Study design

Considering the necessities of the aims described above, a qualitative approach based on the Grounded Theory methodology was chosen chiefly to capture the contextual details. The study was carried out in Turkey, a country which lies between Europe and Asia with a population of 78 million. Turkey is frequently hit by almost all types of natural, technological and complex disasters. Since the Marmara earthquake in 1999, which was a major disaster in its history killing 18,000 people, 157 disasters have occurred in Turkey affecting 2.5 million people [11]. Turkey has often faced massive waves of refugees, especially in the last three decades; more than 300,000 people from Bulgaria in 1989, thousands of people from Iraq during the Gulf War in 1991, 2,500,000 Syrians and over 250,000 from other nationalities who have come to Turkey as refugees since 2011 [12–14].

The method of measurement used in this qualitative study was in-depth interviews using a semi-structured form consisting of three main topics: a) participants' experience in disasters, b) training related to disasters and c) ethical problems encountered during disasters. Interviews were carried out by the first two authors, MMC and KV, in six cities of Turkey; Istanbul, Ankara, Izmir, Bursa, Adana, and Antakya. The first five are the largest cities and have also been exposed to major disasters and have most of the experienced relief workers working in various institutions. Antakya was chosen because it is one of the cities most affected by the migration crisis and war in Syria, and its hospitals have had to face the heavy burden of treating wounded members of armed groups.

A purposeful sampling based on a maximum variation method was chosen in order to reach HCWs with diverse professional backgrounds and experienced in various types of disasters. Another criterion for determining the number of participants was saturation of information. Considering these criteria, 33 HCWs were determined by a snowball sampling technique starting from the disaster response team members of the Turkish Medical Association and Ministry of Health, two of whom declined to participate to the study considering the political dimension of the questions. Therefore 31 HCWs were interviewed between March-May 2014, including physicians whose specialties were general practice, public health, pediatrics, pediatric surgery, cardiovascular surgery, general surgery, psychiatry, anesthesiology and reanimation and medical education. Also a nurse, a psychologist and two medical students were interviewed.

Disasters settings that the participants involved as HCWs were;

• Earthquakes (Erzurum-1983, Adana-1998, Marmara-1999, Düzce-1999, Afyon-2002, Bingöl-2003, Simav-2011, Van-2011)
• Floods (Izmir-1995, Bartın-1998, Istanbul-2010)
• Avalanche (Erzurum-1985, Siirt-1992)
• Chemical explosions (Izmir-1995)
• Mine accident (Soma–2014)
• Explosions (Kırıkkale-1997, Reyhanlı-2013)
• Armed conflict (Antakya- since 2011)
• Refugee camp (Kırklareli-1999)
• Outbreak (Crimean–Congo hemorrhagic fever–2011)
• Mass protests (All over Turkey, esp. Istanbul, Ankara and Izmir, 2013)
• International (Pakistan earthquake-2006, Somali-2011, Sudan-2012)

Working in a mass protest as a HCW is a unique experience, since a) politics is a dominant element in their nature, b) HCWs are targeted directly when they help protesters, and c) in some cases HCWs have not been there as a professional in the first place but as a protester; but after the attack of tear gas, plastic bullets and water-cannons they must suddenly change their societal role and act as professionals. Therefore being a HCW in a mass protest and the ethical problems related to that setting deserve to be explored in a separate study, possibly by using a phenomenological methodology. For that reason, 13 interviews with HCWs involved in the Gezi protests in June/July 2013 were extracted to be presented in a subsequent article.

The duration of healthcare provision during and after disasters was up to four years (3 days to 4 years). The type of services provided were management of services, rapid health assessment, monitoring of post-acute phase, evaluation of the activities of the Red Crescent Society, search and rescue, distributing relief, establishing camps, environmental health, preventive care, curative care, psychological counseling, and training HCWs and the public.

The mean age of participants was 44.7 (24–64); mean experience in practice 20.7 years (up to 40 years), employed in institutions of schools of medicine, state hospitals, private hospitals, the National Medical Rescue Team, '112' ambulance services, and the municipality.

