Disasters Research Paper Example

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Abstract

Disasters cause widespread devastation and destruction and raise many ethical issues in terms of planning and response. Both locally and globally, individuals and organizations have ethical responsibilities regarding these issues. Disaster bioethics is a developing ﬁeld of scholarship and applied ethic, and overlaps with public health ethics with similar dilemmas and ethical frameworks being developed. Within disasters resources are always scarce, necessitating rationing. Injuries are usually widespread after disasters, often far exceeding the available healthcare resources. This necessitates triage strategies which are ethically challenging. Decision-making may need to switch from treating the most critically injured ﬁrst to treating those most likely to survive ﬁrst, which can conﬂict with normal healthcare ethics frameworks. This creates moral distress for many healthcare workers, pointing to the importance of training and preparation in disaster bioethics. Evidence is also needed to guide decision-making in disasters, but is often lacking. This creates a need for more research, which raises additional ethical challenges. These and other ethical issues are examined in this research paper , which also highlight the need for additional reﬂection and training in disaster bioethics.

Introduction

The death, destruction, and displacement from disasters have led to greater attention at local and global levels. Communities, hospitals, and other organizations around the world have developed disaster response plans. The United Nations (UN) coordinates its disaster-related activities through the UN International Strategy for Disaster Reduction (UNISDR; www.unisdr.org). Given that planning for and responding to disasters involve choices based on moral values and other intangible principles, the ethical component of decision-making related to disasters has been identiﬁed. This article provides introductory ideas about the ﬁeld of disaster bioethics and surveys some of the attendant ethical issues.

History And Development

Disasters have occurred throughout human history. Floods of biblical proportions, earthquakes, volcanic eruptions, heat waves, ﬁres, and plagues have devastated human populations. History is punctuated with horriﬁc natural events, including Mount Vesuvius’s destruction of Pompeii (AD 79), the Aleppo earthquake (1138), the Black Death (1348), the Lisbon earthquake (1755), the 1918 ﬂu epidemic, the Tangshan earthquake (1976), and many more. Other disasters have been self-inﬂicted through war, violence, and industrial negligence.

In recent years, the frequency and impact of disasters have been increasing. According to the Centre for Research on the Epidemiology of Disasters (CRED), during the 1990s, 200–300 disasters occurred annually; in the ﬁrst decade of this millennium, this increased to 300–400 per year (www.cred.be). Between 2003 and 2012, an average number of 388 disasters occurred each year, with 106,654 annual deaths on average, impacting 216 million people and costing US$156.7 billion. In 2013, these numbers were signiﬁcantly lower: 330 disasters, 21,610 deaths, 96.5 million people impacted, and costs of US$118.6 billion. The differences arose largely because 2013 did not experience a massive disaster like the 2004 Indian Ocean tsunami, 2010 Haiti earthquake, or 2011 East Japan earthquake and tsunami. At the same time, cyclone Phailin led to ﬂoods in India that killed over 6000 people in October 2013, and the next month cyclone Haiyan claimed over 7000 lives in the Philippines (www. cred.be).

Defining Disasters

One of the ﬁrst conceptual challenges is to deﬁne disasters consistently. The term is used in different ways, ranging from horriﬁc, large-scale events like the 2004 Indian Ocean tsunami, to the more conﬁned but still fear-inducing 2014 Ebola outbreak, all the way to people talking about personal disasters. In addition, several other terms are used for these events, including mass casualty incidents and public health emergencies. Pandemics are large-scale outbreaks of infectious diseases sometimes also viewed as disasters.

A disaster will, to one degree or another, result in what have been called the 6Ds: destruction, death, disease/disorders, displacement, disappearance, and disarray (O’Mathúna et al. 2014). One disaster may not include all factors, but will have many of these. Hence, the World Medical Association (WMA) deﬁnes a disaster as “the sudden occurrence of a calamitous, usually violent, event resulting in substantial material damage, considerable displacement of people, a large number of victims and/or signiﬁcant social disruption” (WMA 2006). Another important characteristic is that disasters overwhelm local response capacity, usually necessitating outside help. Whether this help comes from another city, state, or country adds complexities to the ethical issues involved.

