Ethical Issues in Pandemics

Rationing · Ethics of Triage · Duty of Care · Communicating a Pandemic

Rationing of Scarce Resources

  • Minnesota Pandemic Ethics Project. This project has proposed ethical frameworks and procedures for rationing scarce health resources in Minnesota during a severe influenza pandemic. The frameworks recommend how to decide in what order different groups of Minnesotans should be prioritized to receive resources. There are also recommendations about how to implement the ethical guidance provided by the frameworks. The preliminary recommendations have been developed by a broad-based panel and work groups of more than 100 Minnesotans. An important part of this project is to gather additional public input so that the final recommendations include broader perspectives. You do not need to be from Minnesota to comment. The project is funded by the Minnesota Department of Health and is led by the Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics. Click here to submit comments.

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  • WHO guidelines on the use of vaccines and antivirals during an influenza pandemic
  • Tiered Use of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage – The CDC’s Rationing Plan
A synopsis of the CDC’s rationing plan from the American Hospital Association:
(On Aug 4, 2005) The Centers for Disease Control and Prevention announced a tiered approach to prioritization in the event of a flu vaccine shortage. In the event of a shortage, CDC said people in the first tier should be vaccinated preferentially, followed by those in the second tier, then those in tier three. When local vaccine supply is extremely limited, state and local health officials and vaccine providers should vaccinate people in group 1A before all other groups, CDC said.
  • Group 1A consists of people 65 and older with comorbid conditions and residents of long-term care facilities. In all other vaccine shortfall situations, CDC said people in groups 1A, 1B and 1C should be vaccinated first. Group 1B consists of people aged 2–64 with comorbid conditions and aged 65 and older without comorbid conditions, as well as children 6–23 months and pregnant women. Group 1C consists of health care personnel, and household contacts and out-of-home caregivers of children 6 months and under.
  • Group 2 consists of household contacts of children and adults at increased risk for flu-related complications.
  • Group 3 consists of people aged 2–49 without high-risk conditions.
  • Group 4 is everyone not in one of the above categories.
Eligible persons in group 1C and tiers 2 and 3 should be encouraged to receive live, attenuated influenza vaccine during periods of inactivated influenza vaccine shortfall, CDC said.

Further Reading

  • Ethics & Pandemics Blog from Johns Hopkins
  • Bellagio statement
    About the Bellagio Group
With support from the Rockefeller Foundation, an international group of experts in public health, animal health, virology, medicine, public policy, economics, bioethics, law and human rights met in Bellagio, Italy from 24 July to 28 July 2006 to consider questions of social justice and the threat of avian and human pandemic influenza, with a particular remit to focus on the needs and interests of the world’s disadvantaged. The Bellagio Statement of Principles, above, captures the major conclusions of the group’s deliberations.
  • Ethical Issues in Pandemic Flu
    PowerPoint presentation by Kathy Kinlaw, Emory University Center for Ethics, given at the Pandemic Influenza Working Group meeting on June 15, 2005
  • Ethics of stockpiling flu drugs for doctors’ relatives questioned
    CBC. June 24 2005
  • European avian flu fear leads to drug stockpiling
    CBC News, 18 Oct 2005
  • Run on Drug for Avian Flu Has Physicians Worried
    Washington Post, 22 Oct 2005. Page A01

At a time of resource limitations such as a pandemic, ethical issues abound. Should healthcare providers get preferential treatment? Some doctors might stockpile for their relatives. Oseltamivir (Tamiflu) may help treat an infection but unless it is taken daily (i.e. preventatively) it will not keep health care workers from getting ill. Will health care profesionals go to work if they are afraid of bringing the illness home and threaten their family members? They would be on the front lines of a disease outbreak and thus most likely exposed while tending to patients. In the case of SARS, there were “superspreaders” who passed on a very lethal variant and others whose infection caused only relatively mild symptoms. The sickest would seek professional help.1

The same issues arise for essential workers in all sectors of the economy — everyone who maintains the economy’s infrastructure such as electricity, water, heat, transportation. Where to draw the line? Should we provide for the doctor and not the nurse? Unfortunately, it is easier to ask these questions than to provide answers. If you have ideas, please bring them up.

Another issue: do you treat the elderly first because they have a higher need and have less capacity to withstand an illness or do you treat the young and healthy, whose immune system is stronger but who may succumb to a cytokine storm? The young have more ‘productive years ahead’ while the elderly are less likely to survive without medical assistance. What makes a person ‘essential’ — being a first responder, being a essential worker? What about personal finances? What if you are pregnant or what if you have medical condition? Will Medicaid patients get treated in the United States? Will you get sued for not treating the ‘right person’?

These issues have never been acknowledged in modern times. Much will depened on the virus’ pathogenicity, its transmission vectors and the nature of the infections. In 1918, the illness was more fatal to the young and healthy for reasons that still remain unknown (cytokine storm is suspected). We do not know what will be the case in the next pandemic.