Data collection and analysis

An initial semi-structured form developed by the researchers on the basis of literature and one pilot interview was carried out with the participation of a physician experienced as a disaster relief worker. Considering the delicate nature of the study topic, potential participants were first informed verbally regarding the aim and methods of the study and were allowed to ask questions before deciding whether to participate. They were also informed that the interview would be recorded but their identity and the institutions would be kept strictly confidential; that they could leave questions un-replied and quit the interview if they wish without giving a rationale. After that step, they were given a consent form explaining the aim and methods of the study along with the responsibilities of the researchers including confidentiality, and were allowed enough time to read it and ask questions again if there was any. Finally they were asked to sign the form if they decide to participate. We applied these steps to inform participants thoroughly and build a relationship based on trust, since we assumed that potential participants might refrain to reply some questions due to political nature of disasters.

All interviews were done individually by the researchers in the participants’ office for convenience; tape-recorded; and contemporaneous notes were taken when it was necessary. Three interviews were done by an internet-meeting program. Soon after the interviews, verbatim transcript were obtained and analyzed by the researchers, and used in the report after verification or correction of interviewees. The interviews lasted between 26 to 95 min.

Data collection and data analysis were done in an interrelated manner. Analysis of data was carried out concurrently with ongoing interviews in order to incorporate new insights into future interviews. Constant comparison of data was done and as the study proceeded, new questions relating to emerging themes were considered, and the interview form revised, i.e. the form was adapted to the type of disasters.

With the participants’ permission, the interviews were recorded and verbatim transcription done by a professional company. For thematic analysis, all transcripts were read and coded separately by all investigators. After initial reading, codes were classified as categories by comparing them across code lists. Codes were explored to see whether they were interrelated, and to reveal categories and concepts related to the ethical problems in disasters. Violations of rights and professional duties along with any ethical dilemmas were defined as ‘ethical problems’. Taking the ‘ethical problems’ as the core category, a selective coding process was carried out in order to consolidate the common themes and to depict an explanatory model showing the connection of the problems to their determinants related to disaster context. The Research Ethics Board of Uludag University School of Medicine approved the study (Jan 15, 2013–1/12), including the pilot interview.

Limitations

One of the limitations of this study derived from the wide range of disasters that it aimed to cover. Different type of disasters can pose different value problems in diverse environments. In that sense, the coverage of this study might be questionable. For example, researchers failed to contact or persuade physicians working in Antakya, where the wounded fighters are brought for treatment from conflict zones in Syria; only two physicians accepted to participate. Another limitation was related to the defensive approach that members of the National Medical Rescue Team usually had; they were reluctant to take a critical position possibly due to being employees of Ministry of Health. On the other hand participants who were members of the disaster response teams of the Turkish Medical Association (TMA), which is dissenting of actual health policies as the main professional organization of physicians in the country, were eager to participate and might have been overly critical.

Problems related to context

The participants mentioned various contextual or macro level problems. Those were related to public authorities’ paternalistic and defensive attitudes, media mindsets, relief organizations’ approaches, and insufficient guidelines and regulations which were defined as the traits of the context in which HCWs work.

Problems in patient-HCW relationship

The participants have told us that they encountered ethical problems related to patient-HCW relationships, or micro level issues, such as professional incompetence, difficulties of determining the limits of duty to care, obtaining informed consent, and violations of confidentiality and privacy.

On a micro-level

With regards to the patient-HCW relationship level, or ‘micro-level’, a lack of medical education specific to disasters emerges as one of the most important sources of problems. The participants were partly aware of this unmet need for education. This is particularly true for triage, possibly due to limited/non-present knowledge or practice in it, despite the fact that triage is one of the most prominent topics in disaster bioethics. Similarly, in a study carried out with 205 physicians in Turkey, only 36.3% of participants stated that they had applied triage principles [15]. In fact, lack of specific education on disaster medicine is a widespread problem all over the world [16–18]. Today everyone is aware of the increasing risk of major accidents and disasters, and the importance of active preparation–including training; however, nobody invests in it [19]. Not having the appropriate knowledge and skills causes preventable deaths and injuries, therefore it is possible to claim that training HCWs on disaster medicine is a must.

• Is providing specific training of disaster medicine to HCWs to be sent to disaster settings a moral duty?
• If so, who are the parties that are responsible for this duty?
• If so, is sending uneducated HCWs to disaster settings immoral?
• When triaging patients, is favoritism towards younger victims morally justifiable in some cases? Or is it age-discrimination regardless of conditions?
• Should ‘easing personal consciousness’ be a justification for futile treatment?

