public Engagement Pilot Project on Pandemic Influenza (PEPPPI). (2005). Citizen Voices on Pandemic Flu Choices: A Report of the Public Engagement Pilot Project on Pandemic Influenza. University of Nebraska Public Policy Center.
This report describes the Public Engagement Pilot Project on Pandemic Influenza, the objectives of which were twofold: 1) to discuss and rank goals for a pandemic influenza vaccination program and 2) to pilot test a model for engaging citizens in vaccine-related policy decisions.
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* University of Nebraska Public Policy Center. (n.d.). Public Engagement Pilot Project on Pandemic Influenza Evaluation. (Accessed 10/18/2018.)
This webpage provides links to publications that resulted from public engagement sessions on pandemic influenza vaccination prioritization.
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Resource Allocation and Triage


American Medical Association. (n.d.). Allocating Limited Health Care Resources. (Accessed 12/3/18.)
This webpage briefly describes the 4 main principles for allocating limited health care resources discussed in the American Medical Association’s Code of Medical Ethics Opinion 11.1.3.
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* Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
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This slide presentation by a hospital CMO discusses ethical considerations for making resource allocation decisions during a disaster, and provides practical guidance for plan development and implementation. Descriptions of the respective composition and roles of resource distribution teams used by the author’s facility are included.
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Cookson, R. and Dolan, P. (2000). Principles of Justice in Health Care Rationing. Journal of Medical Ethics. 26(5): 323-329.
The authors compare and contrast need principles, maximizing principles and egalitarian principles with regards to rationing scarce medical resources. Overall, the authors believe that the general public supports a combination of the three principles (based on a study conducted with a relatively small sample where participants reacted to a scenario where they were given a fictional amount of money to use to treat one of four patients with completely different health challenges and demographics).
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Daniels, N. (1988). Am I My Parent's Keeper?. (Book available for purchase.)
The author presents a principled way to allocate healthcare and other resources to different age groups in our society. His argument is rooted in a theory of distributive justice.
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The author emphasizes the need for a transparent, fair process to be in place for any resource allocation frameworks to be successful–a key aspect of disaster planning.
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Daniels, N. and Sabin, J.E. (2009). Setting Limits Fairly: Can We Learn to Share Medical Resources?. (Book available for purchase.) Oxford University Press.
The authors emphasize that without consensus on how to allocate medical resources, a fair decision-making process should be established to help healthcare providers set reasonable limits.
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Hick, J.L., Hanfling, D., and Cantrill, S.V. (2012). Allocating Scarce Resources in Disasters: Emergency Department Principles. Annals of Emergency Medicine. 59(3): 177-187.
The authors summarize key elements contained in the Institute of Medicine work on crisis standards of care. Written for the emergency medicine community, this paper is intended to be a useful adjunct to support discussions related to the planning for large-scale disaster events.
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Iserson K., and Moskop, J. (2007). Triage in Medicine, Part I: Concept, History, and Types. Annals of Emergency Medicine. 49(3):275-81.
This article provides information on the history and evolution of the practice of triage. It includes a chart detailing the “continuum of triage” from “most resources, most social order, to fewest resources, chaos.” (Part II by Moskop and Iserson is also annotated in this collection.)
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Iserson, K. (2007). Part 1: Resource Allocation – The Ethical Justification. The University of Arizona, Arizona Bioethics Program.
In this webinar, the speaker discusses when healthcare resources should be rationed, why healthcare resources should be rationed, and the ethical justification for rationing resources.
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Iserson, K. (2007). Part 2: How to Ration Healthcare Resources. The University of Arizona, Arizona Bioethics Program.
Webinar participants will learn more about: 1) what triggers indicate that healthcare resource rationing is necessary, 2) what actions can be taken to ration healthcare resources, 3) what general treatment priorities should be implemented, and 4) why stakeholder validation is vital.
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Iserson, K. (2007). Part 3 (A). The Most Difficult Healthcare Decisions. The University of Arizona, Arizona Bioethics Program.
This webinar covers four topics about resource allocation: 1) who allocates scarce healthcare resources during a crisis, 2) how crisis triage officers are selected and trained, 3) how crisis triage officers should function, and 4) how the use of risk communication techniques can help maintain the trust of healthcare workers and the public.
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Iserson, K. (2007). Part 3 (B). Who Allocates Scarce Healthcare Resources? The University of Arizona, Arizona Bioethics Program.
More information on the use of risk communication during a crisis in which scarce resources need to be rationed is provided in this webinar.
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Knebel, A., Sharpe, V., Danis, M., et al. (2014). Informing the Gestalt – An Ethical Framework for Allocating Scarce Federal Public Health and Medical Resources to States during Disasters. Disaster Medicine and Public Health Preparedness. 8(1):79-88.
The authors, who have extensive experience in Federal and other related settings, share an ethical framework and logic model for medical decision making in disaster situations when resources are often particularly scarce.
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The purpose of this study was to explore how lay people, general practitioners, medical students and other health professionals evaluate the fairness of ten allocation principles for scarce medical resources. The authors found differences among the groups regarding what each considered to be “fair,” and advise “decision makers” to determine if ethicists, health professionals, and the general public should have equal input into scarce resource allocation protocols.
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Leider, J., DeBruin, D., Reynolds, N. et al. (2017). Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review.. (Abstract only.) American Journal of Public Health. 107(9): pp. e1-e9.
The authors examined peer-reviewed articles to determine “the prevalence and content of ethical guidance offered for disaster response, specifically around crisis standards of care (CSCs).” They found that the majority of the discussion in the reviewed articles focused on triage, and the general need for ethics in disaster response.
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* Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009). Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(SUPPL.2):S132-S140.
This paper discusses a series of stakeholder workgroups (comprising ethicists, lawyers, clinicians, and local and state public health officials, as well as community members) conducted by the Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group in 2006 to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. The planning process and principles for equitable allocation of resources identified by the project may be helpful to other organizations/jurisdictions developing altered standards of care plans.
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Moskop, J. and Iserson, K. (2007). Triage in Medicine, Part II: Underlying Values and Principles. (Abstract only.) Annals of Emergency Medicine. 49(3):282-7.
In this article on the foundations of triage decision making, the authors discuss the "moral significance" of triage and summarize three principles of distributive justice that can guide triage decisions. (Part I by Iserson and Moskop is also annotated in this collection.)
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O'Laughlin, D., and Hick, J. (2008). Ethical Issues in Resource Triage. Respiratory Care. 53(2):190-200.
The authors present several ethical principles emergency medical care providers should take into account when developing a mass care triage plan.
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Persad G., Wertheimer A., and Emanuel, E.J. (2009). Principles for Allocation of Scarce Medical Interventions. Lancet. 373: 423–31.
The authors evaluated four categories of resource allocation principles (treating people equally, favoring the worst-off, maximizing total benefits, and promoting and rewarding social usefulness). Because they determined that no one principle is comprehensive enough, they suggested combining them into "multiprinciple allocation systems." The authors recommended the "complete lives system—which [prioritizes] younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles."
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* Persad, G. (2017). Public Preferences About Fairness and the Ethics of Allocating Scarce Medical Interventions. Interdisciplinary Perspectives on Fairness, Equity, and Justice, DOI 10.1007/978-3-319-58993-0_4.
In this book chapter, the author provides: an overview of different approaches to the ethics of allocating scarce medical interventions; a brief recap of social scientific research on the allocation of scarce medical resources; an examination of different ways in which public preferences could matter to the ethics of allocation; ways in which social scientists could learn from ethics as they conduct research into public preferences regarding the allocation of scarce medical resources.
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* Powell, T., Christ, K.C., and Birkhead, G.S. (2008). Allocation of Ventilators in a Public Health Disaster. Disaster Medicine and Public Health Preparedness. 2(01): 20-26.
This paper details one of the first efforts intended to identify a statewide approach to allocating mechanical ventilators in the setting of a large-scale respiratory emergency event. The authors highlight the ethical principles that govern such decision making, with an emphasis on the “duty to plan,” the “duty to care,” and the “duty to steward resources.”
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* The Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. (2011). Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency. Centers for Disease Control and Prevention.
This document, developed by an expert workgroup, provides a conceptual framework for planning efforts related to allocation of mechanical ventilators during a severe influenza pandemic. It supplements a document released by CDC in 2007, Ethical Guidelines in Pandemic Influenza. The document outlines key assumptions, describes routine versus emergency practice, and discusses principles guiding ventilator allocation, who should make allocation decisions, and other considerations.
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The authors share that healthcare institutions overall have not been able to sustain high staff vaccination rates. They encourage leaders to emphasize biomedical ethics and consider mandating vaccinations (and hypothesize about the effect that would have on pandemic preparedness).
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* Vawter, D.E., Garrett, J.E., Gervais, K.G., et al. (2011). Attending to Social Vulnerability When Rationing Pandemic Resources. (Abstract only.) Journal of Clinical Ethics.
The authors provide an overview of the Minnesota Pandemic Ethics Project, an effort focused on rationing scarce health resources during a severe influenza pandemic. The authors list seven recommendations that can help vulnerable populations (and those who serve and treat them) before, during, and after an influenza pandemic.
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Verweij, M. (2009). Moral Principles for Allocating Scarce Medical Resources in an Influenza Pandemic. (Abstract only.) Journal of Bioethical Inquiry. 6(2): 159-169.
The author shares two ethical principles for resource prioritization: utility and equity. He writes, “Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time.”
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The authors contrast the principles underlying everyday triage with those underlying disaster triage. They note that a “lack of standards and distinct guidelines” could cause distress for nurses, who are expected to act against their normal standards and inclinations when caring for patients during a disaster.
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Winslow, G. (1982). Triage and Justice: The Ethics of Rationing Life-Saving Medical Resources. (Book available for purchase.) University of California Press.
In this classic text, the author lays out model ethical frameworks for allocation of scarce, lifesaving resources.
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Zika and Ethics


