Bioethics in Emergency and Disaster

- Frank J. Leavitt, Ph.D.

Faculty of Health Sciences, Ben Gurion University of the Negev
Beer Sheva, ISRAEL (Home Tel/FAX: +972-2-9963048)
(Disconnected from Friday dark until Saturday dark, Israel times)


Eubios Journal of Asian and International Bioethics 5 (1995), 116-117.
Elsewhere in this issue is a report from Darryl Macer on our bioethical experience in Israel in August (EJAIB 5 (1995), 113-5). We began a number of projects on which more information will follow in future issues. But the most gratifying part of the visit was the personal contact with Darryl and Nobuko, and with the students, Miho Tsuzuki, Takayoshi Umeno and Yuki Niimura. As bioethicists, we must keep the young generations foremost in mind. We can only guess what life will be like in the future. So we don't really know yet what bioethics is going to be. We can only use whatever we have managed to learn from traditional sources, and from reason and insight, to try to point the students in what we hope will be the right direction, and then trust them to create an ethic of life in the future. Each generation seeks, (Psalms XXIV, 6) in its own way. Although we may think that policy is decided by older people, policy is meaningless unless large numbers of people accept it. A good example is the environment here in Israel, where it is said that we have the best environmental legislation in the world but nobody obeys it. And how people behave will largely be determined by the youth. This is what makes bioethics education so important.

We are working to encourage study exchanges between Israeli and Japanese students and would like to include other Asian countries. At the same time, we want to make the next summer visit more organized and even more meaningful than this year's.

An idea arose when Darryl Macer spoke with us about the failure of Japanese rescue crews to respond immediately to the Kobe earthquake, waiting lengthy periods of time for orders from above before acting (or being able to act). The Japanese emergency rescue system has come under considerable criticism for failure to respond quickly to this emergency as well as to a 1985 Japan Airlines crash (1) (and see further details in Darryl Macer's editorial in this issue).

Israelis find this hard to believe. We are so used to dealing with terrorists and acts of war (not to mention our shameful auto accident record) that we have developed a culture of immediate response to life-threatening emergency without waiting for permission.

I do not want to romanticize Israel. Many things believed about us are no longer true or never were. The myth of "Israel democracy" is a joke with government policies of administrative detention with no trial or right to a lawyer and of confiscating the equipment of the opposition radio station. There is a new ideology of closing up our once famed agriculture and making money instead from hedonistic tourism complete with four-wheel drive vehicles and miniature tractors to ruin whatever ecology may be left. And post-modern materialism is turning our Jewish warmth to selfish coldness.

But our culture of quick response to emergency is something we can teach the world. Isaiah Ben Dasan, in a book which was a best-seller in Japan, contrasted the Jewish and the Japanese people (2). He pointed out how our thousands of of years of nomadic exile taught us to live with danger. He contrasted this with the relative security of life in Japan. But is life so secure anywhere today? Terrorism and the accidents of technology can threaten us no matter where we are. The supposed Age of Peace may be as illusory as the peace which was supposed to come after World War I, or as illusory as the End to Infectious Disease which antibiotics were supposed to bring us. And we may be waking up to the fact that non-linear functions, and not the immutable harmonious laws of Greek and Medieval physics, govern both geological events (including earthquakes) and astronomical ones (including the next Shoemaker-Levy). In a chaotic universe immediate response to emergency should be part of everyone's bioethic.

This is very much a part of Jewish Medical Ethics. Scripture says "You shall not stand still before your neighbor's blood" (Leviticus', XIX, 16. The English translations are imperfect. I have translated in accord with Rabbinical commentary.) This is often only taken to apply to a physician's duty to cure a patient (3). But it obviously applies to any person who is in a position to save a life. Indeed our great medieval Biblical commentator, Rabbi Shlomo ben Itshak (Rashi), explained this passage as follows: "Don't stand by and watch someone die when you can save him. For example, if he is drowning in the sea or if an animal or thugs attack him." (loc. cit. my translation). Obviously the commandment applies to anyone (not just a physician), who can save another human being's life. And there is no excuse for hesitating.

In Israel a large percentage of the population learned in army duty basic bandaging techniques for stopping blood loss. And there is a desire to qualify as many people as possible to give more advanced first aid in emergency and disaster situations. Magen David Adom, the Red Star of David, gives a 44-hour course in which my son, Yossie, and I studied this summer. The number of hours and content approximately match a university semester but it is packed into one intensive week. Besides stopping blood loss, we learned Cardio-Pulmonary Resuscitation (mouth-to-mouth ventilation and manual heart massage) which can keep a heart-attack victim or an injured person stabilized with blood and oxygen flowing until a better qualified person, with better equipment, can take over. We also learned care of snake bite and drowning victims, electric shock, burns, broken and exposed bones, familiarity with ambulance equipment, a triage system in multiple victim situations based on medical considerations alone (4), and other subjects too numerous to list here.

