Theme 1: State-Based Guidance on Fair and/or Equitable Provision of Relief Funds, Resources, How These are Informed by a Human Rights or Ethics-Based Framework is Not Clear.

The development of principles to guide public health decision making in emergencies has been previously explored in the Northern American context as published by Barnett, et al in which ten principles were developed by expert consensus with a goal of linking law, ethics, and decision making for allocation of resources in emergencies. ^{Reference Barnett, Taylor, Hodge and Links13} These included maintaining transparency, community participation, respecting individual rights whilst balancing community need, non-discriminatory consideration of public health needs of individuals and groups, adhering to and communicating applicable standard-of-care guidelines, identify public health priorities based on evidence, implement initiatives in a prioritized and coordinated fashion, assess the public health outcomes, ensure accountability, and share personally identifiable health information—with the patients’ consent, where possible—solely to promote the health or safety of patients or other people. ^{Reference Barnett, Taylor, Hodge and Links13} Of note, these principles, whilst developed by expert consensus, have yet to be validated in practice.

Theme 2. Identified Ethical Frameworks Exist in Siloes of Public Health, Clinical Practice, and Humanitarian Care. Ethical Frameworks for Decision Making in Military Operations are Guided by Rules of Engagement, and More Broadly, by International Law and the Conduct of Military Operations.

Literature regarding the use of triage decision making at the individual patient level is substantial and based on an ethical principle of the greatest good for the greatest number of persons. A key difference in differentiating the ethical principles of decision making related to patient care in disasters and broader emergency management decisions can be observed in relation to maintaining critical functions of society. In such circumstances, priority of decision making related to these functions may be equal to or higher than the immediate patient or health care priority it is balanced against. Kalajtzidis noted such variance in decision making theory, models, and practices, a finding that is consistent with those of Penney, et al. ^{Reference Penney, Launder, Cuthbertson and Thompson2,Reference Kalajtzidis14} Kalajtzidis provides an overview of moral dilemma as it relates to ethical decision making in disasters, considering concepts of consequentialism and moral intuition that can inform action, but also concludes noting the unanswered question of how ethical decision should be made or guided in disasters. ^{Reference Kalajtzidis14} Ekmekci and Folayan proposed a theoretical ethical framework to guide decision making in public health emergencies, drawing on practices informed from previous studies by Beauchamp and Childress. ^{Reference Beauchamp and Childress15} The work of Ekmekci and Folayan was influenced by the impacts of the coronavirus disease 2019/COVID-19 pandemic to improve decision-making practices; the proposed framework would benefit from evaluation and testing in the context of an all hazards approach. ^{Reference Ekmekci and Folayan16} Similarly, Knebel, et al proposed a decision-making process for government leadership in allocation of resources in disaster and developed a logic model utilizing a values-based framework. ^{Reference Knebel, Sharpe, Danis, Toomey and Knickerbocker17} A focused investigation of ethical decision making of EMS in Iran undertaken by Torabi, et al revealed themes of maintaining patient dignity and respect and regulation-based actions as key tenets guiding EMS decision making. ^{Reference Torabi, Borhani, Abbaszadeh and Atashzadeh-Shoorideh18} Whilst a small study and only reflective of one service, the findings of moral reasoning and decision making in the broader health care worker context is not unusual, particularly in settings of triage and resuscitation decision making. ^{Reference Torabi, Borhani, Abbaszadeh and Atashzadeh-Shoorideh18}

The Geneva Conventions are the international treaties that establish international humanitarian law during armed conflict. International humanitarian laws describe rules to limit suffering and provide guidance on what is and what is not acceptable during armed conflict. ^{Reference Vollmar19} Thompson and Hendriks explored ethical decision making in the military context. ^{Reference Thompson, Hendriks and Blais20} Previous studies have found variance in military staff behavior and attitude, or have not acted in accordance with expected ethical standards. ^{Reference Thompson, Hendriks and Blais20} Thompson, et al focused on operational ethical conflicts that accompany decision making in military action and investigated how perceptions of harm to self and others influenced decision making through the framework of mission orders. Their findings showed moral conflict in situations where decisions would result in potential harm, but that rules of engagement provide the framework for decision making when in such situations. ^{Reference Thompson, Hendriks and Blais20} A key finding from this study was the recommendation of operational ethics training to support staff. The commonality between use of rules of engagement to provide a framework of decision making and EMS use of clinical practice protocols or guidelines in decision making is worth noting. In both cases, people are making complex decisions in uncontrolled environments; pre-established practice frameworks that are known and understood provide assurance to the providers to guide decision making.

In the humanitarian context of disaster response, principles of humanity, impartiality, neutrality, and independence serve as the ethical framework for decision and action. The United Nations Inter-Agency Standing Committee (Geneva, Switzerland) Operational Guidelines on the Protection of Persons in Situations of Natural Disasters were implemented to protect the rights of persons receiving disaster response or recovery interventions. ²¹ These guidelines describe principles of consent, informed and involved decision making, and local ownership in respect to humanitarian response efforts. ²¹ In addition to this, the Inter-Agency Standing Committee Guidelines are further strengthened by the Sphere (Geneva, Switzerland) Humanitarian Charter and Minimum Standards in Humanitarian Response. ²² The charter core standards represent minimum criteria for appropriate care of an affected population in the humanitarian setting and is an internationally recognized set of common principles and universal minimum standards in humanitarian response. ²² The International Committee of the Red Cross (Geneva, Switzerland) provides ethical codes of conduct for the International Red Cross and Red Crescent movements. ^{Reference Larkin, Koenig and Schultz1,23} Their guidance states that humanitarian aid is neither a partisan nor a political act, and must not be perceived as either; that humanitarian aid is given without consideration of race, creed, nationality, age, gender, or other qualifiers; and is prioritized based on need alone. ²³ Notwithstanding this, the provision of humanitarian care faces ethical challenges in operations as described by Clarinval and Biller-Andomo. In particular that the application of the principles are difficult, if not impossible, in some circumstances to apply in operations or that they are conflicting in settings due to lack of resources and decisions related to distribution; or, where lack of security prevents or potentially limits provision of car despite humanitarian practice operating under the international humanitarian law Rule 32: “the safety and protection from attack of objects used for humanitarian relief operations.” ^{Reference Clarinval and Biller-Andorno24} Clarinval and Biller-Andomo identified that whilst principles exist to guide humanitarian care, no structured reference framework currently exists that can assist aid workers in identifying potential ethical issues and support them in their decision-making process, and as such, developed and recommended a step-wise procedure to identify ethical considerations and address them in decision making. ^{Reference Clarinval and Biller-Andorno24}

