Studies have pointed out that Hurricane Katrina was one of the most deadly storms to ever occur within the US in a period of seven years before it (Pou, 2013). This was because the hurricane left approximately 500,000 people displaced, following their evacuation to safety zones away from their homes. In its aftermath, an area of about 90,000 square meters was declared a disaster zone. Furthermore, the aftermath of this hurricane-more than of any other storm before it- made the numerous ethical dilemmas faced by healthcare providers, usually in case of disaster, more expressed. The proceedings of the whole event that was the storm, further highlighted how the medical community, various government agencies and the overall public were generally ill-prepared to deal with adverse natural catastrophes. It has since been established that, prior to the hurricane, most medical practitioners did not have full proof disaster plans in place, which limited their disaster management capabilities (Danna & Cordray, 2009). It has also been established that, there existed numerous deficiencies within the medical community. Most hospitals were equipped neither with power backup systems nor with evacuation plans for patients delivered to designated drop sites. Only a few hospitals had enough clean running water and were adequately staffed. Studies have further pointed out that, the general public was uneducated on care standards to be maintained during an emergency. Therefore, nurses like all other medical staff working in various hospitals within the Hurricane Katrina disaster zone were faced with a diverse range of ethical dilemmas (Brookings Institution, 2008). This essay will focus on the various ethical dilemmas encountered by Nurses and staff, whose mandate it is to provide medical care even in the aftermath of natural calamities, and will more particularly advocate the prioritization of disaster management capacity-building. This especially necessary in order to ensure the stress on medical resources due to natural disaster is better dealt with.
2. Hurricane Katrina: An Ethical Dilemma
Following the Hurricane Katrina, the medical community had to put in place mechanisms geared at ensuring the limited, available food and water resources were rationed in such a manner that, even though no single patient’s needs got fully-satisfied, no particular patient was left without at least some healthcare (Cable News Network, 2010). Furthermore, should the nurses have given all of the victims of the storm equal care in spite of the diversity of the medical demands they were dealing with? For instance, should the treatment of pregnant women have been given priority over any other patients, so as to protect the right to life of the unborn? The spontaneous development of mechanisms to determine medical cases with respect to their severity, therefore, was an area of many problems. The professional laxity that occasioned the failure to develop proper disaster control and management frameworks in the period before the hurricane, remains an ethical failing on the part of the medical community. It is further clear that, the system although partially flawed, managed to save a considerable number of lives and that there is need to review mainstream palliative care protocols in order to improve medical efficiency. Nurses were for instance, desisted from giving dying patients Ativan or even morphine to avoid litigation.
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3. Contributors to Ethical Dilemma and Moral Distress
3a. Ethical Principles in Conflict
Ethical principles play a critical role with regards to the provision of frameworks for the analysis of ethical dilemma. Any such principles are essential since they facilitate a timely resolution of ethical issues. Application of ethical principles would have been effective in resolving various ethical issues that were encountered by nurses during the Hurricane Katrina. The resolution of the ethical dilemmas in a situation such like this one will be discussed by mean of application of a couple of ethical principles as explained below (Baker, 1997).
The principle of respecting autonomy- This principle states that a person has the right to act and behave in a manner that’s free in relation to their professional convictions and good judgment. This further implies that, humans have the right to make decisions on how to live their lives, independent of pressures from without, but in consideration of the welfare of others. Furthermore, an individual has the right to exercise his or her freedom of choice to the fullest extent possible. This principle incorporates two ethical convictions which should have been applied to the catastrophe at hand-the Hurricane Katrina. First, it would have been important that individual patients be treated as if they were autonomous agents. Most importantly, any one of those individuals whose autonomy the Hurricane appears to have diminished, should have been provided with maximum protection. Respect as a concept, is understood to have two moral provisions, acknowledging autonomy on one hand whilst in equal measure, offering protection to any persons whose autonomy has been greatly compromised by medical incapacitation. With respect to human medicine, respect of autonomy focuses on accommodating divergent medical opinions and choices. Equal respect ought to be accorded to patients in order of their healthcare demands. Individual patients might need varying extents of protection, and this should depend on the level of risks of harm and potential benefit.
