X. EMERGENCY PREPAREDNESS AND RESPONSE...preparedness is a complex and dynamic form of activity ... violent storms and flooding, sea level rise, the contamination of fresh water supplies,

Beauchamp, Dan E. 1988. The Health of the Republic: Epidemics,Medicine, and Moralism as Challenges to Democracy.Philadelphia: Temple University Press.

Beauchamp, Dan E., and Bonnie Steinbock, eds. 1999. NewEthics for the Public’s Health. New York: Oxford UniversityPress.

Berkman, Lisa F., and Ichiro Kawachi, eds. 2000. SocialEpidemiology. New York: Oxford University Press.

Buchanan, David Ross. 2000. An Ethic for Health Promotion:Rethinking the Sources of Human Well-Being. New York:Oxford University Press.

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Daniels, Norman. 2011. “Individual and Social Responsibility forHealth.” In Responsibility and Distributive Justice, edited byCarl Knight and Zofia Stemplowska, 266–86. Oxford: OxfordUniversity Press.

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Feinberg, Joel. 1986. Harm to Self. New York: Oxford UniversityPress.

Gostin, Lawrence O., and Gail H. Javitt. 2001. “HealthPromotion and the First Amendment: Government Control ofthe Informational Environment.” Milbank Quarterly 79 (4):547–78.

Hodgson, Thomas A. 1992. “Cigarette Smoking and LifetimeMedical Expenditures.” Milbank Quarterly 70 (1): 81–125.

Laumann, Edward O., and Robert T. Michael. 2000. Sex, Love,and Health in America: Private Choices and Public Policies.Chicago: University of Chicago Press.

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Daniel Wikler (1995, 2014)Mary B. Saltonstall Professor of Population Ethics and

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Dan E. Beauchamp (1995, 2014)Emeritus Professor, Health Policy,

Management, and Behavior,School of Public Health, University at Albany,

State University of New York

X. EMERGENCY PREPAREDNESS ANDRESPONSE

A public health emergency exists when the ordinary healthservice capabilities of a community are overwhelmed byan extreme situation or event. Emergency preparedness isthat aspect of public health designed to ensure sustainedpublic health and medical readiness in the event of anemergency, minimize the impact of emergencies onaffected communities, and foster safe and healthfulenvironments before, during, and after an emergency(Nelson et al. 2007). Factors that bring about a publichealth emergency situation include terrorism, armedconflict, or civil war; infectious disease epidemics; large-scale fire or explosions; violent weather and flooding; toxic

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chemical or radiation discharge; industrial or transporta-tion accidents; geological (earthquake or volcanic erup-tion) disturbances; the effects of climate change and globalwarming; and other disruptive and large-scale ecologicaltransformations.

This entry provides an overview of ethical issues inpublic health emergency preparedness and response(hereafter referred to simply as “emergency prepared-ness”). It will review the emergence of emergencypreparedness as a field within public health alongsidepublic safety and law enforcement. It will then considervarious attempts to develop a framework for ethicalanalysis and practice in public health emergency pre-paredness.

Much work has been done since 2001 on specificethical issues that arise in the context of certain facets ofemergency preparedness, such as the ethics of allocatingscarce resources like vaccines or emergency medicalequipment. Attention has also been given to ethical issuesthat arise in public health emergencies related to outbreaksof infectious disease, such as influenza (Arras 2006; Battinet al. 2009; Kinlaw, Barrett, and Levine 2009).Nonetheless, a review of federal and state influenzapandemic plans reported in 2007 showed that, with fewexceptions, there were no explicit references to ethicalissues and concepts in these documents (Thomas,Dasgupta, and Martinot 2007). The task of studyingemergency preparedness planning and implementation asa whole from an ethical point of view and from an all-hazards perspective has only just begun.

Emergency preparedness planning has emerged as adistinct subspecialty within the public health profession.At the same time, recognition of the value-laden characterof emergency preparedness work is growing: emergencypreparedness is a complex and dynamic form of activityinformed implicitly or explicitly by important values andcommitments. Ethical rights and obligations are notsuspended or irrelevant during emergency situations.Moreover, the tasks of planning for and recovering fromemergencies are not merely technical or financial; they arealso matters of considerable human impact and ethicalconcern.

