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Ethical Decision Making in Disaster and Emergency Management: A Systematic Review of the Literature

Joe cuthbertson.

1. Monash University Disaster Resilience Initiative, Monash University, Clayton VIC Australia

Greg Penney

2. Fire and Rescue New South Wales, Australia

3. Graduate School of Policing and Security, Charles Sturt University, Australia

Associated Data

For supplementary material accompanying this paper visit https://doi.org/10.1017/S1049023X23006325.

Ethical decision making in disaster and emergency management requires more than good intentions; it also asks for careful consideration and an explicit, systematic approach. The decisions made by leaders and the effects they have in a disaster must carry the confidence of the community to which they serve. Such decisions are critical in settings where resources are scarce; when decisions are perceived as unjust, the consequences may erode public trust, result in moral injury to staff, and cause community division. To understand how decisions in these settings are informed by ethics, a systematic literature review was conducted to determine what ethical guidance informs decision making in disaster and emergency management. This study found evidence of ethical guidance to inform decision making in disaster management in the humanitarian system, based on humanitarian principles. Evidence of the application of an ethical framework to guide or reference decision making was varied or absent in other emergency management agencies or systems. Development and validation of ethical frameworks to support decision making in disaster management practice is recommended.

Introduction

Decision making in disaster and emergency management guides the allocation of resources and subsequent benefits and impacts upon affected communities. Such situations present complex moral and ethical challenges at the time of event to alleviate suffering, and can also influence how allocation of funding is provided post-impact. 1 Application of ethical decision making requires moral awareness and intent to act based on fairness and justice, the perceptions of which can vary not only based on the community affected and their respective values, but also on the individual beliefs of responding personnel. In a recently published study, a systematic literature review was completed of more than 10,000 peer-reviewed English language studies since 2000, within the context of threat assessment, sense making, and critical decision making in police, military, ambulance, and firefighting contexts. 2 The results demonstrated that across emergency and military services personal, ethical values and moral judgment can be highly influential as to inform the potential consequence of an action, the recognition of which can potentially influence the resolve to undertake an action or not. Further, a recent research has confirmed that participating in events that conflict with personal ethics and values can result with moral injury, resulting in loss of trust and on-going feelings of severe shame, guilt, and anger. 3 An ethical framework encompassing organizational values to support such decisions provides a basis upon which decisions and their impacts and consequences can be considered and referenced against, thereby potentially reducing the potential for conflict between organizational and personal values for decision makers facing large-scale disaster events.

The predominant focus of contemporary emergency management education usually relates to practices of managing a disaster, command and control systems, and response processes rather than ethical decision making. 4 The application, or absence, of an ethical framework to guide decisions can influence the perceived or actual fair allocation of resources or burden of impacts. This study evaluates the explicit use of ethical frameworks or guidance applied in disaster and emergency management across different disciplines to identify ethical guidance or standards of practice applied in such settings, and if so, how.

The aim of this study was to systematically review the use of ethical guidance to inform critical decision making in disasters and emergencies. The scope of this review is multi-disciplinary, inclusive of humanitarian care, military services, Emergency Medical Services (EMS), health care, policing, and firefighting services.

The research questions investigated included:

• What ethical guidance exists to inform decision making in disaster management?
• What evidence is there of application of ethical guidance in decision making in disaster management?
• What commonality exists in ethical frameworks developed to guide decision making in disaster management?

This systematic review was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 5

The research question was developed using the Patient, Intervention, Control, Outcome (PICO) standard to frame the search strategy (Table  1 ). 6

Patient, Intervention, Control, and Outcome

Literature Search Methods

Inclusion criteria.

The search strategy included only terms relating to or describing the intervention from Medline/PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), CINAHL Plus (EBSCO Information Services; Ipswich, Massachusetts USA), and ResearchGate (Berlin, Germany); Table  2 . All peer-reviewed statistical studies/reports detailing management of disaster and application of ethical practice, as well as consensus guidelines, protocols, or other policy statements related to management of disaster and application of ethical practice, published by government and non-government organizations, published from 2003-2022, were included. A review of the “grey literature” in Google Scholar (Google Inc.; Mountain View, California USA) was conducted using the same search terms (Table  2 ). This literature review was also informed by a consideration of emergency services literature, policy, and non-peer-reviewed professional journals or publications and non-medical media.

Search Terms

Exclusion Criteria

Non-English-speaking literature, abstracts, citations, thesis, unverified or unsubstantiated press or news media reports, and articles that are not related to management of disaster and application of ethical practice were excluded.

Key data were extracted into an Excel (Microsoft Corp.; Redmond, Washington USA) spreadsheet, including: year; sample size; gender, variables assessed; study design; assessment schedule and follow-up period; analysis used; main findings and conclusions; and limitations.

Quality Assessment

Two review authors independently assessed all included studies for risk of bias; any disagreement was resolved by discussion. The quality of the evidence was classified into four categories according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. 7 Of the articles assessed, the quality was varied with only two studies rated as high. Noting that the GRADE assessment provides a qualitative outcome, this approach was informative in describing perceived strengths and weaknesses of research depth that informs practice in this area.

A narrative synthesis of the literature results and reporting on key findings was completed. 6 A narrative synthesis of findings was selected, as it has proven useful for providing a comprehensive picture of the subject matter in question. 8 – 10

Publication Currency

Acknowledging the range in publication date accepted in systematic literature reviews varies from less than 10 years, to in limited cases, more than 20 years; 11 , 12 the benefit of expanding the search to a broader range of dates is limited, as research beyond this period is either superseded, referenced, or incorporated and built upon in more current studies. 11 In accordance with this guidance, and completed in December 2022, the review included English-language papers published in the last 20 years (2003-2022) to ensure the currency of evidence. Seminal papers from outside the date range could be considered for inclusion on consensus agreement by all authors; however, none were identified in either the handsearching or review of the bibliographies and included studies.

In the identification phase of the review, the initial search strategy of databases yielded 1,772 studies for potential inclusion. Hand searching and a secondary search of bibliographies identified a further 14 studies for inclusion, providing a total of 1,786 studies.

An initial screening phase of title review was conducted by the two authors, with those either not meeting the full search criteria or outside of the defined scope excluded. A study was included for further review if initial screening could not confirm exclusion following review of the title or was not identified as a duplication. A total of 1,749 titles were excluded during this process; in total, 37 studies progressed to eligibility review.

During the eligibility review, the authors initially completed a full-text review of the abstracts of the remaining 37 studies. Studies not meeting the full search criteria, or outside of the defined scope, were excluded (n = 2). Of the remaining 35 studies, one was excluded as the full English text could not be sourced, and one was excluded as it did not meet the scope of research. Any disagreement was resolved by discussion between the authors. Results are presented according to the PRISMA checklist and demonstrated on the literature search flow diagram (Figure  1 and Supplementary Material [available online only]).

Literature Search Flow Diagram (PRISMA).

Quantitative analysis was not able to be performed due to the heterogeneity of the research found in the systematic review.

The search strategy predominantly found peer-reviewed literature on health care practice in disaster, followed by humanitarian care, with limited literature found describing ethical frameworks for decision making in disaster across military, police, and fire and emergency services (Table  3 ). This study found evidence of ethical guidance to inform decision making in disaster management in the humanitarian system, based on humanitarian principles. Evidence of the application of an ethical framework to guide or reference decision making was varied or absent in other emergency management agencies or systems.

Domains of Practice Ethical Decision Making and Disasters

Grounded theory process was used to identify emergency themes from the collective literature. Narrative synthesis of findings was subsequently applied to explain the identified themes, as it has proven useful for providing a comprehensive picture of the subject matter in question to guide new findings and conclusions. 9 , 10 The emergent themes, described in the next section of the paper, are summarized as:

• State-based guidance is unclear.
• Existing frameworks are siloed.
• While Gesalt-based decision making is apparent, it is not supported by a suitable framework and may not account for future risk.

Theme 1: State-Based Guidance on Fair and/or Equitable Provision of Relief Funds, Resources, How These are Informed by a Human Rights or Ethics-Based Framework is Not Clear.

The development of principles to guide public health decision making in emergencies has been previously explored in the Northern American context as published by Barnett, et al in which ten principles were developed by expert consensus with a goal of linking law, ethics, and decision making for allocation of resources in emergencies. 13 These included maintaining transparency, community participation, respecting individual rights whilst balancing community need, non-discriminatory consideration of public health needs of individuals and groups, adhering to and communicating applicable standard-of-care guidelines, identify public health priorities based on evidence, implement initiatives in a prioritized and coordinated fashion, assess the public health outcomes, ensure accountability, and share personally identifiable health information—with the patients’ consent, where possible—solely to promote the health or safety of patients or other people. 13 Of note, these principles, whilst developed by expert consensus, have yet to be validated in practice.

Theme 2. Identified Ethical Frameworks Exist in Siloes of Public Health, Clinical Practice, and Humanitarian Care. Ethical Frameworks for Decision Making in Military Operations are Guided by Rules of Engagement, and More Broadly, by International Law and the Conduct of Military Operations.

