Central Line
Episode Number: 143
Episode Title: Medical Ethics in Mass Casualty Situations
Recorded: September 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome to Central Line.
I'm Dr. Adam Striker, editor and host. I have Dr. Ahmed Shalabi with me today.
Dr. Shalabi is a member of the ACE editorial board with a 21 B issue of ACE out
now, we wanted to focus on one specific topic that's touched on in the issue --
medical ethics and specifically ethics and mass casualty situations. Dr. Shalabi,
we are happy to have you with us today to discuss. So welcome to the show.
DR. AHMED SHALABI:
Thank you, Dr. Striker,
for having me.
DR. STRIKER:
To kick us off. Why
don't you go ahead and introduce yourself to our listeners. Tell us a little
bit about your role and your experiences with ACE specifically.
DR. SHALABI:
My name is Ahmed Shalabi.
I'm a liver transplant and a vascular anesthesiologist at Cedars-Sinai Medical
Center in Los Angeles. I've been part of the ACE editorial board since January
of 2022. So almost reaching a three years landmark there. I'm one of the
editors of this editorial board, which has been a phenomenally enriching
experience for me since I joined it. I get to work with a phenomenal group of
anesthesiologists from all across the country. We work on authoring and editing
this excellent group of questions that we issue biannually for the ACE question
bank. It's been a fantastic experience for myself to know those colleagues, to
learn from their experiences and their practices regionally, nationally, as
well as internationally, to keep myself updated and sharp with my knowledge, working
and learning new editing skill set has been a phenomenal experience for myself.
DR. STRIKER:
Wonderful. Well, medical
ethics is such an enormous topic. I mean, there are so many different lenses we
could view this topic through. From your perspective though, what are some of
the key ethical issues facing anesthesiologists today?
DR. SHALABI:
You're absolutely right,
Dr. Striker. It is an enormous topic, and there are several issues that face us
as anesthesiologists on our day-to-day practice. To name a few of those that we
run on a daily basis, for example, when we're taking care of patients
perioperatively who have a do not resuscitate, do not intubate order, how do we
work around that where we're planning to do anesthesia and intubate those
patients? How do we discuss it with the patients or their families perioperatively
given the fact that there are some issues that could readily happen peroperatively
it could be reversible and how to respect the patient's wishes at the same time
and their autonomy. Another example for other subspecialties in anesthesia,
like for example, educating our pain colleagues where managing pain and
combating the subconscious bias to certain groups while we're treating pain in
our practice. Another example for myself, for example, when I'm taking care of
liver transplant patients, how the allocation of liver transplant to certain
groups and how that could be fair and sometimes questionable in certain groups
that don't have access to medical care and less privileged communities.
With the same token,
like certain Meld exception points, when we use the Meld scoring system for
allocation that I have, for example, a patient that has a Hepatopulmonary
syndrome that would be allocated multiple Meld exception points as compared to
someone who is as sick with end stage liver disease, but does not have that
syndrome, and ends up getting his organ allocated way after the patient that
had the exception points. Also, like when we're dealing with patients who have
some sort of an outside control on their decision making. A good example of
this were patients who were refused blood transfusion or for a variety of
reasons. Some of them could be religious, some of them could be others. They
could have some pressure from their families or some community members. And
they’re always afraid to be ostracized. So when we're consenting them, it's
quite, very important that I make sure that they have an informed consent. And
I try to make sure that they don't have this outside pressure in making their
informed decision.
DR. STRIKER:
Well, I know we want to
talk about ethics and mass casualty specifically because it's currently
highlighted in the in the current ACE issue. In general, as anesthesiologists
deal with ethical issues, comment a little bit on A) what role ethics play in
helping us navigate some of the more complicated ethical issues. And B) are
those services readily available at most institutions?
DR. SHALABI:
So, some of the most
complicated medical issues, one of them is the mass casualty, which normally
don't follow the normal tradition of medical ethics. And we live in a world
where we could face some of those instances due to certain attacks that could
happen. The first thing that comes to my mind, for example, was the Boston
Marathon attacks several years ago, or in even situations of mass casualties
like, you know, a perfect example was the Covid 19 pandemic, where the pandemic
really overwhelmed the health care systems across the country and across the
world. So traditionally, medical ethics teach a physician to put the patient's
interest ahead of their own self-interest or preferences, or even ahead of any
other person or any other patient's interest while they're taking care of that
particular person. But in those kind of situations, sometimes we have to yield
those traditional medical ethics in order for the utilitarian principle of
providing the most good for the greatest number of patients. And institutions
and facilities should have sort of preset protocols. And that's one of the
lessons we should have learned from situations like this. And the most recent
of them, with the Covid 19 pandemic, we should be ready for the next disaster.