Ironic as it might seem, while the participants state that lack of education is an important problem because it might cause preventable harm, a majority of them tell us that they should not be held liable for malpractice. Their argument is based on four premises; that they are the “best shot” of the patient; resources are very limited; they might not be properly educated for that specific and urgent intervention; and they are helping with good intention. As a matter of fact, this is still a controversial issue in medical ethics and law disciplines [20–22]. Analyzing all of these arguments, including the opposing ones claiming that HCWs should be liable to a certain degree, might contribute to the current debate.

• Should a HCW be held legally liable for any harm caused by emergency treatment in disaster settings, when;
  1. ∘ the available resources are not appropriate for the necessary intervention,
  2. ∘ the HCW is not properly trained for that intervention, while he/she is the only one available to perform the intervention.
  3. ∘ the intention of the HCW is purely altruistic.
• If there should be a line to hold HCW liable, then how and where should be that line to be drawn? Should the difference between ‘first aid’ and ‘emergency treatment’ be a measure?
• How should we determine the liability due to healthcare-related harm? (i.e., because of the lack of triage system)

Contrary to their opinion on medical competence, the participants believe that lack of education on medical ethics is not an issue creating significant harm. They usually shift to a utilitarian approach regardless of their prior understanding of what constitutes ‘good’, asserting that saving a maximum number of lives possible has priority over all other concerns. Based on this approach, they believe that they should not be forced to lose precious time by intervening with binding ethical codes, rules or principles. This is also true for their mindset about the duty to obtain informed consent, which seems like one of the least important amongst professional obligations, especially if the situation requires urgent intervention. A study exploring the question of whether the autonomy principle is taken into account or not found a similar rate (4.4%) [15]. Participants think that they should not be obliged to obtain consent for up to five days in the aftermath of a disaster, because ‘beneficence’ is above ‘autonomy’ in those circumstances. This approach is worth further detailed evaluation, even though it might seem obvious, since a) it ignores ‘autonomy’ for the sake of public good which might be linked to some kind of a survival instinct, while claiming that it is the most beneficent thing to do for that particular person as well, b) this approach may be called communitarian, which asserts that the good of the individual is inseparably linked to the good of the community, rather than utilitarian, and c) if communitarianism should be the prevailing approach in disaster medicine instead of utilitarianism, then its reflections and effects should be explored both theoretically and practically. Furthermore, the majority think that the professional values and decision-making capacity they had already acquired in daily practice should be enough for extraordinary situations as well, along with having a “good intention” as a “helper”. Similar to their opinion on malpractice liability, as long as their intention is altruistic, then there is no way for doing ‘evil’, therefore they should be able to do whatever they think benevolent for the victim. This approach seems eclectic because it adopts a Kantian approach by defining ‘good’ with a categorical imperative of having a good will, while it overrides autonomy, which is also based on the Kantian approach in a paternalistic way. Another argument for overriding the victim’s autonomy is based on the presumption that disaster victims lose their decision-making capacity temporarily because of the shock they have experienced. Although it might be true for the majority, whether it is true for every single individual is a question to be explored scientifically. In summary, considering that the special circumstances of disaster settings augment the unequal nature of the relationship between the caregiver who has the specific resources and the patient who needs those resources more than ever, the duty to obtain informed consent is one of the topics that should be investigated thoroughly.

• Does helping / having good intentions, or coming from outside as a “helper” provide a positional superiority for moral aspects?
• Should a paternalistic approach be adopted in certain conditions? Is there a need for a more flexible approach to informed consent during the initial days after a disaster?
• Is there a consensus for using a utilitarian approach in public health emergencies?
• Should communitarianism be adopted instead of utilitarianism while working in disaster settings? What kind of professional duties would it impose different from utilitarianism?