Literature regarding the use of triage decision making at the individual patient level is substantial and based on an ethical principle of the greatest good for the greatest number of persons. A key difference in differentiating the ethical principles of decision making related to patient care in disasters and broader emergency management decisions can be observed in relation to maintaining critical functions of society. In such circumstances, priority of decision making related to these functions may be equal to or higher than the immediate patient or health care priority it is balanced against. Kalajtzidis noted such variance in decision making theory, models, and practices, a finding that is consistent with those of Penney, et al. 2 , 14 Kalajtzidis provides an overview of moral dilemma as it relates to ethical decision making in disasters, considering concepts of consequentialism and moral intuition that can inform action, but also concludes noting the unanswered question of how ethical decision should be made or guided in disasters. 14 Ekmekci and Folayan proposed a theoretical ethical framework to guide decision making in public health emergencies, drawing on practices informed from previous studies by Beauchamp and Childress. 15 The work of Ekmekci and Folayan was influenced by the impacts of the coronavirus disease 2019/COVID-19 pandemic to improve decision-making practices; the proposed framework would benefit from evaluation and testing in the context of an all hazards approach. 16 Similarly, Knebel, et al proposed a decision-making process for government leadership in allocation of resources in disaster and developed a logic model utilizing a values-based framework. 17 A focused investigation of ethical decision making of EMS in Iran undertaken by Torabi, et al revealed themes of maintaining patient dignity and respect and regulation-based actions as key tenets guiding EMS decision making. 18 Whilst a small study and only reflective of one service, the findings of moral reasoning and decision making in the broader health care worker context is not unusual, particularly in settings of triage and resuscitation decision making. 18

The Geneva Conventions are the international treaties that establish international humanitarian law during armed conflict. International humanitarian laws describe rules to limit suffering and provide guidance on what is and what is not acceptable during armed conflict. 19 Thompson and Hendriks explored ethical decision making in the military context. 20 Previous studies have found variance in military staff behavior and attitude, or have not acted in accordance with expected ethical standards. 20 Thompson, et al focused on operational ethical conflicts that accompany decision making in military action and investigated how perceptions of harm to self and others influenced decision making through the framework of mission orders. Their findings showed moral conflict in situations where decisions would result in potential harm, but that rules of engagement provide the framework for decision making when in such situations. 20 A key finding from this study was the recommendation of operational ethics training to support staff. The commonality between use of rules of engagement to provide a framework of decision making and EMS use of clinical practice protocols or guidelines in decision making is worth noting. In both cases, people are making complex decisions in uncontrolled environments; pre-established practice frameworks that are known and understood provide assurance to the providers to guide decision making.

In the humanitarian context of disaster response, principles of humanity, impartiality, neutrality, and independence serve as the ethical framework for decision and action. The United Nations Inter-Agency Standing Committee (Geneva, Switzerland) Operational Guidelines on the Protection of Persons in Situations of Natural Disasters were implemented to protect the rights of persons receiving disaster response or recovery interventions. 21 These guidelines describe principles of consent, informed and involved decision making, and local ownership in respect to humanitarian response efforts. 21 In addition to this, the Inter-Agency Standing Committee Guidelines are further strengthened by the Sphere (Geneva, Switzerland) Humanitarian Charter and Minimum Standards in Humanitarian Response. 22 The charter core standards represent minimum criteria for appropriate care of an affected population in the humanitarian setting and is an internationally recognized set of common principles and universal minimum standards in humanitarian response. 22 The International Committee of the Red Cross (Geneva, Switzerland) provides ethical codes of conduct for the International Red Cross and Red Crescent movements. 1 , 23 Their guidance states that humanitarian aid is neither a partisan nor a political act, and must not be perceived as either; that humanitarian aid is given without consideration of race, creed, nationality, age, gender, or other qualifiers; and is prioritized based on need alone. 23 Notwithstanding this, the provision of humanitarian care faces ethical challenges in operations as described by Clarinval and Biller-Andomo. In particular that the application of the principles are difficult, if not impossible, in some circumstances to apply in operations or that they are conflicting in settings due to lack of resources and decisions related to distribution; or, where lack of security prevents or potentially limits provision of car despite humanitarian practice operating under the international humanitarian law Rule 32: “the safety and protection from attack of objects used for humanitarian relief operations.” 24 Clarinval and Biller-Andomo identified that whilst principles exist to guide humanitarian care, no structured reference framework currently exists that can assist aid workers in identifying potential ethical issues and support them in their decision-making process, and as such, developed and recommended a step-wise procedure to identify ethical considerations and address them in decision making. 24

Theme 3: Gestalt-Based Decision Making is a Feature of Health Care and Disaster Management Leadership, Yet Often Lacks an Ethical Framework to Guide it and/or is Based on A Priory Knowledge which May Not Reflect Future and Emerging Disaster Risk.

Whilst ethical guidance may exist in organizational systems, when such organizations collectively approach a singular threat, the application of an ethical framework to guide or reference decision making is clouded. In some contexts, the reference to legal authority to act on behalf of communities is evident, however, the ethical background to such decisions was based on the local judicial system and Gestalt. Krolik proposed that by incorporating a rights-based approach to disaster management, practitioners are not only ensuring that the rights of affected communities are being protected, but also that the affected communities are participating in and helping to shape the disaster management activities that impact on and involve them. 25 Such an approach is intended to strengthen the disaster management process through involvement of community members to promote and protect human rights in disasters. 25

Crisis standards of care are a method of decision making to inform rationalizing health care resources in a constrained environment. In such circumstances, decisions on provision and limitations of treatment are based on availability of health care resources and demand. Leider, et al systematically reviewed ethical standards that inform crisis standards of care finding that early establishment of practical guidance for invocation and application was required. 4 Ethical frameworks for health care workers are well-established as practice norms and are commonly guided by relevant practitioner leadership bodies. Good has previously referred to this in “Ethical Decision Making in Disaster Triage” and reported the findings of Larkin and Arnold who recommended seven specific virtues to guide triage in disaster. 26 , 27 Whilst the foundation of these is linked to codes of medical ethics, the validation of decision making in their application is yet to be conducted. Further to this, Berstein discussed the writing of Iserson and Moskop who had previously explored both the medical duty to respond in disaster and the ethics of application of triage when doing so. Findings showed that whilst ethical principles of duty to care and utilitarianism (greatest good) are established and known in health care, the practicalities of application and moral consequence of decision making in crisis are not well-established, and in some cases, result in legal action and prosecution. 28 , 29 Similar conclusions were expressed by Holt, who noted the ethical challenges faced by medical practitioners in disasters and a need to provide education, guidelines, and a practical approach a priori to events. 30

Erbay has critically reviewed ethical practice related to prehospital triage. 31 Erbay reported that whilst principles of utilitarianism, beneficence, and justice underpinned triage practices, that the broad range of triage systems combined with balancing priorities of beneficence (greatest good for the greatest amount) and justice (equal chance) can result in subjective decision making. 31 Key findings included recommendations of an ethical framework to guide application of triage practices. 31

The predominant research identified in this review focused on analysis of practice. Lentz, et al conducted a scoping review of literature exploring moral distress in first responders. The scoping review identified a limited number of studies, and no research articles exploring moral injury. 32 Lentz found that first responders were often faced with complex moral dilemmas and difficult ethical decisions that can result in moral distress. 32 Studies reviewed showed that personal values guided decision making. Norberg found similar findings where first responders face complex situations requiring fast decisions with often limited or unclear information. In such situations, individuals take into consideration risks and benefits to individuals, public, and community. 33

Papazoglou and Chopko proposed that the potential of moral harm can be decreased through preparedness, sense of control, and understanding one’s values. 34 Likewise, Norberg recommended the importance of developing practical ethical awareness in tasks and activities; 33 however, these factors did not decrease moral distress. 33 Boin and Nieuwenburg focused on the consequence of an absence of guidance to inform practice, the potential and actual harm to both person requiring help and the provider. 29 In particular, the use of discretion in overwhelming crisis situations resulting from disaster. 29 The case example provided, the moral dilemma of the Memorial Hospital and Srebrenica tragedy, illustrates both tragic outcomes in the face of crisis and complex decision making in frontline military and health care operations. 29 Further to this, the point is well-made by the authors of the unfair and unethical nature of resting the authority of decision making in a complex crisis and morally ambiguous situation with the first line responders attempting to manage the incident they are faced with. Consequently, the unresolved question remains of who should receive what limited resources are available, who makes that decision, and what guides it?

Limitations

The review findings are limited due to low-quality research and lack of literature consistency. Whilst some studies may have been excluded by the search criteria, the authors took all efforts to ensure the study methodology and design were broad enough to capture all research relevant to ethical practice and guidance in disaster and emergency management, yet specific enough to ensure relevance to the contexts of decision making in this environment. A potential side effect of the highly sensitive search strategy combined with inherent limitations of the selected databases is where database searches identified studies where all or only partial search terms were present; however, the study was unrelated to ethical decision making in disaster management.

The literature retrieved via this study was high in heterogeneity, and as such, quantitative analysis was not able to be performed.

Papers not in English language was an exclusion criterion, and as such, papers not in English that may inform ethical practice in other cultures were not included.

Implications of Key Findings

It is recommended that the establishment of a guidance framework for ethical decision making in disasters is developed and agreed upon prior to events so that actions taken are reflective of a mutually understood process. Such guidance requires the input of the communities these decisions will have consequence upon and be contextual of the respective cultural and societal values.

This study found evidence of ethical guidance to inform decision making in disaster management in the humanitarian system, based on humanitarian principles. Evidence of the application of an ethical framework to guide or reference decision making was varied or absent in other emergency management agencies or systems.

Conflicts of interest

The authors declare none.