Whether it happens or not, we should have reinstated protocols or reinstated
guidelines. How to manage those things in an ethical fashion.
DR. STRIKER:
Okay, well, as we're
talking about mass casualty events, can you give me a specific example within
the framework of one of those situations you just highlighted, whether it's the
Boston Marathon or Covid, of what what an anesthesiologist might face in terms
of an ethical dilemma in the mass casualty situation as opposed to their
routine work situation.
DR. SHALABI:
Yes, absolutely. So in a
medical triage situation, the disaster is is defined as any instance where the
local response resources are overwhelmed by the patient needs. And the goals of
the medical management, as I mentioned, they changed from those focused on the
patient individual needs to those for utilitarian goods. So for example, if I
have a situation where I have a terrorist attack next to a small community
hospital, and this community hospital have a very limited number of operating
rooms and a small number of beds, anesthesiologists have the skill sets to
really help in triaging those situations. These skill sets, for example --
airway assessment, management of fluids and blood resuscitation, ICU expertise
and knowledge, our knowledge of the operating rooms and what is available and
what's, for example, if we know are there any other surgeries underway and how
I can allocate the remaining ORSsfor those trauma patients or their casualty
coming in. Uh, other resources, for example, like when we were doing the Covid
19 pandemic. Uh, how do I allocate ventilators and which patients are more
likely to benefit and without compromising other patients? Another example,
even after the initial triaging of patients coming in a mass casualty, it
should be routinely periodic triaging of patients because some patients move
from one category to the other. Ones who initially presented in a less urgent
manner and their medical status changes are becoming in a more urgent manner. A
good example of this is what we call a lifeboat ethics. Well, a lifeboat ethics
is if, in a mass casualty situation, I have critically ill patients. At the
same time, I have a critically ill terminal cancer patient in ICU who's on a
ventilator, and I have multiple trauma patients who are in a critical condition
who might need a ventilator. And this comes a big ethical question. I have a
very limited number of ventilators in the ICU. Which patients should use the
ventilator and which should not? And in a mass casualty situation, all patients,
lifeboat ethics, whether those on the lifeboat or those in the water, should be
treated equally. And we might have to make a decision that terminally ill
patient, we might decide to resort to comfort care in situations where I might
be saving the life of another patient who needs that kind of ventilatory
support.
DR. STRIKER:
I see. Well, let's talk
about a few specific terms that I know you want to define for our audience as
it relates to ethics. We'll start off with one of the terms, if you could
define it for us. But then also, could you just explain to our audience why
these concepts are important as it pertains to medical ethics? And let's start
with the first term Deontology.
DR. SHALABI:
So Deontology ethics is
our day to day ethics as physicians and health care providers, what we call the
duty based ethics. It basically judges our actions based on what most people
consider as morally correct, rather than the outcome or the consequences of
those actions. So it takes into account the type of the action and our
intention when we're determining it, and what is right and wrong in the initial
decision and in our intention, not at the consequences of the act. And that's
what could conflict in what I mentioned earlier about the mass casualty
situations, where I have to make decisions based on the consequences and how to
save as much number of people as possible. Deontology ethics tend to be patient
centered. As I mentioned, consequences are not used to justify the means. And
the specific duties in deontology, so what's right and what's wrong, what's
evidently right, and what we would consider as morally wrong. This is what how
we think in deontology ethics. Like telling the truth, keeping promises, not
letting someone die to save another person's life. A good example, if a
terminally ill patient asks me, doctor, will I be okay after this surgery? And
will I have not have any major complications? Deontology ethics would not
suggest that I would lie to that patient to comfort them. And I have to be
totally honest, as honesty is is part of our obligation and not lie. No matter
what the consequences are.
DR. STRIKER:
Okay, now let's turn to
autonomy then.
DR. SHALABI:
Autonomy is one of the
four pillars of medical ethics the four basic fundamentals of medical ethics.
I'll talk about the economy, and then I'll talk about the other three pillars.
So autonomy is basically giving the patient the freedom to choose freely whenever
and wherever they're able to. The other three main pillars of medical ethics
are beneficence, meaning doing good to the patient; non-maleficence do not do
harm to the patient; and in my personal opinion, justice, which is the most
important of them, ensuring fairness. In the context of medical ethics is a
principle that when I'm weighing if something is ethical or not, we have to
also to keep into consideration whether it's compatible with the law, with
compatible with the patient's right and it's fair and balanced.
