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Mass Medical Care with Scarce Resources: The Essentials

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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2. Ethical Considerations

Key Questions

What ethical challenges do planners face in preparing for a mass casualty event?

How can planners employ a systematic approach to making ethical decisions as they prepare for a mass casualty event?

Ethical issues are critical in shaping and implementing any community's disaster response planning. Who do we protect, and to what level of safety? Disaster preparedness planning almost inevitably has to be concerned with providing some minimum level of protection to all. How do we set budgets and priorities? Who do we evacuate first? Ethical choices must be made clear during the planning process so that on-the-spot decisions will be consistent with those choices.

Transparency also serves the goal of accountability. Citizens have a right to know what decisions public institutions make on their behalf—especially in those life-or-death choices that a disaster can require. Transparency opens the process to public feedback. This can help professionals ensure that their plans reflect community values and concerns.

Understanding of what is meant by rights and fairness is necessary. Planners must define these principles to gain community commitment to any disaster response plan. The public will support difficult choices if they know about and are committed to them beforehand and if they have input into the process.

Collaborative involvement of elected officials from all levels of government with local planners and citizens groups also is necessary. Direct citizen participation also should have a role in planning, including opportunities for discussion among a cross-section of community leaders.

In desperate situations, resources will indeed be overwhelmed. Preparedness activities will always be in competition with other priorities and it is impossible to be 100% prepared, but the better the plan, the easier it will be to carry out that plan when adverse events do occur. In that sense, disaster planners need to defend both their own interests and those of their communities through the planning process.

Deciding how and why to divert resources from one sector of the community to others should rest on predictions of what will produce the best outcome for the most people and on considerations of how resource distribution will work to ensure that Federal, State, and local governments meet their obligations. A balance must be struck between utilitarian (the greatest good for the greatest number) and duty-based (respect for all human beings) planning assumptions.

Ethics Analysis Algorithm: Applying a Systematic Approach to Sorting Through Ethical Disagreements

Debate about which ethical principles and theories to apply and how to prioritize them in a specific situation has been going on for millennia. As noted, there are no simple, formulaic schemes for such choices. There are, however, ways of thinking about ethical principles and theories that can help preparedness planners devise strategies for emergency response. These involve a systematic approach to applying basic ethical principles and theories to any particular situation. One can create an ethics algorithm that, if consistently applied to planning for any particular kind of emergency, can at least provide reasonable confidence that ethical issues raised by an emergency were well-considered. The ethics algorithm might be constructed as follows:

  1. Who are all the possibly interested parties? Think broadly—include not only persons and categories of persons but institutions, organizations, professions, and/or communities.
  2. What is the full range of duties and obligations of each potentially interested party, or at least the primarily interested parties? Think of parties as not only individuals but also institutions and groups.
  3. How might various duties and obligations of each of the various parties clash or conflict?
  4. What might be short-term and long-term consequences, both good and bad, of each possible course of action? How confident are you of your predictive accuracy?
  5. What ethical principles are at stake? (Possible ethical principles include respect for persons, beneficence, nonmalfeasance, justice, truth telling, liberty, opportunity, and reciprocity.) Which ones are in tension?
    1. After enumerating the list of principles at stake, work to specify them; refine the meaning of each principle involved. Work to bring broad abstractions down to the level of the specific situation under discussion.
    2. Make explicit the strategy for use of the principles. For example, for the situation at hand, must all the involved principles be upheld or is the strategy to balance the principles? If a balancing strategy is being applied, make explicit which values/ethical considerations are being balanced against which other values/ethical considerations.
  6. What might be the intentions of the various players? Evaluate the praiseworthiness or lack thereof, of the motives of the people, organizations, and/or institutions involved.
  7. What appears to be the full range of the possible courses of action?
  8. Weed out those possible courses of action that do not appear to be justifiable based on potentially bad consequences, inability to meet duties and obligations, and/or the ethical soundness, or lack thereof, of intentions.
  9. With the remaining possible courses of action, make explicit the justifications for taking each. Then vigorously scrutinize whether or not those justifications are ethically robust.

The sequence in which 2 through 6 above is conducted may not appear to be of major importance. It is necessary, however, to be able to claim convincingly that all points have been thoughtfully considered and deliberated, with all discussions and decisions fully documented.

Evan G. DeRenzo, Ph.D., Center for Ethics, Washington Hospital Center, Washington, DC.

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