Office of Academic Affairs
Difficult Conversations: Evacuation of Older Persons
Research Report
May 2006
Difficult Conversations: Evacuation of Older Persons
Harry R. Moody, Ph.D.
AARP Office of Academic Affairs
When homebound elders are reluctant to leave home in the face of an impending hurricane, we are faced with ethical dilemmas. In this situation do we simply leave people alone or do we actively intervene to insure their protection? Competing arguments present themselves:
(1) “My Home Is My Castle.” There is a strong tradition in American culture that people are entitled to be left alone and make their own decisions. Older people living at home have a lifetime of experience making hard choices and deciding what risks to bear. Deciding whether or not to evacuate under the threat of a hurricane should be left to individuals who are the best judge of their own circumstances. We know that leaving the home in which one has lived for years can provoke “transfer trauma” and even cause death. The risks of leaving are always balanced by the risks of staying. In the end, quality of life counts more than mere survival and each person is the best judge of what quality of life may mean.
Against this View. The vast majority of people who died in Hurricane Katrina were over the age of 75: the “old-old” were therefore those at greatest risk. Many elderly people at home have limited knowledge or experience coping with disasters such as a Category 4 hurricane. Most suffer from some degree of physical limitations and still others have diminished mental capacity. Leaving people to die at home is simply abandonment of our most vulnerable population and is a moral disgrace.
(2) Mandatory Evacuation. It is well established in America that in times of emergency the government can override ordinary liberties: for example, it can impose martial law or require mandatory evacuation. Public health and welfare must sometimes take precedence over individual rights, at least for as long as the emergency lasts. We cannot allow those at risk to die because government fails to act decisively. When a life-threatening hurricane is imminent, the solution is mandatory evacuation.
Against this View. Actions like martial law or mandatory evacuation are imposed because of a threat to public health and safety, not because individuals may be at risk. We allow people to engage in mountain climbing, sky-diving and many other potentially dangerous activities because people have a right to make their own decisions. Moreover, when government requires people to evacuate, is there any reason to believe it will also provide the necessary resources—such as medical care and a safe place to live? Without such guarantees, mandatory evacuation is unreasonable.
(3) Informed Consent. It is an established principle of law that a patient is entitled to refuse medical treatment, even if this endangers his or her life. But, conversely, health care providers are obliged to provide full and complete information about the benefits and burdens of a course of treatment. We should apply this same principle to the evacuation of home-bound elders. Professionals should disclose the risks of both options, whether it be evacuation or remaining at home. As long as this is done, the final decision rests with individuals.
Against this View. The conventional model of medical ethics arose in an acute care setting, and has limited applicability to home care or to people living in community settings. It’s good to provide information to people, but is it really enough? What about those who are frightened or confused, or unable to understand the information? How can we be sure that the information provided is actually received?
(4) Community Responsibility. Insuring that older people at home respond appropriately to life-threatening situations is not the responsibility of government alone. We know that in Hurricane Katrina all levels of government failed repeatedly, and people turned to agencies like the Red Cross, or to religious congregations or social service providers. Above all, they relied on family and friends to help them cope with the disaster. In preparing for future events, we should focus on improving this dimension of community responsibility in caring for home-bound elders.
Against this View. Many very old people living at home lack family members nearby who can actually help them. In Hurricane Katrina many formal service providers were simply overwhelmed by the disaster or were unable to cope effectively. In the face of a major region-wide disaster, the normal community resources cannot be counted on to respond.
Conclusions. Each of these views has some merit, but each is also limited. Taking account of the different perspectives, I offer here some suggestions about the ethics of evacuation:
(1) Individuals are ultimately the best judge of quality of life and the risks and benefits of staying in their own homes.
(2) Simply leaving individuals alone to risk death is tantamount to abandonment of the weakest members of our community and is ethically wrong.
(3) Under the doctrine of parens patria, government does have an obligation to act on behalf of those who cannot protect themselves.
(4) Mandatory evacuation on a collective basis can only be justified when there is a collective threat, which is different from what individuals face in their own homes.
(5) If government mandates evacuation, it must also provide resources necessary for people to live in reasonable health and safety.
(6) The traditional model of informed consent does not take adequate account of problems of capacity and emotional influences on decision-making; nor does it sufficient recognize the important role of family and relationships in the choices we make..
(7) Community agencies did provide essential help in Hurricane Katrina, but they also revealed significant weaknesses. There is a critical need for better training and preparation for future disasters.
(8) Instead of relying on abstract principles (“self-determination,” “mandatory evacuation”), we should look at the best practices of those who have struggled successfully with the ethical dilemmas of evacuation.