Introduction

Webcast archive: Discrimination & natural disasters

A webcast on: natural disasters, hospitals, and situations of discrimination. We look at Hurricane Katrina and the Ebola outbreaks, plus the history, rationale, and examples of triage systems.

Webcast archive: Discrimination & natural disasters

In this episode of Euthanasia & Disability, Amy Hasbrouck, Christian Debray, and Taylor Hyatt discuss:

  • Discrimination in hospitals after natural disasters

Please note that this text is only a script and that our webcast contains additional commentary.

DISCRIMINATION IN HOSPITALS AFTER NATURAL DISASTERS

  • Two weeks ago, we discussed the effects of disability on planning for and recovering from natural disasters. We briefly touched on the ways in which scarce rescue and health care resources are allocated in a major emergency.
  • Hospitals already do this every day; emergency departments and Intensive care units routinely use triage systems (rather than by randomized methods like “first come, first served” or by lottery) to dictate who is treated first and who gets access to limited ICU beds and diagnostic imaging equipment.  In normal conditions (when resources are plentiful and demand is within a normal range), the sicker you are, the sooner you will be treated. For example, someone with a broken bone will probably be seen before a person with a stuffy nose.
  • Napoleon’s battle surgeon Baron Dominique Jean Larry was the first to use a system of triage and field ambulances.  His plan was guided by the idea that “Those who are dangerously wounded should receive the first attention, without regard to rank or distinction,” in keeping with the French revolution’s value of égalité.
  • But the goals in battlefield triage are not the same as in hospitals or disaster situations.  In 1846, British naval surgeon John Wilson assigned a higher priority to people whose treatment was likely to be successful.  His policy delayed treatment to people with less severe wounds, and those whose wounds are probably fatal.  This trend continues to today.
  • Triage has three elements:
    • A situation where there are not enough resources for the number of people who need them;
    • Someone in authority evaluates each person’s needs, and assigns them a priority;
    • Priorities are assigned according to an established system or plan.
  • It’s worth noting that the values that are supposed to guide triage systems may be more dangerous to disabled people than they appear:
    • Preserve and protect endangered human life:  Since disabled lives are often not considered fully human, this value may not be strictly applied to disabled people.
    • Preserve or restore function or health:  Because disabled people cannot be “restored” to “normal” health, this value also acts as a prejudice against us.
    • Efficient use of resources to achieve the best overall outcome:  Where the first two values don’t strongly support the care of disabled people, use of resources to help them will not be considered “efficient”
    • Fairness:
      • Actions that conform to the agreed-upon rules:  The decision-maker’s perception and prejudice will affect whether they apply the rules fairly.
      • Actions that conform to accepted standards or principles of justice:  What is “accepted” in a society that views life with a disability as a fate worse than death?
  • Most triage systems go something like this:
    • Priority 1 – people who need immediate treatment to save their lives (red tag);
    • Priority 2 – People who need urgent, but not immediate, medical care (yellow tag);
    • Priority 3 – People requiring only minor treatment (green tag);
    • Priority 4 – People who are not physically injured but may be traumatized or disoriented (white tag);
    • Priority 5 – People who are dead or so severely injured they are expected to die of their injuries in a matter of hours or days. (black tag).
  • However, the Canadian Triage and Acuity Scale is more optimistic
    • Level 1 – Resuscitation (blue)
    • Level 2 – Emergent (red)
    • Level 3 – Urgent (yellow)
    • Level 4 – Less urgent (green)
    • Level 5 – Non-urgent (white)
  • When we talked about disasters two weeks ago, we mentioned a book by Dr. Sheri Fink, called Five Days at Memorial, about the events and decisions that led to an estimated 20 people being euthanized at a New Orleans hospital after Hurricane Katrina. The staff identified people with “Do Not Resuscitate” orders, those who couldn’t walk or who were difficult to carry as the last to be evacuated, though most of them were not in danger of dying.  As the stressful conditions continued into the third day, and the medical staff were being airlifted out, it became clear that this group of patients would not be evacuated.  Rather than abandoning them, medical staff elected to administer high doses of morphine and sedatives to euthanize them.
  • Where they exist, protocols for medical resource allocation are usually drawn up by government agencies, panels of “experts” or hospital administrators and insurance actuaries.  While some of these policies are flexible, others call for refusing care to older adults and those with medical conditions such as kidney failure or advanced cancer.  Ontario developed a protocol in 2006 following the SARS (Severe Acute Respiratory Syndrome) outbreak to prepare for a large-scale epidemic.
  • In 2016 Sheri Fink reported on a series of public consultations held in the state of Maryland to create a policy for prioritizing healthcare in an emergency. The organizers found that a broader perspective raised some unexpected questions about discrimination and access to ventilators for people in a coma.
  • These issues are not limited to developed or western countries.  Following the 2011 earthquake and nuclear meltdown at the Fukushima facility, those whose evacuations from nearby hospitals were delayed ran a greater risk of radiation poisoning.  And during the 2014 Ebola outbreaks in Africa, health care workers could spend only a short time in biohazard suits that overheated quickly, thus limiting patient care and forcing agonizing choices.
  • It’s not just in triage and allocation policies that disability discrimination shows up.  Under the Trump administration, the Federal Emergency Management Agency in the US has reduced the number of accessibility coordinators available to deal with disability issues at disaster sites from 60 to five.
  • Marcie Roth, of the Partnership for Inclusive Disaster Strategies, is a former FEMA employee.  She anticipates a lot of confusion and unmet need following the cuts. Coordinators are now expected to supervise disaster areas by phone, rather than in person.
  • Some people at Memorial Hospital in New Orleans had family members with them to advocate on their behalf, to get water or medications, or to try to get DNRs removed.  Even so, some of these family members, who would only leave the hospital with the assurance that their loved one would shortly be evacuated, later found out that their relative had been euthanized.  Unfortunately, we have to be vigilant in demanding assistance to live, not to die.