Supplementary material

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Incorporating Ethics in Disaster Communication Strategy: The Case of the U.S. Government in Deepwater Horizon

BP’s Deepwater Horizon oil spill in April 2010 was a major test of the National Incident Management System (NIMS), which the United States federal government mandates for response to all disasters. At the time, this disaster was perhaps the greatest event in scope and duration under NIMS disaster management guidelines since they were revised in 2008 (the third edition was published in 2017). Ten years later, NIMS provides procedures for operating a joint information center (JIC), but still offers no guidelines for ethical communication. This case study examines the ethical implications of 178 news releases distributed by the Deepwater Horizon Incident JIC. Qualitative analysis found that communication was conducted in an open, ethical manner, with few exceptions. Conflicts emerged, however, that may have compromised ethical standards. The authors conclude with recommendations to inform ethical decision making by JIC communicators.

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Reynolds, B., and M. W. Seeger. 2014. Crisis and Emergency Risk Communication . Atlanta: Centers for Disease Control. Search in Google Scholar

Scanlon, J. 2007. “Unwelcome Irritant or Useful Ally? The Mass Media in Emergencies.” In Handbook of Disaster Research , edited by H. Rodriguez, E. L. Quarantelli, and R. R. Dynes, 413–29. New York: Springer Science+Business Media, https://doi.org/10.1007/978-0-387-32353-4_24 . Search in Google Scholar

Schwartz, M. S. 2020. “Beyond Petroleum or Bottom Line Profits Only? An Ethical Analysis of BP and the Gulf Oil Spill.” Business and Society Review 125 (1): 71–88, doi: https://doi.org/10.1111/basr.12194/ . Search in Google Scholar

Seeger, M. W., T. L. Sellnow, and R. R. Ulmer. 2008. Crisis Communication and the Public Health . Cresskill, N.J.: Hampton Press. Search in Google Scholar

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Collapse at Rana Plaza

The deadly collapse of a garment factory building in Bangladesh stirs debate over worker safety in the effort to drive down prices for international manufacturers and consumers.

In 2013, a garment factory in Dhaka, Bangladesh collapsed, killing more than 1,100 workers and injuring many more. This was the deadliest disaster in the history of the clothing manufacturing industry. The Rana Plaza building was known to have been built with substandard materials under faulty conditions, yet the factory remained very active up until the deadly collapse.

An investigation into the building after the collapse found that the mayor of the city wrongly granted approval for construction and allowed the owner to disregard construction codes. The building’s owner, Sohel Rana, illegally constructed the upper floors of the building to house factories with several thousand workers and large power generators that shook the building whenever switched on. The day before the collapse, large cracks appeared in the building and an engineer who was called to inspect the building determined it was unsafe. Rana and the factory owners, however, ordered workers to return the next morning. When the generators were switched on that day, the building collapsed. Murder charges were brought against Rana and 37 others held responsible for the disaster. Three other people were charged with helping Rana flee after the collapse.

This was not the first deadly disaster in a garment factory in Bangladesh—the factory Tazreen Fashions collapsed only five months earlier, killing over 110 people. But the scale of the Rana Plaza collapse brought greater global attention to the unsafe working conditions of many workers in the garment industry. The collapse also raised concerns over the responsibility of American and European companies and governments who employ labor in Bangladesh and other low-wage markets around the world. In efforts to drive down prices for consumers, companies often drive down manufacturing costs. Bangladesh is home to more than 5,000 garment factories, manufacturing clothing for most of the top brands around the world. Garment workers in Bangladesh are among the lowest paid in the world.

Companies that manufactured goods at Rana Plaza included Walmart, the Gap, Adidas, and dozens more. These companies faced growing pressure to take action in the wake of the collapse. Some companies donated money to relief efforts, but many activist groups saw these measures as inadequate. Liana Foxvog, of the International Labor Rights Forum, stated, “What’s important is that the victims receive the full amount that they are owed.” Kurt Cavano, vice chairman of supply-chain logistics company GTNexus, said, “From what I’ve seen, Tazreen and Rana were wake-up calls… Chasing that last nickel of cost has to be done in a way that doesn’t put your business at risk.”

Yet many in the Bangladesh garment industry feared that holding international companies and governments accountable could put them at further financial risk should the companies choose to pull their businesses out of the country. Aleya Akter, union leader and secretary general of the Bangladesh Garment and Industrial Workers Federation, noted, “There are about 4 million garment workers. It’s impossible for them to get work anywhere else, because this is what they’re skilled to do… Not only are we asking for compensation for the brands, we are also asking them: Do not walk away from us. Do not walk away from Bangladesh.”

Related Terms

Framing describes how people’s responses to ethical (and other) issues are affected by the frame of reference through which they view the issues.

Ethical Insight

There is often a conflict between profit goals and the goal of worker safety. Virtually every company focuses on making money, but they also have an ethical obligation to provide reasonable safety to workers. When company officials focus upon only profits and ignore worker safety, this unfortunate framing of their decision can lead to unethical and tragic decisions. This was the case of the Rana Plaza collapse in Bangladesh that killed more than 1,100 people in 2013. The garment factory building was built with substandard materials. An engineer inspected the building the day before it collapsed and warned the owners that it was unsafe. But the owners ordered workers to return the next day, which tragically resulted in the loss of many lives. Business decisions such as this almost always affect others and therefore have an ethical dimension that cannot be omitted from the decision maker’s frame of reference.

Discussion Questions

1. How did framing contribute to the collapse of Rana Plaza? Explain. If this framing was different, how might the outcome be different? Why?

2. The engineer who inspected the Rana Plaza building the day before the collapse determined the building was unsafe, but Sohel Rana and the factory owners ordered their employees to return to work the next day. What factors might have influenced the framing of their decision to do this? Why do you think they did this? Explain.

3. Do you think it plausible that Rana and others omitted their moral responsibility to other human beings when they framed the decisions they made that led to the building collapse? Discuss.

4. Have clothing sellers in the U.S. and elsewhere also suffered from a similar misframing of issues? Explain.

5. How do advertisers for clothing companies such as Adidas and Gap use framing to influence consumers’ decisions? Would knowing that a product was produced at Rana Plaza or under other ethically questionable conditions affect your decision to purchase it? Why or why not?

6. Do you think the international companies that contract out to the Rana Plaza factories should be responsible for ethical lapses made by Rana and the factory owners? Why or why not? Should these companies continue to work with these factories? Why or why not?

7. In 2018, compliancy agreements put together by international companies that contract to factories in Bangladesh are set to expire. After these agreements end, some fear that factory conditions will return to the way they were before the Rana Plaza collapse. If you were part of a third-party regulating body, how would you encourage international businesses to continue their contracts while ensuring that factory employees are safe and properly compensated? Explain.

8. Can you think of a situation where you perhaps did not make an ethically optimal decision because you misframed the choice before you? Explain.

9. Have you read about a business scandal where misframing may have led to the making of poor moral choices? Discuss.

10. Do you have any suggestions for people who wish to act morally about how to keep ethics in their frame of reference when competing factors such as a desire to please the boss, a wish to get along with co-workers, a “need” to hit a production target in order to earn a bonus, or the like can endanger sound moral decision making?

11. Studies show that wealthy people are more likely to donate to a cause if the pitch they are given says: “Be the most generous person in your neighborhood!” than if the pitch is: “Join your neighbors in improving our city!” Could this be an example of, among other things, the power of framing in action? Explain.

Bibliography

The Rana Plaza disaster https://www.gov.uk/government/case-studies/the-rana-plaza-disaster

Report on Deadly Factory Collapse in Bangladesh Finds Widespread Blame http://www.nytimes.com/2013/05/23/world/asia/report-on-bangladesh-building-collapse-finds-widespread-blame.html

Two years ago, 1,129 people died in a Bangladesh factory collapse. The problems still haven’t been fixed. https://www.washingtonpost.com/news/wonk/wp/2015/04/23/two-years-ago-1129-people-died-in-a- bangladesh-factory-collapse-the-problems-still-havent-been-fixed/?utm_term=.b96dcccfc608

Rana Plaza collapse: 38 charged with murder over garment factory disaster https://www.theguardian.com/world/2016/jul/18/rana-plaza-collapse-murder-charges-garment-factory

A Guide To The Rana Plaza Tragedy, And Its Implications, In Bangladesh https://www.forbes.com/sites/alyssaayres/2014/04/24/a-guide-to-the-rana-plaza-tragedy-and-its-implications-in-bangladesh/#31e220642c50

Rana Plaza: A look back, and forward http://www.globallabourrights.org/alerts/rana-plaza-bangladesh-anniversary-a-look-back-and-forward

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Engineering Ethics Case Study: The Challenger Disaster - 3 PDH

• Description

LEARNING OBJECTIVES This course teaches the following specific knowledge and skills:

Common errors to avoid in studying the history of an engineering failure: the retrospective fallacy and the myth of perfect engineering practice

Shuttle hardware involved in the disaster

Decisions made in the period preceding the launch

Ethical issue: NASA giving first priority to public safety over other concerns

Ethical issue: the contractor giving first priority to public safety over other concerns

Ethical issue: whistle blowing

Ethical issue: informed consent

Ethical issue: ownership of company records

Ethical issue: how the public perceives that an engineering decision involves an ethical violation

Learned a significant amount of information both technical and human perspective that I (and I suspect the vast majority of the public) was unaware of. While a tragedy for sure, no one person made the call to risk the astronauts in order to save $ or meet schedules. Too much grey ...and as one of the authors relays- easier to see in retrospect what no one was able to see originally. Well worth the time!

