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Informing the Gestalt: An Ethical Framework for Allocating Scarce Federal Public Health and Medical Resources to States During Disasters
- Ann R. Knebel, Virginia A. Sharpe, Marion Danis, Lauren M. Toomey, Deborah K. Knickerbocker
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- Disaster Medicine and Public Health Preparedness / Volume 8 / Issue 1 / February 2014
- Published online by Cambridge University Press:
- 10 March 2014, pp. 79-88
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During catastrophic disasters, government leaders must decide how to efficiently and effectively allocate scarce public health and medical resources. The literature about triage decision making at the individual patient level is substantial, and the National Response Framework provides guidance about the distribution of responsibilities between federal and state governments. However, little has been written about the decision-making process of federal leaders in disaster situations when resources are not sufficient to meet the needs of several states simultaneously. We offer an ethical framework and logic model for decision making in such circumstances. We adapted medical triage and the federalism principle to the decision-making process for allocating scarce federal public health and medical resources. We believe that the logic model provides a values-based framework that can inform the gestalt during the iterative decision process used by federal leaders as they allocate scarce resources to states during catastrophic disasters. (Disaster Med Public Health Preparedness. 2014;0:1–10)
Contributors
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- By Rose Teteki Abbey, K. C. Abraham, David Tuesday Adamo, LeRoy H. Aden, Efrain Agosto, Victor Aguilan, Gillian T. W. Ahlgren, Charanjit Kaur AjitSingh, Dorothy B E A Akoto, Giuseppe Alberigo, Daniel E. Albrecht, Ruth Albrecht, Daniel O. Aleshire, Urs Altermatt, Anand Amaladass, Michael Amaladoss, James N. Amanze, Lesley G. Anderson, Thomas C. Anderson, Victor Anderson, Hope S. Antone, María Pilar Aquino, Paula Arai, Victorio Araya Guillén, S. Wesley Ariarajah, Ellen T. Armour, Brett Gregory Armstrong, Atsuhiro Asano, Naim Stifan Ateek, Mahmoud Ayoub, John Alembillah Azumah, Mercedes L. García Bachmann, Irena Backus, J. Wayne Baker, Mieke Bal, Lewis V. Baldwin, William Barbieri, António Barbosa da Silva, David Basinger, Bolaji Olukemi Bateye, Oswald Bayer, Daniel H. Bays, Rosalie Beck, Nancy Elizabeth Bedford, Guy-Thomas Bedouelle, Chorbishop Seely Beggiani, Wolfgang Behringer, Christopher M. Bellitto, Byard Bennett, Harold V. Bennett, Teresa Berger, Miguel A. Bernad, Henley Bernard, Alan E. Bernstein, Jon L. Berquist, Johannes Beutler, Ana María Bidegain, Matthew P. Binkewicz, Jennifer Bird, Joseph Blenkinsopp, Dmytro Bondarenko, Paulo Bonfatti, Riet en Pim Bons-Storm, Jessica A. Boon, Marcus J. Borg, Mark Bosco, Peter C. Bouteneff, François Bovon, William D. Bowman, Paul S. Boyer, David Brakke, Richard E. Brantley, Marcus Braybrooke, Ian Breward, Ênio José da Costa Brito, Jewel Spears Brooker, Johannes Brosseder, Nicholas Canfield Read Brown, Robert F. Brown, Pamela K. Brubaker, Walter Brueggemann, Bishop Colin O. Buchanan, Stanley M. Burgess, Amy Nelson Burnett, J. Patout Burns, David B. Burrell, David Buttrick, James P. Byrd, Lavinia Byrne, Gerado Caetano, Marcos Caldas, Alkiviadis Calivas, William J. Callahan, Salvatore Calomino, Euan K. Cameron, William S. Campbell, Marcelo Ayres Camurça, Daniel F. Caner, Paul E. Capetz, Carlos F. Cardoza-Orlandi, Patrick W. Carey, Barbara Carvill, Hal Cauthron, Subhadra Mitra Channa, Mark D. 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Jacob, Arthur James, Maria Jansdotter-Samuelsson, David Jasper, Werner G. Jeanrond, Renée Jeffery, David Lyle Jeffrey, Theodore W. Jennings, David H. Jensen, Robin Margaret Jensen, David Jobling, Dale A. Johnson, Elizabeth A. Johnson, Maxwell E. Johnson, Sarah Johnson, Mark D. Johnston, F. Stanley Jones, James William Jones, John R. Jones, Alissa Jones Nelson, Inge Jonsson, Jan Joosten, Elizabeth Judd, Mulambya Peggy Kabonde, Robert Kaggwa, Sylvester Kahakwa, Isaac Kalimi, Ogbu U. Kalu, Eunice Kamaara, Wayne C. Kannaday, Musimbi Kanyoro, Veli-Matti Kärkkäinen, Frank Kaufmann, Léon Nguapitshi Kayongo, Richard Kearney, Alice A. Keefe, Ralph Keen, Catherine Keller, Anthony J. Kelly, Karen Kennelly, Kathi Lynn Kern, Fergus Kerr, Edward Kessler, George Kilcourse, Heup Young Kim, Kim Sung-Hae, Kim Yong-Bock, Kim Yung Suk, Richard King, Thomas M. King, Robert M. Kingdon, Ross Kinsler, Hans G. Kippenberg, Cheryl A. 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Yee, Viktor Yelensky, Yeo Khiok-Khng, Gustav K. K. Yeung, Angela Yiu, Amos Yong, Yong Ting Jin, You Bin, Youhanna Nessim Youssef, Eliana Yunes, Robert Michael Zaller, Valarie H. Ziegler, Barbara Brown Zikmund, Joyce Ann Zimmerman, Aurora Zlotnik, Zhuo Xinping