Benefiting others (Beneficence) - The principle argues that, any one of the actions we take must significantly promote the overall wellbeing of other members within the larger society. It is important also to secure the overall well-being of society through the application of appropriate medical standards. Two rules are applicable in this principle, first, it is important to minimize possible harm and secondly, to maximize potential benefits, all at the same time. As per the dictates of this rule, therefore, to ration medical supplies in times of emergency, in order that the needs of all patients are somewhat settled, was sound medical practice in this particular case with the storm. Individual doctors should afford all lives equal privileges.
Being just- This principle preoccupies itself with the administration of justice in a manner that’s fair. It requires the performance of a fair balancing act between the rights of an individual with those of other people. By being fair, an individual is required to exercise impartiality, reciprocity, and even equality. A potential injustice will occur when an entitled benefit are denied without a valid reason or in situations where the burden is imposed on an individual unduly. In this case, to prioritize the treatment of affected pregnant women in order to save even the lives of their unborn kids, would have been the appropriate medical action to take.
3b. Personal Factors
Ethical healthcare standards as applied within the nursing community include: promotion of client well-being, respect for client-specific choices, maintenance of doctor-client privacy and confidentiality codes, respect for the right to life and the fair administration of professional medicine. Ethical nursing also comprises acting with utmost integrity, professionalism and with honesty when attending to patients or to colleagues within the healthcare environment. Any qualified nurse must be in a position to identify his or her professional values, beliefs and attitudes before acting on any medical case. It is important that nurses make sure they properly represent the point of views of their clients especially when advocating the prescription of treatment plans. In a situation where nursing ethical values conflict, then an ethical dilemma is bound to exist (Pou, 2013). Usually, this presents medical practitioners such as nurses, with a conflict that has professional as well as moral consequences. Under such circumstances, nurses might experience moral distress especially in the event where they fully understand the prescribed medical action to take, but there exists several realities that somewhat discourage such like scripted action. There is thus the need for the nurses to work through and try to understand various situations critically and to then, take effective actions that will help them resolve potential ethical issues. The most effective way is to involve consulting with the rest of the colleagues and ethics experts (Gray, & Herbert, 2006).
3c. Contextual Factors: Potential Values and Beliefs of Other Stakeholders
Healthcare stakeholders include the families of patients, healthcare professionals, and healthcare facilities. Some of the core stakeholder’s values that could contribute towards ethical dilemma include protection of the hospital image, quality service to their patients, respect, observing the rights of patients, doing good to the society and equality in service delivery. The difficulty in this ethical dilemma emerges from various factors. First, several stakeholders groups might be harmed or even served by a particular decision made. Secondly, the stakeholder groups will believe that they are on the right. In most instances, an ethical dilemma focuses on the aspects of right versus the right decision. Therefore, the various groups involved based on their ethical point of view, they are right. The third factor focuses on the fact that ethical issues are emotional. Groups and individual ethics in most instances are built often constructed from a sum of both social and personal experiences. Therefore, ethical issues tend to evoke emotions while at the same time provoke sacrifice to preserve ethical ideal. Ethical decision-making is challenging and emotional; therefore, there is the need to involve the community or community when addressing ethical issues.
4. Contextual Factors: Regulatory, Policy, and Legal Frameworks
Patient advocacy/rights
Every patient has his or her rights that must be protected and observed. It is important that each patient must understand his or her rights before accessing healthcare for medication. By understanding your right, you can make critical decisions concerning your health and to be listened to. First, every patient has the right to be informed concerning the type of care he or she will receive. Secondly, every patient has the right to information on his or her health, and this must be provided in the patient’s preferred language (Black, 2014). Further, a patient has the right to access information in a manner that is suitable and meets his or her needs taking into consideration the patient’s vision, speech, and even mental impairments. It has also been argued that a patient has the right to either accept or reject care and medication. Respect is paramount, and every patient must be treated with respect and courtesy. A patient can ask questions and pay attention to all the instructions given by his or her caregiver. Further, it is important to note that a patient has the right to access an advocate who can ask questions on behalf of the patient and help when the patient does not get the required medication and care needed. Studies have shown that the patient has the right to informed consent where he or she must understand the choices and risks in treatment provided. The caregivers have the duty to ensure that the patient understands clearly the treatment choices and potential risks that might arise.
