|Ann. Medit. Burns Club - vol. VI - n. 3 - September 1993
ETHICAL PROBLEMS IN MASS DISASTERS
Burn Centre, University Hospital, Prague,
SUMMARY. A survey is made of
current thinking on the matter of ethical problems in mass disasters. One basic question
is the selection of patients to be treated and patients for whom treatment is either
unnecessary or useless. The psychological problems of mass burn victims are also
considered. Predictive models have their advantages but they are not the absolute answer
to all practical problems in individual cases. Euthanasia is another consideration that
brings in ethical and moral problems. However, certain principles are clear: the
timehonoured tradition of medicine is to provide disaster victims with considerate
management of their pain and their fears. Outcome prediction, cost efficiency and quality
of life assessment are important tools for the solution of these problems.
In 1977 Rudolf Frey conveyed his thoughts
on the missions and roles of the medical profession, which include prevention, diagnosis
and treatment not only of the health problems of individual patients but also the
management of disasters which strike communities or nations and result in mass casualties.
In 1988 Peter Baskett and Robin Weller asked: What planning might help alleviate the
effects of disasters? What can be done to help afterwards? (Baskett and Weller, 1988).
The most basic disaster response must include methods for determining which victims will
receive treatment first and what type of treatment will be given during the various stages
of the disaster.
At the International Symposium on Burns in Padua, Italy, organized by the late Prof. Dogo
in September 1980, one session was dedicated to psychology in association with mass burn
disasters. One communication (K6nigovd and Pond(51f&k, 1981), prepared by the Prague
Burn Centre, discussed the psychological problems encountered in burn victims. Many of
these perish not only because of their somatic injury but also as a result of mental
stress and breakdown. They are prone to so-called "blind action" or to chaotic
behaviour. Often they do not realize the seriousness of their injury or even the danger to
their life. This condition has been defined as "trauma agnosis". It expresses a
"dead point" in the conscience of the victims in a state of general panic, which
may be the cause of the death not only of the injured and burned but also of a great
number of healthy individuals. We resolved to draw attention to the psychological aspects
of the affected population. Bearing in mind the consideration that without a psychological
approach the patients' selection triage for treatment and transport is inadequate, we
address the first stage of the ethical problems.
Who shall receive higher and who lower
priority in triage?
Modem triage is based on the assessment of
the patient which is completed at the accident site, in conjunction with the judgement of
the actual and possible severity and prognosis of the bum victims. In 1988 Howard Champion
pointed out the lower priority for patients who will live without treatment and for those
who will die despite treatment (Champion, 1988).
Over-response to the disaster may deplete valuable resources, while under-response may
increase mortality. Over-response may even result in increased mortality, by depleting
scarce resources wasted on hopeless cases. Some types of injury, and in particular bums,
require continuous use of operating-room time over a period of days or weeks for dressings
and grafting. Arrangements need to be made not only to provide sufficient operating-room
time but also sufficient numbers of surgeons and anaesthetists skilled in the management
of such cases.
The identification of savable patients - and again, in burns, there are numerous factors
influencing individual outcome - is difficult under optimal conditions, let alone under
the chaotic circumstances created by a disaster.
"To treat or not to treat" was the topic of Bent Sorensen's "Rudy Hermans
Memorial Lecture" at the 3rd EBA Congress in Prague in 1989 (Sorensen, 1989). The
title did not express exactly the intention of the contents, which dealt with the more
serious ethical question of "how to treat". More than 200 years ago Samuel
Johnson had taught medical students: "It is our duty to serve society..."
However, true service to the society has changed over the centuries and especially during
the last decades. This is due to advances in science, along with changes in the law and
societal perceptions. Critical care has established its place in modern medicine, but in
spite of all the accumulated knowledge and recent innovations the successful treatment of
many critically ill patients seems to be an ever-receding goal. We are confronted with
more complicated syndromes on the one hand and ethical, economic and social considerations
on the other (Crippen, 1992).
Previously inconceivable possibilities have been developed, at a price. This price has
included not only tremendous financial costs but also the additional cost of human
suffering. We cannot cure all patients, and many patients are "saved" but remain
with severe disabilities that may cause socalled "social death" (K6nigovd and
PonWlf(~ek, 1987). Intensive therapy is very expensive and therefore its performance
should be carefully examined even under normal conditions. Under disaster conditions, when
not all can live, we have to decide who shall live, knowing very well that withdrawal of
medical treatment is more difficult than withholding treatment before it has commenced
Various models for prognostic prediction
provide rough estimates of patient outcome, but they cannot be applied prospectively to a
single patient with any confidence. Several scoring systems seek to measure the severity
of injury or illness and thus quantify the risk of death. Their primary use in disaster is
to triage patients for treatment and to allocate resources.
There are statistical reasons why a predictive model may not work when tested in different
populations. Another consideration regards the misclassification rate and the specificity
of the rule. The model should not incorrectly predict death in patients whose recovery is
feasible. What level of specificity is chosen, and who sets it, is a difficult problem.
The balance required to set a reasonable level of specificity is not solely based on
mathematics. It also includes factors such as the wishes and options of relatives and
society to continue to treat such patients despite the cost, both in human and financial
terms (Crippen, 1992).