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- The Cambridge Dictionary of Christianity
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- 05 August 2012
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- 20 September 2010, pp xi-xliv
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Cheshire Calhoun, Feminism, the family, and the politics of the closet: Lesbian and gay displacement. Oxford: Oxford University Press, 2000, ISBN 0198295596
- Virginia Ashby Sharpe
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- Hypatia Reviews Online / Volume 2004 / 2004
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- 31 March 2021, E32
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- 2004
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9 - Unnecessary surgery
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 194-212
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Summary
In the context of surgery, the term ‘iatrogenic illness’ or ‘iatrogenic complication’ has been reserved for surgical mishaps and adverse surgical outcomes. Although these outcomes may secondarily give rise to an assessment that a procedure was itself unnecessary or inappropriate, unnecessary surgery per se has not traditionally been recognized as an iatrogenic harm. One explanation for this may be that attention to unnecessary surgery has primarily come from private or governmental insurers who have tended to focus on the direct aggregate economic costs of the phenomenon rather than on its indirect or intangible human costs in morbidity, mortality, pain, suffering, or loss of livelihood to individuals. In other words, from the point of view of health policy, unnecessary surgery has been understood principally as a problem of ‘surgical overuse’ rather than iatrogenic harm. Another reason why unnecessary surgery has not itself been regarded as a patient harm may be a general skepticism about even the occurrence of unnecessary surgery. If we understand an unnecessary surgery to be one that offers no anticipated preponderance of benefit to the patient, then many would argue that no doctor would perform such a surgery. This view is of course countered by another common impression that such surgeries do occur and that the only identifiable benefits that accrue from them are remunerative ones to the physician.
In this chapter, we explore both what is meant by the term unnecessary surgery and the evidence that has been offered to explain the scope and nature of the problem.
Part II
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 79-80
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7 - From hospitalism to nosocomial infection control
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 153-174
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Historic debates: puerperal fever, antisepsis, and the germ theory of disease
What is now known as nosocomial or hospital-based infection made its indelible mark on history during the childbed fever epidemics of the eighteenth and nineteenth centuries. During this period, puerperal deaths in hospitals and lying-in institutions were estimated to be as high as 150 per 1000 deliveries, whereas the same disease afflicted less than 20 in 1000 women delivering at home. One of the first indications of the physician's role in the etiology of childbed fever was given by Alexander Gordon in 1795 in his account of 28 cases of the disease at the Aberdeen dispensary, Scotland. In this account, he expressed his conviction, based on empirical evidence from his own practice, that he and certain midwives had been the source of transmission.
The most significant epidemiological work on the physician's role in the transmission of puerperal fever was done in the mid-nineteenth century by Ignaz Semmelweis at the Allgemeines Krankenhaus in Vienna. During this period, pathological anatomy was becoming an integral part of the medical curriculum, and medical students and physicians moved freely between the autopsy and delivery rooms. Based on astute clinical observation of the two obstetric wards at the hospital, Semmelweis identified physicians going from cadavers to parturient women as the main vector of the disease. In Ward 1, where deliveries were performed by physicians and students, 600 to 800 women or 20% died each year from childbed fever.