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Columbia Disaster Bibliography

A bibliography looking at the engineering ethics and policy issues of the Columbia Shuttle explosion of 2003.

Butler, D. 2003. Shuttle inquiry to piece disaster together from the ground up. Nature, 421 (6924), 677. doi:  10.1038/421677a . This article focuses on the progress of the investigation into the Columbia shuttle disaster and emphasizes the use of reverse-engineering analysis called ballistic trajectory to plot the trajectories of the pieces of debris.

Chen, Phillip. 2006. Columbia, final voyage: the last flight of NASA’s first space shuttle . New York: Copernicus Books. This book describes not only the days and hours leading up to the launch of the Challenger and its fatal explosion, but also the training of the crew members aboard, the delays that plagued the mission, the technological and safety issues faced by NASA, and the ingenuity of the scientists who d designed Columbia’s experiments.

Langewiesche, W. 2003. Columbia's Last Flight . The Atlantic Monthly (November).

A detailed account of the moments before during, and after the Columbia explosion.

Lawler, A. 2003. Shuttle Disaster Puts NASA Plans in Tailspin. Science, 299 (5608), 796-797.  doi:  10.1126/science.299.5608.796 . The disintegration of the Columbia space shuttle heralded not only disaster but also an unwelcome era for thousands of engineers and scientists around the globe. Beyond the terrible human toll, the 1 February disaster abruptly halts construction of the international space station, cripples life and physical sciences research, and calls into question NASA's plans to move beyond Earth's orbit.

Space Shuttle Columbia and Her Crew (NASA) A tribute to the crewmembers killed during the Columbia shuttle explosion.

PBS. 2008. Space Shuttle Disaster . [video] An investigation uncovers the human failures and design flaws between the 2003 Columbia Tragedy.

Engineering Ethics & Policy Issues

Brong, J. 2004. Learning From Columbia. Quality Progress, 37 (3), 38-45. This article studies causes of disintegration of the space shuttle Columbia. A 1.67 pound slab of supercooled insulating foam from an external tank struck the wing of the Columbia 81.7 seconds after its launch on January 16, 2003. The foam hit the leading edge of the left wing where it angles away from the fuselage. Sixteen days later, at the lime the shuttle was beginning its landing approach, the damage allowed superheated gas into the wing. Findings from the accident have significance in all operations because organizational culture, management systems and effective thinking are required in all fields. The accident confirmed why quality professionals must be placed at decision making levels in their organizations.

Cass, S. 2003. How to Fix the NASA Disaster.  IEEE Spectrum, 40 (10), 10-12.  doi:  10.1109/MSPEC.2003.1235615 . Discuses the findings of the Columbia Accident Board’s investigation and its conclusion that NASA’s safety culture has become complacent and under a major conflict, as individuals who were in charge of safety were also under pressure to get projects completed on time and on budget.

Davis, Michael 2003. Columbia, Hamlet, and Apollo 13 . Teaching Ethics. 4(1): 77-79. Almost seventeen years to the day after the space shuttle Challenger came apart during launch, another space shuttle, the Columbia, came apart during re-entry. While the details differ much, the main characters are familiar: the shuttle itself; an old problem suddenly more severe; the pressures of a public-relations-based schedule; managers, who are also engineers, disregarding engineers concerned with safety; an absence of hard evidence that would have forced everyone to agree; and a disaster confirming the engineers’ worst fears. The author considers what seems new in the Columbia disaster. In seventeen years, much an organization learns must be lost unless incorporated into procedures. Youth brings energy, daring, and innovation, but not the peculiar caution of those who have suffered. That the veterans of 1986 would have avoided the mistake Ham made, we cannot know. What we can know is that they should have found it easier to avoid than she did.

Dombrowski, P.M. 2007. The Evolving Faces of Ethics in Technical and Professional Communication: Challenger to Columbia. IEEE Transactions on Professional Communications 50:306-319. Our view of ethics in professional and technical communication has evolved, paralleling developments throughout society. Earlier views on ethics and values have grown into a broad perspective of complex gradations with people at many levels affecting eventual practical outcomes. The organizational culture of NASA, for example, was specifically identified by the Columbia Accident Investigation Board (CAIB) as one of the causes of faulty communication leading to a terribly tragic event. The Challenger investigations of 20 years earlier, on the other hand, focused primarily on physical events, secondarily on professional judgments, and only little on the social and cultural context of the disaster. We learn by failures but also by self-examination. As we see how ethics and values impact technical events, we understand that technological progress is ultimately a human endeavour in which reflection and judgment is as important as measurement and observation.

Donovan, A. and Ronald A. Green. 2003. Setup for Failure: The Columbia Disaster . Teaching Ethics 4(1):69-76.  This case study looks at the details of the Columbia Disaster of 2003 and discusses the tensions that can exist between managers and engineers in organizations.

Hall, J. 2003. Columbia and Challenger: organizational failure at NASA.  Space Policy  19: 239-247. The National Aeronautics and Space Administration’s flagship endeavour—human spaceflight—is extremely risky and one of the most complicated tasks undertaken by man. It is well accepted that the tragic destruction of the Space Shuttle Challenger on 28 January 1986 was the result of organizational failure. The surprising disintegration of the Space Shuttle Columbia in February 2003—nearly 17 years to the day after Challenger—was a shocking reminder of how seemingly innocuous details play important roles in risky systems and organizations. This paper outlines some of the critical features of NASA's organization and organizational change.

Kauffman, J. 2005. Lost in space: A critique of NASA's crisis communications in the Columbia disaster. Public Relations Review, 31 (2), 263-275. doi:  10.1016/j.pubrev.2005.02.013 . The explosion of space shuttle Columbia on 1 February 2003 threatened to destroy the image and confidence NASA had labored years to restore in the wake of its poor handling of the Challenger disaster. This paper examines NASA's crisis communications regarding Columbia's explosion. It argues that the space agency did most things right in responding to the crisis, but it made errors that reflect serious and long-standing problems with its organizational culture. It proposes that the space agency must fix flaws with its organizational culture, or it may be forced into the unenviable position of relying on crisis communications to protect its image and reputation.

Lawler, A. 2003. After Columbia, a New NASA? Science, 299 (5609), 998-1000. doi:  10.1126/science.299.5609.998 . This article reports on U.S. National Aeronautics and Space Administration (NASA) Administrator Sean O'Keefe's plans to build a complement to the destroyed space shuttle Columbia, with hopes of receiving funds, on its surviving current investigations, as of February 14, 2003.

Mason, R. O. 2004. Lessons in Organizational Ethics from the Columbia Disaster:: Can a Culture be Lethal? Organizational Dynamics, 33 (2), 128-142. doi:  http://dx.doi.org/10.1016/j.orgdyn.2004.01.002 . Using coverage of the explosion and the results of the final investigation of the accident, the author discusses some failures of organizational cultural and NASA that contributed to the disaster, and, discusses how NASA and other organizations can begin building an organization culture that overcomes hubris and carelessness.

Niewoehner, R. J., & Steidle, C. E. 2009. The Loss of the Space Shuttle Columbia: Portaging Leadership Lessons with a Critical Thinking Model. Engineering Management Journal, 21 (1), 9-18. doi:  10.1080/10429247.2009.11431793 . This article evaluates the suitability of Richard Paul's Critical Thinking model as a template for evaluating engineering enterprise thinking habits and organizational behavior, using the Columbia Accident Investigation Board (CAIB) report as a case study. With minor refinement, Paul's model provides a powerful vocabulary for complicated case study analysis; familiarity with the model provides participants with both a mechanism for analysis and a means for portaging lessons to other professional situations and organizations.

Seife, C. 2003. Columbia Disaster Underscores The Risky Nature of Risk Analysis.  Science  299:1001-1002. doi:  10.1126/science.299.5609.1001 . The breakup of the space shuttle Columbia, the second such catastrophe in 113 flights, suggests that NASA's most recent official risk estimate of 1 failure in 250 is off. Why can't NASA get it right? The answer lies in a field known as probabilistic risk assessment.

Sumpter, R. S., & Garner, J. T. 2007. Telling the Columbia Story: Source Selection in News Accounts of a Shuttle Accident. Science Communication, 28 (4), 455-475. doi:  10.1177/10755470073022306 . This content analysis of newspaper stories seeks to answer three questions about the Columbia space shuttle disaster: What sources did journalists cite in telling the Columbia story? What did those sources say? Which sources were heard most often? Sources most often communicated "neutral" facts and observations while not placing blame for the accident or evaluating the shuttle program's progress. Astronauts and their relatives, NASA contractors who built and maintained the shuttle fleet, and government accident investigators from agencies other than NASA or the Columbia Accident Investigation Board rarely appeared in the stories. Journalistic routines call for reporters to balance their story narratives with sources representing different viewpoints. In the Columbia story, however, this was not necessarily the case.

Van der Voort, H., & de Bruijn, H. 2009. Learning from Disasters: Competing Perspectives on Tragedy. IEEE Technology & Society Magazine, 28 (3), 28-36. doi:  10.1109/MTS.2009.93416 . The article offers ways on how to manage disaster and implement safety standards. It highlights the investigation reports from Holland regarding a fire that killed 11 persons in a detention center at Schiphol airport and the reports from the U.S. on the 9/11 attack and the Space Shuttle Columbia Accident. It presents the strengths and weaknesses of those approaches used by decision-makers.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

Engineering Ethics Case Study: The Challenger Disaster

Topic outline.