DR. STRIKER:
And then finally, can
you explain what consequentialism is and and how would that be salient to
practitioners?
DR. SHALABI:
So consequentialism is a
type of utilitarian ethical concept when we apply utilitarian ethics in the
medical field. And it basically states that the morality of the action is based
on the consequences, meaning that the end justifies the mean. And this is
totally opposite of what I just mentioned about deontology ethics. So for
example, as in mass casualty situation, the resources may be redirected from
patients with a low chance of survival in order to improve the chance of other
patients who have a higher chance of survival. And this is what
consequentialism is. It is not accepted in our standard day to day medical care
of our normal course of patient care. However, it might be necessary in mass
casualty to ensure the whole welfare of the public and save as many people as
possible. Consequentialism might be a legitimate framework to make decision
making. How resources may be allocated in such disastrous situations not to
overwhelm our resources, the health care delivery. Um, but it's not an ethical
framework that I can use in my day-to-day medical practice.
DR. STRIKER:
So, practically
speaking, do practitioners need to know these terms? I'm sure everyone
listening is familiar with these lines of thinking. They may not have known
that there was a name to those lines, or a definition to how they were applying
ethics. But how do most of our practitioners that are listening make sense of
these different terms, these different philosophies, as it pertains to their
daily practice.
DR. SHALABI:
That's a very good
question. And I think while the names themselves are not as important as the
concept, and many, as you mentioned, do come as logical frameworks, while we do
practice in situations like this, sometimes there are areas where it could conflict
and there are gray zones. And that's why knowledge of these situations, or some
examples of those could help us giving from previous precedents. What are the
potential conflicts that we could face in situations like this and how to to
solve and resolve those issues?
DR. STRIKER:
Okay, now turning back
to mass casualty, specifically, how important is it for hospitals or other
healthcare organizations to predetermine the criteria that will be used in mass
casualty situations.
DR. SHALABI:
So regardless of whether
I'm applying consequentialism or any utilitarian frame of ethics versus a
deontological ethical frame, it's very important that I apply the principle of
justice, which is one of the main pillars of medical ethics. Because if I'm in
a mass casualty situation, our decision making might erode the trust of our
patients in us. But if we have a predetermined framework and predetermined
criteria--how am I going to allocate those resources and my guide me in my
decision making--that's paramount in applying the principle of justice to be
informed. So all patients should be treated, regardless of what kind of
framework I'm using in my decision making, all patients should be treated based
on their physical and mental condition only rather than their social worth. No
other characteristics should warrant any special consideration in the disaster
situation. That includes age, gender, or any other race or any other
characteristics. However, there are only a few exceptions to this rule where I
can prioritize certain social criteria, and a perfect example for this was the
prioritizing the Covid vaccines for physicians and other essential health care
workers during the pandemic. So this was a perfect example of a mass casualty
or a pandemic where I'm in a situation I need to vaccine the health care
workers before anyone else so they don't get sick, and they could care for the
rest of the public. So they're very, very few exceptions where I can violate
this rule about applying justice and equally providing the care based only on
the physical medical condition and one of them is vaccination during pandemic.
DR. STRIKER:
Many health care
organizations have plans in place for mass casualty situations or they've run
mass casualty drills. Do you feel that the ethics questions that we've been
discussing so far are not addressed enough in those plans or in those drills, then,
when these situations arrive, each one which has their different
considerations, it's left up to the practitioner at the time. But is there not
enough prep work as it pertains to ethics? And does that end up causing the
practitioners on the ground level when the mass casualty event happens to have
to sift through these ethical questions in a very urgent fashion?
DR. SHALABI:
Well, the short answer
to your question, I think, there is room to do more prep, though I don't think
it should be enough. Meaning that I think Covid 19 showed us that we were not
ready enough. And not only in our nation, but also across the world for
situations like this. And I hope we learned the lesson from that. We should
have the experience from the last few years, how to address, God forbid, if
they happen, similar future epidemics or pandemics.
And the second part of
the question is, in situations, for example, like mass casualties, there are
some well-known triaging protocols which help the physicians guide how to
prioritize those situations. And I think integrating those in our teaching with
our trainees or even in our continuous medical education, for us to expand our
knowledge of those. Because sometimes, despite being really well intended, in
situations like this where a lot of stake, we could still make a decision to
spend and use a lot of our resources, taking care of casualties that have very
little chance of survival, which could compromise the likelihood of survival
for patients who had initially a higher chance of survival should have been
addressed earlier, and a perfect example of this. There are some triaging color
coding protocols that have been used in mass trauma situations or mass casualty
situations.