Medical Harm
- Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness
- Virginia Ashby Sharpe, Alan I. Faden
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- 22 September 2009
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- 13 February 1998
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It is estimated that up to thirteen percent of hospital admissions result from the adverse effects of diagnosis or treatment, and that almost seventy percent of iatrogenic complications are preventable. The obligation to 'do no harm' has been central to medical conduct since ancient times, yet iatrogenic illness has now come to be recognized as a significant risk factor in health care delivery. This book integrates history, philosophy, medical ethics and empirical data to examine the concept and phenomenon of medical harm. Issues covered include appropriateness of care, acceptable risk and practitioner accountability, and the book concludes with recommendations for limiting iatrogenic harm. Essential reading for medical ethicists, physicians and those involved in health care policy and administration, this stimulating and highly readable book will be of interest to all providers of health care, and many of their patients.
Index
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 271-280
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10 - The concept of appropriateness in patient care
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 213-229
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Appropriateness, values and risk
The shift to appropriateness in health services research underscores that judgments about surgical overuse and the provision of unnecessary services depend on prior judgments about the criteria for appropriate use. This shift is, in other words, an acknowledgment that clinically sound utilization decisions depend on a sound evidentiary basis regarding what works in clinical practice. Because only a small minority (15 to 20%) of treatments have been evaluated in rigorous scientific trials, however, this is a daunting task. It is also one that raises important and controversial questions about what counts as an authoritative form of evidence in determinations regarding efficacy, effectiveness, and safety – or in other words, regarding clinical benefit and harm. The shift to appropriateness also raises important questions regarding the values that do and should guide medical decision making. To say that something is ‘appropriate’ is to say that it is ‘suitable or fitting for a particular purpose, occasion, or person’. The term ‘appropriate’ is, thus, fundamentally evaluative; it implies the endorsement of some goal. ‘Appropriate for what and whom?’ and ‘appropriate to what and whose ends?’ are questions that must be answered, therefore, if the term is to be made meaningful.
Traditionally, the authority for clinical decision-making has rested with the physician; the physician was believed to know what was best or appropriate for a patient and due deference was paid to medical judgment.
1 - Divided loyalties: harm to the profession vs. harm to the patient
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 21-35
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Recent scholarship in the history and sociology of American medicine provides a compelling account of how the professional authority of physicians was consolidated in the mid-nineteenth and early twentieth centuries. This consolidation occurred both by chance and by design. The introduction of surgical antisepsis (and later asepsis) and of diagnostic technologies such as the stethoscope, and X-ray as well as diagnostic tests, enhanced the credibility of the ‘regular’ physician and distinguished his abilities from the less demonstrative ones of homeopaths and botanics. This was also the most dramatic period of hospital growth in the United States. In 1873, there were 178 hospitals and by 1910 there were more than 4000. The role of physicians – and especially surgeons – was essential to this growth, for it was surgeons who provided the patients to fill the ever increasing number of hospital beds. By the late 1920s, surgical admissions outnumbered medical admissions by almost two to one. Further, as the public began to respond to the promise of surgical cures, the availability of surgical resources provided the all important argument for the advantage of hospital over home care. During this period, the hospital as a social institution was changing dramatically. In the early 1800s, hospitals were essentially charitable institutions, indeed, almshouses for the ‘deserving poor’. A patient's admission to the hospital was based on an assessment by hospital trustees of the moral character of the potential ‘inmate’.
5 - Due care as a specification of the duty to ‘do no harm’
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 100-114
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In practice, the obligation to do no harm has traditionally been articulated in the doctrine of ‘due care’; the notion that patients are due or owed a certain standard of care by health care providers. According to Beauchamp and Childress, these requirements follow from the imposition of risk. In the treatment of the patient, standards of due care ‘can be met only if the goals sought justify the risks that must be imposed to achieve the goals’. Historically, the standards governing practice have been determined largely by the medical profession. They have also been mandated by governmental regulation.
In recent years, third-party payers attempting to get more value for their health care expenditures, have begun to place greater emphasis on knowing what works, using what works, and doing well what works in the delivery of care. In so doing, these economic agents have emerged as a new and powerful source of standards oriented not only to the quality of medical and nursing care but also to its cost. As more explicit attention is given to quality and cost in health care, we will need to determine whether and to what degree new efforts at standardization are coincident not simply with greater efficiency and economy but, more importantly, with the duty to do no harm. In this chapter, we argue that the shift to more evidence-based standards in medicine is a promising one to the extent that it is guided primarily by moral, rather than financial considerations.