Theme 3: Gestalt-Based Decision Making is a Feature of Health Care and Disaster Management Leadership, Yet Often Lacks an Ethical Framework to Guide it and/or is Based on A Priory Knowledge which May Not Reflect Future and Emerging Disaster Risk.

Whilst ethical guidance may exist in organizational systems, when such organizations collectively approach a singular threat, the application of an ethical framework to guide or reference decision making is clouded. In some contexts, the reference to legal authority to act on behalf of communities is evident, however, the ethical background to such decisions was based on the local judicial system and Gestalt. Krolik proposed that by incorporating a rights-based approach to disaster management, practitioners are not only ensuring that the rights of affected communities are being protected, but also that the affected communities are participating in and helping to shape the disaster management activities that impact on and involve them. ^{Reference Krolik25} Such an approach is intended to strengthen the disaster management process through involvement of community members to promote and protect human rights in disasters. ^{Reference Krolik25}

Crisis standards of care are a method of decision making to inform rationalizing health care resources in a constrained environment. In such circumstances, decisions on provision and limitations of treatment are based on availability of health care resources and demand. Leider, et al systematically reviewed ethical standards that inform crisis standards of care finding that early establishment of practical guidance for invocation and application was required. ^{Reference Leider, DeBruin, Reynolds, Koch and Seaberg4} Ethical frameworks for health care workers are well-established as practice norms and are commonly guided by relevant practitioner leadership bodies. Good has previously referred to this in “Ethical Decision Making in Disaster Triage” and reported the findings of Larkin and Arnold who recommended seven specific virtues to guide triage in disaster. ^{Reference Good26,Reference Larkin and Arnold27} Whilst the foundation of these is linked to codes of medical ethics, the validation of decision making in their application is yet to be conducted. Further to this, Berstein discussed the writing of Iserson and Moskop who had previously explored both the medical duty to respond in disaster and the ethics of application of triage when doing so. Findings showed that whilst ethical principles of duty to care and utilitarianism (greatest good) are established and known in health care, the practicalities of application and moral consequence of decision making in crisis are not well-established, and in some cases, result in legal action and prosecution. ^{Reference Bernstein28,Reference Boin and Nieuwenburg29} Similar conclusions were expressed by Holt, who noted the ethical challenges faced by medical practitioners in disasters and a need to provide education, guidelines, and a practical approach a priori to events. ^{Reference Holt30}

Erbay has critically reviewed ethical practice related to prehospital triage. ^{Reference Erbay31} Erbay reported that whilst principles of utilitarianism, beneficence, and justice underpinned triage practices, that the broad range of triage systems combined with balancing priorities of beneficence (greatest good for the greatest amount) and justice (equal chance) can result in subjective decision making. ^{Reference Erbay31} Key findings included recommendations of an ethical framework to guide application of triage practices. ^{Reference Erbay31}

The predominant research identified in this review focused on analysis of practice. Lentz, et al conducted a scoping review of literature exploring moral distress in first responders. The scoping review identified a limited number of studies, and no research articles exploring moral injury. ^{Reference Lentz, Smith-MacDonald, Malloy, Carleton and Brémault-Phillips32} Lentz found that first responders were often faced with complex moral dilemmas and difficult ethical decisions that can result in moral distress. ^{Reference Lentz, Smith-MacDonald, Malloy, Carleton and Brémault-Phillips32} Studies reviewed showed that personal values guided decision making. Norberg found similar findings where first responders face complex situations requiring fast decisions with often limited or unclear information. In such situations, individuals take into consideration risks and benefits to individuals, public, and community. ^{Reference Norberg33}

Papazoglou and Chopko proposed that the potential of moral harm can be decreased through preparedness, sense of control, and understanding one’s values. ^{Reference Papazoglou and Chopko34} Likewise, Norberg recommended the importance of developing practical ethical awareness in tasks and activities; ^{Reference Norberg33} however, these factors did not decrease moral distress. ^{Reference Norberg33} Boin and Nieuwenburg focused on the consequence of an absence of guidance to inform practice, the potential and actual harm to both person requiring help and the provider. ^{Reference Boin and Nieuwenburg29} In particular, the use of discretion in overwhelming crisis situations resulting from disaster. ^{Reference Boin and Nieuwenburg29} The case example provided, the moral dilemma of the Memorial Hospital and Srebrenica tragedy, illustrates both tragic outcomes in the face of crisis and complex decision making in frontline military and health care operations. ^{Reference Boin and Nieuwenburg29} Further to this, the point is well-made by the authors of the unfair and unethical nature of resting the authority of decision making in a complex crisis and morally ambiguous situation with the first line responders attempting to manage the incident they are faced with. Consequently, the unresolved question remains of who should receive what limited resources are available, who makes that decision, and what guides it?