7/23/2018 Disa ste r Vig ne tte . A ma jo r e a rthq ua ke ro c ke - - PDF document

SLIDE 1

7/23/2018 1

HOW BE HAVI ORAL HE AL T H SHOUL D RE ACT E T HI CAL L Y I N A DI SAST E R

Da vid J. Ca rte r, Ph.D. Unive rsity o f Ne b ra ska – Oma ha d c a rte r@ uno ma ha .e d u

P A C

Disa ste r Vig ne tte . A ma jo r e a rthq ua ke ro c ke d the c e ntra l re g io n o f the US e a rly this mo rning . T he US Ge o lo g ic a l Surve y re po rte d a ma g nitude o f 7.7, the la rg e st e ve r in tha t re g io n sinc e 1812. Do ze ns we re kille d insta ntly a nd hund re d s tra ppe d in the rub b le o f c o lla pse d b uild ing s. Mo me nts a fte r the q ua ke we ta lke d with Ma rk Withe rs, fro m a vo lunta ry re spo nse o rg a niza tio n who re po rte d , a ll c o mmunic a tio ns in the imme d ia te a nd surro und ing a re a we nt d o wn. T ra nspo rta tio n ro ute s we re a lso b lo c ke d. Ga s a nd wa te r ma ins rupture d ig niting ma ssive b la ze s. No o ne wa s the re to fig ht the fire s, b e c a use with ro a d wa ys c ripple d , the a re a wa s c ut o ff fro m me d ic a l supplie s a nd a id . In o ne a re a , e a rthq ua ke d a ma g e d le ve e s g a ve wa y a nd wa te r fro m the surro unding rive r rushe d into the b o rde ring c itie s. Hund re ds

• f re sid e nts in the c ity fle e ing fro m the fire s a nd c ha o s, e va c ua te d to

she lte rs se t up b y the lo c a l g o ve rnme nt.

T he re a re witne ss a c c o unts o f the g ro und o pe ning up a nd swa llo wing who le se c tio ns o f la nd, b uilding s to ppling , a nd po we r line s c ra shing to the g ro und. Pe o ple a re tra ppe d in the ir c o lla pse d ho me s; e a rly mo rning c o mmute rs we re c rushe d o n c rumb ling hig hwa ys. T he injure d a re po uring into me dic a l fa c ilitie s. T wo ma jo r ho spita ls c o lla pse d so injure d survivo rs a re lining the stre e ts o utside o f the fa c ilitie s tha t a re still func tio ning . We we re a b le to ma ke c o nta c t with o ne lo c a l o ffic ia l who is re po rting tha t a la rg e po we r pla nt a lso e xplo de d, c utting o ff po we r g rids. It is ha rd to de te rmine the e xte nt o f the da ma g e a t this po int. Do ze ns a re de a d. Hundre ds injure d a nd ma ny, ma ny mo re missing a nd fe a re d de a d. E T HICS AND DISAST E RS: A T OPIC OF E PIC PROPORT IONS

• Disa ste rs a nd e me rg e nc ie s a re :

Inte rna tio na l a nd lo c a l Multic ultura l, multi-e thnic , multi-re lig io us E

nviro nme nta l a nd ma n ma d e

Invo lve g o ve rnme nts, NGO’ s, c o rpo ra tio ns, vic tims,

wo rke rs, a nd the pre ss

E

thic s implic a tio ns a re a t the c o re o f pre pa ra tio n, po lic ie s, re spo nse a nd re c o ve ry

DI SAST E RS

Altho ug h the d e finitio n o f disa ste r c ha ng e s b e twe e n c o untrie s a nd the a c c ura c y o f c o lle c te d d a ta va rie s a c ro ss the g lo b e a nd thro ug h time , o ne tre nd is c le a r. E ve nts we la b e l “na tura l disa ste rs” a re o c c urring mo re fre q ue ntly tha n in the pa st.

WHAT I S A DI SAST E R?

“A disa ste r is a n e ve nt (o r se rie s o f e ve nts) tha t har

m or kills a signific ant numbe r

• f pe ople or
• the r

wise se ve r e ly impair s or inte r r upts the ir daily live s in c ivil so c ie ty.