Credits : 4 PDH

Pdh course description:.

• Common errors to avoid in studying the history of an engineering failure: the retrospective fallacy and the myth of perfect engineering practice
• Shuttle hardware involved in the disaster
• Decisions made in the period preceding the launch
• Ethical issue: NASA giving first priority to public safety over other concerns
• Ethical issue: the contractor giving first priority to public safety over other concerns
• Ethical issue: whistle blowing
• Ethical issue: informed consent
• Ethical issue: ownership of company records
• Ethical issue: how the public perceives that an engineering decision involves an ethical violation

To take this course:

Space Shuttle Challenger Disaster and Ethical Issues Case Study

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

The case study details the procedures that took place before the launch of the Challenger Space Shuttle. The author notes that NASA was under pressure from politicians and competing space agencies, which is why the management pushed for the launch despite insufficient testing and the faulty design of the O-rings. Delays due to weather conditions put more pressure on the management and the team. As a result, the O-rings did not close properly, causing an explosion of the Challenger soon after the launch. Seven astronauts were killed in the blast.

The key ethical issues evident in the case were the lack of communication between managers and poor safety culture, which prevented adequate technology testing before the launch. The primary ethical issue, in this case, was the lack of a proper safety culture. It manifested in the management’s decision to launch the shuttle despite insufficient testing and the faults in the design of the O-rings. Since both of these problems increased the risk of explosion during launch, the decision of the management violated the ethical principles of public good and human well-being. Upholding these principles is among the key professional duties of engineers because failure to do so may result in terrible accidents. Besides exploding in the air, the shuttle could have fallen, harming even more people. Hence, the case illustrates the consequences of unethical decision-making in engineering.

Nevertheless, there was another option of how the case could have progressed. Better decision-making from the management could have prevented the explosion from happening. For example, the management could order further testing and delay the launch until the trial has been finished. Additionally, the managers could have canceled the launch to fix the faults in the design of the shuttle, thus also avoiding the explosion. Their subordinates could have also influenced the progression of the case. For instance, drawing the attention of the higher management to the problem could have helped to resolve the failure in communication. This, in turn, could lead to a delay or cancellation of the launch. All in all, both the managers and the subordinates should have prioritized safety by insisting on further testing and design corrections. Stronger safety culture and ethical decision-making would have assisted NASA in avoiding the disaster.

• The Challenger Space Shuttle Accident Analysis
• Examining the Challenger Explosion Case
• The Space Challenger Shuttle: Advocacy vs. Inquiry
• Responsible Citizenship and College Experience
• Ethics of Stem Cell Research Creating Superhumans
• The Right to Suicide: Arguments in Favor
• Anthropocentric and Non-Anthropocentric Environmental Ethics
• Publishing Controversial Photographs: To Be or Not To Be?
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2021, August 25). Space Shuttle Challenger Disaster and Ethical Issues. https://ivypanda.com/essays/space-shuttle-challenger-disaster-and-ethical-issues/

"Space Shuttle Challenger Disaster and Ethical Issues." IvyPanda , 25 Aug. 2021, ivypanda.com/essays/space-shuttle-challenger-disaster-and-ethical-issues/.

IvyPanda . (2021) 'Space Shuttle Challenger Disaster and Ethical Issues'. 25 August.

IvyPanda . 2021. "Space Shuttle Challenger Disaster and Ethical Issues." August 25, 2021. https://ivypanda.com/essays/space-shuttle-challenger-disaster-and-ethical-issues/.

1. IvyPanda . "Space Shuttle Challenger Disaster and Ethical Issues." August 25, 2021. https://ivypanda.com/essays/space-shuttle-challenger-disaster-and-ethical-issues/.

Bibliography

IvyPanda . "Space Shuttle Challenger Disaster and Ethical Issues." August 25, 2021. https://ivypanda.com/essays/space-shuttle-challenger-disaster-and-ethical-issues/.

Natural Disaster, Tax Avoidance, and Corporate Pollution Emissions: Evidence from China

• Original Paper
• Published: 23 May 2024

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• Rui Xu 1 , 2 &
• Liuyang Ren 1  

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Our study explores how climate risk affects the tax behavior of governments and local firms, subsequently affecting corporate pollution emissions. Using data on Chinese non-state-owned industrial enterprises from 1998 to 2014, we empirically investigate the impact of natural disasters on corporate tax avoidance. The results indicate that companies in earthquake-damaged areas are less likely to avoid taxes than those in unaffected areas. Furthermore, companies that pay more taxes after a disaster can secure favorable government environmental policies, as indicated by a rise in pollution emissions. Moreover, this effect is more pronounced for less polluting firms and firms with higher financial constraints. Our study contributes to the literature on taxation and ESG from the perspective of favor-exchange in government–firm relationships.

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Do Natural Disasters Affect Corporate Tax Avoidance? The Case of Drought

The environmental cost of tax administration: evidence from a regression discontinuity design in China

Tax incentives and environmental protection: evidence from china’s taxpayer-level data, data availability.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

The risk appears to be manifesting itself along several physical dimensions: a) earthquake risk, which can cause extensive damages in a relatively short period; b) hurricane risk, which has increased in intensity and frequency in different parts of the world; c) drought risk, occur in some particular regions; d) flood risk, affecting predominantly some regions; e) heat risk, which refers to increase in average temperatures over time.

Tax-sharing system gives Chinese local governments tax autonomy to control local corporate taxes.

See the Chinese National Earthquake Response Plan on this page https://www.gov.cn/yjgl/2012-09/21/content_ 2,230,337.htm. (Notice this page is in Chinese; Google Translate can be used to view the content.).

See Earthquake Response Plan in Huangshan City on this page https://www.huangshan.gov.cn/zwgk/public /6615714/10703207.htm. (Notice this page is in Chinese; Google Translate can be used to view the content.).

Adrian, C., Garg, M., Pham, A. V., Phang, S. Y., & Truong, C. (2023). Do natural disasters affect corporate tax avoidance? The case of drought. Journal of Business Ethics, 186 , 105–135.

Article   Google Scholar  

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Acknowledgements

This work was supported by the National Natural Science Foundation Project of China (Grant No.72302061), the Guangdong Office of Philosophy and Social Science (Project GD23YGL21) and Philosophy and Social Science Foundation of Guangzhou (Project 2023GZGJ58). The corresponding author is Liuyang Ren. All errors remain ours. All co-authors make equal contributions to the formation of this paper.

Guangdong Office of Philosophy and Social Science, GD23YGL21, Liuyang Ren, National Natural Science Foundation of China, 72302061, Liuyang Ren, Philosophy and Social Science Foundation of Guangzhou, 2023GZGJ58, Rui Xu.

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Paramedics’ experiences of barriers to, and enablers of, responding to suspected or confirmed COVID-19 cases: a qualitative study

• Ursula Howarth 1 ,
• Peta-Anne Zimmerman 2 , 3 , 4 , 5 ,
• Thea F. van de Mortel 2 &
• Nigel Barr 6  

BMC Health Services Research volume  24 , Article number:  678 ( 2024 ) Cite this article

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Paramedics’ work, even pre-pandemic, can be confronting and dangerous. As pandemics add extra stressors, the study explored paramedics’ lived experience of the barriers to, and enablers of, responding to suspected or confirmed Coronavirus Disease 2019 (COVID-19) cases.

This exploratory-descriptive qualitative study used semi-structured interviews to investigate Queensland metropolitan paramedics’ experiences of responding to cases during the COVID-19 pandemic. Interview transcripts were analysed using thematic analysis. Registered Paramedics were recruited by criterion sampling of staff who experienced the COVID-19 pandemic as active officers.

Nine registered paramedics participated. Five themes emerged: communication, fear and risk, work-related protective factors, leadership, and change. Unique barriers included impacts on effective communication due to the mobile nature of paramedicine, inconsistent policies/procedures between different healthcare facilities, dispatch of incorrect information to paramedics, assisting people to navigate the changing healthcare system, and wearing personal protective equipment in hot, humid environments. A lower perceived risk from COVID-19, and increased empathy after recovering from COVID-19 were unique enablers.

Conclusions

This study uncovered barriers and enablers to attending suspected or confirmed COVID-19 cases unique to paramedicine, often stemming from the mobile nature of prehospital care, and identifies the need for further research in paramedicine post-pandemic to better understand how paramedics can be supported during public health emergencies to ensure uninterrupted ambulance service delivery.

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Introduction

The COVID-19 pandemic disrupted healthcare globally and significantly impacted lives, including those of paramedics who perform essential frontline health care [ 1 ]. In Australia, emergency ambulance services are run/contracted by the state/territory and most qualified paramedics have a paramedicine diploma or degree and can provide advanced life support [ 2 ].

Prior to the COVID-19 pandemic, lessons learnt from other healthcare settings about processes of care and behaviours during disaster and emergency responses were applied to the prehospital environment [ 3 , 4 ]. A recent review [ 5 ] found only nine studies that included the paramedic experience of the COVID-19 pandemic, with various foci, including leadership strategies, psychological/social wellbeing or resilience, attitudes and stressors, and knowledge and preparedness; while including two Australian studies [ 6 , 7 ], none focused specifically on the experiences of paramedics in attending suspected or confirmed COVID-19 cases to examine the barriers to, and enablers of, responding to those cases. Exploring paramedics’ experience of responding under COVID-19 specific conditions may provide insights into how to increase the willingness of paramedics to respond during future public health emergencies to ensure uninterrupted ambulance service access and delivery.

