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Applying Altered but Ethical Standards of Care. David A. Fleming, M.D., MA, FACP Professor of Clinical Medicine Director, MU Center for Health Ethics University of Missouri School of Medicine 573-882-2738 Objectives.

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Applying altered but ethical standards of care

Applying Altered but Ethical Standards of Care

David A. Fleming, M.D., MA, FACP

Professor of Clinical Medicine

Director, MU Center for Health Ethics

University of Missouri School of Medicine



  • Understand the ethical complexities of emerging threats requiring emergent responses with limited resources

  • Recognize that altered standards are still evidence based standards deployed in nontraditional ways and places

  • Ethical guidance in establishing standards when all cannot be saved

Emerging threats
Emerging Threats

  • Pandemic: H5N1 (“bird flu”), VRSA, SARS

    • CDC estimates that the next influenza pandemic will result in 89,000 to 207,000 lost lives and $71.3 Bil. to $166.4 Bil. economic loss.

  • Terrorist attack: anthrax, radiation, bombing

  • Natural: hurricane, earthquake, flood

Potential problem
Potential Problem

  • Many epidemic and bioterrorist agent illnesses will overwhelm current health care resources.

  • Current ethics-based criteria for allocation of resources will not apply in situations of mass casualty.

    • Duty to Respond and Treat

    • Allocation of scarce healthcare resources

Six critical challenges in pandemic planning
Six Critical Challenges in Pandemic Planning

  • The concept of preparedness is not clearly defined.

  • Some preparedness efforts can’t be resolved by individual hospitals.

  • Demand for healthcare will exceed capacity.

  • Staffing will be inadequate.

  • Funding is inadequate.

  • Hospital solvency may be threatened.

Center on Biosecurity, University of Pittsburg Medical Center

Influenza pandemic
Influenza Pandemic

  • 90 Mil sick (~1/3 of population 303,824,640)

  • 10 Mil hospitalized

  • 1.5 Mil requiring ICU

  • 1.9 Mil deaths

USDHHS. HHS Pandemic Influenza Plan. 2005

Ventilators needed
Ventilators Needed

  • 105,000 ventilators available in U.S.

    • during a regular flu season, 100,000 are in use (McNeil, 2006)

  • National Preparedness Plan indicates a potential need for 742,500 ventilators in a worst case scenario pandemic.

  • $3.8 billion authorized for flu preparedness by Congress

    • But to buy enough ventilators for a flu outbreak similar to that of 1918 it is estimated that

      $18 billion will be required.

Missouri pandemic estimates 2007 hospital industry data institute cdc
Missouri Pandemic Estimates 2007Hospital Industry Data Institute, CDC

  • If 35% attack rate (population 5.6 Mil)

  • >27,000 admissions

  • >5,500 deaths (500-800 a week)

  • Non ICU beds available (staffed) 21,890

  • ICU beds available (staffed) 1,629

    • capacity exceeded by week 4

  • Ventilators available 386 (20% of 1,931)

    • capacity will be exceeded by week 2 and last over 8 weeks

Choosing an ethics framework
Choosing an ethics framework

  • Traditional focus on “respect for patient autonomy” is ineffective for resource poor environments

  • A Utilitarian or “distributive justice” model is more effective for scarce resource allocation.

Ethical complexities
Ethical Complexities

  • Challenges of professional obligation

    • Selectively not treating those who otherwise might be saved

      • Meeting “altered” standards of care

    • Moral discomfort … conscientious objection

    • Work force integrity

      • Physical and emotional exhaustion

      • Personal risk

    • Alternative providers

    • Alternative sites of care

    • Organizational integrity … loss of resources

  • Public trust

    • Many will not have access who once did

    • Unexpected questions of Futility

    • Questions of fairness, bias, and disparity

    • Questions of transparency, consistency, accountability

Ethical options considered
Ethical Options Considered

  • Utilitarian (White)

    • Maximize lives saved

    • Maximize “life years” saved

    • Opportunity to life through all “life stages”

    • Elderly and those with functional impairment denied access

  • Values, virtues and duties (Tuohey)

  • Solidarity and duty (Brody)

  • Community (Berlinger)

Who should receive life support white et al ann int med 2009 150 132 138
Who Should Receive Life Support?White et al. Ann Int Med 2009;150:132-138

  • Utilitarian perspective

  • Based on prognosis for survival to discharge

  • Life, life years, life stages

  • Social value

  • Instrumental value (“multiplier effect”)

  • Public engagement

Applying altered but ethical standards of care

A Matrix for Ethical Decision Making in a Pandemic

John Tuohey, Ph.D., St. Vincent Med. Ctr. Portland OR

Ethical considerations
Ethical Considerations

  • Contextual realities—communities rather than only hospitals and clinics

  • Solidarity within the profession

    • Duty to treat even if at risk

    • Same professional standards but in a different context

  • Solidarity within and between institutions

  • Solidarity between providers and community

  • Social solidarity

  • Shared duty

Importance of the context of the response
Importance of the Context of the Response

  • For Hospitals  resource centered

    • ”altered standards protocols”

    • unquestioned authority and objectivity

  • For first responders  person centered

    • Viability (futility)

    • Compassion and comfort (beneficence)

    • Parity (Justice)

    • Room for variability (regional, personal)

    • Alternative sites available

Maintaining integrity
Maintaining Integrity

  • Mission-goals-ideals

  • Hospital—objective criteria for resource allocation

  • Community—person centered criteria

  • Professional—adapting competencies, standards, and practices to contextual changes


  • Do what is clinically indicated

  • Proportionate consideration of…

    • Medical effectiveness (prognosis)

    • Benefits/Burdens

  • Room for personal preference

  • Limits of autonomy (right to demand and refuse treatment)

Guiding principles obligations in a social context
Guiding Principles(obligations in a social context)

  • Consistency

  • Accountability

  • Transparency

  • Honesty

  • Reliability (safety)

  • Fairness

Guiding values personal context
Guiding Values(personal context)

  • Medical Effectiveness

  • Benefit/Burden (Quality of Life)

  • Urgency

  • Safety

  • Preferences

  • Compassion


Healthcare resources are allocated fairly with a special concern for the most vulnerable

With limited resources:

  • The fair distribution of scarce resources in an emergency is governed not by what is best for the individual, but rather “the greater good of the community.”

  • Decisions will be made that result in certain people getting some resources while others do not.

  • Not every need will be fulfilled in a disaster.


All, by nature, are worthy of esteem and respect.

All must know they will be cared for and treated with dignity.

With limited resources:

  • some persons will receive treatment

  • some will receive limited treatment

  • some will receive palliative treatment

Missouri altered standards committee
Missouri Altered Standards Committee

  • MO DHSS (Nancie McAnaugh)

  • Ventilator Protocol

  • Pediatric subcommittee

  • Regional triage team for rural systems

  • Prehospital triage protocol

  • EMS engagement (first responders)

  • Just-in-time “grief training” for managers and supervisors

  • Dialogue with trial attorneys association

  • Public feedback mechanism


  • MU CHE and MO DHSS

  • Consortium of 4-5 ethics centers

  • Ethical guidelines of palliative care triage for Missouri

  • Statewide network of ethical committees

  • Availability of ethics consults and support