The World Health Organization has issued guidelines on the use of vaccines and antivirals during influenza pandemics. Regarding vaccines, the WHO advises:

  • Essential service providers, including health care workers
    Goal → Maintain essential services
    Definition of those considered ‘essential’ will vary from country to country. The purpose of vaccinating these individuals would be to allow them to continue to provide services, including health care, to those in need. As vaccine supplies will most likely be inadequate, prioritization within individual categories of essential service workers may be necessary.

Note that the WHO advocates a further prioritization within individual categories of essential workers in order to deal with the global shortage of neuraminidase inhibitors and the lack of an effective vaccine. The document also has guidelines regarding the healthy/frail split:

  • Groups at high risk of death and severe complications requiring hospitalization
    Goal → Prevent or reduce deaths and hospital admissions
    In the interpandemic period, those who have underlying disease or are older are the ones most likely to experience severe morbidity and mortality2. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the “high risk group” who have the greatest risk of hospitalization and death. Such persons should be targeted for vaccination if the goal is to prevent such events. They are individuals who are 65 years of age or older and have a high-risk condition (see above). Younger individuals with underlying disease are also at higher risk of experiencing severe morbidity and mortality. Owing to difficulties in prioritization on the basis of chronic diseases, age is often used as a surrogate for identifying those at greatest risk of complications. However, the epidemiologic characteristics of the pandemic will need to be considered, as the main population groups affected may vary.

The document also suggests not to mass immunize children:

There is no evidence that use of inactivated vaccine in children will reduce the spread of a pandemic in the community, and this strategy is not recommended.

Further discussions in advance are essential to assure rational use of resources as well as a perception of fairness.

There are some interesting recommendations from the University of Pittsburgh’s Center for Biosecurity advising politicians and health officials how to lead in a bioattack or epidemic:

  • Earning confidence in the use of scarce resources despite existing social and economic gaps
  • Case Study — Polled Americans Expect Discrimination during Smallpox Outbreak
  • Account for income disparities in response plans; anticipate the need for free or low-cost prevention and treatment.
  • Make planning transparent so that the public sees that access to life-saving resources is based on medical need and not on wealth or favored status.
  • Be open about eligibility criteria for goods and services, especially when tough choices arise unexpectedly—for example, which botulism attack victims will receive the limited antitoxin that exists.
  • Show thorough preparations to protect vulnerable populations like children and the frail elderly, thus bolstering everyone’s sense of security.
 

1 for more on the history of the H5N1 virus, see this page. The WHO provides a thorough history of the H5N1 virus in its January 2005 report Avian Influenza: Assessing the pandemic threat · pdf (↑)

2 Individuals (adults and children aged more than 6 months) in the community who have chronic cardiovascular, pulmonary, metabolic or renal disease, or are immunocompromised. (↑)

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The Ethics of Triage in a Pandemic

  • Lifeboat Ethics: Considerations in the Discharge of Inpatients for the Creation of Hospital Surge Capacity
  • The ethical framework for the response to pandemic influenza from the United Kingdom, released April, 2007 (.pdf, 124K)
  • Ethical Guidelines in Pandemic Influenza The Ethics Subcommittee of the Advisory Committee to the Director, CDC, .pdf
  • Ethical Values for Planning and Responding to a Pandemic from New Zealand’s National Ethics Advisory Committee (NEAC), .pdf
  • Stand on Guard for Thee building on the previous report, released Nov 28, 2005
  • Ethics and SARS: Learning Lessons from the Toronto Experience including ethics of quarantine, revealing personal info, duty to treat, and more

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Healthcare Workers’ Duty of Care

Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care
see also Forum discussion here under health care workers.

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Communication: “Truth-telling” vs. “Panic-mongering”

From the University of Pittsburgh’s CBS report (link under repair… see link):

Breaches of social trust are a common predicament for leaders during outbreaks and are likely to arise during a bioattack. Social and economic fault lines as well as preconceived notions about ‘the government,’ ‘the public,’ and ‘the media’ can alienate leaders and the public, and community members from one another.
  • Preventing unproductive fear, denial, or skepticism on the part of the public when delivering crisis updates
    • Case Studies
      2001 — Mayor Leads Mourning New Yorkers
      2001 — EPA Reassures Ground Zero Residents that Air Is Safe
  • Share what you know. Do not withhold information because you think people will panic. Creative coping is the norm; panic is the exception.
  • Hold press briefings early and often to reach the public. Answering questions is not a distraction from managing the crisis; it is managing the crisis.
  • Confirm that local health agencies and medical facilities are prepared to handle an onslaught of questions from concerned individuals, in person and by phone.
  • Convey basic health facts clearly and quickly so that people have peace of mind that they are safe or so that they seek out care, if need be; similarly, brief healthcare and emergency workers so they have a realistic understanding about job safety.
  • View rumors as a normal sign of people’s need to make sense of vague or disturbing events. Refine your outreach efforts; the current ones may not be working.

See also

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Page last modified on April 15, 2009, at 06:34 AM by Bronco Bill