Disa ste rs ma y b e natur

al or the r e sult of ac c ide ntal or de libe r ate human ac tion. Disa ste rs inc lude , b ut a re no t

limite d to , fire s; flo o ds; sto rms; e a rthq ua ke s; c he mic a l spills; le a ks o f, o r infiltra tio n b y, to xic sub sta nc e s; te rro rist a tta c ks b y c o nve ntio na l, nuc le a r o r b io lo g ic a l we a po ns; e pide mic s; pa nde mic s; ma ss fa ilure s in e le c tro nic c o mmunic a tio ns; a nd o the r e ve nts tha t o ffic ia ls a nd e xpe rts de sig na te “disa ste rs”

SLIDE 2

7/23/2018 2

WHAT I S A DI SAST E R? (CON)

“Disa ste rs a lwa ys c a use surprise a nd sho c k;

the y a re unwa nte d b y tho se a ffe c te d b y the m, a ltho ug h not always unpre dic table. Disa ste rs a lwa ys g e ne ra te na rra tive s a nd

me dia re pre se nta tio ns o f the he ro ism, fa ilure s

a nd lo sse s o f tho se who a re a ffe c te d a nd re spo nd.”

DMC

Pre ve ntio n Pre pa re d ne ss Ale rt Re spo nse Re c o ve ry Po st Disa ste r

E ME RGE NCI E S

E

me rg e nc ie s a re typic a lly lo c a l a nd c a n b e d e a lt with lo c a l re so urc e s

E

me rg e nc ie s a re typic a lly o f a sho rte r d ura tio n

A de c la ra tio n o f a sta te o f e me rg e nc y is

usua lly do ne fo r disa ste rs – no t e me rg e nc ie s. OUR SOCI AL CONT RACT

“ Gove r

nme nt has an obligation, b a se d o n the

justific a tio n o f its o rig ins, to pr

e par e c itize ns for sur vival c a use d b y disa ste r. Suc h pre pa ra tio n

re q uire s imple me nta tio n thro ug h pub lic po lic y.” Jo hn L

• c ke

T

he se rig hts a re pre sume d in the US De c la ra tio n o f Inde pe nde nc e a nd pro te c te d b y the first te n a me ndme nts o f the c o nstitutio n.

WHAT IS SPE CIAL ABOUT DISAST E RS T HAT MOT IVAT E S PE OPL E T O ACT AND RE SPOND E T HICAL L Y? Ba sic huma n va lue s o f

Co mpa ssio n Pa tie nc e E

mpa thy

Ge nuine ne ss Re spe c t fo r dig nity o f o the rs Pro fe ssio na l c o de s o f c o nduc t

E T HI CAL T HE ORI E S AND E T HI CAL PRI NCI PL E S

E

thic s is no t a b o ut wha t is - b ut wha t sho uld b e .

E

thic a l re la tivism: mo ra lity va rie s b e twe e n pe o ple a nd so c ie tie s ac c or

ding to the ir c ultur al nor ms

Unive rsa list o r o b je c tivist mo ra l the o rie s: fund a me nta l

princ iple s tha t a re inva ria nt thro ug h o ut time a nd spa c e .

 “Pe o ple have a basic right to safe ty and it is a fundame ntal o bligatio n o f all go ve rnme nts

to e nsure that the ir c itize ns are pro te c te d to a re aso nable de gre e fro m kno wn risk, and that c itize ns are info rme d and warne d o f any risks kno wn to go ve rnme ntal o ffic ials that thre ate n public safe ty.”

 “T

• re spe c t the e qual dignity o f all human be ings, re c o gnizing a basic right to life and

subsiste nc e ”

 “T

he c o nde mnatio n o f c o arse public se c to r c o rruptio n”

 “T

he o bligatio n to re spe c t human auto no my”

The Search for Principles of Disaster Management. Etkin D, Davis I

SLIDE 3

7/23/2018 3

GE NE RAL E T HI CAL PRI NCI PL E S

 So lida rity  Jo int re spo nsib ility  No n-disc rimina tio n  Huma nity  I

mpa rtia lity

 Ne utra lity  Co -o pe ra tio n  T

e rrito ria l so ve re ig nty

 Pre ve ntio n  F

a irne ss

 Re spe c t fo r pe rso n  L

imiting ha rm

 Ro le o f the me dia

PROF E SSI ONAL CODE S OF E T HI CS

“Pro fe ssio ns g o ve rne d b y Co d e s o f E

thic s a ppro ve d b y the ir me mb e rs func tion on the

assumption tha t the se c o d e s will no t b e

vio la te d in pra c tic e . Whe n the y a re vio la te d , pra c titio ne rs ma y b e g uilty o f ma lpra c tic e , inc urring c rimina l a s we ll a s c ivil a nd pro fe ssio na l, pe na ltie s”