EMERGENCY PREPAREDNESS IN PUBLIC HEALTH

The threat of sudden disruption in the health care systemand serious danger to life and health on a large scale seizedthe attention of the public health community (and thenation) in the 1990s because of the threat of terrorism,including incidents in the United States such as thebombings in a parking garage at the World Trade Centerand at the federal office building in Oklahoma City, andalso numerous incidents around the world, such as thepoison gas release in the Tokyo subway system. In the

United States, legislation at the time established adomestic preparedness program and broadened themandate of the Federal Emergency Management Agency(FEMA) to include attacks by weapons of mass destruc-tion as well as natural disasters. In 1998, the Centers forDisease Control and Prevention (CDC) took steps toimprove laboratory, surveillance, and emergency responsecommunication capabilities and established a nationalstockpile of pharmaceuticals and vaccines.

Nonetheless, in 2000 and early 2001, simulationexercises revealed many remaining shortcomings inemergency preparedness and the ability to respond,including poor interagency and intergovernmental com-munication and coordination, the lack of local planning,and inadequate surge capacity, or the ability to mobilizeadequate numbers of trained health personnel rapidly inthe face of sudden, overwhelming public need (O’Toole,Mair, and Inglesby 2002).

Needless to say, such concerns increased exponential-ly in the aftermath of the terrorist attacks of September11, 2001, and the use of anthrax as a means ofbioterrorism shortly thereafter. In 2003 the US govern-ment initiated a smallpox vaccination plan—which wasprompted by concerns about a possible bioterrorist use ofsmallpox virus—that earmarked health care workers andfirst responders for inoculation with limited vaccinestocks. This initiative bogged down owing to disagree-ments over risk-benefit considerations and lack of trustand cooperation among target populations. In 2005Hurricane Katrina caused massive flooding and disloca-tion in New Orleans and nearby areas and has become asymbol of inadequate and failed emergency preparedness(Cooper and Block 2006; Daniels, Kettl, and Kunreuther2006). Soon after, many other emergency events,including the destructive earthquake in Haiti, the tsunamiin Japan that compromised nuclear reactors and releasedradiation over a wide area, Hurricane Sandy in New YorkCity, and concerns about global pandemic influenza andother infectious diseases, have shifted the orientation ofpublic health preparedness from bioterrorism to an all-hazards planning approach. The all-hazards approach isnow recognized as central to the public health mission andhas been a focal point of a massive infusion of funding,manpower, training, and other resources at the federal,state, and local levels.

Improvements have been made in many states andlocales in their capacity to respond to epidemic andenvironmental contamination events. Conditions such asWest Nile virus, severe acute respiratory syndrome(SARS), multi-drug-resistant tuberculosis (MDR-TB),and Escherichia coli contamination in the food supplyhave required public health responses. Additional publichealth challenges loom on the horizon, including avianinfluenza and the prospect of long-term climate change

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with its multiple threats to public health and well-being,including fatal heat waves, violent storms and flooding,sea level rise, the contamination of fresh water supplies,drought, malnutrition, the spread of zoonotic disease,aggravation of chronic conditions such as allergies andpulmonary disease, and large-scale human migration withattendant sanitation and epidemic side effects (Center forHealth and the Global Environment 2005; Frumkin andMcMichael 2008).

Moreover, a consensus has emerged among publichealth officials and practitioners regarding the appropriateplace of emergency preparedness within public healthand its proper scope. Emergency preparedness is nowunderstood to encompass more than adequate equipment,deployment of health professionals, training, and supplies.It also crucially involves community engagement andparticipation from the outset of the pre-emergencyplanning process. Preparing written emergency plansdrawn up behind closed doors and followed up withoccasional practice drills is no longer regarded as sufficientfor the challenge of emergency planning. A much moreelaborate and ongoing process of community asset andneeds assessment, stakeholder participation, and publicawareness and engagement is required. Public trust andconfidence are essential in emergency preparedness, andpublic health decision making will be most effectivegenerally when it is transparent and has direct links to thecommunities it serves. To be sure, however, emergencypreparedness understood in this way is challenged by thetypical cycle of public engagement in which intenseinterest is manifest in the immediate aftermath of anemergency event but gradually ebbs into the apathy andindifference of normal everyday life.