Deﬁning disasters is not just an academic exercise. War and violence have disastrous impacts on people and property, yet sometimes are excluded from deﬁnitions of disasters (WMA 2006). The 2014 Ebola viral disease outbreak was often called a disaster, but the number of people infected and killed in this is tiny compared to those killed by malaria every year. Yet outbreaks of malaria and other infectious tropical diseases are rarely described as disasters.

Whether or not something is declared a disaster has ethical implications because of how it triggers different types of responses. The 2010 Haiti earthquake was rightly declared a disaster given that over 200,000 people died and a very poor nation was devastated. This led to an outpouring of international aid, although questions have been asked about the quality and appropriateness of some of this aid. Yet during the same year, a heat wave in Russia led to the deaths of over 56,000 people. It was not declared a disaster, received little media attention, and little external help. Perhaps, the Russian experience was an instance where political climate and international relations shaped the nature of what constituted disasters. This further raises the problematic value-laden question of whether or not the notion of disasters and the responses they elicit are inherent in the events or may be externally determined.

Deﬁnitions sometimes distinguish between natural and man-made disasters. However, as Hurricane Katrina showed, even apparently natural disasters are always complicated by human factors such as poor planning, uncoordinated responses, and human errors (Fink 2013). Given the role of human planning and decision-making in disasters, the distinction between natural and man-made makes little sense. Since human decisions are involved, ethics is always an important element. While one deﬁnition is not universally accepted, this research paper will focus on events that cause extensive damage and human suffering and which also overwhelm the local capacity to respond effectively and efﬁciently.

Ethical Dimension

Ethical dilemmas permeate every aspect of disaster relief. They range from decisions made by individuals, such as when a nurse or doctor must decide which victims to treat ﬁrst, or a truck driver deciding whether to let looters take some of his supplies so that he can get the rest to the other survivors, or a ﬁeld manager deciding whether to violate organizational policy because she believes the situation on the ground demands another approach, or government ofﬁcials deciding whether to allow outside military forces to assist in humanitarian relief.

The scale of the impact differs, but the ethical quandaries persist. When ethics is overlooked, or people think things are not being handled ethically, trust, morale, and enthusiasm can wane. When ethical guidance is available, and people understand the values and principles underlying tough ethical decisions and policies, beneﬁts accrue beyond the decisions. A group that examined ethical issues arising during the 2003 outbreak of severe acute respiratory syndrome (SARS) concluded: “SARS showed there are costs from not having an agreed-upon ethical framework, including loss of trust, low morale, fear and misinformation. SARS taught the world that if ethical frameworks had been more widely used to guide decision-making, this would have increased trust and solidarity within and between health care organizations” (University of Toronto 2005).

Disasters And Healthcare Workers

A Canadian research team has been interviewing humanitarian healthcare workers about the ethical dilemmas they face (O’Mathúna et al. 2014). They identiﬁed four general themes underlying most ethical difﬁculties in humanitarian work, including within disasters.

Resource scarcity and deciding how to allocate those resources, including triage
Responding to social injustice that arose from historical inequalities, political and commercial structures, or cultural differences
Frustration with aid agency policies or agendas, especially when they conﬂicted with what were perceived as professional or ethical duties
Addressing healthcare professional hierarchies, poorly deﬁned roles, and differing scopes of practice or standards of care

Such ethical challenges can arise in any setting, but they are intensiﬁed in disasters. Increasingly, disaster training is recognized as important for healthcare professionals. Hurricane Katrina showed that all healthcare professionals need to be prepared for disasters, including how to address the ethical dilemmas that typically arise (Fink 2013). Yet a systematic review of qualitative research involving nurses and disasters found nurses were clinically and emotionally unprepared for disasters with “a failure to directly address the issue of ethical considerations in planning, preparedness, and response to public health emergencies and disasters by nurses” (Johnstone and Turale 2014). At the same time, nurses and other healthcare professionals do face ethical challenges in disasters, particularly around triage decisions, being asked to do things outside their normal scope of practice and balancing professional duties with concern for their own health and their families. Healthcare professionals who are unprepared to deal with such ethical dilemmas are at risk of emotional, psychological, and moral distress (Wagner and Dahnke 2015).