American Nurses Association (ANA) Code of Ethics for Nurses (2015)
According to American Nurses Association (2007), American Nurses Association (ANA) Code of Ethics for Nurses was established to act as a guide when undertaking various nursing responsibilities in a way that is considered consistent with ethical obligations and even nursing care revolving around this profession. For a nurse to practice competently and with utmost integrity, there are core elements that must be adopted to guide the profession including education’s accreditation process, effective code of ethics and a certification system. Nurses often encounter various ethical issues particularly in the area of biomedical ethics including dilemmas within organizations, health-related issues affecting the society and those affecting individual patients. Effective nursing ethical code offers guidance on the management of ethical issues that might occur at all levels including, clinical, societal or even at the organizational level. The most common ethical problems are the informed consent and the patient’s autonomy. Other issues include surrogate decision making, the breach of confidentiality issues and even the end of life issues (American Nurses Association, 2007).
Health Insurance Portability and Accountability Act (HIPAA) of 1997
HIPAA was developed to amend the Internal Revenue Code of the year 1986 with the aim of enhancing overall health insurance’s portability and continuity to combat potential waste, health insurance abuse or even fraud. The Act defines specific policies and guidelines essential for privacy and security maintenance while at the same time outline certain offenses that are related to healthcare hence addressing potential ethical issues. Further, it has established programs aimed at controlling abuse and fraud in the overall healthcare system. HIPAA Privacy Rule, on the other hand, monitors the use and the disclosure of specific protected patients’ health information. The protected patient’ health information must be disclosed within a period of 30 days upon the request by an individual or by the law. This focuses on the ethical issues of protection of information and the patients’ right to information. Privacy Rule, therefore, gives an individual a right to request for the correction of inaccurate personal information while at the same time ensures information confidentiality (Louisiana State Board of Nursing, 2010).
5. Analyzing the Dilemma with Kerridge's Ethical Decision-Making Model
Several resources are available to support the resolution of the dilemma under analysis. A huge proportion of the resources are found among the NGOs and International Federation of Red Crescent Societies and its members. These private donors contribute the huge amount of resources that could be used to fund emergency relief. Ethics Committee plays a significant role in determining what is right and what is wrong during the disaster. The highly qualified rescue team is another greatest resource during a disaster. Kerridge's ethical decision-making model was the most effective model to apply in addressing ethical dilemma in decision making. It provides seven distinct steps to be followed when making an ethical decision to solve the identified ethical dilemma. It is effective because it aids in the identification of ethical issues in addition to the evaluation of the core values of an identified issues. The ethical issues identified during the Hurricane Katrina in this essay were on advocating for prioritization of dwindling resources while under adverse conditions including (Black, 2014).
Ethical dilemma:
It is considered complicated issues at hand during Hurricane Katrina because the resources were very limited and the people’s needs were increasing. First, after the floods, the crops and foods were destroyed resulting in the general lack of food, limited medicines and nursing care, no clean water, and the temperatures were very high. All these conditions made it difficult for medical practitioners and nurses to provide medicine and for the victims to be taken care of well. The ethical decision making and dilemma encountered was where to direct the few resources available whether for the care of the patients or on those displaced by the hurricane. The problem was therefore where nurses should prioritize the dwindling resources (Fink, 2009).
5a. Identify facts
As mentioned above, resources were dwindling hence could not be adequately and effectively allocated to address the needs of all the people. Those who survived the hurricane sustained serious injuries that demanded an urgent need of quality care but since resources were limited this was not possible. Most patients died since they could not access quality care. The environment was not favorable to enhance the healing process. There were very many survivors compared to the available resources forcing the nurses to make the critical decision where to allocate them.