Determining the limits of duty to care in outbreaks, armed conflicts and emergencies might create profound tension between a patient’s best interest and personal concerns/values. Recent cases of some HCWs who refused to treat Ebola patients, went on strike and left the country, and Iraqi physicians who refused to treat ISIS militants and were killed for that reason have brought questions regarding the duty to care into the agenda [23–25]. Some argue that physicians should not “pick” their patients. As William Boghurst (who did not flee when the Great Plague struck London in the 17th century) wrote, “Every man that undertakes to be of a profession or takes on himself an office must take all parts of it, the good and the evil, the pleasure and the pain, the profit and the inconveniences all together and not pick and choose; for Ministers must preach, Captains must fight and Physicians attend upon the sick” [26]. However, there are no clear guidelines on how to act in such dramatic circumstances, and there is an urgent need of a wide consensus on this unsettled issue, guiding HCWs on the line between duty and heroism, right to refuse to care—if there is any, and how those patients should be served. As another dimension of the issue, political pressure on HCWs’ professional autonomy should be taken into account.

• Under which conditions do the grounds of duty to care become controversial? Could we define a limit? Based on which criteria?
  1. ∘ Which attributes should a communicable disease be included or excluded? (Availability of efficient prevention methods and/or treatment methods, morbidity and mortality rates, social stigma…)
  2. ∘ What if there is violence towards HCWs?
  3. ∘ What if there is an immediate threat to HCWs?
  4. ∘ When do personal values conflict with professional values?
• How can the right to health be protected under those circumstances? Who should care for diseases outside the scope of duty to care?
• When their professional autonomy is violated by political pressure, how should HCWs determine the limits of duty to protect professional autonomy?

Breaches of confidentiality and privacy seem like another neglected problem. The nature of disaster conditions might prevent HCWs caring about the necessary conditions for respecting confidentiality and privacy. It should always be kept in mind however that disaster conditions are not limited to urgent treatment; they also cover provision of healthcare in temporary settlements like camps or field hospitals. Keeping patient information safe and respecting personal rights should be dealt with as an issue to be managed carefully, so that there should be regulations for even the usage of social media. Ethics teaching should aim to contribute to the ethical sensitivity of HCWs regarding this issue. Providing professional and educated interpreters is another requirement for a service respectful to patient rights.

• Who are the responsible parties to keep patient data safe and secure? Who should be able to access to which kind of data and when?
• What are the responsibilities of humanitarian organizations and authorities regarding data sharing?
• How should the data be handled after the relief operation is over in the field?
• What are the conditions under which we can breach confidentiality in disaster settings? Are they different than normal healthcare provision?

Problems on macro level

As well as the problems on the micro level, the participants mention factors on the macro level that surround the patient-HCW relationship: public authorities’ and politicians’ attitudes, mismanagement of services, problems related to relief, relief organizations, guidelines, and media. In fact, this is the central theme of the participants’ narratives, when asked to relate the ethical challenges they face in disaster settings.

Disaster conditions inevitably create gaps in the hegemonic area of the power of authorities, who attempt to restore command immediately and decisively. Therefore public authorities take a ‘paternalistic’ position, claiming everything is under their control as if omnipotent. This can seem partly justifiable in order to prevent unfounded panic among the public, but because of unwillingness for cooperation and criticism, opportunities to improve services are missed, and at least some of the problems are ignored. Along with a defensive attitude which can lead the authorities to hide information, their approach might jeopardize public health and decrease their own credibility which contributes to any actual chaos. As much as possible, transparency and accountability seem like vital conditions for community participation and mitigation. Also, politicians might abuse their power for the sake of their own political or individual agendas. Although this seems unpreventable to a degree, violations on basic rights such as discrimination and pressures on HCWs such as threatening cannot be justified in any case.

More than 90% of disasters occur in developing and underdeveloped countries, where inequities are profound and resources are already limited or simply nonexistent [27, 28]. As O’Mathuna put it, “Addressing such inequalities in disaster risk reduction is an ethical issue. Disaster preparedness must therefore go deeper than preparing to rescue people after the disaster strikes. It must go to the core of why such social inequalities exist and are permitted to continue” [29]. Therefore, in addition to those negative factors mentioned above, people who hold authority and power in their hands for the public good have positive responsibilities as well, such as providing proper housing, decreasing inequality, and implementing policies for preparedness to prevent harm as much as possible, both before and after disasters.

• Under which conditions and to what degree is it justifiable, if ever, for public authorities to:
  1. ∘ act as if everything is under their control, so they don’t need any help from outside, and
  2. ∘ hide information from the public?
• Which duties do HCWs have to protect public health? Do they have a duty to inform society?
• What should HCWs do if they are requested to hide information related to public health?
• For the harm related disasters, what are the ethical responsibilities of people with authority and power to make policies and decisions? How can it be measured?

