July–September 2007 Journal of Trauma Nursing • Volume 14, Number 3 163

Ethical Decisions in Times ofDisaster: Choices HealthcareWorkers Must Make

Mary Elizabeth Grimaldi, BS, BSN, RN, CNOR

■ ABSTRACTHealthcare providers are faced with increasing ethicalchallenges in providing care for patients during times ofdisaster and other public health emergencies. The code ofethics for most healthcare professions is somewhatambiguous when addressing the responsibilities of health-care providers during these times. The American MedicalAssociation has created new, stronger language address-ing physicians’ duty to care for patients since the eventsof September 11, 2001, but other professions have notfollowed suit. Until such time, healthcare providers willcontinue to be faced with making challenging ethicaldecisions with little direction.

■ KEY WORDSDisaster, Ethics, Rationing, Triage

■ INTRODUCTION

Healthcare workers have always faced many chal-lenges. Dating back to ancient times, communicable

diseases have presented risks for those individuals whosetask it was to provide care for the afflicted. Throughouthistory, healthcare workers have placed themselves indanger as they care for their patients, whether it be themedic on the battlefield, the research scientist searchingfor a cure for the highly contagious disease, the phle-botomist drawing a blood sample from the patientinfected with the Hepatitis B virus, the surgical team per-forming a procedure on the patient infected with humanimmunodeficiency virus, or the emergency departmentnurse in New Orleans who remains on duty duringHurricane Katrina, knowing that the hospital will bereceiving mass casualties and not knowing the fate of her

Mary Elizabeth Grimaldi, BS, BSN, RN, CNOR, is OperatingRoom Manager, Froedtert Hospital, Milwaukee, Wisconsin.

Corresponding Author: Mary Elizabeth Grimaldi, BS, BSN,RN, CNOR, Froedtert Hospital, 9200 West Wisconsin Ave,Milwaukee, WI 53226 (mgrimald@fmlh.edu).

own home, family, or even herself if she does not evacu-ate the area soon. While healthcare workers have alwaysplaced themselves at the forefront of dangerous situationsand placing the well-being of their patients before theirown well-being, it seems that since September 11, 2001,this has become an ethical dilemma for many. With thethreat of biological weapons, such as anthrax, Ebola, andricin, that can be as deadly to the exposed healthcareworker as it is to the primary victim, and the events of9/11 still fresh in our memories, along came HurricaneKatrina and with it the idea of making ethical decisionsin times of disaster suddenly has become a reality thathealthcare workers must be prepared for every day.

Some professions have a code of ethics to provideguidance with these decisions. A code of ethics is basedon standards of best practice guidelines, which are devel-oped on the basis of the fundamental principles and val-ues of the particular profession.1 A code of ethics issometimes referred to as an instrument of soft law sinceit is nonlegislative in nature.2 Because of this, a code ofethics should serve only as a guide for ethical reasoningand how to treat individual patients rather than a direc-tive of mandatory treatment or behavior.3

The American Medical Association has made attemptsto address the issue of duty to care by adopting severalnew ethics policies that directly address the physician’sobligations and responsibilities during public healthemergencies. The following is from a policy adopted bythe American Medical Association in 2004:

National, regional, and local responses to epidemics, terroristattacks and other disasters require extensive involvement ofphysicians. Because of their commitment to care for the sick andinjured, individual physicians have an obligation to provideurgent medical care during disasters. This ethical obligationholds even in the face of greater than usual risks to their ownsafety, health, or life. The physician workforce, however, is notan unlimited resource; therefore, when participating in disasterresponses, physicians should balance immediate benefits to indi-vidual patients with the ability to care for patients in the future.4

The American Medical Association is the first medicalassociation or professional organization to even try to

E T H I C S

164 Journal of Trauma Nursing • Volume 14, Number 3 July–September 2007

provide guidance for its members by stating physicians’obligations. It is unknown whether other healthcare pro-fessions will also take a stand.

