Specific Topic(s): special populations, special provisions, disability discrimination.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’

• The primary task of health-care personnel is to preserve human physical and mental health and to alleviate suffering. They shall provide the necessary care with humanity, while respecting the dignity of the person concerned, with no discrimination of any kind, whether in times of peace or of armed conflict or other emergencies.

Geneva Conventions:

Rule 87. Humane Treatment. Civilians and persons hors de combat must be treated humanely. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter32_rule87 - specific categories of persons: the wounded, sick and shipwrecked, persons deprived of their liberty, displaced persons, women, children, the elderly, the disabled and infirm.

Rule 138. The elderly, disabled and infirm affected by armed conflict are entitled to special respect and protection. At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter39_rule138

Ethical principles:

WMA INTERNATIONAL CODE OF MEDICAL ETHICS: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ - A PHYSICIAN SHALL …. act in the patient’s best interest when providing medical care… respect the rights and preferences of patients, colleagues, and other health professionals.

WMA DECLARATION OF LISBON ON THE RIGHTS OF THE PATIENT: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests. ... Right to medical care of good quality, every person is entitled without discrimination to appropriate medical care.

Discussion:

Review of the question: this question examines the responsibility of healthcare providers to make special provision for patients with special additional needs compared to the majority.

Interpretation of the principles/policy from the references:

• Healthcare workers have a duty to act in the best interests of their patients.

• There should be no discrimination between patients of equal clinical need – or other needs such as assistance for evacuation.

• There are special populations who have special needs during conflict – elderly, disabled, infirm, women, children.

• Special provision should be made for populations with predictable special needs, including support in an emergency such that all patients have equitable access to support.

Framework for answering the scenario/question:

• What predictable emergencies might occur in your medical facility? – fire, flooding, loss of key services (electricity, heating/air-conditioning, water), enemy attack, requirement to evacuate.

• What contingency plans need to be developed, communicated and practiced to address these emergencies?

• What patient groups are more vulnerable and would need more support in these circumstances?

• How might this support be organised?

Further issues for consideration:

• What other aspects of conscious or unconscious discrimination in protecting patients in a health facility might need to be considered?

• Can disability be used as a discriminator in the allocation of scarce medical resources?

provision of and ability to use personal protective equipment for patients – e.g. helmets, body armour, chemical protective equipment (respirators), language of emergency notices, language of emergency tannoy messages.

Emily Johnson. Disability, Medicine, and Ethics. AMA J Ethics. 2016;18(4):355-358. doi: 10.1001/journalofethics.2016.18.4.fred1-1604.

Solomon MZ, Wynia MK, Gostin LO. Covid-19 Crisis Triage - Optimizing Health Outcomes and Disability Rights [published online ahead of print, 2020 May 19]. N Engl J Med. 2020;10.1056/NEJMp2008300. doi:10.1056/NEJMp2008300

COVID 19 and the disability movement. At: http://www.internationaldisabilityalliance.org/content/covid-19-and-disability-movement