Zack, Naomi Ethics for Disaster, Rowman & Littlefield Publishers. Series: Studies in Social, Political, and Legal Philosophy

SOL I DARI T Y

De lib e ra te a nd fre e ly c ho se n unity a mo ng c e rta in, g ro ups o r

po pula tio ns. T his pre suppo se s the a wa re ne ss o f unity a nd the a c c e pta nc e o f the c o nse q ue nc e s o f unity. “Whe n re fe rring to he a lthc a re , so lid a rity me a ns the obligation to shar

e the financ ial r isks of illne ss and handic ap with othe r s not ne c e ssar ily of one ’s own soc ial gr

• up.”

“So lid a rity o f inte re sts is b a se d o n the princ iple o f re c ipro c ity:

pe o ple sha re risks tha t a re c o mmo n to e a c h o the r”

T

he princ iple s o f so lid a rity will b e pa rtic ula rly a pplic a b le to me mo ra nd ums o f unde rsta nd ing with lo c a l o rg a niza tio ns.

JOINT RE SPONSIBIL IT Y AND NON-DISCRIMI NAT I ON

Joint r

e sponsibility

E

me rg e nc y ma na g e me nt is no t so le ly the d o ma in o f e me rg e nc y ma na g e me nt a g e nc ie s; ra the r, it is a shar

e d r e sponsibility be twe e n gove r nme nts, c ommunitie s, busine sse s and individuals.

F

e d e ra l c ivil la ws re q uire e qual ac c e ss for

, and pr

• hibit

disc r imination against, pe ople with disabilitie s in all aspe c ts of e me r ge nc y planning, r e sponse , and r e c ove r

• y. T
• c o mply with

F e d e ra l la w, tho se invo lve d in e me rg e nc y ma na g e me nt sho uld unde rsta nd the c o nc e pts o f a c c e ssib ility a nd no nd isc rimina tio n a nd ho w the y a pply in e me rg e nc ie s.

T HE GUI DI NG PRI NCI PL E S ON I NT E RNAL DI SPL ACE ME NT

 T

he Guid ing Princ iple s se e k to pro te c t a ll inte rna lly d ispla c e d pe rso ns in inte rna l c o nflic t situa tio ns, na tura l disa ste rs a nd o the r situa tio ns o f fo rc e d d ispla c e me nt

 Inte rna lly displa c e d pe rso ns sha ll e njo y, in full e quality, the sa me rig hts a nd

fre e d o ms und e r inte rna tio na l a nd d o me stic la w as do othe r pe r sons in the ir c ountr y.

 T

he se Princ iple s sha ll b e a pplie d witho ut d isc rimina tio n o f a ny kind , suc h a s ra c e , c o lo r, se x, la ng ua g e , re lig io n o r b e lie f, po litic a l o r o the r o pinio n, na tio na l, e thnic

• r so c ia l o rig in, le g a l o r so c ia l sta tus, a g e , disa b ility, pro pe rty, b irth, o r o n a ny
• the r simila r c rite ria .

 Ce rta in inte rna lly displa c e d pe rso ns, suc h a s c hildre n, e spe c ia lly

una c c o mpa nie d mino rs, e xpe c ta nt mo the rs, mo the rs with yo ung c hildre n, fe ma le he a ds o f ho use ho ld , pe rso ns with disa b ilitie s a nd e lde rly pe rso ns, sha ll b e e ntitle d to pro te c tio n a nd a ssista nc e re q uire d b y the ir c o nditio n a nd to tre a tme nt whic h ta ke s into a c c o unt the ir spe c ia l ne e ds.

ST ANDARD OF CARE 1

Wha t is the me a ning o f “sta nda rd o f c a re ”? Ho w ha ve disa ste rs a ffe c t o ur unde rsta nding o f the

e thic a l implic a tio ns o f Sta nda rd o f c a re ?