An additional point of consensus in the field today isthat emergency preparedness—although a specialized areaof expertise—should not be separated unduly from thenonemergency concerns of public health policy andcapacity. A well-prepared community is a community inwhich the population is medically well served, a strongpublic health infrastructure is in place, and community-based public health services are not neglected but arerobust and well integrated into everyday life.

APPROACHES TO ETHICAL ANALYSIS

Emergency preparedness is an activity that requires ethicalanalysis at several different levels. First, as a part ofprofessional public health practice, emergency prepared-ness falls within the general domain of public healthethics, a field that has developed substantially since the1990s (Callahan and Jennings 2002; Bayer and Fairchild2004; Powers and Faden 2006; Holland 2007). Publichealth policy and practice generally raise a number ofcomplex ethical issues that are also pertinent to the special

context of preparing for and responding to public healthemergencies. The public’s trust in public health expertiseand their perception of risk and fairness influence thewidespread and largely voluntary response to andimplementation of public health recommendations.

Several ethical issues have been singled out as coreethical problems in the domain of emergency prepared-ness. For example, since emergency preparedness andresponse involve coercive state action and efforts tocontrol individual behavior, one key issue is the problemof justifying limitations on the liberty of individuals andgroups. The complex ethical and social values invokedwhen coercive measures are included in an emergencyplan should be examined before such measures need to beimplemented.

In addition, since emergency situations often involvescarcity of important personnel and resources, anotherissue involves standards of distributive justice, theallocation of scarce resources, rationing, and triage.Examples are the allocation of vaccines and microbialsin the context of an influenza pandemic or the allocationof mechanical ventilators during an outbreak of acuterespiratory disease (University of Toronto Joint Centre forBioethics 2005).

A third major issue has to do with arrangements toaccommodate persons with special needs and vulnerabil-ities in the planning, response, and aftermath ofemergencies. It is generally held that public officials andemergency planners should attempt to identify in advancethe potential burdens of emergency preparedness andresponse measures, and they should take steps to mitigateundue burden and discriminatory impact on particularsegments of the population through the provision ofspecial resources, recovery programs for loans and specialcompensation, and the like.

Finally, there are a number of ethical issues thatpertain to the planning, communication, and coordina-tion process of emergency preparedness. These processand policy issues contain many ethical assumptions thatare often implicit and many consequences that are ofethical concern, both to the types of issues listed aboveand to the question of legitimacy and trust in democraticsocieties under stress owing to extraordinary circum-stances. These issues include (1) the relationship betweenexperts, leadership, and elected representatives, on onehand, and the diverse body of citizens and ordinarymembers of society, on the other; (2) the role of the pressand other forms of mass communication in mediating thisrelationship during emergencies; (3) the obligations andduties of individuals who play important roles in theemergency preparedness process, particularly healthprofessionals, when they must respond to a public healthemergency (at such times, the professional obligations of


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public health practitioners may conflict with theirpersonal and family obligations); and (4) the sense ofresponsibility and cooperation on the part of privatecitizens that will facilitate effective and ethically soundpreparation, response, and recovery in a community.

A study by the Nuffield Council on Bioethics (2007)clarified other aspects of public health ethics that informan appropriate ethical perspective on emergency prepared-ness. Emergency planners and officials should employ theleast restrictive alternative to achieve emergency publichealth goals. They should facilitate and encouragecommunity involvement in the planning process. Theyshould strive for transparency in decision making andpublic communications. Nonetheless, although the use ofcoercion or deliberately withholding information from thepublic should be avoided if possible and as a general rule,such measures cannot be ruled out categorically. Theethical justification of coercion in particular instances willbe a matter of context and circumstance (Gaylin andJennings 2003; Gostin 2003; Conly 2013). Mandatoryevacuation measures or quarantine may be unavoidableand ethically justified under extreme circumstances (Fair-child, Colgrove, and Jones 2006; Gostin 2006). With-holding information from the public may be necessary inorder to prevent panic and counterproductive behavior ona large scale. It is precisely because measures may be takenin emergencies that would ordinarily be unacceptable innormal times that it is so important that public healthplanners not wait for disaster to strike before working outa viable scheme of carefully orchestrated decision making.The role of ethics in the planning phase before a crisis, asin the recovery phase afterward, is to define reasonablyjust, humane, and responsible parameters for action anddecision making (Upshur 2002). Even within thoseparameters, there is no way to be sure that moral mistakeswill not be made.