Not being prepared for providing healthcare services when a disaster strike leads to mismanagement of relief activities. Hunt showed that organizational forms and structures in disasters shape everyday moral experience [30]. Sending HCWs and relief without doing a rapid health assessment or considering actual needs, along with the lack of disaster-specific organization of services linked to the misallocation of resources and therefore diminished access to care, and HCWs become a part of the chaos. Secondly, HCWs should be trained properly as mentioned before, and be sent contingent upon need-based planning. Otherwise the attitude arises that they have wasted already-limited resources without any meaningful contribution, and their psychological mood can finally become one of anger and exhaustion. Also, an HCW’s willingness while performing their task in a disaster zone is another point to be considered carefully. In a study, healthcare workers’ willingness to work during a disaster is found to vary with the type of event, ranging from a high of 84% during a mass casualty incident to a low of 48% during a SARS outbreak [31]. On the other hand, motivations behind volunteering in rescue or relief activities might not always be justifiable. They may be personal, such as a ‘life of adventure’, universal and ethical, such as ‘desire to participate in meaningful change’ or ‘promotion of human rights’, or religious or accidental [32]. The ‘heroism’ instinct could be another factor. For those in search of adventure or worse disaster tourism, it provides ‘adrenalin of war without being at war’ [32].

In sum, the finding of this study suggests that relief healthcare service should be prepared beforehand in all its dimensions in order to serve effectively and justly in disasters.

• Should HCWs be assigned if they did not volunteer? Under which conditions?
• What underlying motivations for voluntarism can be justified?
• How should a service be organized to be sensitive to the needs of vulnerable populations?
• Should HCWs be allowed to work in acute phases if personally affected by that disaster?

Sufficiency of guidance for decision-making when facing an ethical problem was another issue indicated by the participants. There are several guidelines specific to disaster settings such as World Medical Association Statement on Medical Ethics in the Event of Disasters, the Code of Conduct for the International Red Cross and Red Crescent Movement (ICRC), the Sphere Project’s Humanitarian Charter and Minimum Standards in Humanitarian Response, MSF’s Charter and Principles, or Ethical Principles on Disaster Risk Reduction and People's Resilience of Council of Europe [33–37]. However, it is argued that guidelines are “not known, not universal, not applicable in early response phase, providing conflicting moral injunctions, and not decreasing moral stress” [38]. There is also a need for a consensus on a virtue-based, yet practical ethical approach to medical care under such extreme conditions, as Holt suggested [39]. There are some suggestions in the literature formulated for decision-making [40–42]. In addition, Lepora suggests usage of checklists for HCWs as a practical tool for “what to do when, what to discuss, what not to do” [43]. Yet their effectiveness is to be researched [10].

Another common problem with the guidelines is that they usually focus on micro-level resource allocation problems. As the participants of this study suggest, the guidelines should be improved in a way to cover all issues other than clinical ones, including the responsibilities of different parties. A group of experts who had explored the Code of Conduct of ICRC recommended a similar approach to improve it, for instance [44]:

• Updated definition of disaster
• The code should strongly promote disaster risk reduction, capacity building, participation of local communities, and respect for local culture
• Gender issues need central prominence
• The code should mention the importance of humanitarian needs assessment
• More emphasis is needed on vulnerable and marginalized groups in different cultural settings
• Disaster relief in conflicts needs elaboration
• Prevention and reduction of risk need to be addressed
• Ethical issues for research in disaster settings and with humanitarian aid need to be addressed
• The code promotes accountability to donors and recipients but needs more guidance to deal with unethical practices such as discrimination, favoritism or corruption, and various conflicts of interest
• Issues related to liability of aid providers and responders need to be included.
• Importance of cooperation with local governments is highlighted but local organizations should also be mentioned

On the other hand, it is a fact that written codes and regulations cannot cover every aspects of life nor are they as dynamic as life. If the guidelines and alike could provide enough guidance in all circumstances, then there would be no ethical dilemmas. They cannot be valid in every circumstance every time; there will always be a critique of insufficiency. Therefore a) “a code of ethics should serve only as a guide for ethical reasoning” [45], and b) virtue-based training on implementing guidelines and finding/creating the right action to protect the right to health and professional values is important.