As a bioethicist it was valuable to get some training in things which many of my students, especially the nurses, do every day. It was refreshing to be taught an ethic of "never give up". And we heard many stories from the instructors' personal experience of people to whom they gave mouth-to-mouth and manual C.P.R. for as long as two and a half hours until they began to breath on their own and regained consciousness. Many are alive and healthy today. This may be contrasted with the over-emphasis on death in much medical ethics. Letting (or helping!) people die is discussed so often that I often think the appropriate word for much of what is going on should be "thanatoethics" (ethic of death) rather than "bioethics" (ethic of life). Bioethics should encourage a culture of loving life and learning how to save it.

And when the need arises to save a life, we are taught not to wait for instructions or orders (nor to worry about malpractice suits, which happens so often in America) but just to act. And we believe that it is better to act and make a mistake than not to act at all. This is, perhaps, the essence of bioethics. Of course, "do no harm" is an important principle of bioethics. But emphasizing it too much can lead to indecision and loss of life. On the other hand someone who does not know how to treat an accident victim can cause more harm, including permanent damage or loss of life, than would have resulted from leaving the victim alone until professionals arrive. This is why as many citizens as possible should be taught first aid and CPR, so they will know what to do if the need arises.

In Israel the first aid system is part of a national organism of response to danger. We may seem to believe in Western "individual autonomy" when we give philosophical lectures. But when we are faced with danger, our bioethics in action is the entire people acting as one organism. Indeed our holy philosopher of Judaism in the time of the Redemption, Rabbi Avraham Itshak Kook, saw the entire Israeli people in the Land of Israel as one whole, one soul. And now in practice our Civil Defense authority has the power to declare a virtual military dictatorship in the immediate vicinity of a disaster, to draft into service cranes, bulldozers and other equipment owned by civilians, and to begin acting to save lives not within days or hours but within minutes or less.

If I sound too critical of the Japanese for the slow response to the Kobe earthquake, I sincerely apologize. But anything I can say or do to help people be more prepared the next time human beings are in danger has to be said or done (again see Leviticus XIX, 16).

Wondering what could be done practically to help prepare for future emergencies, I spoke about these matters with Yuki, Takayoshi and Miho during their visit here. I think it was as we relaxed and dried off by the banks of the Jordan River after kayaking. I suggested as a first step that the next East Asian students' bioethical visit to Israel might include that 44-hour course in Israeli First Aid, given in English. The student's responded enthusiastically. I think such a thing might be arranged if there is a demand. Of course an arrangement would have to be made with licensed instructors and organizations. And much would be at the students' own responsibility. On the other hand if it seems there really is a demand for such a programme, I can begin checking into established, properly insured institutions.

I think that next summer's Israeli bioethics programme might include, in addition to First Aid in Emergency and Disaster Situations, an expanded course in Jewish Medical Ethics involving additional specialists in Jewish Law and Medicine (I gave a few lectures in this subject to the Japanese students this year, but it was not enough). We should also involve more lecturers from Ben Gurion and other Israeli universities than we did this year, continuing and expanding the emphasis on areas in which Israel is particularly strong, like neonatal intensive care, fertility, help for Chernobyl radiation victims, etc.

There might also be intensive courses in Wilderness Survival and in Response to Terrorist Attacks. (Pacifists might be happy to know there are ways to respond to violence without killing or even injuring anyone, although you have to know how to scare them.) I have already spoken with Israeli survival instructors, and an intensive course could be organized which would include wild food and medicinal plants, navigation (path-finding), animal tracks, rappelling including lowering injured people from cliffs or collapsing buildings, wilderness camping, finding water in the desert, etc. All this could be part of next year's Bioethical Experience in Israel for East Asian Students. It could be done in about four or five weeks. And it would all be focused on encouraging a bioethical culture of quick decisive response when human life in is danger.

I think I have enough contacts to organize this from the Israeli side. But it depends on East Asian Response. We need more partners on your end of our continent to prepare the students and take care of organization over there. The contact in Japan for this is, of course, Darryl Macer. And in this too-real world, we need considerable funding. The students would have to pay for themselves and for the courses. Since I see this as being of great human value, I'll try to find out if any funding is available. But I cannot make any promises. If others agree that disaster response and these other skills are an important part of the bioethics which Israel has to teach then be in touch with practical suggestions for organization and funding. This expanded summer programme should, of course, include further kibbutz experience both at Shoval near Beer Sheva, which hosted the students this year, and at Lotan in the Arava, which is interested in moving towards a more environmentally friendly agriculture, and which also hosted us for an informative evening. And my family and I would like our East Asian friends to spend more time with us in Hebron.


References

(1) The Japan Times: 24/1/95 p. 1; 10/2/95 p. 1; 23/8/95 p. 2.
(2) Ben Dasan, Isaiah (1970) Nihonjin to Yudayajin (The Japanese and the Jews), Tokyo; Yamamoto Shoten. And published in English translation by Weatherhill, 1972.
(3) Leavitt, FJ Responsabilite medica. in Leone S & Privitera S. Dizionario di Bioetica. Palermo. Instituto Siciliano di Bioetica. 1994: 843-846 (Italian).
(4) Yeshua, I. First Aid in Emergency Situations. Tel Aviv, Centre for Educational Technology, 1987. (in Hebrew. If readers know of sources in English and other languages, especially on triage in multiple victim disasters, please send references to EJAIB; and check General Medical Ethics Section).


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