Most healthcare providers are inexperienced in caring for people in disasters. However, in a national disaster that hinders mobility both into and out of an affected area, available skilled personnel are limited. A disaster response asks more of the scarce manpower: Providers must work longer hours and extend their customary scope of expertise to aid the largest number of victims. While these mandates are designed to maximize the care provided, the emotional and physical burdens on providers and victims in these circumstances are significant, and it is important that we remember the fundamental duty to prevent unnecessary harm in the provision of healthcare.
Should healthcare providers be held to different standards in times of disaster? If so, what are acceptable limits to disaster care, and what ethical dilemmas result during such exceptional times?
Unique Circumstances Call for Unique Standards of Care
Standards in a variety of areas differ in the face of a large-scale disaster, but the fact that standards must change to accommodate the circumstances does not mean that they cease to exist entirely. In the event of a large-scale disaster where populations become isolated and no new resources will arrive in the immediate future, the risks of inaction are magnified and we accept a higher risk resulting from relief action. When only one doctor is available, that doctor is obligated to provide whatever care he or she can to whoever is in need.
When the alternative is that no help will be given, any able doctor should provide whatever help they can. However, there are limits to this responsibility. Greater risks may be justified, and standards may be different, but physicians’ fundamental duties to patients are unchanged and avoidable mistakes causing injuries still need to be prevented. The basic duties of beneficence and non-malfeasance must still guide physician behavior, and the reality of the circumstances in disaster response favors pre-emptive determination on the safety limits that physicians should observe in providing disaster assistance.
Disasters inherently influence doctors to both continue to provide care when they are impaired by sleep or grief and to provide care that under other circumstances they would consider their experience inadequate to undertake. These are realities of disaster response, and all skilled personnel can and should exceed the limits that normally exist in a fully functional system with adequate resources. However, at some point a doctor becomes too impaired or too inexperienced to provide care to patients—even if no one else is available. Doctors are neither trained nor encouraged to weigh the global risks and benefits in this manner; in fact, we are trained to push ourselves beyond our reasonable limits even when absolute scarcity of resources isn’t an issue. People are quite willing to compromise their own comfort and safety in the event of a disaster, but there comes a point at which they may do more harm than good.
There is extensive evidence that sleep deprivation impairs judgment and performance in the medical setting.1-2 Despite the fact that standards change in emergencies and greater risk must be undertaken by both providers and victims, there must still be safety limits. At some point a doctor becomes so sleep deprived that he or she is more dangerous providing care than leaving people entirely without a provider, and further may have impaired judgment on the severity of the various conditions they are facing and the reasonable limits on their expertise. This problem is inherent to the setting. How much risk should doctors subject patients to? In the face of a life-threatening condition should a completely inexperienced physician undertake care? What if the doctor is mistaken as to the severity of the illness or the proper response to it?