World Medical Association, Statement on Medical Ethics in the Event of Disasters (1994)

Adopted by the 46th WMA General Assembly
Stockholm, Sweden, September 1994


1. The definition of a disaster for the purpose of this document focuses particularly on the medical aspects.

A disaster is the sudden occurrence of a calamitous event, usually sudden and violent, resulting in substantial material damage, considerable displacement of people and/or a large number of victims and/or significant disruption of society, or a combination of these. The definition in this context excludes situations arising from conflicts and wars, whether international or internal, which give rise to other problems in addition to those considered in this paper. From the medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between the capacity and resources of the medical profession and the needs of the victims or the people whose health is threatened, over a given period of time.
2. Disasters, whether they are natural (e.g. earthquakes), technological (e.g. nuclear or chemical accidents) or accidental (e.g. train derailments) are characterized by several features which give rise to particular problems:
a) their sudden occurrence, demanding prompt action;
b) the inadequacy of medical resources, which are geared to normal circumstances: the large number of victims means that available resources have to be used most efficiently in order to save as many lives as possible;
c) material or natural damage making access to the victims difficult and/or dangerous;
d) adverse effects on the health situation due to pollution and the risks of epidemic;
e) a context of insecurity calling for police or military measures to maintain order;
f) media coverage.
Accordingly, disasters call for a multifaceted response involving many different types of relief ranging from transportation and food supplies to medical services, against a background of tight security (police, fire service, army,...). These operations require an effective and centralized authority to coordinate public and private efforts. Rescue workers and physicians are confronted with an exceptional situation in which their individual ethics must somehow blend with the ethical requirements demanded by the community in such an emotionally exacerbated situation.
Ethical rules defined and taught beforehand should complement the individual ethics of physicians.

Inadequate and/or disrupted medical resources on site and the large number of people injured in a short time present a specific ethical problem.

Providing medical services under such conditions involves technical and organizational issues that add to the ethical issues. The World Medical Association therefore recommends the following ethical attitudes in the physician's role in disaster situations.

3.
TRIAGE
3.1. Triage poses the first ethical problem owing to the limited treatment resources immediately available in relation to the large number of victims in varying states of health. Triage is a medical action of prioritizing treatment and management based on making a diagnosis and formulating a pragnosis. Patient survival will depend on triage. It must be carried out quickly, taking into account the medical needs, medical intervention capabilities and available resources. Vital acts of reanimation may have to be carried out at the same time as triage.
3.2. Triage should be entrusted to an authorized, experienced physician, assisted by a competent staff.
3.3. The physician should separate victims as follows:






a) victims that can be saved but whose lives are in immediate danger, requiring treatment straight away or as a matter of priority within the next few hours;
b) victims whose lives are not in immediate danger and who are in need of urgent but not immediate medical care;
c) injured persons requiring only minor treatment, who can be treated later or by relief workers;
d) psychologically traumatized victims needing to be reassured, who cannot be taken care of individually but who might need reassurance or sedation if acutely disturbed;
e) victims whose condition exceeds the available therapeutic resources, who suffer from extremely severe injuries such as irradiation or burns to such an extent and degree that they cannot be saved in the specific circumstances of time and place, or complex surgical cases requiring a particularly delicate operation which would take too long, thereby obliging the physician to make a choice between them and other patients. For these reasons, all such victims may be classified as cases "beyond emergency care". The decision to "abandon an injured person" on account of priorities dictated by the disaster situation cannot be considered "failure to come to the assistance of a person in mortal danger". It is justified when it intends to save the maximum number of victims.
f) Since cases may evolve and this change category, it is essential that the situation be regularly reassessed by the official in charge of the triage.
3.4 a) From the ethical standpoint, the problem of triage and the attitude to be adopted towards victims "beyond emergency care" fits within the framework of the allocation of immediately available means in exceptional circumstances beyond human control. It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere. However, the physicians must show his/her patients compassion and respect for the dignity of their private lives, for example by separating them from others and administering appropriate pain relievers and sedatives.
b) The physician must act according to his/her conscience considering the means available. He/she should attempt to set an order of priorities for treatment which will save the greatest number of serious cases that have a chance of recovery and restrict morbidity to a minimum, while accepting the limits imposed by the circumstances.
The physician should pay particular attention to the fact that children may have special needs.


4.
RELATIONS WITH THE VICTIMS
4.1. The type of care given to victims will be first-aid and emergency medical care. In the event of a disaster the physician should provide medical assistance to every victim indiscriminately without waiting for a request for help.
4.2. In selecting the patients who may be saved, the physician should consider only their emergency status, and should exclude any other consideration based on non-medical criteria.
4.3. Relations with the victims are governed by first-aid medical care and the state of need, with the result that the need to protect patients' best interests shall be respected, if possible, by obtaining their consent in the immediate emergency. However, the physician should adjust to the cultural differences of the populations concerned and act in accordance with the requirements of the situation. He/she should be guided by the concept of optimal care which includes both technological care as well as emotional care to save as many lives as possible and to reduce morbidity to the absolute minimum.
4.4. Relations with victims also involve aspects associated with mourning loss of life that are quite apart from technical medical acts recognizing and supporting their psychological distress. These include respecting the dignity and morals of victims and their families and lending a helping hand to survivors.
4.5. The physician must respect the customs, rites and religions of the victims and act in all impartiality.
4.6. If possible, the difficulties encountered and the identification of the victims should be reported for medical follow-up.

5.
RELATIONS WITH THIRD PARTIES
The physician has a duty to each patient to exercise discretion and ensure confidentiality when dealing with the media and other third parties, and to exercise caution and objectivity and act with dignity in respect to the emotional and political atmosphere surrounding disaster situations.

6.
DUTIES OF PARAMEDICAL PERSONNEL
The ethical principles which apply to physicians also apply to personnel under the physician's direction.

7.
TRAINING
The World Medical Association recommends that disaster medicine training be included in the curricula of university and postgraduate courses in medicine.

8.
RESPONSIBILITY
The World Medical Association calls upon Member States and insurance companies to establish a form of diminished responsibility or responsibility without misconduct to cover both civil liability and any personal damages to which physicians might be subject when working in disaster or emergency situations.

The WMA requests that governments:
a) afford assistance and protection to foreign physicians and accept their action and their appearance and presentation, (e.g. Red Cross, Red Crescent) without discrimination on the basis of race, religion, etc.
b) give priority to the rendering of medical services over visits of dignitaries.