This research sought to understand paramedics’ lived experience during the COVID-19 pandemic. The research question was ‘What were Queensland metropolitan paramedics’ experiences of barriers to, and enablers of, attending suspected or confirmed COVID-19 cases?’

Study design

An exploratory-descriptive qualitative approach [ 8 ] was applied to understand the experience of paramedics during the COVID-19 pandemic. A constructivist paradigm was chosen to explore paramedics’ experiences because it assumes there are multiple subjective realities, insider knowledge can be valuable, there is a holistic emphasis on the experience being investigated, and rich data are obtained whilst addressing context and processes [ 8 , 9 ].

Participant selection and setting

Registered paramedics from metropolitan south-east Queensland, Australia were invited to participate (few COVID-19 cases were occurring elsewhere at the time). Advanced Care Paramedics (ACP) and Critical Care Paramedics (CCP) in patient-facing roles with at least one year of operational experience during the COVID-19 pandemic were included. Patient Transport officers, doctors or paramedics working in supervisory roles were excluded. Criterion sampling [ 10 ] was applied to find participants with diverse education levels, age, gender and experience.

Recruitment and data collection

The primary researcher’s management position created a potential power imbalance given the position they worked in at the time, and their previous experience in operational paramedic roles made it likely they would know participants. Consequently, they had no direct contact with participants. A research assistant (RA) was utilised to ensure participant confidentiality and to ensure they felt safe to express themselves freely. The RA had a health science doctoral qualification and invited expressions of interest via an email containing an information sheet sent by the ambulance research department. Thirty-four responses were received. After an initial screen against the inclusion criteria, the RA sent a de-identified list to the primary researcher who authorised eleven invitations to be sent out in June 2022 that maximised sample diversity. After eight interviews, no new codes were generated; one more participant was interviewed to confirm this. Four open-ended interview questions on participants’ experiences of responding to patients during the COVID-19 pandemic, and the barriers and enablers to responding to these patients were asked. The interview was piloted with a paramedic who was not part of the study; no changes to the questions were required. The RA conducted, audio-recorded and transcribed interviews (approximately 30-min in duration) in July, 2022.

Data analysis

The research team included the primary researcher, and three doctoral qualified academics, one of whom was also a Registered Paramedic. Trustworthiness and rigour during data collection and analysis was addressed using the Lincoln-Guba framework, which underpins credibility, dependability, confirmability, and transferability [ 11 ]. During the interview and analysis phase, this included utilising a RA, member checking at the end of each interview, and researcher reflection on their own biases and preconceived thoughts after each transcript was reviewed. Researcher discussion supported rigour by identifying preconceptions the primary researcher may have that could influence data analysis [ 12 ]. Further member checking of transcripts was not deemed necessary due to the clarity of the participants’ comments.

Thematic analysis was conducted using the six-phase process outlined by Braun and Clarke [ 13 ]. The inductive method was used as the analysis was driven by the data, each participant’s language, and concepts [ 14 ], and aligns with the exploratory-descriptive qualitative approach, which focused on investigating the essence of the paramedics’ experiences during COVID-19 and remaining open to emerging themes. The transcripts were analysed by UH and all researchers discussed the coding and agreed on the themes. This discussion was informed by a range of illustrative quotes that exemplified each code.

Ethics approval was obtained from Royal Brisbane and Women’s Hospital Human Research Ethics Committee (Ref. no:84446) and Griffith University Human Research Ethics Committee (Ref. no:2021/819). The ambulance service approved paramedic recruitment. Participants gave informed consent.

Nine Registered Paramedics, four female and five male, aged 27–52 years (median 42; IQR = 32, 43), with 3–24 years of experience (median 8; IQR = 5, 15.5) were interviewed. Eight were ACPs, one was a CCP, all had a Bachelor of Paramedicine and two had paramedicine-related Master’s degrees. The analysis generated 26 codes and five themes: communication, fear and risk, leadership, work-related protective factors, and change.

Communication

This theme included the codes: organisational communication, media, public health messages, and interagency communication (Table  1 ). Participants perceived communication - from the ambulance service, media or formal health channels – substantially impacted paramedics during the pandemic. Communication ranged from being helpful and building trust, to lacking clarity and becoming overwhelming, confusing, and frustrating.

Fear and risk

The fear and risk theme included the codes: paramedic safety prioritised, physical risk to paramedic, healthcare barriers, unnecessary risk, fear of unknown, and having contracted COVID-19 (Table  2 ). Most indicated fear and risk influenced their personal and professional lives, with a flow on effect to patient care. Whilst mostly seen as a barrier to responding to cases, fear and risk also led to more empathetic approaches to patient care, and adherence to effective infection prevention and control practices.

The leadership theme included the codes: organisational leadership and lack of trust in organisation and government through the pandemic (Table  3 ). Some commented on the challenge of leadership through a pandemic, and appreciated open information-sharing, while others mistrusted decision-making and indicated the need for a consistent, visible leader.

Work-related protective factors

Work-related protective factors covered emotional, physical, or financial support, including vaccines, leave entitlements, personal protective equipment (PPE), secure employment and comradery (Table  4 ). However, wearing PPE in hot, humid environments, and difficulty accessing entitlement information caused frustration and distress.

The theme of change included the codes: adapting to their role and expectations, effect on personal life, emotional/mental health, evolution of pandemic normalised responding to cases, workload, and public reaction (Table  5 ). Paramedics reported issues as barriers earlier in the pandemic, but adapted as the community became highly vaccinated, their exposure to COVID-19 cases increased and it became more endemic, normalising responding to cases. Paramedics were often the first point of contact to navigate patients through the healthcare system, e.g., when patients called the ambulance service because they did not know what to do.

Barriers to, and enablers of, Queensland metropolitan paramedics responding to suspected or confirmed COVID-19 cases were identified. Some barriers had previously been reported in studies of other healthcare workers, including communication issues, change in work practices, increased burnout, psychological distress, fear of infection to self and loved ones, lack of PPE and vaccines, and unpreparedness [ 15 , 16 , 17 , 18 ]. Barriers unique to the prehospital environment included ineffective communication due to the mobile nature of paramedicine, inconsistent policies/procedures between different facilities, dispatch of incorrect information, assisting people to navigate the changing healthcare system, and wearing PPE in hot, humid environments.

Communication difficulties related to the mobile nature of paramedicine

While there can be communication issues in everyday work at the best of times, effective communication during a global infectious disease outbreak is particularly challenging due to mass media coverage, public concern, and uncertainty related to the disease [ 19 ]. Email-based communication is not always received, and communication failure can occur due to one-time message delivery, and communication fatigue [ 20 ]. In addition, media coverage, and widespread mis/disinformation created communication challenges [ 21 ].

Overwhelming, changing information during an outbreak is not unusual [ 7 ]. What was unique to the paramedic experience was the impact of the mobile nature of prehospital care. Attending multiple healthcare facilities per shift meant paramedics were exposed to multiple interpretations of pandemic guidance and local practices. Inconsistencies and lack of communication regarding different procedures, caused frustration, delays, and unnecessary exposure to infectious patients. This experience was confirmed in recent studies [ 5 , 7 , 22 , 23 ].

One paramedic [ 22 ] attended a case where four paramedics on scene had four different oxygenation strategies, due to frequent guideline changes and the timing of accessing updates, highlighting the need for better communication strategies as an outbreak evolves.

Increased safety risks due to receiving incorrect information from the ambulance service dispatch

Another unique communication barrier related to case dispatch. Paramedics rely on receiving correct information prior to arriving on scene to assess and mitigate risk based on what is known about the case. Miscommunication arose from the dispatcher either misunderstanding information or receiving incorrect information from the person requiring assistance, causing an increase in stress to the paramedic. Whilst case dispatch errors can occur outside of pandemic situations, the pandemic itself added an extra layer of stress in relation to paramedic safety. More stringent organisational procedures and public education are required to prevent this.

Paramedics assisted patients to navigate the new healthcare rules

The pandemic disrupted the way healthcare was delivered and/or accessed by both health professionals and consumers [ 17 , 24 , 25 ]. Paramedics were affected by increased hospital waiting times, and the move to telehealth changed the types of cases they were called to [ 7 ]. Paramedics often had to navigate patients through the healthcare system to access the most appropriate help in addition to the many changes they were experiencing in their workplace and community. This indicates the need for further investigation into how paramedics can effectively assist patients when there are so many changes occurring during a pandemic, often with limited information.

Wearing PPE in hot, humid environments, caused discomfort and fatigue

Globally, healthcare workers felt the adverse effects of wearing PPE more frequently and for longer periods [ 26 ], however, the prehospital environment created additional challenges for paramedics working in hot, humid conditions. While there is limited literature specifically on paramedics and heat-related illness when wearing PPE, during the African Ebola outbreak, the Centers for Disease Control and Prevention [ 27 ] indicated wearing PPE impairs the body’s ability to reduce body heat through sweat production, PPE holds excess heat and moisture and increases the physical effort to perform duties and the wearer can’t drink, increasing the risk of heat-related illness [ 27 , 28 ]. Other common risk factors in prehospital environments include direct sun exposure, physical exertion, dehydration, and indoor heat sources at patients’ homes. Clinicians need to balance having an impermeable layer of PPE to protect against viral contamination, and the heat stress caused to the wearer [ 29 ]. While personal cooling garments are available, the effectiveness of these to decrease PPE-related heat stress has not been studied [ 28 ].