Jamrozik, E. and Selgelid, M.J. (2018). Ethics, Health Policy, and Zika: From Emergency to Global Epidemic. (Abstract only.) Journal of Medical Ethics. 44(5): 343-34.
The authors provide an overview of ethical issues associated with Zika related to reproduction, prenatal diagnosis of serious malformations, and unjust disparities in health outcomes. They also share that the outbreak has reenergized interest in public health ethics (e.g., vector control, climate change, and resource disparity).
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Nuffield Council on Bioethics. (2016). Zika: Ethical Considerations.
This document highlights Zika-specific ethical considerations related to public health ethics, research in developing countries, solidarity, the sharing of biological and health data, and the regulation of emerging biotechnologies.
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This report is the result of the Zika Ethics Consultation convened by the Pan American Health Organization (PAHO) in 2016 to examine ethical duties related to health care delivery, public health activity, and research, in the context of the Zika outbreak.
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Agencies and Organizations


Bioethics Library at Georgetown University. The Ebola Outbreak: A Global Conversation and Resources. (Accessed 7/5/2019.)
This website includes links to Ebola-specific resources such as blogs, a training module, and organizations with pages or teams dedicated to the disease.
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Johns Hopkins Berman Institute for Bioethics. Public Health Ethics.
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National Library of Medicine; Disaster Information Management Research Center. Information Sources on Ethics in Disaster Medicine and Public Health.
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The Hastings Center. Pandemic Planning.
This webpage includes links to articles on pandemic, Ebola, and Zika-related ethical issues.
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