Disasters And Public Health Ethics

When resources are scarce, decisions must be made about who gets whatever is available and when. Other ethical dilemmas arise over people’s responsibilities in a disaster. Healthcare professionals are caught between their duty to care for patients and their duties to their own health and their families. Such ethical debates were intensiﬁed with Ebola. Similar ethical dilemmas arise in public health ethics, which has been characterized as focused on questions of rationing, restrictions, and responsibilities (Petrini 2010). Restrictions here focus on questions of quarantine and isolation, but these are not addressed in this research paper.

Because similar ethical issues arise, disaster bioethics is sometimes addressed within a public health ethics approach. Public health has been deﬁned as various procedures “whereby local, national and international resources are mobilized and committed in order to make sure that people are in a position to live healthily” (Petrini and Gianotti 2008). While aiming at something universally valued, conﬂicts arise in the details. Public health itself has recently been widening its scope to include global health (Petrini and Gianotti 2008), which makes the overlap between public health ethics and disaster bioethics more clear.

While earthquakes are very different to infectious outbreaks, the ethical dilemmas have many similarities. Procedures that promote public health and well-being may not be accepted by everyone involved, such as vaccination programs or relief distribution. Decisions must be made about which people get limited medical treatments or vaccines. People’s freedom to go where they want may have to be restricted. Healthcare workers will have to consider their own and their families’ health and safety, not just that of patients. The event may cross international boundaries raising questions about proper jurisdiction. International incidents bring cultures together, sometimes generating conﬂicts even when the collaboration is motivated by a desire to help. The available evidence to guide decision-making may be far from ideal, leading to uncertainty and debate over the best interventions or policies. On top of this, decisions will need to be made urgently, without the usual time for deliberation and consultation, and there may not be an agreement about who should make those decisions.

Both public health ethics and disaster bioethics must balance the common good with individual liberties and rights. When healthcare professionals enter disasters, two approaches to ethics can come into conﬂict. Healthcare ethics is primarily based on doing the best for each individual patient and respecting each patient’s autonomy and other rights. Transitioning into a disaster context, where some injured people may be triaged to receive no treatment beyond comfort care throws up distinct issues. According to Wagner and Dahnke (2015), this:

runs counter to the moral intuition of most people and most nurses, as well as counter to the typical ethical principles that normally inform daily nursing practice. The nurse’s instinct is to help and nurture the patient. To ignore this instinct causes great consternation with extreme and potentially long-lasting moral distress.

In disasters, the needs and rights of some individuals may be given lower priority in order to maximize the good of many people. Some conclude that utilitarianism is the obvious ethical theory to apply in public health and disasters (Wagner and Dahnke 2015). However, concerns are also raised that utilitarianism can lead both to individual well-being and rights being undermined and to overly paternalistic approaches being endorsed in the name of the common good. As a result, other ethical theories and principles are put forward to balance the excesses of utilitarianism. Kantian or deontological theories emphasize the importance of respecting all humans by treating all persons as ends in themselves and not as means to others’ ends. However, disagreements exist among deontologists over which rights must always be protected and how involved the state should be in promoting the health of individuals. Other ethical theories emphasize the role of signiﬁcant relationships (like families) and communities in ethical decision-making and also personal character traits or virtues, such as solidarity and compassion. Such alternative ethical principles will see the mainstream moral dilemmas sometimes differently and respond to them in different ethically justiﬁable ways.