For example, using like
simple color code triaging systems red, yellow, green, blue and black. And
basically the first two, the red is basically for patients who are extremely
critical but may survive with simple life saving maneuvers, for example, like alleviating
airway obstruction or treating a hemorrhage with transfusion or resuscitation,
or treating a cardio respiratory failure by some hemodynamic and respiratory
support. And this is where an anesthesiologist has skill set could really come
into play. And those have to be allocated to immediate care. Patients who are
triaged yellow are those who are next priority or basically patients who have
penetrating wounds, but they are in a more stable condition, so they might not
receive the immediate care of the resources of overwhelmed, but they could go
into the next priority right after we address the first category. The other two
categories, which is like the green and the blue, the green are basically the
patients, what we call the walking wounded, where patients are quite stable,
they have wounds, but they can wait, and those can be addressed as soon as the
resources are available, as soon as the other more critical patients are
addressed. The blue, which we call the dying, or the black who are already dead.
Those could be allocated to comfort care only if still alive. So the green and
the blue category, if I'm able to identify them early, I could more wisely
allocate my limited resources in situations of mass casualties. The main
difference between this and warfare triaging strategies is warfare, I'm trying
to treat the less wounded soldiers to get them more readily back to combat. In
medical triaging mass casualty situation, I'm trying to treat those who have,
as soon as possible, critically ill, who have a higher chance of survival, and
allocating the resources to them more than who have very limited chance of
survival, or those who have minor injuries that could wait for later care.
DR. STRIKER:
Yeah, I understand you
chose this topic, right?
DR. SHALABI:
Yes.
DR. STRIKER:
For the ACE issue. Okay.
Can you talk to our listeners a little bit about, in general, the process of
selecting topics to highlight in ACE, and then also why this one specifically?
DR. SHALABI:
So I'm going to answer
the second part of your question first. So um, I remember in December of 2020
when the first vaccines for the Covid 19 were approved by the FDA, myself and
my wife were working at the same hospital then, and we got vaccinated, being
first line specialties and first line responders in the hospital, in the first
week, as soon as FDA got approved. At the same time, going back home with my
son couldn't be vaccinated and our friends and family who couldn't reach the
vaccine. And that really was, at that point, I really wanted to understand
that. The reasoning, it was quite obvious, that we were first line responders
who were at higher risk, and we wanted to care for the population. But going
back when I chose this topic and looking back at it in retrospect and looking
how we saw our colleagues getting sicker while they're taking care of the
patients and getting Covid 19, some of them had to stay out of work until they
they recovered, some of them actually getting critically ill. And we took care
of them in ICU. And I think this is what we wouldn't normally do in our
day-to-day practice. Prioritizing ourself or prioritizing specialties like us
as anesthesiologists or high risk specialties in medicine to receive the
vaccine. And I thought that this might be a point where we to dig more into the
literature and see where the origin behind these kind of ethical questions, or
where answers to this come from. And I chose to bring this up to to the
audience of the ACE question Bank to test their knowledge and to to highlight
on the importance of knowing those few concepts.
But in general, when we
use topics for the ACE question banks, we try to to discuss updated evidence
based medicine and anesthesia, cutting edge technologies that change our
anesthesia practice, and newer societal guidelines. We try to to keep our
audience updated with the new medications that are approved or in the process
of being approved by the FDA that we're using in our day-to-day practice. We
try to choose our topics from all subspecialties to be comprehensive to the
audience practicing in different subspecialties in anesthesia. And the same
time, our group is very diverse in their subspecialty skill set, we also try to
look into topics that we tend to overlook in our day to day training with our
residents and fellows. And medical ethics is one of the things I think we
should be emphasizing in our training and in our didactics, as well as in our
products, to to help enrich our audience, enrich their knowledge about many
factors that we can be used in situations like this.
DR. STRIKER:
Well, Dr. Shalabi, thank
you for joining us, giving us a peek behind the scenes of ACE, but more
importantly, talking about some of the intricacies of a very important topic:
medical ethics and a lot of facets that we oftentimes don't think about until
we're placed in a situation like that. So thank you so much for for joining us
for a very interesting conversation.
DR. SHALABI:
You're very welcome, Dr.
Striker, and thank you for having me.
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DR. STRIKER:
Absolutely. And for our
listeners who are interested in the 21 B issue of ACE, you can find it at asahq.org/ace.
And thanks for tuning in to this episode of Central Line. And don't forget to please
tune again next time. Take care.
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