BY: BRUCE COMPTON
Creating a Discernment Process
Natural disasters resulted in an expensive and deadly 2017. Wildfires relentlessly scorched dry land from California to Portugal. Super-strength hurricanes and tropical storms slammed homes from the Caribbean to Ireland. Famine continued in Somalia and Yemen, while avalanches killed more than a hundred people in Afghanistan.
Although the monetary costs of these disasters got the headlines, Catholic health care organizations are called to look at far more than financial implications as they respond to disasters in communities they serve in the United States and internationally.
Health systems and hospitals play a critical role in providing treatment and support to victims in a disaster's aftermath, yet it is significant that the magnitude of some 21st-century disasters has either threatened to shut down or significantly overwhelm responding Catholic hospitals and medical missions. Examples: Hurricane Katrina (2005), the Haiti earthquake (2010), Hurricane Harvey and the active shooter incident in Las Vegas (both in 2017) and Hurricane Florence (2018).
In recognition of the significant and increasing effect that disasters can have on hospital care in the United States as well as on Catholic missions overseas, Catholic Health Association members gathered this summer at "When Disasters Strike: A Special Convening for International and Domestic Response," a forum for sharing insights and lessons learned. Participants and panelists with vast and varied experience discussed the numerous effects that Catholic health care should anticipate in a disaster.
Participants described a resounding sense of religious and moral obligation to help during a disaster, a commitment shared across individuals and their organizations. This discussion led to a conversation regarding a discernment process and ethical framework to assist health care and aid organizations when making decisions related to natural disaster response.
Theologian and ethicist Carl Middleton, DMin, MDiv, MA, MRE, has continued to think about the subject and offered the following insights:
CHA: During the recent CHA special convening, When Disasters Strike, you mentioned the potential need for a disaster-specific discernment process and ethical framework for decision-making. Why?
Middleton: Disasters often require some form of triaging, allocation and rationing of resources because the demand is far greater than the supply. Recent disasters that have involved Catholic health facilities and Catholic health systems have emphasized the importance of preparedness for all types of disasters. A discernment process and ethical framework are needed to provide guidance in decision-making for a wide variety of disasters.
CHA: What might be included in this type of discernment process and ethical framework?
Middleton: The major Catholic health [care] systems have their own discernment process that could be used as a model for disasters/humanitarian crises. A discernment process from a faith-based perspective would typically include clinical, organizational and public health ethics. Usually there are at least three parts to a discernment process: the analysis phase, resolution phase and evaluation.
CHA: Can you tell me a little more about each of these phases (analysis, resolution and evaluation) of the discernment process?
Middleton: As a former executive at Catholic Health Initiatives, I am most familiar with their discernment process, and from my experience using their process, I would suggest the following elements are typically involved:
THE ANALYSIS PHASE
- Begin with prayer and reflection
- Define the issues, identifying key facts, factors and stakeholders
- Establish the facts of the issue: who, what, where, when, why and how
- Clarify who will own the decision
- Frame the perspectives: Identify your own perspective and appreciate the perspectives of others
- Identify who will be affected by the decision
- Identify all possible alternatives
- Brainstorm options — including doing nothing — and determine the pros and cons of each
THE RESOLUTION PHASE
- Analyze the values: What values are at stake?
- What are the significant value conflicts?
- What values are being affirmed, and what values are being negated?
- Conduct prayerful reflection upon the alternatives in light of your mission and values
- Determine what is the right thing to do for the right reason
- Make a decision: Identify which alternative/option best advances your mission, values and core strategies
- Choose your path among the possible alternatives
- Implement the decision: Develop a process for carrying it out
- Determine how and when the decision will be communicated to all stakeholders
EVALUATION PHASE
- Evaluate whether the solution addressed the defined problem
- Determine if your actions produced the desired outcomes
- Document and use lessons learned for future planning and response
CHA: How would the ethical framework for decision-making in disasters be developed?
Middleton: Prior to implementing the discernment process and ethical framework, you would need to go through a selection process to identify a team of persons with appropriate expertise and experience that will be involved and conduct the discernment. The ethical framework would be developed from Catholic moral and social teaching, the Ethical and Religious Directives for Catholic Health Care Services and other ethical literature. You would need to identify the key ethical values that would have pertinence to decision-making in various disasters. Each value would have a definition and a series of questions to be reflected upon and answered as part of the decision-making process. An example might be: The duty to provide care and to respond to suffering is inherent to all health care professionals' code of ethics.
Decision-makers should assess who among the staff is willing to serve during a crisis; work collaboratively with stakeholders and professional staff in advance to establish practice guidelines; work collaboratively to develop fair and accountable processes to resolve disputes; and provide support to ease the moral burden of those with the duty to care.
CHA: You mentioned duty to care. What other values might be considered in an ethical framework?
Middleton: Some of the values to be considered might include the following, adapted from [Allison K. Thompson et al.,] "Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making," [BMC Medical Ethics]:
- Reasonableness: Decisions should be based on reasons (i.e. evidence, principles, values) that stakeholders can agree are relevant to meeting health needs during a disaster
- Responsiveness: Leaders should revisit and revise decisions as new information emerges throughout the crisis
- Duty to provide care: The duty to provide care and to respond to suffering is inherent to all health care professionals' code of ethics
Some other values that Catholic health care might want to include are:
- Equity: During a crisis, tough decisions will need to be made when resources are limited
- Individual liberty: Restrictions to individual liberty may be necessary to protect the public from serious harm
- Privacy: In a crisis it may be necessary to override this right to protect the public from serious harm
- Proportionality: Requires restrictions to individual liberty and measures taken to protect the public from harm
- Do no harm: A foundational principle of ethics is the obligation to protect the public from serious harm
- Common good: During a crisis, people need to have the basic necessities, food, shelter, water, clothing, etc.
- Reciprocity: Requires that society supports those who face a disproportionate burden in protecting the public good and take steps to minimize its impact.
- Solidarity: A disaster will require collaboration between local, national and global partners
- Stewardship: Trust, ethical behavior and good decision-making are utilized in allocation and rationing decisions
- Trust: Early engagement and transparent communication with stakeholders
CHA: Wow. That is a lot to grapple with. What do you think are the next steps for hospitals and health systems?
Middleton: For those hospitals and health systems that have discernment processes, the processes need to be evaluated through a collaborative effort by the ethics committee and the disaster preparedness committee. They should make sure the process is relevant to making decisions, especially triage and allocation decisions that have to be made during a disaster or crisis.
For those facilities that do not have a discernment process, they should research and find or develop a discernment process appropriate for their institutions and setting. Another step may be for Catholic hospitals and health systems to partner and collaborate with CHA on developing a disaster preparedness discernment process that could be used throughout Catholic health care.
BRUCE COMPTON is senior director, international outreach, the Catholic Health Association, St. Louis.