As with many areas of ethics, what is needed is an approach that balances a number of competing principles and theories. Each on its own can lead to extremes. But when taken in combination, and prioritized through open, transparent discussion with all stakeholders in each situation, a framework can be developed which allows ethical dilemmas to be resolved acceptably. One such framework is called personalism, an approach to ethics based on the premise that the public good is best promoted by care and respect for individual rights and well-being (Petrini and Gianotti 2008; Petrini 2010). Personalism starts from the premise that all humans share a common human nature or personhood which demands that all humans be treated with respect. This leads to ﬁve personcentered principles that should be taken into account as ethical dilemmas are reﬂected upon case by case in disasters or any other situation.

The principle of inviolability: all human life is inherently valuable and should be protected and respected. Actions should not diminish the dignity of individuals. This prohibits using any human as an instrument for the public good.
The therapeutic principle states that interventions on human life should always promote life. In clinical ethics, a part can be sacriﬁced for the good of the whole body (e.g., amputation of a gangrenous limb). In contrast, public health interventions should not deliberately cut short some human lives for the good of all. In extreme circumstances, some may be allowed to die who might have been saved in other circumstances. All interventions should promote health and well-being, even if they cannot be provided to everyone.
The principle of subsidiarity: public health measures that preserve and promote individual choice are preferred over compulsory

approaches. Education is preferable to coercion. Mandatory programs require a higher level of justiﬁcation and evidentiary support.

The principle of solidarity: individuals should take into account the needs of others and their communities as they make individual choices. A sense of togetherness, even in a global context, should lead to a prioritization of the needs of the most disadvantaged. Through promoting concern and care for the least well off, all will beneﬁt.
The principle of justice calls for fair distribution of resources and avoidance of discriminatory actions and policies.

Rather than focusing exclusively on consequences or duties, personalism seeks to express the core insights of several ethical theories in broadly accepted principles. Ethical dilemmas arise, and rather than seeking one ideal solution, personalism accepts that ethical decision-making involving balancing various principles that often conﬂict. Wisdom and experience are needed to balance competing principles well. Various perspectives need to be considered through open, transparent dialogue that respects all persons impacted. Approaches like personalism have only recently been applied to public health ethics and are beginning to be explored in the context of disaster bioethics (Petrini and Gianotti 2008).

Ethics In Disaster Preparedness

Disasters often occur with little or no warning, which adds to the ethical complexities. Even when a region is known to be prone to a certain type of disaster, exactly when one will occur or the magnitude of a speciﬁc incident will rarely be known. At the same, there has been a growing recognition that this uncertainty places ethical responsibilities on people, professions, and authorities to prepare for disasters. Disaster preparedness and contingency planning have become seen as important requirements for individuals and organizations. While such planning will not prevent disasters, it can do much to reduce the loss of life during disasters and improve the speed and effectiveness of responses. Disaster planning and disaster drills aim to build resilience and conﬁdence within communities so that they will be able to withstand and recover from disasters. Preparedness planning is thus an ethical responsibility that needs to be taken up by all communities, both local and global.

Triage

Disasters are characterized by insufﬁcient resources. Many people may be injured and at the same time the healthcare infrastructure may be demolished. During a pandemic, all available resources may need to be directed towards those infected leaving insufﬁcient resources to care for those with more “normal” illnesses and disabilities. Electricity and fuel may be scarce, food and clean water unavailable, communication lines knocked out, and transport impossible. All of these situations will create ethical dilemmas regarding who will receive the limited resources available. Such decision-making is called triage, rationing, or allocation of scarce resources.

The word “triage” comes from the French word “trier,” meaning to sort and was originally used in military contexts to sort the wounded into those who would and would not be treated (Petrini 2010). Decisions were to be based on need rather than rank, thus introducing an egalitarian dimension to triage ethics. Although triage is highlighted in battleﬁeld and disaster settings, triage also occurs in more ordinary situations. In emergency departments, triage decisions are made regularly to decide which patients will be treated in which order based on the urgency of their condition. Usually, the most needy get the most resources. However, in disasters, resources may be so limited that triage involves deciding that the most seriously injured receive the fewest resources and only comfort care. Such triage decisions involve balancing the needs and goods of some people (those unlikely to survive no matter what) against others (those who can be saved through using the available resources), balancing the needs of victims and responders (to ensure responders remain available to help others), and balancing short-term and long-term beneﬁts and harms.

