Holt, G. Richard MD, MSE, MPH, MABE, D.BIOETHICS
From the University of Texas Health Sciences Center, San Antonio.
Reprint requests to Dr G. Richard Holt, Professor Emeritus, University of Texas Health Sciences Center, San Antonio, TX. Email: email@example.com
The author has no financial relationships to disclose and no conflicts of interest to report.
Accepted September 6, 2012.
Beginning with the first World Trade Center bombing in 1993, the Oklahoma City bombing in 1995, the tragedies of September 11, 2001, and subsequent hurricanes, tornadoes, and manmade tragedies, many American physicians have been faced with responding to disasters equipped with only a general knowledge of emergency casualty care. The tragic mass shootings at Columbine High School (1999), Fort Hood (2009), and the Aurora, Colorado movie theater (2012) demonstrate how unexpected mass casualties can challenge medical facilities and providers. In addition, the threats of anthrax bioterrorism (2001), severe acute respiratory syndrome, and avian influenza (H5N1) outbreaks or pandemics seem to linger just over the horizon. In accordance with their educational missions, the Southern Medical Association and the Southern Medical Journal believe that it is vitally important for physicians across the United States to be aware of and prepared for a potential role in responding to natural disasters, bioterrorism attacks, and human-induced tragedies in their local area and beyond. This special issue of the Southern Medical Journal features excellent articles by experts in the medical response to disasters and individuals who have participated in patient care after natural disasters. The lessons learned from experience, the educational and clinical challenges, and the importance of physician preparedness are highlighted in this special issue.
An introduction by Harold Timboe, MD, MPH, retired US Army major general, provides the necessary clinical perspective for the articles that follow. Timboe is a decorated medical combat leader (Vietnam, Gulf War I), and as Commander of Walter Reed Army Medical Center in Washington, DC, was responsible for the health-support efforts following the terrorist attack on the Pentagon on September 11, 2001 and the subsequent anthrax bioterrorism events. He also led a team of volunteer physicians and nurses for Project HOPE on the US Navy hospital ship Mercy for humanitarian relief efforts in Indonesia after the 2004 tsunami.1 In his introduction to this special issue, Timboe has expertly emphasized the importance of physician preparedness to respond to disasters that occur unexpectedly and often with major challenges to the healthcare system and clinicians.
I take the position that it is a professional and an ethical responsibility to potential patients and society for physicians to engage in sufficient self-learning that would provide them with at least an acceptable level of clinical preparation to meet the demands of caring for victims of a disaster in their town, city, county, or state. We have seen that such disasters can strike anywhere and at any time, so the practical warning all of us has received has been the knowledge of previous disaster events that required physicians to mobilize, triage, organize, and manage casualties of a nature that is not a regular occurrence in our practices.
Do we really have a fiduciary responsibility to respond to disaster relief efforts, even when our own health and well-being may be jeopardized? The American Medical Association (AMA) Code of Medical Ethics addresses this responsibility directly in Opinion 9.067, Physician Obligation in Disaster Preparedness and Response2:
Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life…. Moreover, individual physicians should take appropriate advance measures to ensure their ability to provide medical services at the time of disasters, including the acquisition and maintenance of relevant knowledge.
This obligation of physicians is clearly tied to our commitment to place the patient’s welfare above all, and reflects the physician virtues of trust, compassion, fortitude, and integrity. When professional duty to our patients has become part and parcel of our own personal character, then there will remain no doubt as to our actions when a call to respond to disaster is placed.
The AMA Council on Ethical and Judicial Affairs has further characterized our responsibilities in times of dire circumstances concerning disasters and other medical catastrophes in the following statement3:
Preparedness for the threat of epidemics, disasters, or terrorism requires physicians to express a renewed commitment to the ethical foundation of the practice of medicine. Indeed, when the health of large populations is threatened, society should expect that the medical profession will be prepared to provide medical care in a cohesive and comprehensive manner. To accompany this goal, the obligation to provide care must reside not only with individual physicians, but with the profession as a whole.
In light of this perspective, we must accept the requirement to prepare ourselves properly, in the event that we will be called forth to take responsibility for the care of victims or casualties of disastrous events. It is also likely that the better prepared we are medically, the more likely we are to step forward willingly to participate.
In a 2003 article, Alexander and Wynia evaluated, through a random survey of practicing physicians, their sense of preparedness and willingness to respond to a bioterrorism event. They found that although 80% of respondent physicians indicated their willingness to continue to care for patients in the event of an outbreak of an unknown but potentially deadly illness, only 21% believed that they were sufficiently prepared to play a role in handling a bioterrorism event.4 Wynia was a colleague of mine as a Project HOPE volunteer on the US Navy hospital ship Mercy during humanitarian relief efforts following the tsunami disaster in Banda Aceh, Indonesia. This landmark study alerted me to the previous paucity of formal training for physicians and other healthcare providers in disaster medical management that is now being addressed. The National Disaster Life Support Foundation developed, in conjunction with the AMA Center for Public Health Preparedness and Disaster Response, the National Disaster Life Support Program, which provides training courses in disaster life support around the United States—Core Disaster Life Support Course, Basic Disaster Life Support Course, and the Advanced Disaster Life Support Course.5 I encourage physicians and other healthcare providers who are interested in excellent, focused preparation for a possible disaster response to consider these courses.
Following the natural disaster of Hurricane Katrina, I commented on the ethical issues that needed to be addressed in physician education, which had not previously been a part of our medical training6:
It is necessary to develop a national consensus on the ethical guidelines for physicians who care for patients, victims, and casualties of disasters, and to formulate a virtue-based, yet practical, ethical approach to medical care under such extreme conditions. Important issues for resolution include inpatient and casualty triage and prioritization, medical liability, altered standards of care, justice and equity, informed consent and patient autonomy, expanding scope of practice in disaster medicine, and the moral and ethical responsibilities of physicians to care for disaster victims.
Although considerable progress has been made in defining the ethical guidelines and boundaries for medical care in disaster relief, pandemics, and bioterrorism events, education has not been widespread nor has it been incorporated into medical school curricula and residency program training where it must serve as a foundation for future preparedness. We are hopeful that this special issue of the Southern Medical Journal will stimulate clinicians to acquire additional learning and preparation in the event that they would need to respond to a disaster. Finally, as is the case with all modern warfare, clinical lessons learned from combat casualty care in Iraq and Afghanistan during the past decade are making their way into private practice and academic medicine, better preparing community physicians to contribute meaningfully to casualty care in the event of a disaster in their vicinity.
1. Timboe HL, Holt GR. Project HOPE volunteers and the Navy hospital ship Mercy. Mil Med 2006; 17: 34–36.
3. Morin K, Higginson D, Goldrich M. Physicians’ obligation in disaster preparedness and response. American Medical Association Council on Ethical and Judicial Affairs. Camb Q Healthc Ethics 2006; 15: 421.
4. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood) 2003; 22: 189–197.
6. Holt GR. Making difficult ethical decisions in patient care during national disasters and other mass casualty events. Otolaryngol Head Neck Surg 2008; 139: 185.