This is a series of presentations I gave in the Eastern Mediterranean Public Health Network (EMPHNET)'s Public Health Ethics (PHE) that was held in Amman in June 2014. This presentation outlines the ethical issues in public health emergencies and disasters.

1. Ethical issues in Public Health
emergencies and disasters s
EMPHNET
Ghaiath M. A. Hussein
MBBS, MHSc. (Bioethics), PhD Researcher
Email: ghaiathme@gmail.com
Regency Hotel, Amman, Jordan
15-19 June 2014

2. Module’s objectives
2
• Distinguish between the different levels of
effects of disasters (mainly pandemics) and
their ethical implications
• Apply the ethical frameworks to analyse and
manage the ethical issues associated with
provision of public health care during
disasters
• Compare the appropriateness of
implementation of the PH ethical core values
to the settings of disasters

3. Module’s Outline
• Different types of disasters (natural & man-made)
• The ethical implications of disasters and the
associated PH interventions
• Triage, evacuation and Resource allocation
• Duty of care & Standard of care during disasters
• Privacy and confidentiality (safety of collected data)
• Duty to report
• Consent
• Media and its role in balancing information coverage
during disaster and protection of privacy and rights.

4. Different types of disasters
(natural & man-made)
Let’s give it a thought …
• What do we mean by a disaster?
• Natural vs. manmade
• Any examples from EMR?

5. Mapping of ethical issues in
(natural) disasters
Disproportional
burden
COI (®Tamiflu,
vaccine)
Resource
allocation
Consent
Public
engagement
Sub-optimal
products
Surveillance
(research?)
Inequalities
Trials (review)
Loss of
property
&work
hours
Access to
care
Restricted
movement
Confiden
tiality
Professional
duty

6. Ethical values
• Individual liberty
• Protection of the public from harm
• Proportionality
• Reciprocity
• Transparency
• Privacy
• Protection of communities from undue stigmatisation
• Duty to provide care
• Equity
• Solidarity
(Singer et al., 2003)

7. Triage, evacuation and
Resource allocation
How should we decide on who gets what?
• Concept of need
• Concept of utility
• Non-comparative concept
• Privileging concept or ‘social worth’

8. Duty of care/share?
• Do (public) health professionals have the duty to provide
healthcare services even if that would endanger their lives?
• What are the factors that help us draw that extent?

9. Duty of care/share?
Indonesia refuses to share H5N1 virus samples (1)
• Since July 2005 to December 2007, Indonesia has reported
the highest number of influenza A (H5N1) human cases in
the world, i.e., 116 cases with an extremely high fatality
proportion of 81%.
• Indonesia designated hospitals in which clinical specimens
from suspect human H5N1 are obtained (swabs, aspirates,
and lung biopsies from deceased patients)
• For 1&1/2 years, Indonesia had sent all clinical
specimens to a couple of international laboratories
participating in the WHO global influenza surveillance.

10. Duty of share?
Indonesia refuses to share H5N1 virus samples (2)
• Since January 2007, however, the Government of Indonesia has
decided to withhold the specimen (virus) sharing and pulled out of
the Global Influenza Surveillance Network (GISN).
• It was concerned that its strains of H5N1 would be used to make
vaccines in the rich countries then “resold” to Indonesia at
unaffordable prices. They were also concerned that scientists in high-income
countries would be able to take out patents based on these
strains, which they asserted was their sovereign property.
Discussion:
• What are your initial responses to this situation? What are the most
important ethical considerations in this scenario?
• Discuss if there is a moral duty on Indonesia to keep/share the
samples? AND whether rich countries are morally obliged to help
Indonesia facing the pandemic and to what extent?

11. Privacy and confidentiality
• What is the key difference?
• When it is ethically (& legally required) to breach them?
• Examples from disasters?

12. Consent
• What constitutes an informed consent?
• How does disasters affects the consent giving process?
• In a disaster, what needs consent?
– Surveillance?
– ‘assessment surveys’?
– Vaccine clinical trial?
– Photography?