The ethical basis of triage is often derived from a utilitarian justiﬁcation (Petrini 2010). When many people are injured, and resources are limited, the right decision is to save as many people as possible. For example, after an earthquake, many people will be injured. The ﬁrst ﬁeld hospital available may receive hundreds of injured people. If one surgeon is available and operates on the most seriously injured patient ﬁrst, it could take hours to save one person’s life. Meanwhile, lots of other people may deteriorate. On the other hand, if those less seriously injured are operated on ﬁrst, several people might be saved in the same timeframe. A utilitarian triage ethic would approve of this approach.

Clinicians often struggle with an ethic of the greatest good for the greatest number of people. Clinical ethics focuses on the good of individual patients, not the common good. In emergency department triage, the most seriously injured patients will be rushed to the top of the queue and given the most resources. In a disaster, the most seriously ill or injured may be given the lowest priority, such as happened in Memorial Hospital after Hurricane Katrina (Fink 2013). This “reversed care priority” can be very disturbing for clinicians (Johnstone and Turale 2014).

Even from an ethical perspective, this approach to triage can be questioned. Utilitarian triage prioritizes the principle of utility, seen in a military context as providing treatment to the injured who can return to battle. Yet even in triage, utility must be balanced against other ethical principles, such as those suggested within personalism, since quantiﬁable injury scales do not remove all the ethical quandaries. Petrini (2010) uses the example of a lone doctor coming upon a bus crash and having to decide who to treat ﬁrst: the most injured passenger, an injured nurse who could then help him, or his brother, also an injured passenger. Utility would prioritize the nurse, who can then help with the other injured passengers. But Petrini holds that the principle of solidarity also must be taken into account in triage. “Solidarity emphasizes a sense of togetherness that implies a commitment to provide priority to the most disadvantaged” (Petrini 2010). Solidarity is based on important values and virtues, including those of altruism, sympathy, benevolence, and justice. Even if solidarity is accepted as being important, tension arises over whether the doctor’s solidarity should be ﬁrst for his brother or for the most seriously injured passenger. In some cultures, taking care of one’s relatives is viewed as the most important value, outweighing other principles. Rather than pointing to a clear, universal answer, this discussion highlights the deeply challenging aspects of triage in disaster settings. It also echoes the idea earlier expressed about how non-Western ethical principles may both interpret and respond to the ethical quandaries of disasters differently.

The limited resources that often exist in disasters warrant the need to make them available in just and transparent ways. Practically, however, dozens of different triage tools, algorithms, and strategies have been proposed, tested, and used. A systematic review found that these various strategies can be grouped into four broad categories (Timbie et al. 2013):

Managing or reducing less urgent demand for healthcare services (e.g., canceling elective procedures and urging nonurgent cases to avoid hospitals or discharging less critical patients early to make way for urgent cases)
Optimizing the use of existing resources (e.g., triaging patients in the ﬁeld, asking healthcare workers to work longer hours)
Augmenting existing resources (e.g., use stockpiled supplies, request outside additional help)
Implementing crisis standards of care (e.g., use triage principles to allocate critical resources, conduct “damage control” surgery)

Having reviewed the different strategies and the evidence for their effectiveness, the reviewers found sufﬁcient evidence to reach conclusions about only two strategies and in both cases rated the strength of the evidence as weak. One effective strategy to reduce demand on healthcare services was by designating dispensing points to distribute biological countermeasures (e.g., vaccines). The second area for which several studies were identiﬁed involved “ﬁeld triage” strategies. These are classic decision-making models used to classify patients according to their injuries to prioritize those who should be treated ﬁrst when resources prevent everyone being treated. The review concluded that the most commonly used triage strategies perform inconsistently in the ﬁeld and that drills and simulations lead to different results compared to when the strategies are used during actual disasters. The review found insufﬁcient evidence to inform policymakers or healthcare professionals on the most effective methods of allocating scare resources during disasters. They concluded that “it is deeply concerning how little high-quality evidence is available” for decision-makers and that research is “urgently needed” to provide such evidence (Timbie et al. 2013).