Aside from the fact that public health emergenciesmay require some coercive and paternalistic measures, afundamental question arises about the civic and demo-cratic implications of emergency response. There is atendency to see the ethics, law, and governance ofemergencies as requiring the centralization of top-downauthority and as outside normal democratic governance.The so-called emergency exception is the legal suspensionof the ordinary rule of law (Gostin 2003; Agamben 2005;Schmitt 2005). However, it has been argued that thisperspective fails to appreciate the actual capacity forresponsible conduct, self-discipline, and social cooperationand coordination that exists in society at all times, and ittherefore exaggerates the necessity for the extralegality ofthe emergency exception in times of crisis and peril(Annas 2002; Rosner and Markowitz 2006; Annas,Mariner, and Parmet 2008; Honig 2009; Solnit 2009;Scarry 2011).

ETHICAL FRAMEWORKS AND PRINCIPLES

The bioethics of emergency preparedness studies normsand values that are pertinent to how emergencypreparedness should be conducted in a generic senseand in regard to specific types of hazards or emergenciesthat might arise. In the current ethics literature onemergency preparedness it is common to find thearticulation of various frameworks of principles or rules,and in this regard discussions of emergency preparednessemulate and derive from more general works in bioethicsand public health ethics. The purpose of such analyses isto provide general principles that can then be specifiedand applied to guide particular decisions concerningemergency preparedness policies and practical activities. Inthis approach, the object of analysis tends to be specificactions, choices, and decisions by particular individuals orgroups. The actions and agents are critically assessed inlight of general ethical norms, and recommendations aremade concerning educational training and procedural orinstitutional reforms that may lead to improved compli-ance with these general norms or principles in the future.

This model has served bioethics well for several decadesas it has examined diverse arenas in biomedicine, healthpolicy, and biomedical research and technology. In bioethicsthe rise of arguments centered on principles was stimulatedby the influence of the Belmont Report (National Com-mission for the Protection ofHuman Subjects of Biomedicaland Behavioral Research 1978), which has become the basisfor ethical regulations governing the use of human subjectsin research both in the United States and worldwide. Alsoimportant as a model for public health ethics was thereception in clinical medicine and medical education of aninfluential book by Tom Beauchamp and James Childress,Principles of Biomedical Ethics, first published in 1979 andreissued in seven expanded editions to date (2013). Theseworks canonized the four principles of (1) respect forautonomy; (2) beneficence; (3) nonmaleficence; and (4)justice.

Interest in public health ethics, both by public healthprofessionals and by ethicists, has increased, and theapproach based on the application of general principleshas become influential. James Childress himself is nowactively working with colleagues in the field of publichealth ethics and brings his careful philosophical andconceptual attention to the study of the foundations andframeworks of public health ethics.

It has been argued that this standard approach is notas well suited to the context of public health and theconditions of its practice as it is to clinical medicine. Theprinciples necessary to promote population health maydiffer from those designed to promote individual healthand well-being. Moreover, and more fundamentally, thereis an ongoing discussion and debate concerning the


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adequacy of the model of moral agency and moral life onwhich “principlism” (as this applied framework approachhas come to be called) rests (Arras 1991). Rather than seeethics as involving the application of general rule-likeimperatives, some argue that ethical reasoning is less oftendeductive (reasoning from general principles to particulardecisions or actions) than analogical in form. That is,ethical reasoning involves moving from puzzling andunfamiliar moral situations and assimilating them to well-understood moral paradigm cases. This approach to ethicshas been called “casuistry,” and it represents an alternativeto the application of moral principles (Jonsen andToulmin 1988). Still others suggest that individualdecisions or actions should not be the exclusive focus ofethical analysis, but that ethics should also addresspatterns of activity and forms of life extending over time,which are better understood by narrative and interpretivemethods rather than analytic methods (McCarthy 2003).

Nonetheless, it is fair to say that most work inbioethics ethics since the 1970s has been done byreference to ethical principles. Public health ethics, thusfar, is no exception to this. Part of the reason for thissurely has to do with the appeal to public healthpractitioners and policy makers of easily grasped andlogically cogent lists or “frameworks” of ethical principles.