Healthcare workers are at increased risk of self-contamination when doffing PPE if they are experiencing PPE-related discomfort [ 30 ], have trouble completing procedures, and experience facial injuries and skin conditions, and decreased well-being and job satisfaction. These issues are particularly relevant for paramedics in hot, humid parts of Australia. Paramedic-specific research is required to better support paramedics working in these environments in full PPE.

After contracting COVID-19, participants’ perceptions of risk reduced and empathy towards COVID-19-positive patients increased

One enabler - a decreased perception of risk and associated anxiety, and increased empathy for COVID cases after contracting COVID oneself - has not been previously reported, possibly because paramedics are used to experiencing risk in their work [ 31 , 32 ].

This exploration of paramedics’ experiences of barriers to, and enablers of, responding to suspected or confirmed COVID-19 cases uncovered challenges unique to the prehospital field that can potentially impact service delivery. Paramedicine is often the ‘forgotten profession’ overshadowed by community and acute care, and emergency department issues [ 31 ]. While studies based on a hypothetical public health emergency and willingness to respond are helpful, there are limitations compared to exploring this phenomenon during an actual public health emergency [ 33 ].

Limitations

Paramedics in non-metropolitan areas were not recruited and may have provided new insights into responding to cases in a geographically diverse state that includes logistical and resourcing challenges common in rural/remote areas. Given the specific recruitment for this study, the findings may not be transferable to other prehospital settings. Culture and personal beliefs and how these may have affected paramedics’ experience of working during a pandemic were not explored.

Recommendations

Further research is required on methods to improve communication to paramedics, particularly cross-facility communication, and how to flag critical information changes so these changes are implemented as soon, and consistently, as possible. Strategies to mitigate the effects of PPE when worn for extended periods in hot, humid conditions should also be explored. In the meantime, supervisors should prioritise regular rehydration, breaks, and welfare checks. Research on barriers and enablers during a public health emergency from the perspective of managers, executive leadership and other ambulance service providers would provide a deeper understanding of the issues.

The value of this research is that it captures Queensland metropolitan paramedics’ experience while working through the most significant public health emergency of our generation. This study uncovered barriers and enablers to responding to COVID-19 cases and thus to ambulance service delivery unique to paramedicine stemming from the mobile nature of prehospital care. It is vital that we support healthcare workers to maintain their physical and mental health, and willingly provide essential services, and that the healthcare system is ready to provide a cohesive response to public health emergencies across all sectors. This study highlights the importance of further research into paramedics in their roles.

Data availability

The datasets generated and analysed during the current study are not publicly available to protect the confidentiality of participants but are available from the corresponding author on reasonable request.

Abbreviations

Advanced care paramedic

Critical care paramedic

Coronavirus disease 2019

Personal protective equipment

Research assistant

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We thank the Queensland Ambulance Service) for facilitating paramedic recruitment, Dr. Megan Rattray for her research assistance, and participants for their insights.

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• Published: 30 May 2024

Automatic removal of soft tissue from 3D dental photo scans; an important step in automating future forensic odontology identification

• Anika Kofod Petersen 1 ,
• Andrew Forgie 2 ,
• Dorthe Arenholt Bindslev 1 , 3 ,
• Palle Villesen 4 , 5 &
• Line Staun Larsen 1 , 3  

Scientific Reports volume  14 , Article number:  12421 ( 2024 ) Cite this article

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• Data processing
• Forensic dentistry

The potential of intraoral 3D photo scans in forensic odontology identification remains largely unexplored, even though the high degree of detail could allow automated comparison of ante mortem and post mortem dentitions. Differences in soft tissue conditions between ante- and post mortem intraoral 3D photo scans may cause ambiguous variation, burdening the potential automation of the matching process and underlining the need for limiting inclusion of soft tissue in dental comparison. The soft tissue removal must be able to handle dental arches with missing teeth, and intraoral 3D photo scans not originating from plaster models. To address these challenges, we have developed the grid-cutting method. The method is customisable, allowing fine-grained analysis using a small grid size and adaptation of how much of the soft tissues are excluded from the cropped dental scan. When tested on 66 dental scans, the grid-cutting method was able to limit the amount of soft tissue without removing any teeth in 63/66 dental scans. The remaining 3 dental scans had partly erupted third molars (wisdom teeth) which were removed by the grid-cutting method. Overall, the grid-cutting method represents an important step towards automating the matching process in forensic odontology identification using intraoral 3D photo scans.

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Introduction.

Identifying casualties after a disaster is a critical task 1 . Forensic odontology identification, which is one of the primary identification methods according to Interpol 2 , involves forensic odontologists comparing ante mortem dental records with post mortem dental findings 1 , 2 , 3 . Unlike the other primary identifiers (fingerprints and DNA), dentitions can provide information about the estimated age and lifestyle of the victim, thus providing a dental profile of the individual even when identification is not possible at this stage 4 . Dentitions are made up of the most resilient material of the human body and dentitions are well protected in the oral cavity and therefore less likely to deteriorate and more likely to withstand trauma 4 . Identification of individuals with little to no dental work is difficult as the dental record generally contains sparse data with little to no identifying traits in these cases 2 , 3 , 5 . These cases most often end up with the conclusion identification probable, identification possible , or insufficient evidence , especially in disasters with many victims 4 . 3D photo scanning is increasingly used in dentistry and although individuals may have no previous dental work done, their dental records may contain intraoral 3D photo scans (dental scans); e.g., recorded for orthodontic screening and treatment planning 6 . Currently, 3D photo scans are not fully implemented in ordinary disaster victim identification 7 . Dental scans create detailed 3D recordings of the dental surfaces, allowing computational analysis of dentitions by using the 3D tooth shapes 6 , 8 , 9 , 10 . For future forensic dental comparison it is recommended to use the short distance tooth shapes, as inaccuracies have been reported on the long-distance measures 10 , 11 , 12 , 13 . Performing post mortem dental scans could facilitate an initial, automated comparison of tooth shapes with a database of ante mortem dental scans as shown by Reesu et al. 9 , 10 . This potential automation could streamline a part of the matching process within forensic odontology identification in the future 9 .

Surrounding soft tissue in both ante mortem and post mortem scans may interfere with accurate comparison because soft tissue can add unwanted variation between scans, without contributing significant discriminative information 14 , 15 . Therefore, the amount of soft tissue included in the dental scans before automated comparison should be limited. One approach is to remove soft tissue from the dental scan using the acquisition software, which requires manual data cleaning for each dental scan. Especially in cases with many victims, manual removal of soft tissue from ante mortem dental scans would require a significant investment of human resources. A few studies have reported on automated soft tissue removal from 3D dental scans 15 , 16 , 17 , 18 , 19 . The methods of these studies aimed at determining the precise border between dentition and soft tissue but some of the methods suffer from poor performance on dentitions with missing teeth, malocclusion or dental scans not originating from plaster models 15 , 16 . The use of supervised deep learning for tooth segmentation has also been emerging 15 , 17 , 18 , 19 . For supervised deep learning, the lack of representation of dentitions with multiple missing teeth in the training data poses a concern for their performance in a forensic setting 15 , 17 , 18 , 19 . The aim of the present study was to develop a new robust method for automated soft tissue removal from dental scans that works with scans from both living and deceased humans with or without missing teeth and malocclusion. Unlike earlier methods focusing on defining the dentition/soft tissue border 15 , 16 , our method aims at limiting the amount of soft tissue in dental scans. Our study mimics real-life disaster victim identification scenarios since the goal is to automate data cleaning to support future automated forensic odontology identification.

The study was conducted in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki. Further, the study was registered with the Data Protection Unit at Aarhus University, Denmark (file number 2016–051-000001, serial number 2534 and file number 20220367531, serial number 3155) and complied with the European Union General Data Protection Regulation legislation. The chairmanship of The Danish National Committee on Health Research Ethics (NVK) has assessed that the study and its protocol is exempt from notification (case number: 2400741) and the study is thus approved. The study was conducted in two parts. Part A was a pilot study with in vivo scans of six dental arches from three consenting donors from the donation programme at Department of Biomedicine, Aarhus University, with missing teeth and gaps in the dental arches. Since the new robust method successfully removed soft tissue from all six dental arches without removing teeth, a larger study (B) was conducted. Part B used sixty dental arch scans from thirty healthy volunteers after giving written informed consent (12 self identified males, 18 self identified females, ages 23–61 years). Seven of the 60 dental arches in part B had at least one missing tooth (not including dental arches with missing third molars (wisdom teeth)) and all the dental arches were scanned in vivo.

The scanning was performed by a forensic odontologist or by trained personel using an intraoral 3D photoscanner [Primescan AC, Sirona Dental Systems GmbH, Germany]. The dental scans were not subject to any prior removal of soft tissue. The dental scans were stored in STL-files as meshes using vertices (points in 3D space), edges between vertices, and faces (a plane defined by its edges) (Fig.  1 ), with unit size of the cartesian coordinate system of 1 mm.

Nomenclature of meshes. Simplified mesh showing a vertex, an edge, and a face.

In short, the grid-cutting method applies a grid to the dental scan in the xy-direction, whereafter each grid square is cut independently with a plane to remove soft tissue from the teeth of the dental scan. The grid-cutting method can be divided into four distinct steps. The first step entails approximating the occlusal plane through the use of algorithm 1 (supplementary, algorithm 1 ). The second step involves dividing the dental arch into contiguous squares by means of a grid. Subsequently, each square is analyzed individually in the third step, using algorithm 2 (supplementary, algorithm 2 ), in order to determine how much of the original dental scan that needs to be removed. Finally, the three steps are combined into a single function using algorithm 3 (supplementary, algorithm 3 ).