Rationing

Triage decisions are patient-care focused and are one type of rationing required in disasters. Rationing decisions received much attention in the 2014 Ebola outbreak because they arose in numerous places. Personal protective equipment was in limited supply, as were beds in isolation units. With only a handful of doses of the experimental treatment (ZMAP) available, decisions had to be made about which infected people would receive them. Expatriate healthcare workers were prioritized, both for treatment and evacuation, raising questions about why this was ethically acceptable. As Ebola vaccines become available, ﬁrst in experimental phases and later as (hopefully) safe and effective vaccines, questions are being asked about who would receive them ﬁrst.

Vaccine distribution in pandemics is an issue discussed extensively within public health ethics. This reveals a complex set of principles and disagreement over how they should be prioritized. Gostin (2006) usefully reviewed several different approaches to pandemic rationing. Random allocation (e.g., by lottery, or ﬁrst-come, ﬁrst-served) is seen as just and nondiscriminatory. Yet it would be the least effective approach given that some sort of targeted distribution would get the resources to those who would beneﬁt the most. Maximizing the impact of any public health strategy would require priority be given to those producing or delivering healthcare interventions. That suggests, for example, that vaccine manufacturing workers and healthcare providers be prioritized. Likewise, during pandemics, public service workers would need to be protected, including police, ﬁreﬁghters, food and water distributors, as well as undertakers and cemetery workers. Some would include those working in legislative and judicial systems to ensure the maintenance of necessary regulation and due process. On the other hand, medical need is an important priority. However, different decisions would be reached depending on whether priority was given to the most ill (including the elderly) or those with the most to gain from treatment (the young). Should priority be given to those who have already contributed most to society (the elderly) or those who have most to contribute in the future (the young)? Given existing social inequities, special efforts might be targeted at those least well-off in society, whereas others might argue for market forces being allowed to inﬂuence allocation. This issue came to prominence with Hurricane Katrina and the disproportionate impact of the disaster on poor, African-American citizens. From a global perspective, just allocation is even more challenging. Lower-income countries have a crucial role to play in infectious disease surveillance, yet often are unable to afford or access the resulting vaccines. The ethical principle of beneﬁt sharing challenges this situation and calls for a fairer approach to global rationing.

Underlying all of these competing ethical principles and priorities is the importance of open, honest, and transparent discussions in deciding policy. Public trust is key to the effectiveness of public health, which centers on policy being seen to be ethically based. This is challenging within local communities and even more so across the globe. In this regard, Gostin (2006) remarks that:

Citizens will agree to fair allocation if they believe the allocation process is fair. However, if they believe that others are jumping the queue due to inﬂuence or money, they will be less likely to behave selﬂessly. This is all the more reason for fair and transparent decision-making processes in advance of a pandemic.

Evidence And Ethics

Disaster response is underpinned by a desire or duty to help those in need. When motivated by the principle of beneﬁcence or solidarity with other persons, the intention is ethically sound. However, good intentions are not enough. On one level, this is a truism reﬂected in the titles of popular books like When Helping Hurts and Toxic Charity. On another level, lessons fail to be learned, leading to hurt, harm, and mistrust. For example, after the 2004 Indian Ocean tsunami, Sri Lanka received much international assistance. However, a lack of attention to understanding the local capabilities and needs led to unneeded items being sent to Sri Lanka while other resources were desperately needed. In some cases, services were duplicated by a lack of coordination between overseas nongovernmental organizations (NGOs). Inaccurate assumptions were made about prevalent diseases, leading some to be given unnecessary cholera vaccines or malaria prophylaxis (Yamada et al. 2006). Some camps for displaced persons received too much food and inappropriate clothing, while other camps were short of food and water. In Sri Lanka, sleeping mats and hygiene kits were always needed, but international aid arrived with “winter jackets, expired cans of salmon, stiletto shoes, winter tents, thong panties, and even Viagra” (http://nbcnews.com/id/6954302). One woman reacted to such inappropriate supplies saying, “We’re not beggars. We don’t need these hand-me-downs.” Such mistakes can deeply impact the personhood of survivors, raising additional ethical concerns.

