• KODAMA Satoshi
  Professor, Graduate School of Letters, Kyoto University

What is a “contingency”? Some people may view contingency as a state of non-peace, since the concept of contingency is the opposite of "peacetime.” However, to characterize peacetime simply as a state of non-contingency is as circular as it is uninformative. The Ministry of Defense, which uses the term “contingency legislation,” defines a contingency as “a situation in which the Prime Minister orders the Self-Defense Forces to mobilize for defense when Japan is attacked or faces an imminent threat of attack from another country.” Yet, the definition of contingency has no legal background. While often associated with warfare, the term contingency is increasingly used in today’s context to describe events such as large-scale terrorism or major disasters, in addition to armed conflict. Also, contingency is sometimes used interchangeably with terms like emergency or extraordinary situation.

One reason for conflicting views about what is ethically appropriate in such situations, which are called contingencies, may arise from differing assumptions about the degree to which an extra-ordinary contingency situation contrasts with peacetime. In the end, it all comes down to our assumptions about how bad we think the "worst case scenario" could be.

To examine this point more specifically, let us look at the "Crisis Standards of Care" (CSC) currently under discussion, primarily in the United States. CSC, a discussion about the appropriate level of medical care in the event of a large-scale disaster or public health crisis, has been debated by the U.S. National Academies of Sciences, Engineering, and Medicine and associated academic societies since around the time before and after the 2009 novel influenza pandemic.

CSC discussions define three levels of medical care, according to the surge in the number of patients that healthcare organizations can handle. The first level, "conventional care," refers to the standard level of medical services that can be provided under normal, non-disaster conditions. “Contingency care," on the other hand, is a phase in which "functionally equivalent care" can be provided at the same level as in normal times by optimizing existing medical personnel and resources when there is a surge in patients, typically during a disaster. At this stage, practices such as ICU triage should be avoided. Finally, when the number of patients escalates to the point where there is a severe shortage of medical personnel and resources, this phase is classified as "crisis care.” In such circumstances, it becomes necessary to transition from patient-centered to population-centered care, which may involve difficult decisions about “life choices,” such as ICU triage.

While the CSC discussion is confined to the field of medicine, it offers two valuable insights into the consideration of “contingencies.” The first point is that the discussion considers contingency and peacetime not as absolutes, but as something that exists on a continuum. During the recent COVID-19 pandemic, there was considerable debate about the appropriate time to declare a state of emergency. However, the distinction between peacetime and contingency is not always black and white, and there are times when one must decide to draw the line somewhere.

The second point is that the discussion distinguishes between “contingency” and “crisis (situations).” For instance, individuals who assert that “ICU triage should not be performed even during a contingency” may have in mind the CSC's definition of “contingency,” defined as “a stage at which functionally equivalent care to peacetime standards can still be provided.” Conversely, those who argue that “ICU triage needs to be performed in a contingency” may be assuming a contingency in a more severe stage, such as a "crisis situation," in which it is, by definition, impossible to provide medical care that meets the standards typically maintained under normal circumstances.

Initially, there seemed to have been some ambiguity in Japan as to whether the declaration of a state of emergency signaled the beginning of a crisis or served as a declaration to take proactive steps to prevent one. In discussing the ethics of contingency, it is essential to examine possible discrepancies in such underlying assumptions about contingency.

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