The weightiest decisions in medicine are not about which tests to order, or what drugs to

prescribe; they actually take place at the sharp intersection of medicine and ethics.

A. Utilitarianism
According to utilitarian principles, actions are appropriate if they produce the greatest amount of
good for the greatest number of people. Actions need not have similar or identical consequences
for all impacted individuals; rather, they must achieve the maximum overall benefit.

In the context of triage, the principle of utility might translate into a policy of attempting to
save the greatest number of lives
to direct treatment to those who are most likely to benefit from it.
health care providers may withhold medical resources from individuals considered unlikely
to benefit significantly from care.
might deny care to injured patients who require considerable resources because of
underlying infirmities or disabilities in order to save multiple patients who are healthier and
require less treatment.

Not all philosophers embrace utilitarianism principles. Some commentators criticize utilitarianism on
at least three grounds.
I.

II.
III.

First, utilitarianism may lead to results that defy moral and ethical values. For example, at its
extremes, utilitarianism might lead one to justify killing a single individual in order to
transplant her organs in others, saving multiple lives.
Second, it can be difficult to predict who will actually benefit most from treatment and who
will live the most valuable lives post- treatment.
Third, even assuming the ability to predict these subsequent developments, utilitarianism
requires unpalatable assumptions about the value of one life over another.
eg is the life of a quadriplegic patient less worth saving than the life of a nondisabled
person? How can we assume that the quadriplegic individual does not derive as much
pleasure from living, has a shorter life expectancy, or cannot contribute as much to society
as others? What if the quadriplegic individual is Stephen Hawking?

Thus, utilitarianism can raise as many questions about distributive justice as it answers.

B. Equal Chances
A second approach to distributive justice is the principle of equal chances. This principle requires
health care providers to give each individual an equal chance to survive on the theory that each
persons life is equally valuable to him or her.

rejects the utilitarian argument that decision makers should calculate the sum of all
anticipated benefits and burdens at issue in making treatment determinations.

The philosopher John Taurek presented the following example to illustrate the theory of equal
chances:

I have a supply of some life-saving drug. Six people will all certainly die if they are not treated with
the drug. But one of the six requires all of the drug if he is to survive. Each of the other five requires
only one-fifth of the drug. What ought I to do?

Taurek concludes that he should give each person an equal chance to survive and flip a coin
to decide whether to give the drug to the one person who needs all of it or to the five who
need only a fraction of the available amount.
The individual requiring all of the medication, like the other five, would have a fifty-fifty
likelihood of being saved.
For purposes of establishing a disaster triaging policy, a lottery system could be established.

Critics of Taureks philosophy argue that allowing many to perish in order to save the few is
irrational.

Why the Numbers Should Sometimes Count, John Saunders presents a hypothetical in which
there is a choice between saving a single life and saving ten billion lives.
Saunders asks whether even in these circumstances, Taurek would give the same priority to
the single individual as to the ten billion. He argues that if human beings are valuable as
human beings, it is only right to attempt to save as many of them as possible and to count
the numbers.

Still, the equal chances principle raises thought-provoking questions as to whether, in the face of
scarce resources, the default rule should be to try to save the many and sacrifice the few who need
the most care.

The equal chances theory does not support prioritizing the vulnerable over other disaster
victims.
Rather, it establishes an ethical non-discrimination mandate that forbids deeming the
disadvantaged to be less eligible for rescue based on the medical, social, or economic
resources that they may require during and after disasters.

C. The Best Outcome for the Least Well Off

A third normative argument, the theory of the best outcome for the least well off, supports
prioritizing the needs of vulnerable populations over others. According to this theory, authorities
should distribute limited resources unequally in order to maximize benefits for the least well off.

John Rawls articulates the rationale behind this approach in A Theory of Justice.
Rawls outlines the principles of justice that hypothetical decision makers would choose were
they operating behind a veil of ignorance. These decision makers would not know their
own specific circumstances in life, such as their social status, personal strengths, and
weaknesses. Consequently, the decision makers would not be prejudiced by their own
agendas and expectations in life.
the veil of ignorance would promote procedural justice and would prevent decision makers
from exploiting peoples diverse social and personal circumstances for their own advantage.

posits a difference principle, according to which unequal distribution of wealth and

income is permissible only if it is to the advantage of those who are least fortunate.

Emergencies involving illness and injuries, however, may complicate this approach.

The worst off will presumably be the sickest, and their risk of death will be highest. Thus, it is
arguably irrational to plan to expend sizeable medical resources on what may well be futile
attempts to save them.
Thus, in the face of scarcity, officials may be justified in prioritizing the needs of those who
are socially, economically, or medically vulnerable because these individuals could suffer
particularly acute and long-lasting harm.

D. What Ethics Teaches Us

Utilitarianism, equal chances, and the best outcome for the least well off constitute three distinct
approaches to distributive justice.

no clear, single answer to the question of how emergency planners and responders should
prioritize the needs of various populations and to whom resources should be allocated in the
face of scarcity.

Therefore, the optimal approach is to minimize the need for difficult ethical choices, as I argue
below.