Disaster responses should be evidence based. Otherwise, people will not be helped effectively, resources will be wasted, and harm and mistrust may result from delays to providing appropriate aid. The ﬁrst step in a disaster response should be a careful needs assessment. This can be challenging to conduct, but is vital to ensure that appropriate aid is sent. Local communities and organizations must be involved here. In addition, what is provided should be effective and safe, especially in healthcare relief. Yet much remains uncertain here. For example, after the Haiti earthquake, thousands of people received amputations (Gerdin et al. 2012). Since then it has been identiﬁed that some surgical teams carried out numerous amputations, while others did very few.

Analyses have shown that the differences cannot be explained by medical criteria alone. Cultural and ethical factors were involved in deciding who should be amputated and who should undergo the more difﬁcult and challenging reconstructive surgeries that would save their limbs.

Part of the problem is that the evidence does not strongly support any particular intervention, as noted above with triage strategies. Much disaster relief is based on expert opinion, authority, or non-rigorous studies, in part because high-quality evidence from rigorous research studies is lacking. The general problem is that “much of the existing operational research related to emergencies and disasters lacks consistency, is of poor reliability and validity and is of limited use for establishing baselines, deﬁning standards, making comparisons or tracking trends” (UNISDR 2011).

The ethical imperative to base responses to disasters on high-quality evidence is increasingly accepted (O’Mathúna 2015). However, much remains to be done. This was seen with the 2014 Ebola viral disease (EVD) outbreak where initially questions existed over how to diagnose EVD, how best to care for infected patients, and who needed to be isolated or quarantined (and when). As a result, debate can rage on the ﬁeld and in governmental circles over appropriate quarantine procedures (Drazen et al. 2014). To be ethical, such policies need to be evidence based. With Ebola, guidance improved as more evidence became available, highlighting the ethical importance of collecting relevant data carefully and thoroughly even while treating patients in a disaster. Effective treatments and vaccines remain unavailable for Ebola, highlighting the need for continued research on disasters and on interventions needed in disaster response. However, any form of research on humans must be done ethically, and research in disasters raises additional challenging ethical issues.

Disaster Research Ethics

Research in disaster settings is ethically justiﬁed when it aims to provide evidence to show which interventions, practices, or polices are most effective and safest. Effective treatments and vaccines currently are not available for Ebola viral disease and experimental ones will need to be tested in humans. Research studies should be appropriately designed and carried out by qualiﬁed researchers to identify which interventions are effective and safe. Interventional research is needed to answer many questions in disaster preparation and response. Social science research is needed to understand the experiences of people in disasters and the broader impact on their lives of the disasters, the responses, and the subsequent aftermath.

The lack of knowledge and certainty provides ethical support for research in general, but does not justify every approach to research or any particular research project. There are widely accepted ethical standards for research that must be upheld. These include that the study should be of value, have an appropriate design for the research question, enroll subjects or participants ethically, balance risks and beneﬁts properly, be independently reviewed, gather informed consent, and respect the individuals and communities in every way feasible (O’Mathúna 2015). How exactly ethical principles are enacted varies between projects, but even with the challenges of disaster settings, they can almost always be followed.