The grid-cutting method requires only three flexible user variables: the grid ( G ) size, the inclusion criterion ( I ) and the ratio of inclusion ( R ). G specifies the degree of granularity when dividing the grid. I determines how much of the mesh within each square to exclude in the resultant cropped dental scan. R dictates which grid squares are included in the final resultant cropped dental scan.

Part one: occlusal plane approximation

The orientation of the dental scan is determined by the user's specifications regarding whether it is a maxillary or mandibular dental scan. The dental scan is automatically oriented with the occlusal surfaces/incisal edges in the positive z direction (up), effectively flipping the upper jaw upside down, to ensure equal processing of maxillary and mandibular dental scans.

Algorithm 1 approximates the occlusal plane of the dental arch. To do so, algorithm 1 removes all vertices and faces below a fitting plane found using Mean Squared Error (MSE). The remaining vertices and faces are split into six sections, dictated by one plane in the y-direction, and two planes in the x-direction (Fig.  2 ). For each of the sections, a section representative vertex is chosen, to serve as an approximate occlusal point of that section. The section representative vertices are the vertex in each section with the largest distance to the fitting plane. Of the six section representative vertices, the four with the largest z-coordinate are chosen to estimate the occlusal plane. The occlusal plane is estimated using MSE on the four chosen points (Fig.  2 ).

Plane sectioning and section representatives. To approximate the occlusal plane, the dental arch was split into 6 sections by 3 planes. For each section, a section representative vertex was found according to largest distance to the fitting plane. The four section representative vertices with the largest z-coordinate were chosen to estimate the approximated occlusal plane.

Part two: grid splitting

Once the occlusal plane has been estimated, the dental scan is divided into squares of a user-defined size. These squares are created in the xy-direction (Fig.  3 ) and are analysed individually in part three.

The effect of grid size. A smaller grid size causes a more fine-grained grid, since each square becomes smaller, and consequently, the number of squares increases.

Part three: square analysis

Algorithm 2, which independently analyses each grid square, focuses on the vertex with the highest z-value. This vertex is referred to as the evaluation point. To expedite the computation of each grid square and enhance the speed of the algorithm, the evaluation point of the grid square is used, rather than the vertex closest to the approximated occlusal plane. To quickly eliminate squares with no teeth, the distance between the evaluation point and the approximated occlusal plane is compared to the total z-range of the scan. If the distance is larger than the ratio of inclusion ( R ) (default 33%, empirically determined) of the total z-range (the highest point in the square is far below the approximated occlusal plane), all vertices within that grid square are excluded from the cropped dental scan. If the z-value threshold is met, an inclusion threshold is established for that particular grid square. This inclusion threshold is defined by Eq. ( 1 ).

where \(E_{p}\) is the evaluation point of the grid square, I is the user defined inclusion criterion and \(N_{o}\) is the normal vector of the approximated occlusal plane. The inclusion threshold is located I units (mm) from the evaluation point in the direction of the approximated occlusal plane normal vector. Any vertex with a z-value higher than the inclusion threshold will be included in the cropped dental scan. In other words, vertices closer to the approximated occlusal plane than a given threshold will be kept.

Part four: method collection

Algorithm 3 integrates all previous stages into a unified method. Initially, the occlusal plane is estimated, followed by dividing the dental scan using a grid and analysing each grid square independently. Finally, vertices identified for removal during the square analysis are eliminated, and the cropped dental scan returned.

Code availability

The unified method can be found at https://github.com/AnikaKofodPetersen/Grid-Cutting .

Visualisation

Visualisation of dentitions was made using ParaView 20 .

Since study A showed no unwanted removal of dental surfaces, the findings from study A and study B are jointly presented. All dental arches were subject to grid-cutting ( G  = 1, I  = 7, R  = 0.33). The grid-cutting method successfully removed soft tissue on 58/66 dental arches without removing teeth. Three examples are shown in Fig.  4 .

Grid-cutting on 3 dental arches. Grid-cutting was performed with grid size = 1, inclusion criterion = 7 and ratio of inclusion = 0.33 on all three dental arches.

The soft tissue remaining on the dental scans after grid-cutting was either a) the tissue in immediate proximity to the teeth (the gingiva) or b) part of a cheek, lip, or the area behind the last molar (retromolar area). Eight dental arches suffered removal of at least one grid square from one or more teeth. Five of these cases comprised removal of one or more partly erupted/ectopic third molars (wisdom teeth) positioned relatively far from the approximated occlusal plane (Fig.  5 a). The three remaining cases of removal was due to inclusion of the retromolar area on one side, causing the approximated occlusal plane to be inaccurate (Fig.  5 b).

Examples of causes of unsolicited removal of grid squares. Depicted in relation to the approximated occlusal plane. ( a ) Ectopic and partly erupted third molar (wisdom tooth). ( b ) Retromolar area distorting the approximated occlusal plane.

The extent of dental surface preservation depends on the user defined variables, inclusion criterion ( I ), grid size ( G ) and ratio of inclusion ( R ). I affects how far from the occlusal surfaces and incisal edges the grid-cutting method removes tissue. G dictates the area to be analysed in each grid square. Thus, G dictates the granularity of the method. R is used to evaluate whether the content of a grid square should be included in the final model. Consequently, the grid-cutting method's effectiveness in preserving dental surfaces depends on the user-defined variable I, G and R . The eight dental arches which had unwanted partial removal of teeth were resubjected to grid-cutting ( I  = 5, G  = 5, R  = 0.4), resulting in unsolicited removal of a third molar (wisdom tooth) in only three dental arches. In these specific cases, the tooth in question was only partly erupted and disclosed less than half of the dental crown (Fig.  6 ).

Examples of third molars (wisdom teeth) which were subject to unsolicited removal. Specific dental arches each with a partly erupted third molar (wisdom tooth). In these three cases, grid-cutting removed the tooth as if it was soft tissue due to its location compared to the approximated occlusal plane.

The grid-cutting method was tested on 66 dental arches, successfully removing soft tissue from 58/66 dental arches without removing teeth. The eight dental scans which suffered from unsolicited removal of one or more grid squares within teeth were characterized by either the inclusion of the retromolar area on one side, causing the approximated occlusal plane to be inaccurate, or the position of a partly erupted third molar (wisdom tooth) in relation to the approximated occlusal plane. These shortcomings were overcome in 5/8 dental arches by tweaking the user defined variables I, G and R . This is an improvement to the previously published methods 15 , 16 , as the significance of maintaining teeth surpasses that of removing all soft tissue. The grid-cutting method shows robustness compared to previously published methods 16 , as the grid-cutting method was able to handle data acquired orally (not originating from plaster models), as would be the case in disaster victim identification. Since the aim of the grid-cutting method is to limit soft tissue without removing teeth, the grid-cutting method does not accurately trace the teeth in order ensure complete removal of soft tissue. By adjusting the user-defined variables (inclusion criterion, grid size and ratio of inclusion), this method can be tailored to suit specific-use cases. If loss of teeth in certain cases is of no issue, the grid-cutting method can be tweaked, using the user defined variables, to remove more tissue, including dental tissue. This would be beneficial in cases where only occlusal surfaces and incisal edges are of particular interest. Currently forensic odontology identification mainly includes comparing ante mortem 2D dental record data with post mortem dentitions 1 , 2 , 3 , 7 . Prospectively, the degree of detail of intraoral 3D photo scans should be utilised in the identification process 6 , 7 , 8 , given that the unwanted variation caused by the soft tissue is limited 14 , 15 . Unwanted variation can be caused by notable differences in the soft tissue condition between dental scans, or due to difference in scanning techniques resulting in different levels of soft tissue included in the dental scans 8 . The grid-cutting method presented in this study successfully removes soft tissue from dental scans, showing the potential of automating parts of the forensic odontology process. To assess the practicability of this new promising method in future 3D-based forensic odontology identification, the next step will be to compare manual soft tissue removal with the grid-cutting method.

Data availability

The data could be shared after publication upon reasonable request via communication with the corresponding author.

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Acknowledgements

We thank Specialist Mette Mørch for valuable technical support during the clinical recordings. This study was funded by Aarhus University Research Foundation (AUFF NOVA).

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Anika Kofod Petersen, Dorthe Arenholt Bindslev & Line Staun Larsen

School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland

Andrew Forgie

Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark

Dorthe Arenholt Bindslev & Line Staun Larsen

Bioinformatics Research Centre, Aarhus University, Aarhus, Denmark

Palle Villesen

Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

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The conceptualisation of this manuscript, its methodologies, formal analysis and validation of results was performed by A.K.P., L.S.L. and P.V. A.K.P. wrote the code and wrote the first draft. All authors (A.K.P., A.F., D.A.B., P.V., L.S.L.) wrote, reviewed and edited all following drafts.

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Kofod Petersen, A., Forgie, A., Bindslev, D.A. et al. Automatic removal of soft tissue from 3D dental photo scans; an important step in automating future forensic odontology identification. Sci Rep 14 , 12421 (2024). https://doi.org/10.1038/s41598-024-63198-2

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Received : 27 February 2024

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Published : 30 May 2024

DOI : https://doi.org/10.1038/s41598-024-63198-2

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• Forensic odontology
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• Automated comparison
• IOS (intraoral scanner)

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