Ho w is the c o nc e pt o f tria g e a ffe c te d b y c risis

sta nda rds o f c a re ?

Wha t a re the le g a l implic a tio ns o f c risis sta nda rds o f

c a re ?

SLIDE 4

7/23/2018 4

ST ANDARD OF CARE 2

 T he Standar d of Car e is a c a se - a nd time -spe c ific a na lytic a l pro c e ss

in me dic a l de c isio n-ma king , re fle c ting a c linic al be nc hmar

k o f

a c c e pta b le q ua lity me dic a l c a re . T his b e nc hma rk, whic h is use d to

e valuate and guide the pr ac tic e of me dic ine , e nc ompasse s the le ar ning, skill and c linic al judgme nt or dinar ily posse sse d and use d by pr ude nt he alth c ar e pr

• vide r

s in simila r c irc umsta nc e s.  T

he sta nda rd o f c a re must re fle c t the ar

t (c o nse nsus o f o pinio n o f

c linic a l judg me nt) and sc ie nc e (pub lishe d pe e r re vie we d lite ra ture )

• f me dic ine a nd must b e unifo rm fo r a ll he a lth c a re pe rso nne l

whe the r the y a re pro viding dire c t c linic a l c a re o r re vie wing the me dic a l ne c e ssity o f pa st, pre se nt o r future me dic a l c a re .

ST ANDARD OF CARE 2

A vio la tio n o f sta nda rd o f c a re ma y re sult in unde r-

utiliza tio n o f me dic a l c a re , b ut a lso o c c urs whe n unne c e ssa ry c a re (o ve r-utiliza tio n) is pro vid e d .

T

he sta nd a rd o f c a re ha s a na tio na l a nd c linic a l b a sis, ra the r tha n a lo c a l pro vide r c o mmunity o r pa yo r re vie w b a sis.

American College of Medical Quality, policy 3 http://www.acmq.org/policies/policies3and4.pdf

RE COMME NDAT I ONS 1:

 De ve lo p c o nsiste nt sta te c risis sta nda rd s o f c a re pro to c o ls with 5 ke y

e le me nts A stro ng e thic a l g ro und ing Inte g ra te d a nd o ng o ing c o mmunity a nd pro vid e r

e ng a g e me nt, e d uc a tio n a nd c o mmunic a tio n

Assura nc e s re g a rd ing le g a l a utho rity a nd invo lve me nt Cle ar

indic ator s, tr igge r s and line s of r e sponsibility

E

vide nc e b a se d c linic a l pro c e sse s a nd o pe ra tio ns

IOM: Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report 2009 http://www.iom.edu/~/media/Files/Report%20Files/2009/DisasterCareStandards/Standards%20of%20Car e%20report%20brief%20FINAL.pdf

RE COMME NDAT I ONS 2:

 Se e k c o mmunity a nd pro vide r e ng a g e me nt

 Spe c ia l a tte ntio n sho uld b e g ive n to vulne ra b le po pula tio ns

 Adhe re to e thic a l no rms during c risis sta nda rds o f c a re .

 Co nditio ns o f ove rwhe lming sc arc ity limit autonomous c hoic e s for both patie nts and prac titione rs re garding the alloc ation of sc arc e re sourc e s, but do not pe rmit ac tions that violate e thic al norms

 Pro vide ne c e ssa ry le g a l pro te c tio ns fo r he a lthc a re pra c titio ne rs a nd

institutio ns imple me nting c risis sta nda rds o f c a re

 E

nsure c onsiste nc y in c r

isis standar ds of c ar e imple me ntation  T

ria g e te a ms, e tc , Pa llia tive c a re , Me nta l he a lth suppo rt, Atte ntio n to vulne ra b le po pula tio ns, R

e al time infor mation shar ing  E

nsure intra sta te a nd inte rsta te c o nsiste nc y a mo ng ne ig hb o ring jurisdic tio ns

PRE PARI NG F OR DI SAST E RS: T HE CHAL L E NGE

Disa ste rs c a n le a d to shor

tage s of c r itic al me dic al r e sour c e s

Sho rta g e s re q uire har

d de c isions, fo r e xample —

 Who sho uld b e a t the fro nt o f the line fo r va c c ine s o r a ntivira l d rug s?  Whic h pa tie nts sho uld re c e ive life sa ving ve ntila to rs o r b lo o d?

