How Could Emergency Modify our Normal Ethics Standards? A Brief Review of Selected Chapters in Emergency Ethics

This review is about Emergency Ethics, the first in the four-volume series Emergency Ethics, Law and Policy. It analyses chapters addressing the question: How could emergency modify our normal ethics standards? The chapters offer three angles on the question: conceptual analysis, empirical analysis and case study.


Introduction
Emergency Ethics [1] is the first of a four-volume series entitled Emergency Ethics, Law and Policy.The objective of this series is to bring together recent and interdisciplinary articles about emergency.The first volume, Emergency Ethics, includes twenty-five articles grouped into five thematic parts: the significance of emergency; ethical issues in public health policy and law; supreme emergency such as war and terrorism, and public health and humanitarian emergency.The objective of this first volume is to present what an emergency is and how it could challenge ethics and decision-making.It puts forward important ethical questions raised in the context of medical or humanitarian intervention such as: During an emergency, is it acceptable to condemn some people to save many?Can we judge an emergency intervention like other actions?Right from the introduction, the two editors insist on the fact that these questions are not only important to understand and manage emergency, but also for a general reflection about ethics theories and their applications.For example, consequentialism argues that a good decision is based on the principle of the greatest happiness of the greatest number.But during an emergency, such as a humanitarian tragedy, asking whether it is acceptable to condemn some people to save a lot of them could generate fatal consequences.Avoiding those fatal consequences could conform to utility but not be deontologically acceptable.During an emergency, our moral standards could be modified by the possibility of great harm: "what we might allow individuals or collectives to do in times of normalcy may no longer be sustainable in the face of emergency events" (p.xiii).How, when, and to what extend moral standards can be allowed to shift in times of emergency, and how do we justify it is an open question where ethical reflection is needed.
This book review focuses on three articles that contribute to this reflection: "Morality and Emergency" by Tom Sorell [2], "The Moral Black Hole" by Per Sandin and Misse Wester [3], and, finally, "Lifeboat Ethics and Disaster" by Noami Zack [4].These articles offer three different points of views on the same question: How could emergency modify our normal ethics standards?To answer this question, Sorell offers reflections about different kinds of emergencies and about the "moral black hole."For their part, Sandin and Wester concentrate their analysis on empirical observations during natural crises and develop a critical point of view of Sorell's moral black hole.Finally, Zack studies real and theoretical cases to understand the collapse of normal ethics during emergency.

A Conceptual Analysis: The Moral Black Hole
Sorell begins his article (chapter 2) by offering a definition of emergency: "An emergency is a situation, often unforeseen, in which there is a risk of great harm or loss and a need to act immediately or decisively if the loss or harm is to be averted or minimised" (p.16).In other words, one cannot rapidly act and think at the same time during an emergency.However, emergency doesn't have absolute excusing power; the more an emergency is preventable, the less a wrong intervention is justifiable and excusable.Sorell distinguishes "standard emergency" and "unexpected emergency." The first category includes all emergencies that can be managed by routines such as fire drills or firstaid training.These routines do not really prevent emergency but they "keep us from being at a loss in the face of them" (p.19).The second category, unexpected emergency, could produce a moral black hole: an increase of non-ethical actions such as looting, distrusting others and taking pre-emptive actions against others.To prevent a moral black hole, Sorell argues that we should be prepared for emergencies, especially public emergencies because they undermine everyday life and normal morality to a greater degree (p.26).This affirmation has many implications for health policies: health managers have to foresee dangers and plan responses for many kinds of emergency.But the difficulty with Sorell's recommendation from both is how could it be possible to account for all possible dangers and to be ready for them?How could it be possible for health managers to have the time and human resources necessary to plan for all possible emergencies?