The ineffectiveness of humanitarian relief is another topic as a source of ethical problems revealed with this study that leads to unjust resource allocation and diminished access to care. Sending unsorted relief instantly without basing distribution on needs assessment wastes time and effort and causes environmental pollution. The reasons behind sending relief without thinking might be various, from altruism to “easing one’s conscience”; the line between them might not be clear as well. Many of the observable facts about giving/donating could not be explained by pure altruism [46]. It could be “herding behavior” [47], or giving charity or sending relief during humanitarian crises can serve as a conscience pacifier at a micro level; “I have done my bit for mankind so I don’t need to bother with structural inequalities” [32]. In any case, over the years this has been a prevailing, well-known problem. “Humanitarian assistance must be needs-driven, not resource-driven,” as it was put in the training material of the UNDP [48]. Distributing relief might be even more important, since its mismanagement can cause the humiliation of victims, black-markets, and a bias in favor of healthy and powerful persons instead of more needy. “In all disaster situations, people who are more powerful before the disaster will be able to use relief aid to increase their power relative to those who were weak” [48]. Pressure from politicians for distributing relief to their voters is a clear case of discrimination, and violation of the right to health.

• Does altruism include a sort of egotism and self-interest? If so, does it make a difference in practice regarding relief and aid activities in general?
• Do HCWs have any responsibility in the just distribution of relief? If so, what are the limits? (Assessment of needs, informing authorities about these needs, etc)
• Are healthcare and HCWs just ‘instruments’ or a ‘relief item’ to be used by governmental authorities as they see fit? How is the medical profession different from a blanket or a tent regarding fulfillment of function?
• How should HCWs respond when they are pressed to be a tool of political discrimination?

Non-discrimination is a guiding principle also for relief organizations. According to the Code of Conduct of the ICRC, “Aid is given regardless of race, creed or nationality of the recipients and without adverse distinction of any kind. Aid priorities are calculated on the basis of need alone. Aid will not be used to further a particular political or religious standpoint.” [34] Although humanitarian aid should not be used as an instrument of religious, political or financial motivations, the research participants gave many counter examples in practice, in which relief organizations discriminate according to their own priorities. Lyon defines this phenomenon saying “altruistic interventions are often blurred with self-interested power pursuits” [49]. Likewise, Stehrenberger and Goltermann emphasize that disaster medicine “shifted to foreign operations often in the global south conducted by Western agencies during disasters after 1945 and increasingly after the end of the Cold War.” [50]. They state that it is very important to understand “the historicity of disaster medicine as a political phenomenon and of the discourses denying its political nature”. Thus, the instrumentalization of humanitarian activities, together with the question of whether humanitarian aid itself is an instrument or not seem like significant points for moral deliberation. It is possible to argue that the instrumentalization of relief activities for the organizations’ own agendas devalues the concepts of ‘helping’ and ‘solidarity’, and decreases trust toward relief organizations and other societies. Paternalistic and non-cooperative attitudes of international relief organizations might also be related to this issue. Ironically, their preparedness and competence might be so questionable as to even possibly see examples of quackery.

• What are the responsibilities and duties of humanitarian organizations towards disaster victims, local aid workers, authorities, and other NGOs? Is it possible to develop common standards of conduct? Is it possible to implement them effectively?
• Could instrumentalization of humanitarian aid be justified? Is it realistic to expect relief organizations not to pursue their own agenda? To what extent is it acceptable? Which motives are acceptable?

Another macro-level factor is the mindset of the media, when it prioritizes its own interests over public good. While media has the vital function of informing people and broadcasting the problems in the aftermath of disasters, they might not respect their own ethical codes. They can publish unverified information, exaggerate situations, and violate personhood rights to increase ratings. Therefore HCWs try to stay distant and protect patients from media if the right to be informed properly and timely is being violated and the reliability of any information diminishes. The mainstream media’s relationship with political power is also problematic when it comes to keeping independence and integrity intact. In this study there have even been examples of hostile feelings being spread among people by publishing false accusations toward physicians. It is possible to remind journalists of their responsibilities to the public and ethical codes at this point; but at the same time how naive or realistic it would be is an issue to consider. Also, as social media thrives in the digital age, whether ‘citizen journalism’ could provide a meaningful contribution towards the right to know, and whether it could shake up the status quo of the media seem like questions worth deep thought.

