Disasters have devastating effects. Recent examples like Japan in 2011, the 2010 earthquake in Haiti, Hurricane Katrina in 2005, and the 2004 Indian Ocean tsunami reveal the extensive damage and human suffering caused by disasters. The number of natural disasters is increasing steadily, with 2010 being the deadliest year in decades: 373 natural disasters killed 300,000 people, impacted 200 million more people, and cost over $100 billion in damages.[1] Largely due to the Japanese earthquake, 2011 was the costliest year on record, with damages estimated between $350 and $380 billion.[2] The frequency of disasters is expected to increase. One assessment found that climate-related disasters (which make up 98% of all disasters) will impact 375 million people annually by 2015, a 50% increase on recent averages.[3] Little wonder that disaster preparedness and disaster risk reduction are top priorities for many governments and international organizations.
Disasters involve complex issues of global inequalities and our responsibilities towards our fellow humans. They also raise challenging ethical issues. Decisions made at high levels by governments and on the ground by individuals have ethical components. As a result, ‘disaster bioethics’ is a developing field of interest. Even the decision to classify an event as a ‘natural disaster’ has ethical implications. Public responses to natural events are more positive than to those caused by humans, especially those involving conflict and violence. Stories and images of disaster survivors are used in public appeals for aid. But do these convey respect for the dignity of the survivors? The notion that disaster survivors sit around stunned, waiting for outside help, is a myth based on some of these images. In reality, most survivors are rescued by those closest to the disaster.[4] The choice of image reflects concern for the ethical values projected directly or indirectly, intended or unintended.
When medical teams respond to disasters, they face serious ethical challenges. Triage decisions are commonplace, which some feel inadequately prepared to address. The best treatment may be unclear, especially when short-term benefits (such as with amputation) may lead to long-term challenges. Doctors and nurses may feel powerless as patients are prioritized based on status or wealth, not medical need. Ethical compromises may be insisted on by the ‘head office’ in an attempt to retain permission to stay in a region. Military medical units sometimes treat civilian casualties, but then transfer them to local hospitals when severely injured soldiers arrive. In one case, a doctor watched as a young girl on a ventilator was transferred to a local hospital that had no ventilators. “He knew she would be dead within minutes. But there was no other choice.”[5]
Such ethical dilemmas deeply impact healthcare professionals. One doctor working in the aftermath of a major earthquake became physically and emotionally exhausted because he “constantly was finding himself troubled by moral and ethical dilemmas.”[6] Afterwards he was overwhelmed with guilt that he had not done enough to help people. A qualitative study of twenty Canadian-trained healthcare professionals who had volunteered in disaster settings identified four general types of ethical challenges experienced:
While some of these arise in high-income settings, they are intensified by the degree of scarcity, the extent of need, lack of familiarity with cultural, social and professional norms, and poorly defined roles. Sending organizations seldom have specialized ethics training for field workers, but rely on them using their professionalism and standard codes of ethics.[8]
The variety and complexity of ethical issues in disasters is great. To help in disaster planning, evidence from disaster research is being generated. As with any human subjects research, ethical issues are involved. In fact this is where I began to engage with disaster bioethics, having been asked to write an article on disaster research ethics.[9] This led to a funding application to organize a symposium on disaster bioethics. With the support of CBHD and others, the Brocher Foundation funded a symposium at their conference center in Geneva, Switzerland (www.Brocher.ch). An edited volume from this symposium will be published in 2012.[10] A network of scholars and international humanitarian organizations developed from this symposium. We have submitted an application to the EU COST program which funds conferences and workshops in Europe on innovative research topics (www.cost.eu). If funded, this project aims to improve ethical decision-making during disasters by understanding the ethical dilemmas encountered in disasters and developing training materials and resources to assist policy makers, humanitarian organizations, healthcare professionals, and researchers involved with disasters.
For further information, see www.DisasterBioethics.com.
[1] United Nations International Strategy for Disaster Reduction, “Killer Year Caps Deadly Decade - Reducing Disaster Impact Is ‘Critical’ Says Top UN Disaster Official,” United Nations, http://www.unisdr.org/archive/17613 (accessed March 27, 2012).
[2] United Nations International Strategy for Disaster Reduction, “Heavy Disaster Losses for Insurance Companies in 2011,” United Nations, http://www.unisdr.org/archive/24588 (accessed March 27, 2012).
[3] Oxfam International, “Forecasting the Numbers of People Affected Annually by Natural Disasters up to 2015,” Oxfam International, http://www.oxfam.org/sites/www.oxfam.org/files/forecasting-disasters-2015.pdf (accessed March 27, 2012).
[4] Claire Magone, Michael Neuman, and Fabrice Weissman eds., Humanitarian Negotiations Revealed: The MSF Experience (London: Hurst & Company, 2011).
[5] Jim Ritchie, “When Every Turn is Toward Death,” Today’s Christian Doctor 42 (2011): 14-17.
[6] M. S. Bilal, M. H. Rana, S. Rahim & S. Ali, “Psychological Trauma in a Relief Worker – A Case Report from Earthquake-Struck Areas of North Pakistan,” Prehospital and Disaster Medicine 22 (2007): 458-461.
[7] L. Schwartz, et al, “Ethics in Humanitarian Aid Work: Learning from the Narratives of Humanitarian Health Workers,” AJOB Primary Research 1, no. 3 (2010): 45-54.
[8] Ibid.
[9] Dónal P. O’Mathúna, “Conducting Research in the Aftermath of Disasters: Ethical Considerations,” Journal of Evidence-Based Medicine 3, no. 2 (May 2010): 65-75.
[10] Dónal P. O’Mathúna, Bert Gordijn & Mike Clarke eds., Disaster Bioethics: Normative Issues When Nothing is Normal (Dordrecht: Springer, forthcoming).
Dónal P. O’Mathúna, "Disaster Bioethics,” Dignitas 19, no. 1 (2012): 8–9.