13. Media and its role
• Too soon or too late?
• Inadequate and incorrect
information about the
disaster
• Photography and
Breaching privacy
• Promoting injustices &
blaming the victims
• Conflicts of interest
(advocacy vs. news
reporting)

14. DUTY TO CARE SCENARIO (1)
(Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)
• The media is reporting that the World Health Organization has
officially determined that a pandemic influenza is now
underway.
• The Public Health authorities has confirmed person-to-person
spread in several cities.
• The local media is reporting increased demands for emergency
room and family physician office visits.
• Some deaths have been reported, but no one is really certain
how serious the problem may be.
• Little is known about the actual virus at this point.

15. DUTY TO CARE SCENARIO (1)
(Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)
• Maria is a 35-year-old family physician and mother of three children
aged 4-8. She works in a primary care clinic in a main hospital and is
one of 12 doctors practising in the clinic.
• Her husband, hearing the media reports, is concerned that she may
become ill or bring home illness to her family because of the
increased exposure at work. He encourages her not to go to work.
Maria is concerned for the care of her children. They attend a day
care centre. Her husband works in an accounting firm. She is also
worried about abandoning her patients and increasing the
workload of her colleagues, many of whom, like her, have young
families.
• First Set of Questions
– What are your initial thoughts and feelings about this?
– What do you think are the most important considerations for Maria in
making her decision?
– Would your opinion change if the day care centre was closed? Why?

16. DUTY TO CARE SCENARIO (1)
(Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)
• Maria decides she will go to work. She is concerned that her clinic
lacks the appropriate amount of protective equipment. The clinical
group meets and decides that they are committed to providing care
to people with influenza, but will only do so if the ministry of health
provides appropriate protective equipment.
• 2nd group of questions:
– What do you think of the clinical group's decision?
– Do you think society has an obligation to health care workers in the
event of a pandemic outbreak?
– One of Maria's colleagues is close to retirement. He has diabetes and
heart disease. He tells the clinic that he will not come to work as he
feels the risk to his own health is too great.
– In your view, is the health status of a health care worker an acceptable
reason not to respond to a pandemic virus?

17. DUTY TO CARE SCENARIO (1)
(Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)
The influenza outbreak is now well advanced. Many people are sick, including
a large number of health care workers. Many health care providers in
hospitals and clinics are not showing up for work. Many refuse to work
because they fear infection.
• Should health care providers face consequences for refusing to show up for work?
• If no, why? If yes, what sorts of penalties do you think would be fair?
The government has now officially declared a health emergency. It is enacting
legislation mandating health care workers to participate in the efforts to
control the outbreak.
• What do you think about this possibility?
• Do you think such laws would violate the rights of health care workers?
Final Questions
– In your view, is it justifiable for health care providers to refuse to provide care?
– Who should make these kinds of decisions?
– How should these kinds of decisions be made? In the absence of a consensus, how should these
decisions be made?

18. References & readings
• SINGER, P. A., BENATAR, S. R., BERNSTEIN, M., DAAR, A. S., DICKENS,
B. M., MACRAE, S. K., UPSHUR, R. E. G., WRIGHT, L. & SHAUL, R. Z.
2003. Ethics and SARS: lessons from Toronto. BMJ, 327, 1342-1344.
• Chong, S. A., Capps, B. J., Subramaniam, M., Voo, T. C., & Campbell,
A. V. 2010, "Clinical Research in Times of Pandemics", Public Health
Ethics.
• Hawryluck, L., Lapinsky, S., & Stewart, T. 2005, "Clinical review: SARS
and lessons in disaster management", Critical Care, vol. 9, no. 4, pp.
384-389.
• 2004, Humanitarian Charter and Minimum Standards in Disaster
Response, Sphere Project., Geneva.
• Sztajnkrycer, M. D., Madsen, B. E., & ejandro B ez, A. 2006,
"Unstable Ethical Plateaus and Disaster Triage", Emergency
Medicine Clinics of North America, vol. 24, no. 3, pp. 749-768.