In e xtre me c a se s, some pe ople will not r

e c e ive all of the tr e atme nt the y ne e d

How do we give the be st c ar

e possible unde r the wor st possible c ir c umstanc e s?

T HE RE S PONS E : “CR

ISIS ST ANDAR DS OF CAR E ” Guide line s de ve lo pe d be for

e disaste r str ike s—

T

• he lp he a lthc a re pro vide rs de c ide ho w to

a dministe r...

T HE BE ST POSSIBL E ME DICAL CARE

…whe n the re a re no t e no ug h re so urc e s to g ive a ll pa tie nts the le ve l o f c a re the y wo uld re c e ive unde r no rma l c irc umsta nc e s.

SLIDE 5

7/23/2018 5

WHE N MIGHT WE NE E D CRISIS ST ANDARDS OF CARE

E

xtre me Crisis

 Hurric a ne  F

lu Pa nd e mic

 E

a rthq ua ke

 Bio te rro rism

Sc a rc e Me dic a l Re so urc e s

 Blo o d  Ve ntila to rs  Drug s  Va c c ine s  Sta ff

POSSIBLE REA POSSIBLE REASONS ONS FOR CRISIS STANDARDS OF CARE

T

• ma ke sure tha t c ritic a l re so urc e s g o to tho se who will

be ne fit the most

T

• pr

e ve nt hoar ding a nd ove r use o f limite d re so urc e s

T

• c onse r

ve limite d r e sour c e s so mo re pe o ple c a n g e t the

c a re the y ne e d

T

• minimize disc r

imination a g a inst vulne ra b le g ro ups

So a ll pe o ple c a n tr

ust tha t the y will ha ve fa ir a c c e ss to

the b e st po ssib le c a re und e r the c irc umsta nc e s POSSIBL E ST RAT E GIE S T O MAXIMIZE CARE

 Spac e  Put pa tie nt b e d s in ha llwa ys, c o nfe re nc e ro o ms, te nts  Use o pe ra ting ro o ms o nly fo r urg e nt c a se s  Supplie s  Ste rilize a nd re use d ispo sa b le e q uipme nt  L

imit d rug s/ va c c ine s/ ve ntila to rs to pa tie nts mo st like ly to b e ne fit

 Prio ritize c o mfo rt c a re fo r pa tie nts who will d ie  Staff  Ha ve nurse s pro vid e so me c a re tha t d o c to rs usua lly wo uld

pro vid e

 Ha ve fa mily me mb e rs he lp with fe e d ing a nd o the r b a sic pa tie nt

ta sks

WHE N T HE RE ISN’T E NOUGH T O SAVE E VE RYONE…

HOW SHOUL D WE DE CIDE WHO GE T S WHAT ? Some options--

1.

F irst-c o me , first-se rve d?

2.

L

• tte ry?

3.

Sa ve the mo st live s po ssib le b y g iving mo re c a re to pe o ple who ne e d it the mo st?

4.

F a vo r c e rta in g ro ups?

 T

he o ld OR the yo ung ?

 He a lthc a re wo rke rs a nd o the r e me rg e nc y re spo nd e rs?  Wo rke rs who ke e p so c ie ty running (utility wo rke rs, tra nspo rta tio n

wo rke rs, e tc .)?

WHERE DO YO YOU COME IN? Co mmunity Co nve rsa tio ns he lp po lic y ma ke rs:

Unde r

stand c ommunity c onc e r ns about the use o f

limite d me dic a l re so urc e s during disa ste rs

De ve lop c r

isis standar ds of c ar e guide line s tha t

re fle c t c ommunity value s and pr

ior itie s PR E PAR ING F OR DISAST E R

 Cr isis Standar ds of Car e (“CSC”)--- a pie c e of the puzzle

SLIDE 6

7/23/2018 6

E T HICAL PRINCIPL E S APPL IE D PRIOR T O DISAST E RS

 Intro duc tio n o f pr e ve ntion me asur e s  Impo rta nc e o f g o o d q ua lity

he a lthy e nviro nme nt

 E duc ation, tr aining and awar e ne ss r aising  Pa rtic ipa tio n – public input

a t na tio na l a nd lo c a l le ve l

 F

re e do m o f e xpre ssio n

 Ac c e ss to justic e  Disa ste r pre ve ntio n a t the

wo rkpla c e

 Disa ste r pre ve ntio n in r e c r e ation and tour ist ar e as  Disa ste r pre ve ntio n in pub lic

pla c e s – sc hools and hospitals

 Spe c ia l pre ve ntio n me a sure s fo r

the most vulne r

able gr

• ups

 Org a niza tio n o f a nd par tic ipation in e me r ge nc y dr ills  Pr e ve ntive e vac uation of populations