Prediction rules suffer from criticisms that are not based upon their design (Krob et al.,
1. They have not been shown to be better
than clinical judgement (APACHE 111 modification is being developed);
2. There is disagreement on how much computer predictions should influence clinical
judgement, when the use of such rules may lead to clinical nihilism. If treatment is
withdrawn on the basis of a prediction rule, the prediction will almost certainly be
A computer-generated prediction of death
is an objective statement concerning the patient's inability to overcome the initial
insult despite therapy. Nevertheless, appropriately used prediction rules may represent an
advanced form of audit. They will confirm early decisions about the relevance of
The channelling of resources to the most appropriate patients is an important aspect of
clinical management, particularly in mass disasters.
In 1991 Kroh, D'Amico and Ross inquired: "Do trauma scores accurately predict
outcomes for patients with bums?" (Krob et al., 1991).
The scoring systems of Baux, Edlich and Zawacki place significant emphasis on bum size and
the patient's age, the two most important factors in determining survival. Other factors
that are considered in the formulae (Baux et al., 1989) are:
- partial pressure of arterial oxygen at
the time of admission;
- presence of inhalation injury; and
- history of bronchorespiratory disease.
The short-term outcome is still the most
commonly used measure for the efficacy of treatment, but in disaster triage the long-term
outcome must not be disregarded, this being influenced not only by age but also by
underlying diseases and primary services (medical and/or surgical).
In making triage decisions, apart from age factors, the mechanism of injury should be
considered. There is a tendency to prolong resuscitation in children, leading to a higher
survival rate but also an increased incidence of sequelae (Miranda, 1990).
Concern over management, cost and efficiency could reduce our concern for the patient as a
person, but interest in the assessment of quality of life (following ICU treatment)
provides a framework for maintaining the importance of the total patient. Quality of life
measurement requires also that the clinicians make an effort to determine how the patient
was functioning prior to his injury or illness - information vital for prognosis, but also
Potentially useful for tailoring treatment to an individual's ability to benefit.
In 1989 Reichel and Dyck published their contemplation on euthanasia - a contemporary
moral quandary. They stressed that the highest goal of a community is to protect the lives
of all its members. The affirmation of life is not just the concern of a particular
religion or culture but is the basis for the whole human community. What Albert Schweitzer
called a "reverence for life" underlies all our moral principles and values of
civilized society, and is the basis of a professional ethic that has served humanity well
over the past 2000 years. Our role as physicians should be to maximize the potential for
life, even though death is inevitable. On the other hand, with limited resources in mass
disasters, the patients with end-stage injury or disease should not be given intensive
care, even if the recognition of terminal condition, on emergency admission, can be very
difficult. Permitting death without intervening (passive euthanasia) avoids unnecessary
distress and expense.
When we no longer heal, our ethical duty is to palliate and comfort. We can best serve
disaster victims by considerate management of fear and pain. This has been the
time-honoured tradition of medicine (Knaus, 1989).
Outcome prediction, cost efficiency and quality of life assessment have not been taught in
medical schools, nor are they emphasized in residency or postgraduate training. However,
they may be among our most important tools for meeting the challenges of tomorrow.
RESUME. Cet article
considère les opinions actuelles sur la question des problèmes éthiques présentés par
les catastrophes. Un problème fondamental est le triage des patients à traiter et les
patients pour lesquels le traitement est superflu ou inutile. Les problèmes
psychologiques des victimes des désastres d'incendie sont aussi considérés. Les
modèles prédictifs offrent des avantages mais ils ne représentent pas la solution
parfaite de tous les problèmes pratiques dans les cas particuliers. L'euthanasie est une
autre considération qui introduit des problèmes éthiques et moraux. Il y a quand même
certains principes très précis: la tradition consacrée de la médicine, pour ce qui
concerne les victimes des désastres, reste toujours la gestion attentive de leur douleur
et de leur peur. La prédiction des résultats, l'efficacité-coût et l'évaluation de la
qualité de la vie sont tous des outils importants pour la solution de ces problèmes.
- Baskett P., Weller R. (eds): "Medicine for
Disasters", p. 230, Wright, Oxford, 1988.
- Baux S., Mimoun M., Saade H. et al.: Burns in the
elderly. Bums, 15: 239, 1988.
- Champion H. In: Baskett P. and Weller R. (eds):
"Medicine for Disasters", Wright, Oxford, 1988.
- Crippen D.: Dealing with families who demand
inappropriate medical treatment for moribund patients. Intensive Care World, 9: 78, 1992.
- Knaus W. A.: The changing challenges of critical
care. . Intensive Care Med., 15: 415, 1989.
- KOnigovj R., Pond61fdek L: Euthanasia: Psychology
associated with mass bum disasters. Burns, 8: 64, 1981.
- KOnigovd R., Pond(51iéck L: Psychological aspects
of bums.Scand. J. Plast. Reconstr. Surg., 21: 311, 1987.
- Krob M. J., D'Arnico F. J., Ross D. L.: Do trauma
scores accurately predict outcomes for patients with burns? J. Burn Care Rehabil., 12:
- Miranda D. R.: Quality of life after intensive care.
Crit. Care Digest, 9: 34, 1990.
- Reichel W,, Dyck A. J.: Euthanasia: a contemporary
moral quandary. Lancet, 2: 1321, 1989.
- Sorensen B.: To treat or not to treat. Third EBA
Congress, Prague, 1989.
- Sprung L.: Changing attitudes and practices in
forgoing life sustaining treatments. JAMA, 263: 2211, 1990.