An Empirical Analysis: Natural Disaster and Critique of the Moral Black Hole
In chapter 5, Sandin and Wester affirm that the moral black hole has not been observed during natural disasters such as hurricane Katrina.After a synthesis of Sorell's concept, these authors develop a point of view critical of "the myth of looting" (p.79) and of the increase of selfishness, two bases of the moral black hole concept.To demonstrate their point of view, they present a lot of empirical evidence about reactions during natural crises.For example, they quote empirical research [5] to affirm that arrest reports for looting did not increase during hurricane Katrina.Sandin and Wester also argue that it is important to distinguish real looting from looking for water and food to satisfy basic needs (p.80).For example, during Katrina, some people went into other people's homes to look for food.The authors affirm that this was not real looting, since these people did not have any criminal intentions, and acted only on the grounds of survival.They also quote real examples of altruistic initiatives during hurricane Katrina and the Kobe earthquake.The authors conclude that there is no empirical evidence for the moral black hole during natural crises, although this concept has been commonly used as a justification for exceptional and costly measures.Like all comparative studies, this chapter offers a great analysis of specific cases, but it may be difficult to apply its conclusions to other natural disaster cases with different economic, geographic and cultural realities.

A Case Study: The Limits of Consequentialism and Deontology
The third article, written by Zack (chapter 4), offers another way of thinking about the modification of our normal ethics standards during emergency events.It relates and analyses six cases where both consequentialism and deontology have not offered any certain and univocal way to act.The mercy killing of some patients during hurricane Katrina (p.42-45) is given as a case.On September 14, 2005 in the aftermath of the hurricane, the staff of the Memorial Medical Center were ordered to leave the hospital and abandon any patient who could not be evacuated because of their dependence on continuous treatment.To limit the suffering of four elderly patients that the staff could not evacuate, a doctor and two nurses gave them lethal injections.They were accused of second-degree murder for these actions.This case's dilemma is between the moral and legal interdiction of killing and the good intention of reducing harm.In others words, if a doctor has to stop caring for some patients during an emergency evacuation, could mercy killing be more acceptable than protracted suffering?Moreover, the evaluation of consequences is complicated by the impossibility to evaluate the certainty of the harm: whether patients could be evacuated or saved before their death.With this kind of case, Zack demonstrates that the assessment of actions made during emergency -facing harm and emotionsis complicated when normal legal and moral systems are restored.Mercy killing could appear to be a good action in an emergency context, but it would be judged like a murder in a normal court of justice.He also demonstrates that our ethics principles should be taken seriously during emergencies, but that they are not absolute.In this case of mercy killing, utility was taken seriously, but it was not absolute; utility can generate moral and legal difficulties in such a situation.

Conclusions
These three articles, in chapters 2, 5 and 4, offer a great introduction to the concepts of emergency and the moral black hole.They offer some useful reflexive avenues for the assessment of decisions and actions during emergencies.However, the limited length of articles reduces the possibility to develop and nuance some important aspects.For example, Sorell's short distinction between "standard emergency" and "unexpected emergency" generates two questions.First, how could a routine of standard emergency, such as first-aid training, decrease the possibility of a moral black hole?These routines are occasions to embody how to act during an emergency; they are not real occasions to think about ethics, they are only operational plans.Proper thinking about emergency actions can be done before or after real situations.One can plan or reflect about general cases, but each emergency situation remains unique.Second, what are the effects of these routines on our normal judgments?For example, how could new drills for school shootings, recently established in Québec, transform our conceptions of public space and of children's safety?One of Sandin and Wester's conclusions also needs more elaboration.These authors affirm that arrest reports for looting did not increase during hurricane Katrina.How could the exceptional prevention measures taken during this crisis influence looting?These results should be compared with data on other crises with different prevention measures.
The book Emergency Ethics offers to bioethics researchers and students an introduction to emergency ethics, its central concepts, and its debates.All of the chapters had been published previously as articles in scientific journals or books before the series was edited.Consequently, the relevance of this series is not its new contributions but its usefulness as an overview of emergency ethics and as documentation of this evolving field.
This first volume will certainly be of interest for bioethics students and researchers who want an introduction to questions pertaining to medical or humanitarian intervention.However, for the sake of the non-specialised reader, I would have liked a common thread across the chapters and a more explicit articulation of how the issues raised in each chapter could resound with other questions brought by the other chapters.In this review, I concentrated the analysis on one single question addressed in three chapters: How could emergency modify our normal ethics standards?The other ISSN 1923-2799 3 / 4