2 - Medical epistemology, medical authority and shifting interpretations of beneficence and nonmaleficence
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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- Medical Harm
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- 22 September 2009
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- 13 February 1998, pp 36-60
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Summary
When Ernest Codman identified patient benefit as the ultimate standard and measure of the quality of care, he provided no explicit argumentation to justify his claim. Most likely, he saw it as self evident since his position reflected one of the most fundamental ethical commitments of medicine since the time of Hippocrates. The Hippocratic referents for the obligation to benefit the patient (beneficence) and to avoid patient harm (nonmaleficence) are found in the Oath and the Epidemics. In the Oath, the Hippocratic physician vows ‘to use my treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing’. and to come ‘to whatever houses I may visit… for the benefit of the sick …’ In Epidemics I, the physician is instructed to ‘make a habit of two things – to help, or at least to do no harm’.
In order to make historical sense of medical harm and the shifting interpretations of beneficence and nonmaleficence we examine the tradition of humoralism and its gradual displacement by scientific medicine in the nineteenth and twentieth centuries. We find, in each of these therapeutic traditions a paternalistic cast to the interpretation of these duties. Whereas the medical paternalism of the early nineteenth century may have been relatively unproblematic from the patient's point of view (since patient and physician had a common understanding of disorders and their treatments) the paternalism accompanying scientific medicine is grounded in the presumed epistemic authority of the physician.
Acknowledgments
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Introduction
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Summary
'Tis impossible to separate the chance of good from the risk of ill.
David HumeThe phrase ‘medical harm’ seems paradoxical. It defies our expectations about medicine; our expectations that medicine will benefit, rather than harm us and that individual and institutional providers will improve rather than diminish our health. But iatrogenic illness – literally, illness that is ‘induced by the physician’ – has come to be recognized as a significant source of patient risk. In the United States, it has been estimated that during hospitalization, as many as a third of patients suffer from complications related to their medical or nursing care. Between 5% and 13% of hospital admissions result from the adverse effects of diagnosis or treatment. The 1991 Harvard Medical Practice Study concluded that almost 70% of iatrogenic complications are preventable and affect more than 1.3 million hospitalized patients annually. During the fee for service era, patients were believed to be at considerable risk for unnecessary treatments. Today, there is growing concern regarding the risks associated with economically-motivated denials of necessary care.
In the last half of the twentieth century, attention to the problem of medically induced illness in the United States has come from a number of sources including the medical and legal professions, federal agencies and consumer advocacy groups.
It was in the 1950s and 1960s, after the enormous post-war expansion in pharmacological therapies, that the occurrence of iatrogenic complications – particularly adverse drug reactions – began to receive attention in the medical literature.
Part I
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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8 - Adverse effects of drug treatment
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Summary
Sir William Osler said that, ‘a desire to take medicine is, perhaps, the great feature which distinguishes man from other animals’. Unfortunately, no medicinal agent is without potential side-effects. The noxious actions of drugs were well-recognized in early nineteenth-century medicine in the United States and even before; indeed, drugs were often chosen precisely for such effects during the era of counter-irritant/depletion therapy promulgated by Rush and his disciples. Medicinal remedies often included toxic minerals, such as mercury, arsenic, and antimony. Use of patent medicines, popular in the eighteenth century, expanded considerably after the revolutionary war, in part due to extensive advertising. Even as promoters of patent medicine criticized regular practitioners for using mercury-containing purgatives, they also not uncommonly included mercury in their nostrums, as well as substantial amounts of opium and alcohol.
Since the mid-nineteenth century, government legislation and regulation relating to drugs have served to reduce consumer and physician control of drug choices. Until the Drug Import Law of 1848, the majority of medications were imported into the United States. The Federal Food and Drug Act of 1906, and the Federal Food, Drug, and Cosmetic Act of 1938 to standardize medicinal preparation and availability, with the intent of protecting the consumer. However, prescription drug use since the late- 1920s has increased dramatically.
Appendix
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Bibliography
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Frontmatter
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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Part III
- Virginia Ashby Sharpe, Alan I. Faden, Georgetown University, Washington DC
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