At the same time, disaster research raises distinctive ethical challenges which require detailed examination (O’Mathúna 2010; O’Mathúna et al. 2014). People in disasters will typically be more vulnerable than usual, but this does not mean that they are incapable of consenting to research. Some research found that disaster survivors welcomed the opportunity to help researchers understand how the disaster impacted them. However, the heightened vulnerability needs to be taken into account by researchers. A particular challenge for disaster research has been called the “humanitarian misconception” (O’Mathúna 2015). People may agree to participate in research believing they are more likely to receive humanitarian aid or fearful they will lose aid if they do not participate. This misconception prevailed in a notorious drug trial conducted during a 1996 meningitis outbreak in Nigeria (O’Mathúna 2010). Researchers should be distinguishable from medical care providers to minimize the risk of such misconceptions and other conﬂicts of interest. Such factors create challenges for disaster research projects, but should not lead to lower ethical standards in disasters. In some cases, this may mean that a certain study should not be conducted in a speciﬁc setting or at a particular stage in the disaster response. The ﬁnal determinant must be respect for the persons being asked to participate in the research.

Independent approval and oversight of disaster research is another particular challenge for disaster research. Under normal circumstances, research ethics approval can take weeks or months. When a disaster strikes, some research projects may want to begin within days. Time may not allow for the usual approval process. Proposals have been made to have research projects preapproved in the usual way, with an expedited step permitted once the location and details of the disaster are known. Médecins Sans Frontières (MSF), the international medical humanitarian aid organization, has such a mechanism for projects conducted by MSF researchers (O’Mathúna et al. 2014). This approach permits careful planning, reﬂection, and adjustment before the urgency and pressures of the disaster hit and allows for ﬁnal adjustments once the disaster occurs. This type of approach shows the importance of both careful preparation and ﬂexibility in disaster planning and responding.

Conclusion

Disasters are large-scale events that create havoc in many ways, including a diversity of ethical challenges. Some major challenges have been noted here, but many others exist. Acute disaster relief can conﬂict with long-term development, such as when free aid undermines local economies or local workers leave community organizations to obtain higher wages from international agencies. Many of these issues have received little analysis and need to be addressed. Some form of triage strategy is necessary, and steps must be taken to ensure that cultural prejudices are not built into such frameworks. Women, children, pregnant women and their unborn, the disabled, the elderly, and other groups of people are particularly vulnerable during disasters. Concerns have been raised about the way disaster planning and operational guidelines, whether intended or not, can overlook or undervalue those with heightened vulnerabilities (Twigg 2014).

Disasters often lead to displacement, and major disasters lead to mass movements and camps for refugees and internally displaced people. These should be safe havens for those who have already lost everything, yet they can turn into places where disease spreads, vulnerabilities are exploited, and violence against women and children proliferates. This places ethical responsibilities on those designing, constructing, and running such camps to ensure they respect the dignity of all persons living there and truly are camps of refuge. Post-disaster reconstruction likewise raises challenges including how and if people will be recompensed for losses or helped to rebuild their lives. Crossing international boundaries raises questions about immigration policies. Ethical issues arise in ending disaster relief projects. Ethical exit strategies have been elusive; yet when the ﬁeld is not left properly, local communities can feel abandoned and long-term damage done to trust and future development.

The need to better understand the ethical issues experienced by those impacted by disasters and humanitarian workers, the development of initiatives in ethics training and ﬁeld support, examination of the ethical implications of policies and procedures, and the development of theoretical frameworks for disaster ethics are some of the issues which still require further reﬂection and ethical landscaping. Hence, creative strategies are needed to ensure that plans for and responses to disasters are as ethically sound as possible. A disaster can take away almost everything from those in its path. Responses and responders must aim for the highest ethical standards to ensure that dignity, respect, and justice are not washed away also. This is difﬁcult in a disaster setting, but the consequences of not upholding ethical standards are far-reaching. Dilemmas are real in disasters, and people may not be able to do all they want or do what they would in other circumstances. But people can still be treated with respect, have their dignity upheld, and be cared for with compassion and justice. That is ultimately what ethics is all about. The challenge for disaster bioethics is to develop proposals, strategies, training, and policies that best achieve those aims.

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