5b. Further information required
The question raised was how long the victims in a critical condition and need of urgent medical care with limited resources at hand could survive. Further, who was responsible for making such a critical decision on where to allocate these limited resources? Lastly, there was the decision to be made on where medical care provided to the critically ill victims should have been continued or terminated.
5c. Fundamental ethical principles
From this situation, three major ethical principles are involved including the principle of non-maleficence, beneficence, and justice. The beneficence principles will address the issue of active well-doing for the good of others. It is thus the obligation of the health practitioners arising from the role played or ethical concept. In this situation, doing good would imply provision of a continuous care to the critically ill victims to save their life after the disaster because when care is stopped these victims will die. In this case, active well-doing is critical to prolonging life. The principle of non-maleficence focuses on the aspect of does not harm. There are instances where medical care will cause harm to these victims or the members of the society and the environment. However, it has been argued that it is difficult to predict such an outcome. There are minimal chances that the critically ill victims will survive under current limited resources. An intense care in other situation could not have prolonged critically unfortunate victim’s life. Therefore, in the event where long life expectancy cannot be guaranteed, the principle of Non-maleficence will be critical while they live.
The principle of justice, on the other hand, focuses on the aspect of equality and rights that the society owes its members. All the victims of the hurricane are entitled to be treated and well taken care of without discrimination. Justice is considered an issue regarding the distribution of the limited resources available. The ethical question raised focuses on whether the dwindling resources should have been allocated to support short-term guaranteed life (Pou, 2013).
5d. Ethical conflict
In the Hurricane Katrina case, the primary conflict takes place between the principle of beneficence and non-maleficence. Nurses are willing to save the life through carrying out the test and feeding the patients, but the resources available are very limited to support quality care. An intense care (beneficence) could have extended the life of the critically ill victims, but the resources are not enough to care for other victims at the same time. Restrain care (non-maleficence) will help stop pain and enhance the quality of life for the victims, but life could end very soon because resources are limited and could not support the life of these victims for long. The other ethical conflict can be seen from justice and non-maleficence point. Each victim of the hurricane had the same level of care services that would suit their current condition. To meet the principle of non-maleficence, focusing on causing no harm, resources should be allocated to patients with most deserving needs but by doping this, other victim’s rights to justice interns of equal resource allocation would have been breached.
5e. Consider the law
The clients in this situation are adults and children and with legal capacity to make the decision but children might not have the legal capacity to make their decision. The victims are thus under the government protection and the medical team who look after them. The government authorities together with the medical team will have to be involved in the decision-making on where to allocate the limited resources. However, the question raised is whether when medical team opts to apply the principle of non-maleficence, it will be considered as negligence (Pou, 2013).
5f. Making the ethical decision
The ethical dilemma will occur provided the nurse’s principles appear to be in conflict with one another. Therefore, it is critical to observe both the legal as well as the ethical aspects of nursing profession. In this situation, it can be argued that meeting the principle of beneficence significantly outweighs the principles of non-maleficence and justice (Fink, 2009). Nurses are required to respect the client’s dignity while at the same time uphold competent care causing a complex situation in this case. Resources are very limited, and the demand for the same is increasing. The victims have the legal capacity while at the same time have the autonomy that they do not want to be restrained.
6. Ethical Dilemma Decision Recommendation and Potential Consequences
It is evident that what make a moral decision difficult is the fact that they involve conflicts between beliefs, values, and morals. To make an informed ethical decision, nurses must consider the values of the patients. Medical practitioners will value the quality of care to all the victims, value an informed decision making and value safety culture (Pou, 2013). The first step that I would like to recommend in solving ethical dilemma is for the nurses to know their values. It is clear that there exist certain values that the society agrees on such as honesty, doing good for other and protecting clients. The next step is to select a suitable model which in this case, I would recommend that consequential theory is adopted where our actions will be judged by the outcomes. This will ensure that the nurse decision will be founded on the potential outcome which must be beneficial to the client. However, there are situations where the decision to be made, risks exceeds the benefits. In this situation, the nurse should focus on the concept of doing good unto other people. He or she must weigh how the decision will impact positively to the public rather than focusing on how the decision will be beneficial to the patient alone. If in a situation where the action will result in a positive outcome, then it will be considered morally right and if not, it will be considered morally wrong (Louisiana State Board of Nursing, 2010). The next step should be using a problem-solving process to solve the problem at hand. When following this process to solve the ethical dilemma, the ultimate decision will be good. This will ensure that an individual takes into consideration potential alternatives and select the best alternative under such circumstances. Potential consequences, in this case, might involve doing whatever is right for the patient and impacting negatively to the public; therefore it is important to weigh both positive and negative impacts to the patients and to the general public taking into consideration the limited resources. In the Hurricane Katrina situation, it can be argued that meeting the principle of beneficence significantly outweighs the principles of non-maleficence and justice hence the need for the nurses to consider the general benefits addressing the issue of doing well for the good of others (Danna & Cordray, 2009).