Ethical Principles on Disaster Risk Reduction and People’s Resilience, Prieur M. European and Mediterranean Major Hazards Agreement (EUR‐OPA) http://www.coe.int/t/dg4/majorhazards/ressources/pub/Ethical‐Principles‐Publication_EN.pdf

E T HICAL APPROACH T O AL L OCAT I ON OF SCARCE RE SOURCE S AND T RIAGE

F

a irne ss – inhe re ntly just to a ll individua ls

Duty to c a re duty to ste wa rd re so urc e s

 Duty to a tte mpt to o b ta in b e st o utc o me fo r the g re a te st

numb e r o f pa tie nts with a va ila b le re so urc e s – do e s no t me a n sa ve the mo st live s – a c o mfo rta b le de a th ma y b e a g o o d

• utc o me .

T

ra nspa re nc y

Co nsiste nc y Pro po rtio na lity Ac c o unta b ility

Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012 Mar;59(3):177‐87. Epub 2011 Aug 19. Review. PubMed PMID: 21855170.

PUBL I C HE AL T H DE CI SI ON MAK I NG

Co nc e rne d with po pula tio ns ra the r tha n ind ividua ls Utilita ria n: g re a te st g o o d fo r the g re a te st numb e r Pub lic he a lth inte rve ntio ns must b e ne c e ssa ry a nd

e ffe c tive to a d d re ss the pub lic he a lth issue b a se d o n c urre ntly a va ila b le info rma tio n

Pub lic he a lth a utho ritie s must use le a st re stric tive

a lte rna tive inte rve ntio n a va ila b le

Be ne fits a nd b urd e ns o f pub lic he a lth d e c isio ns sho uld b e

d istrib ute d e q uita b ly a mo ng so c ie ty: “e q uita b le d istrib utio n”

Ne e d fo r a fa ir pro c e ss a nd tra nspa re nc y in d e c isio n

ma king

PRI NCI PL E S OF AL L OCAT I ON

Princ iple o f so c ia l wo rth – pe o ple who ha ve instrume nta l va lue –

he a lthc a re wo rke rs, g o ve rnme nt, e tc

Ra nd o m Se le c tio n – L

• tte ry

Princ iple o f fa ir c ha nc e s – a nyo ne ne e d ing re so urc e s g e ts the m

until the y run o ut

Allo c a tio ns b a se d o n a g e , o ve ra ll he a lth o r d isa b ility – se e ks to

ma ximize q ua lity life ye a rs

L

ife Cyc le princ iple – c hild wo uld re c e ive pre fe re nc e

Allo c a te re so urc e s to tho se mo st like ly to survive to ho spita l

disc ha rg e

Sic ke st first Re so urc e s ma y b e use d o n tho se mo st like ly to d ie

E T HI CAL PRI NCI PL E S APPL I E D DURI NG DI SAST E RS

 Huma nita ria n a ssista nc e  Info rma tio n a nd

pa rtic ipa tio n during disa ste rs

 Co mpulso ry e va c ua tio n o f

po pula tio ns

 Re spe c t o f dig nity  Re spe c t o f pe rso ns  E

me rg e nc y a ssista nc e fo r the mo st vulne ra b le pe rso ns

 T

he impo rta nc e o f re sc ue wo rke rs

 Me a sure s to sa fe g ua rd a nd

re ha b ilita te the e nviro nme nt

 Ne c e ssa ry me a sure s to sa fe g ua rd

a nd re sto re so c ia l tie s Ethical Principles on Disaster Risk Reduction and People’s Resilience, Prieur M. European and Mediterranean Major Hazards Agreement (EUR‐OPA)

http://www.coe.int/t/dg4/majorhazards/ressources/ pub/Ethical‐Principles‐Publication_EN.pdf

QUE ST I ONS?