The American Nurses Association addresses 9 provi-sions in its code of ethics and leaves a good deal of roomfor individual interpretation in its ambiguity. Provision 3states: “The nurse promotes, advocates for and strives toprotect the health, safety, and rights of the patient.”5 InProvision 5 of the code, the nurse’s obligations to self areaddressed. “The nurse owes the same duties to self as toothers, including the responsibility to preserve integrityand safety, to maintain competence and to continue per-sonal and professional growth.”5 While stating that thenurse has an obligation to provide care for their patientsin Provision 3, they clearly state that nurses are obligatedto care for themselves in Provision 5. This does not pro-vide clear guidance. Nurses may ask, “When does myduty to care for my patients usurp my duty to care forme?” According to the American Nurses Association, Wehave an ethical duty to care for our patients, but also anethical duty to care for self and family. How do wechoose to do what is right? Furthermore, what is right?

Wynia6 lists 3 primary ethical challenges facing thehealthcare provider during public health emergencies,rationing, restrictions, and responsibilities. Rationingdeals specifically with the allocation of resources. Triagewould fall under this challenge. Triage is the action of pri-oritizing medical treatment and management of patients,based on a rapid diagnosis and prognosis for eachpatient, taking into account available resources, medicalneeds, and capabilities. Triage can pose an ethicaldilemma because there may be limited resources in rela-tion to a large number of persons in need of treatment.Some may even question whether triage is ethical.Patients who can be saved and whose lives are in imme-diate danger should be treated first. Patients who cannotbe saved are not treated.7 If you were the medical profes-sional triaging patients in an emergency, would you beable to classify a friend or a family member as one whowill not receive treatment?

The second challenge, restrictions, deals with isola-tion and quarantine. These are strategies that may needto be implemented during disease outbreak or suspectedbiological weapon use. Restrictions can limit freedomand liberty in both the patient and the healthcareworker.

The third ethical challenge is responsibilities. This isperhaps the biggest challenge since it is hard to predict

what people will do during times of crisis.8 As stated ear-lier, the code of ethics for most of the healthcare profes-sions only suggest that the care providers carry out theirobligation to their patients, while at the same time theyare ambiguous by stating that there also exists a duty totake care of oneself. Some hospitals in New York havedeclared that they would not treat patients presentingwith suspected smallpox.9 Should there be laws passed tomandate that healthcare providers take care of thesepatients? Legal enforcement should not be the method weuse to ensure care is provided to patients. Even whenthere is no public health emergency, healthcare providersplace themselves at risk every day with every patient theycare for. The only way to avoid these risks would be tochange professions. Some may do just that. Others real-ize that there is risk and they are willing to live with it.

There is no easy solution to the ethical issues sur-rounding the duty to care for healthcare professionals. Itmay be easier if professional organizations were to take astronger position, but it appears that for now, they willcontinue to provide guidance with little or no direction sothe healthcare professional will still have to make thesechallenging decisions on their own. “We are not heroes,we are just doing our job.”10

REFERENCES

1. Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and theduty to care: whose duty? Who cares? http://www.biomedcentral.com/472-6939/7/5. Published 2006. Accessed April 3, 2007.

2. Campbell A, Glass K. The legal status of clinical and ethics policies,codes, and guidelines in medical practice and research. McGill Law J.2000;46:473.

3. Kluge EH. Codes of ethics and other illusions. Can Med Assoc J.1992;146:1234–1235.

4. American Medical Association: Physician obligation in disaster pre-paredness and response. http://www.ama-assn.org/apps/pfnew/Pfonline?fn�browse&doc�policyfiles/HnE/E-9.067.HTM. AccessedApril 1, 2007.

5. American Nurses Association. Code of Ethics for Nurses WithInterpretive Statements. Washington, DC: American NursesPublishing; 2001:5–7.

6. Wynia MK. Ethics and public health emergencies: Rationing. Am JBioeth. 2006;6(6):4–7.

7. The World Medical Association. Policy: World Medical AssociationStatement on medical ethics in the event of disasters. http://www.wma.net/e/policy/d7.htm. Published 2006. Accessed April 3, 2007.

8. Wynia MK. Ethics and public health emergencies: restrictions on lib-erty. Am J Bioeth. 2007;7(2):1–5.

9. Herrick T. Some hospitals plan to rebuff bioterror cases. Wall Street J.2003;16:B1.

10. Littleton MR, Wright C. Doc: Heroic stories of Medics, Corpsmen andSurgeons in Combat. St Paul, MN: Zenith Press; 2005.