FROM PRINCIPLES TO PRACTICES

Even so, diverse methodological approaches to ethicalanalysis are beginning to show up in work on emergencypreparedness. Generally speaking, the more specific theissue in emergency preparedness and the more it involvesemergent conditions and acute clinical medical care(usually in the response phase of an emergency), themore likely it is that the general principlist approach takenfrom bioethics will be used. For example, the discussion ofmedical triage that one finds in public health emergencysituations differs little in an ethical sense from paralleldiscussions taking place in non–public health emergencysettings such as battlefield medicine or admission anddischarge decisions in the ERs or ICUs of large cityhospitals.

However, as one moves away from the medicalizedaspects of the response phase of a public health emergencyand toward the processes of communication, culturalmeaning, and group dynamics of the planning andrecovery phases, one finds patterns of activity andpractices that are themselves meaningful and value-ladenfor the participants involved in them. Specific decisions orchoices to which general ethical principles can be appliedbecome less pertinent than the lifeworld of relationships.These relationships are constituted by their own internalnorms and value narratives. Ethical analysis and evaluationfrom an external standpoint gives way to ethical

interpretation and critique rooted in the internal purposesand ideals of a lifeworld under stress. In short, someaspects of emergency preparedness involve the applicationof the ethical rules of everyday life to an unusual, andunusually demanding, set of circumstances. Other aspectsof emergency preparedness ethics, however, require anapproach that is responsive to the struggle human beingsface when their moral lifeworld, settled expectations, andidentities are confronted by a large-scale anomaly to whichthey must respond.

More detailed consideration of these general trends inthe ethics of emergency preparedness can be given by abrief discussion of three contributions to this literature:(1) the work on principles of public health ethics andemergency preparedness ethics by Nancy Kass (2001,2004) and by James Childress and his colleagues (2002);(2) work on the ethics of infectious disease by Margaret P.Battin, Leslie P. Francis, Jay A. Jacobson, and Charles B.Smith (2009); and (3) work on the ethical issues in publichealth emergency planning by Bruce Jennings and JohnD. Arras (2012).

ETHICAL QUESTIONS AND CONSIDERATIONS

The ethical framework developed by Nancy Kass explicitlydistinguishes itself from a code or set of rules and offersinstead of what she calls an analytic tool for consideringthe ethical implications of public health interventions,policies, and programs. Although not aimed specifically atemergency preparedness, this framework can be readilyextended to that area (Kass 2005).

This framework comprises six questions that shouldbe asked in an ethical evaluation of any public healthpolicy or practice. These are: (1) What are the publichealth goals of the proposed program? (2) How effective isthe program in achieving its stated goals? (3) What are theknown or potential burdens of the program? (4) Can theburdens be minimized, or are there alternative appro-aches? (5) Is the program implemented fairly? (6) Howcan the benefits and burdens of a program be fairlybalanced?

The lasting value of a framework such as that developedby Kass, however, is the richness and insight with whichthese questions are interpreted and fleshed out. In acommentary on each question, Kass demonstrates that thereal contribution of public health ethics lies with thesubstantive human interests, both personal and social, thatinform the ingredients that would constitute good answersto these questions in a program assessment exercise.

A sizable team led by James Childress, and includingNancy Kass, made an important contribution to thefoundations of public health ethics with an article titled“Public Health Ethics: Mapping the Terrain” (2002).This article identifies what the authors call “general moral


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considerations” for public health ethics. These are: (1)producing benefits; (2) avoiding, preventing, and remov-ing harms; (3) producing the maximal balance of benefitsover harms and other costs; (4) distributing benefits andburdens fairly (distributive justice); (5) ensuring publicparticipation, especially by affected parties (proceduraljustice); (6) respecting autonomous choices and actions,including liberty of action; (7) protecting privacy andconfidentiality; (8) keeping promises and commitments;(9) disclosing information as well as speaking honestly andtruthfully (transparency); (10) building and maintainingtrust.

