Facing Ethical Challenges, Dealing with Outcomes: Stories from the Field

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Facing Ethical Challenges, Dealing with Outcomes
Stories from the Field
Harvey Kayman, MD, MPH, PHMO III University of
California, Berkeley California Department of
Public Health
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Learning Objectives

• List and describe public health ethical
  principles and an ethical framework to resolve
  moral tensions disasters might bring up
• Review scenarios that will illustrate how the
  framework and principles can be used
• Develop methods to make decisions with
  collaborators in the midst of a disaster

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Biomedical and Public Health Ethics
Personal autonomy vs. the common good Obligation
vs. responsibilities
Autonomy Beneficence
Beauchamp, TL, Childress, JF. Principles of
Biomedical Ethics. Oxford University Press, New
York, any edition.
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Biomedical and Public Health Ethics (cont)
Non maleficence, minimize harm Justice
Authority and decision making Least unfair
distribution of benefits and burdens
http//plato.stanford.edu
Kayman, H, Ablorh-Odjidja, A. Revisiting Public
Health Preparedness Incorporating Social Justice
Principles Into Pandemic Preparedness Planning
for Influenza J Public Health Management
Practice. 2006. 12(4), 373380.
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transparency inclusion in decision-making
process accountability
precautionary principle
Kurland, J. Editorials and The Heart of the
Precautionary Principle in Democracy. Public
Health Reports. 2002. NovDec. 117,491500.
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The Precautionary Principle
Action, even coercive action, must be taken when
there is a serious threat to the publics
welfare, often in the face of uncertainty.
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Personal autonomy and the common good
Least unfair distribution of benefits and burdens
Jay Johnson Rob Elkins
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Obligation and responsibilities
Mark Oberle
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Authority and decision making
Carl Osaki
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Poll Question
Have you encountered any situations similar to
these in your work?

• Yes
• Sort of
• No
• No, but I have encountered other kinds of ethical
  dilemmas

Click on the down arrow if you cant see the
response choices.
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Poll Question
Do you have a mechanism for handling ethical
dilemmas such as these in your workplace?

• Yes
• Sort of
• No
• No, but I have some ideas of how we might handle
  these situations

Click on the down arrow if you cant see the
response choices.
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Decision Making and Problem Solving
Step 1 Identify the problem
Step 2 Explore alternatives
Step 3 Select an alternative
Step 4 Implement the solution
Step 5 Evaluate the situation
FEMA IS 241
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Step 1. Identify the Problem
Protocol for Decision Making in the Midst of
Crises Role of Convener
Gather discusswith participantstrained to
usemethod
Determine that adecision must be made
Define problem clearly
Assure data are accurate, complete and up to date
Describe desiredoutcomes
Gather all pertinent data
Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Step 1 Identify the Problem
Protocol for Decision Making in the Midst of
Crises Role of Convener
Gather appropriate stakeholders
Present data from evidence, models, expert input
Describe problem, resources, and desired outcome
Discuss analyze problem, data, and options
Describe timeframe to implementation
Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Step 2 Evaluate Alternatives

• Does this solution fit the circumstances?
• Is the action worth doing?
• Will this option meet the objectives?
• Has the cost/benefit ratio been considered?

FEMA IS 241
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Step 2 Evaluate Alternatives
Identify Constraints
Technical
Political
Safety
Financial
Social
Human resources
Environ-mental
Time urgency
Legal
Ethical
FEMA IS 241
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Step 2 Evaluate Alternatives
Checklist of Questions to Consider

• If you should take on the responsibilities, who
  are your important partners, other stakeholders,
  consultants, etc.?
• Do you have the data to support your choices?
• Do you have the capacity to deliver the resource?
• If not, what materials, resources and trainings
  are needed to expand capacity?

Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Step 2 Evaluate Alternatives
Ethical Questions to Consider (cont)

• Is your decision about resource allocation
  equitable or does that matter?
• Will it result in the least unfair distribution
  of benefits and burdens?
• What gives you the authority to make this
  decision?

Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Step 2 Evaluate Alternatives
Ethical Questions to Consider

• Do you have the time and expertise to examine for
  bias?
• Will implementation interfere with some groups
  autonomy in support of the common good?
• What are potential consequences negative,
  positive, undesired, not anticipated in the past,
  etc.?

Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Social Solidarity
Professionalism
attachment interdependence shared beliefs
commitment involvement
public order subsidiarity safety common
good ready access
evidence based competence
consistency adaptive consensus driven
duty to act reciprocity transparency
integrity
Justice
informed consent/refusal disclosure/truth-telling
nonmaleficence confidentiality
beneficence
stewardship autonomy
equality equity difference principle
proportionality due process
liberty
J. F. Tuohey. A Matrix for Ethical Decision
Making in a Pandemic. The Oregon Tool for
Emergency Preparedness. Health Progress 88 (6)
NovemberDecember 2007
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Step 3 Select an Alternative
Determine Objectives
Used to monitor progress and establish priorities
Based on analysis of the situation and
contingencies
Objectives measurable targets
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Step 4 Implement the Solution
Develop an Action Plan

• Identify needed resources
• How much will it cost?
• Do you have the money to support implementing
  your decisions?
• If not, can you get the money in time?
• What is the likely source of funding?
• Will your partners provider in kind resources?

Proposed by Harvey Kayman, with adaptations from
FEMA IS 241
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Step 4 Implement the Solution
Build a Plan

• Who?
• Will do what?
• With whom?
• By when?
• Where?
• How?

FEMA IS 241
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Step 5 Evaluate the Situation
Later Steps
Adapt for use by others
Create after action report
Share knowledge with others
Evaluate process
Improve as needed
Proposed by Harvey Kayman, with adaptations from
FEMA IS 241