7. Policy Recommendation
The policy of distributive of justice is the most effective policy that can be applied to address the ethical dilemma focusing on dwindling resources during a disaster in Johns Hopkins School of Medicine which is located in Baltimore, Maryland, United States (Fink, 2009). There is the need to develop a framework that will be applied in the allocation of scarce resources during an event of critical care. The framework will ensure that the scarce resources available are used uniformly and in an objective way. The policy will take into consideration both the legal and ethical issues.
It is evident that ethical decisions are key in shaping a country’s disaster response. A major question raised was related to the aspect of dwindling resources where they were not adequate to fund the medical care and treatment to the victims of the hurricane. Various issues faced the victims during these disasters. For instances, the dwindling resources resulted in limited food, inadequate medicine and nursing care, no water, poor sewage system, and temperatures of 100 degrees Fahrenheit with no air conditioning. Due to dwindling resources, the dilemma emerged on how to effectively allocate the limited resources to the victims to ensure that each is well taken care of. There was the poor response from the government and donors that could have contributed to the dilemma. Among the victims, there were those who were critically ill an required urgent care, but resources were unlimited to put them on life support. To resolve the ethical dilemma, there was the need to focus on the principle of ethics and determine what the most effective decision to make is.
References
Baker, S. (1997). Applying Kidder’s ethical decision making checklist to media ethics. Journal of Mass Media Ethics, 12(4), 197-207. Retrieved from http://ezproxy.csp.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&am p;db =ufh&AN=400827 American Nurses Association. (2007). News release: American nurses association and the American medical association issue a joint statement on criminalizing medical decisions. Retrieved from http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/ 2007 /JointStatementonCriminalizingMedicalDecisions.pdf Black, B.P. (2014). Professional nursing: Concepts & challenges. (7th ed.). St. Louis, Missouri: Saunders. Fink, S. (2009, August 25). The deadly choices at Memorial. The New York Times. Retrieved from http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=1&ref %20s herifink&_r=0 Pou, A. M. (2013). Ethical and legal challenges in disaster medicine. Southern Medical Journal, 106(1), 27-30. Retrieved from www.medscape.com/viewarticle/777544_2 Danna, D. & Cordray, S. (2009). Nursing in the storm: voices from hurricane Katrina. New York, New York: Springer Publishing Company. Retrieved from http://site.ebrary.com.ezproxy.csp.edu/lib/cusp/reader.action?docID=10354047
Brookings Institution. (2008). Hurricane Katrina timeline. Retrieved from: http://www.brookings.edu/fp/projects/homeland/katrinatimeline.pdf
Cable News Network (CNN) (2010). Release Katrina hospital death file, Louisiana judge says. Retrieved from: www.cnn.com/2010/CRIME/09/09/louisiana.katrina.hospital.deaths/index.html?iref=alls earch Gray, B.H., & Herbert, K. (2006). After Katrina, hospitals in Hurricane Katrina, challenges facing institutions in a disaster. Urban Institute. Retrieved from http://www.urban.org/UploadedPDF/411348_katrinahospitals.pdf
Louisiana State Board of Nursing. (2010). Law governing the practice of nursing: Part I registered nurses, 929 exceptions. Retrieved from http://www.lsbn.state.la.us/Portals/1/Documents/rules/npafull.pdf