• Which information about disasters should be received from the media? What information is newsworthy?
• How can we define the limits of the ‘right to share the information’ in disaster settings? Which images and information can be used without consent?
• What are the responsibilities of different parties, including HCWs, to protect the dignity of victims from the media?
• What should be done for an independent medium that provides news about facts in the aftermath of a disaster?

An explanatory model

The findings of this study have provided insights on the variety and nature of ethical problems in disaster settings. They can be summarized with an explanatory model including the context, the features of moral agents, and the problems emerging at the level of the patient-HCW relationship (Fig 1).

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Fig 1. An explanatory model for ethical problems in disaster settings*.

* The term “Oceans of need” was quoted by Hunt [3] from M. Michael & A.B. Zwi [51].

https://doi.org/10.1371/journal.pone.0174162.g001

When initially considering ethical problems in disaster settings one might tend to isolate them into issues of life & death during the acute phase. However, our study reveals that ethical problems are not limited to triage level decisions amid tragic scenes, nor to a few days. Disaster conditions generate various ethical challenges on a variety of levels including the macro level which can emerge or persist into the post-acute phase, years in some instance. Secondly, elements on the macro level create ethical problems on a larger scale, including factors such as discrimination, violation of personhood rights and waste of limited resources. And thirdly, it is possible to argue that these factors on the macro level are also a directly cause of, or facilitator of, the emergence of ethical problems on the micro-level. This is especially true when HCWs know what course of action is ethically justifiable, but are unable to act or hesitate because of the factors surrounding the micro-level.

Considering the model, it is possible to infer two conclusions. First, if the factors on the macro level affect the ethical problems on both levels, then intervening in those factors would have a significant effect on problem prevention. Preparedness especially seems as an important factor for avoiding moral tension and violations. Geale expressed this necessity, stating “the most ethical approach would be to spend time and money in mitigation of disasters through prevention of, and planning for those disasters that are unavoidable” [52]. Therefore, it could be argued that policy-makers and healthcare authorities have a moral responsibility in this regard. Improving guidelines and professional codes, and educating HCWs both for medical and ethical competence are also areas with potential for significant improvement. Training on how to manage crisis situations would be helpful for ethically justifiable decision-making and to increase benevolence.

Another point to emphasize is that the nature of ethical problems emerging in disaster settings have a political dimension. The political characteristics and power relationships of the society that disaster strikes play an important role on macro level factors such as public authorities’ attitude, politicians’ interventions and media’s approach. Besides, when a disaster hits, the hierarchic balance and hegemony networks inherent in that society are disturbed, and the interests of different parties conflict. “Politicians seek political support, caregiving institutions want additional resources, and various first-responder agencies will maneuver for authority and leadership” [53]. This is also true for the relationships between HCWs and the other actors of disaster scenes, since HCWs might be in a position to protect the patient’s best interest and professional duties against conflicting demands and pressures. In addition, the discourse and practice of humanitarianism has become increasingly politicized [54]. Recognizing that ethical problems in disaster settings have a political nature inevitably necessitates some professional responsibility of HCWs, such as rights advocacy, creating awareness, and informing authorities and the public about problems. It also requires Bioethics as a discipline to have a holistic view and to consider the relationship between the macro and micro levels in its ethical analysis and normative claims regarding disaster settings. Adopting a biopolitical approach would entail a role of providing guidance to HCWs, which includes not just a definition of an abstract good, but also advocating the right thing to do in the name of right to health and professional duties. Otherwise, mainstream debates of Bioethics will continue to limit the moral deliberations to the clinical setting. It is clear that ignoring the very nature of these ethical problems is contradictory to the principle of benevolence.

Further studies are needed to deepen the understanding of the role of macro factors on both levels. Studies and analysis should take into consideration the pre-disaster conditions, especially social injustice and inequality in order to improve the explanatory model. Besides, we did not focus on the analysis of the cases revealed in this study one by one, in order to consider how guidelines and professional codes are instructive, what options to act are open to HCWs in each specific case, and which option is relatively best and by which justification. These concerns are certainly necessary to be addressed after this descriptive study through further ethics inquiries. In addition, we think that the questions we have defined with this study should be dealt with through Bioethics, both for developing guidelines and education programs, and guiding HCWs in the field for ethically justifiable decision-making.