The Duty of Mind: Ethical Capacity in a Time of Crisis

In a disaster, physicians are forced to make challenging and heartbreaking ethical decisions under conditions of physical and emotional exhaustion. Evidence shows that the conditions of stress that mark disasters can undermine the process of ethical decision-making. This results in biased allocation of scarce resources, fewer utilitarian and altruistic decisions, and a wider variation in decisions. Stress also predisposes clinicians to decision strategy errors, such as premature closure, that lead to poor outcomes. The very ability to make sound and ethical decisions is thus a scarce resource. Ethical frameworks underpinning disaster protocols enumerate many physician obligations, but seldom articulate the risk posed by having decisions made ad hoc by decision-makers who are compromised by the stress of the concurrent crisis. We propose, therefore, that a "duty of mind"-the obligation to make critical decisions under the clearest possible state of thought-be added to ethical frameworks for disaster response. Adding the duty of mind to the pillars on which planning is based would force attention to a moral imperative to include decision support tools in disaster planning. By moving the consideration of possible choices to a moment when time and consultation facilitate clear and considered thought, the duty of mind is upheld. (Disaster Med Public Health Preparedness. 2018;12:657-662).