This framework recognizes that respect for personsincludes liberty, privacy, and access to informationnecessary to make informed choices. It also includes ademocratic dimension to the usual stipulation concerningdistributive justice. Finally, the framework underscoresthe importance of promise keeping and trust in publichealth. The ethical practice of public health generally, andof emergency preparedness in particular, must becommitted to sustaining that relationship of legitimacyand trust.

This analysis does not simply lay out a scheme ofprinciples and offer interpretive commentary on them; italso provides a sophisticated analysis of how such conceptsmay be used in ethical discourse concerning public health.There are two dimensions to the use of a framework ofprinciples: the scope of the principles and their relativemoral weight. The scope dimension pertains to the actualbehavioral and programmatic requirements that a princi-ple imposes in a public health context. Respectingautonomy, for example, does not always entail providingan opportunity for informed consent. The dimension ofmoral weight pertains to resolving conflicts among thevarious principles and prioritizing them.

Consideration of the scope and weight of ethicalprinciples takes us directly into the specifics and details onthe ground in a public health emergency situation. Ethicaltheory does not provide a basis for an absoluteprioritization of principles such as these. Childress andcolleagues propose a set of subsidiary principles—tie-breakers, so to speak—for guidance in resolving practicaldilemmas and conflicts. These criteria are: effectiveness,proportionality, necessity, least infringement, and publicjustification. Here the basic idea is that if tragic ethicalchoices between important principles or fundamentalvalues must be made, and if important rights and interestsmust sometimes be overridden, then public healthmeasures that do so should undergo tests of strict andpublic scrutiny.

More needs to be said about this last consideration. Abetter understanding is required by leaders in the field ofpublic health emergency preparedness and by those in

ethics of how an effective participatory and deliberativeform of democracy could be made practical in oursocieties and how this could be done under the seeminglyinauspicious circumstances of an emergency. What type ofmotivation would lead to genuine deliberation and notsimply special interest advocacy? What kinds of institu-tional forms would facilitate enhanced grassroots partici-pation and discussion of key public health (and othersocial) issues?

VICTIM AND VECTOR

Margaret Battin and colleagues question the value ofdeveloping principles for emergency preparedness as awhole or in a generic, all-hazard sense in their book ThePatient as Victim and Vector (2009). Taking the subset ofemergency situations involving infectious disease control,they provide a thorough and wide-ranging analysis of theways in which public health measures are embedded in acomplex web of historical, cultural, and emotionalmeanings.

At the heart of the ethical issues here is the questionof how to manage the moral ambiguity inherent in thebiology of infectious disease—namely, that individualsmay be both victims to be cared for and carriers of thepathogens, or “vectors,” who must be controlled. Careand control, concern and coercion, are two sides of thesame coin in an infectious disease emergency.

Ethical frameworks will provide little guidance inthese contexts. What is needed is an interpretiveframework through which to articulate what the ethicalquestions really are when emergency preparedness andresponse measures are looked at from a certain perspec-tive. The interpretive framework Battin and colleaguesdevelop is based on the fact that human beings are caughtup in a biological web that contains both beneficialsymbiotic and pathogenic microorganisms. Our bodiesand activities are integral parts of the mobility and lifecycle of these microorganisms, and hence we are “waystation” selves. Emergency preparedness and public healthmore generally is then interpreted in terms of efforts toescape from this biological net and cycle, this web ofdisease.

RESILIENT COMMUNITIES AND CIVIC PRACTICE

Finally, Bruce Jennings and John Arras in theirmonograph Ethical Guidance for Public Health EmergencyPreparedness and Response (2008) develop a framework ofethical goals and social goods for the emergencypreparedness process as a whole. The goals these authorsformulate are not general moral rules or imperativesdesigned to produce a certain outcome or to arriveethically at a particular destination—the right answer orthe right action. Instead of focusing on the right


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destination, these goals and goods focus on the properethical orientation. They concern not so much the endpoints, but the compass points of ethical public healthpolicy and practice. They also emphasize key, but oftenneglected, dimensions of bioethics such as communitycapacity and resilience, community participation, civicresponsibility, and public trust.

Rather like Battin and colleagues, Jennings and Arrasargue that ethics involves an interpretation of the type ofenterprise that emergency preparedness is and anunderstanding of its meaning for those engaged in itand affected by it. They portray emergency preparednessnot as a series of discrete situations, decision points, orcases, but as an ongoing narrative or drama unfolding,often surprisingly, over time. Whereas Battin andcolleagues view emergency public health through the lensof the person as victim and vector, Jennings and Arrasview it as a civic practice.