The utilitarian goal of maximizing the net benefit to society may be intuitively appealing,
especially in the context of disasters.
If really need to use utilitarianism, show that the issue is the uncritical use of utilitarianism
without considering others. Also supplement it with transparency and accountability.
However, alternative conceptions of distributive justice also exist. These promote
egalitarianism or emphasize the needs of the disadvantaged.130 Many commentators argue
vigorously that considerable resources should be invested in assisting vulnerable individuals
such as the poor, institutionalized, and disabled, because they are the least able to
withstand the hardships caused by catastrophic events.

Some offer a hybrid form of utilitarianism.

one article categorizes the following considerations as permissible for purposes of making
emergency treatment decisions when faced with scarce resources: likelihood, duration, and
extent of benefit as well as urgency of need and amount of required resources.
However, the following factors should not be deemed relevant: [a]ge, ethnicity, or sex;
[t]alents, abilities, disabilities, or deformities; [s]ocioeconomic status, social worth, or
political position; [c]oexistent conditions that do not affect shortterm prognosis; [d]rug
or alcohol abuse; and [a]ntisocial or aggressive behaviors.

Accordingly, decision makers pursuing the goal of maximizing the net benefit to society would focus
on shortterm outcomes, prioritizing based on resources, need, and benefit considerations but not
based on value judgments concerning who is deserving of care or who will live the most valuable

lives in the future.

An essential goal of emergency planning efforts should be to minimize unanticipated and

complicated resource allocation problems involving the disadvantaged and vulnerable.

Moreover, disaster readiness for the general population and disaster readiness for the
vulnerable are mutually beneficial goals.
The best outcomes for the vulnerable are most likely to be achieved with optimal
preparation for those without special needs. The more prepared and well equipped the
general population is to react appropriately during emergencies and the more the healthy
and strong can care for themselves, the more likely it is that resources will be available for
the acute needs of the disadvantaged.
Advance planning and preparedness initiatives for all populations should aim to curtail the
need for difficult moral choices and for sacrificing some victims for the sake of others.

Also ensure that there is transparency and equal participation, accountability. Idea of ethical
theories as a guideline.

Ebola
11 August 2014, WHO convened a consultation to consider and assess the ethical implications for
clinical decision-making of the potential use of unregistered interventions.

the panel reached consensus that it is ethical to offer unproven interventions with as yet
unknown efficacy and adverse effects, as potential treatment or prevention.
Ethical criteria must guide the provision of such interventions. These include transparency
about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the
person, preservation of dignity and involvement of the community.

Safety

Value speed over safety ethics. Cases are said to be doubling every 2 weeks.
10 months in what usually takes 10 years.
If individuals seem to benefit from it, do you administer to the rest of the population
immediately? There may be adverse effects down the road in a few months time.
The thing is no one really knows fully how the ebola vaccine works.

Should there be a placebo group? Fastest way of knowing- Gold standard for testing

Drug trials conventionally compare the outcomes in patients who get an experimental
medicine with the outcomes for those given normal care both groups chosen by random
selection.
In Sierra Leone, Liberia and Guinea, there is no treatment for Ebola patients except
rehydration.
To give some people a drug such as ZMapp and others a placebo would be wrong,

Who to give?

First responders? As they deal with patients all the time?

Or the most sick first?

Supply chain ethics

To prevent ethical issues arising within a company's global supply chain and potentially causing
lasting damage to their brand, some basic principles should be followed.
Keep it simple: Cost pressures mean there is often a tendency for supply chains to become more
complex as companies try to trim overheads by switching suppliers. But this extra complexity, which
sometimes results in the use of tiers of sub-contractors and impacts on supply chain visibility,
inevitably exposes the buyer to increased risk.
Make ethical considerations part of every buying decision: Most businesses have corporate and
social responsibility objectives as part of their overall corporate strategy but are these being applied
across the supply chain? Do such criteria get overlooked when commercial considerations come to the
fore? Ethical criteria should be a part of every buying decision.
Collaborate, but stick to your principles: When setting up a relationship with a new supplier it is
important to be clear about what you expect from them at the outset. Businesses should emphasise any
ethical expectations, alongside any commercial ones. If sub-contracting is against the rules, make this
clear and part of any contractual agreements. Tell the supplier what will happen if they are found to
have breached the rules.
Use the 'how would it look to you?' test: If you are unsure about whether activities conducted by a
particular supplier should be tolerated or not, consider how you would feel if you could see it
happening for yourself. The trouble with complex supply chains is that they distance us from what is
happening so we feel one step removed and less responsible. In most cases, if business decisionmakers could see it happening in front of their own eyes, they would probably feel differently about it.
Use your buying power to good effect: Thanks to market globalisation, modern corporates have
significant power to exercise a positive influence in the countries they buy from and trade in.
Recognising this is the first step to leveraging this benefit in developing economies. As a big firm at
one end of the buying chain, you shouldn't be afraid of getting involved at the other end of the supply
chain by being prepared to visit suppliers and operate with them to improve working conditions or
contribute to the local community.

Communicate your ethical achievements: Ethical consumerism is on the rise and buying decisions
within every industry sector are increasingly influenced by ethical considerations. Make the most of
this by ensuring that your customers and their markets know what you are doing and how your
business is actively involved in supporting global development initiatives.
Roy Williams is managing director at Vendigital, a firm of supply chain consultants operating
globally and across industry sectors.