28. crisis allocation

Disaster allocation

• When disasters overwhelm healthcare systems, not everyone can receive the same level of care.

• If the situation is bad, we might need to ration things we don't usually have to ration and make other very hard choices.

• If the situation is really, really bad, things can get pretty ugly.

The AMA Code of Medical Ethics says

"Because of their commitment to care for the sick and injured, individual physicians have an

obligation to provide urgent medical care during disasters. This obligation holds even in the face of greater than usual risks to physicians' own safety,

health, or life."

Conventional care

Normal standards of care.

Contingency care

Modified practices to stretch resources.

Crisis care

Rationing life-saving resources.

1 oxygen tank and 4 patients

- 15-year-old girl: Severely disabled, treatable

pneumonia

- 40-year-old woman: HIV, likely TB, has 3 children with her

- 25-year-old man: Nurse post-op from bowel surgery, likely pulmonary embolism

- 18-year-old girl: Acute heart failure (treatable); underlying issue not treatable

"When it became apparent that need and

medical effectiveness alone were not sufficient to assign priority to these four patients, I considered

other factors to help me determine for whom the

resource use seemed the most appropriate."

What considerations guided her decision?

• Medical considerations like short-term and long-term survival

What else?

• Parental status

• Role in society

• Likely level of future dependence on others

• Likely future health risk posed to others

• Feelings of empathy or kinship

• Quality of life

She eventually ranks the patients in this order

- 25-year-old man: Nurse post-op from bowel surgery, likely pulmonary embolism

- 40-year-old woman: HIV, likely TB, has 3 children with her

- 18-year-old girl: Acute heart failure (treatable); underlying issue not treatable

- 15-year-old girl: Severely disabled, treatable

pneumonia

"First and foremost, I considered short- and long-

term survivability in determining medical

effectiveness, recognizing the inherent inaccuracies of such predictions.

I then considered the patients' roles in society and disaster recovery, their dependents, and their potential for saving or harming others. I likely also considered our shared life experiences, the empathy a given patient evoked, and their perceived quality of life."

Daniel had to think quickly!

• "My decision was made in less than five minutes."

• In disasters, moral reasoning operates under extreme strain (fear, exhaustion, scarcity, and collapsing systems).

• Even conscientious people will make moral errors, and, given the circumstances, those errors may be morally excusable.

But that doesn't mean anything goes...

• Excusing imperfection is not the same as suspending ethics entirely.

• Some decisions might still cross the line between a decision that was imperfect but understandable to one that is seriously moral wrong.

• The case of Dr. Anna Pou at Memorial Hospital after Hurricane Katrina shows how blurry that line can be.

Memorial Hospital in the wake of Katrina

• Hurricane Katrina left Memorial Medical Center in

New Orleans without power, water, or air-conditioning.

• Temperatures inside exceeded 100 °F; backup generators failed; communication from the outside world was spotty.

• Staff and patients were trapped for days.

• Opportunities to evacuate patients were sporadic and unpredictable.

Dr. Pou's actions at Memorial Hospital

• Patients were sorted into priority groups for evacuation.

• Those expected to survive were evacuated first.

• The sickest and many with Do Not Resuscitate (DNR) orders were left for last.

• Note that DNR does not mean "do not treat".

Day 4

• "Hellish" conditions.

• Most life-support systems had failed; many ventilators and monitors no longer worked.

• Staff were exhausted, operating under extreme stress and heat.

• Some clinicians began giving high doses of morphine or midazolam to keep certain patients "comfortable."

• Bodies began to accumulate.

• Final evacuations of remaining staff and patients took place the next day.

Aftermath of Hurricane Katrina

• 45 bodies were recovered from Memorial

(more than any other hospital in the city).

• 17 patients were found to have

received potentially lethal doses of sedatives.

• Some of these patients were not near death

and would likely have survived if evacuated.

• Dr. Anna Pou and two nurses were arrested, but a grand jury declined to bring criminal charges against them.

Health equity issues

• People with disabilities often face greater risks and barriers during disaster response.

• Some pandemic triage plans have de-prioritized patients based on projected "quality of life."

• Similar inequities have affected other marginalized groups.

• Black and Hispanic patients are frequently assigned lower acuity triage scores than white patients.

• This can lead to longer wait times, less aggressive care, and worse outcomes.

Ethical questions

• Should the DNR patients have been deprioritized for evacuation?

• When does palliative care cross into euthanasia or mercy killing?

• Is euthanasia ever acceptable?

• Are moral errors excusable under extreme circumstances — and if so, how far does that go?