Jennings and Arras single out seven ethical goals andsocial goods that they take to be the core orientations ofthe civic practice of emergency preparedness. They aim toprovide conceptual tools for discussion and clarificationleading to agreement and common resolve. In that sense,ethical analysis itself is internal to emergency prepared-ness, not external to it; dialogue on ethics and valuesbuilds the capacity to prepare for and respond toemergencies in just, responsible, and effective ways.

The ethical goals and social goods proposed byJennings and Arras are: (1) Harm reduction and benefitpromotion. Emergency preparedness activities shouldprotect public safety, health, and well-being. They shouldminimize the extent of death, injury, disease, disability,and suffering during and after an emergency. (2) Equalliberty and human rights. Emergency preparednessactivities should be designed so as to respect the equalliberty, autonomy, and dignity of all persons. (3)Distributive justice. Emergency preparedness activitiesshould be conducted so as to ensure that the benefits andburdens imposed on the population by the emergency andby the need to cope with its effects are shared equitablyand fairly. (4) Public accountability and transparency.Emergency preparedness activities should be based on andincorporate decision-making processes that are inclusive,transparent, and sustain public trust. (5) Communityresilience and empowerment. A principal goal ofemergency preparedness should be to develop resilient,as well as safe, communities. Emergency preparednessactivities should strive toward the long-term goal ofdeveloping community resources that will make themmore resistant to destructive system breakdown and allowthem to recover appropriately and effectively afteremergencies. (6) Public health professionalism. Emergen-cy preparedness activities should recognize the special

obligations of certain public health professionals andpromote competency of and coordination among theseprofessionals. (7) Responsible civic response. Emergencypreparedness activities should promote a sense of personalresponsibility and citizenship.

For Jennings and Arras, these goals are based on thenotion that the emergency preparedness process ought tobe guided by explicit and plural values that are accessibleand reasonable to the community as a whole, even as theyare subject to an ongoing reinterpretation, clarification,and discussion. These values are the compass points of ageneral orientation and a mode of thinking designed toincrease the likelihood that public health emergencypreparedness will be both effective and trustworthy. LikeKass and like Childress and colleagues, Jennings and Arrasstress that ethical goals are difficult to prioritize and attimes are in conflict with one another. There is noabsolute priority among them that ethical theory canestablish.

One conclusion at least may be drawn from thisdiverse body of work on emergency preparedness. Ethicalanalysis can clarify but it cannot replace ethical judgment.Emergencies are inevitable; responding badly to them isnot.

SEE ALSO Hospital, Contemporary Ethical Problems of the;Hospitals, Ethical Issues in the Governance of;Humanitarian Relief; NGOs in Health Care; Pain andSuffering; Pandemics; Vaccination and Immunization;Warfare: IV. Chemical and Biological Weapons

BIBL IOGRAPHY

Agamben, George. 2005. State of Exception. Translated by KevinAttell. Chicago: University of Chicago Press.

Annas, George J. 2002. “Bioterrorism, Public Health, and CivilLiberties.” New England Journal of Medicine 346 (17):1337–42.

Annas, George J.; Wendy K. Mariner; and Wendy E. Parmet.2008. Pandemic Preparedness: The Need for a Public Health—Not a Law Enforcement/National Security—Approach. NewYork: American Civil Liberties Union. https://www.aclu.org/files/images/asset_upload_file399_33642.pdf.

Arras, John D. 2006. “Rationing Vaccine during an AvianInfluenza Pandemic: Why It Won’t Be Easy.” Yale Journal ofBiology and Medicine 78 (5): 287–300.

Arras, John D. 1991. “Getting Down to Cases: The Revival ofCasuistry in Bioethics.” Journal of Medicine and Philosophy 16(1): 29–51.

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Bruce JenningsDirector of Bioethics,

Center for Humans and Nature


Public Health


X. EMERGENCY PREPAREDNESS AND RESPONSE...preparedness is a complex and dynamic form of activity ... violent storms and flooding, sea level rise, the contamination of fresh water supplies,

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