Ethics in an Epidemic: Ethical Considerations in Preparedness Planning for Pandemic Influenza

Introduction In the event of an influenza pandemic, a host of difficult decisions will have to be made, including stark choices about allocation of limited resources such as antivirals, the imposition of restrictive measures such as quarantines, the level of risk that health care workers should be expected to face while caring for the sick, and the use of travel restrictions and other measures to contain the spread of disease. These decisions will affect population survival rates and impact fundamental individual rights and freedoms. (1) The World Health Organization has recommended that every country develop and maintain an up-to-date national influenza preparedness plan. (2) Further, to assist with preparation and planning, the WHO has developed a checklist of essential and desirable elements of national preparedness plans. (3) The checklist specifically includes discussion of legal and ethical issues. (4) The purpose of this paper is to present an overview of a more detailed report produced by the Pandemic Influenza Working Group at the University of Toronto Joint Centre for Bioethics [JCB]. The full report, Stand On Guard For Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza, is freely available on the Internet. (5) An elaboration of the methodology used for developing the report's ethical framework is presented elsewhere. (6) Background Government leaders and health care officials in many parts of the world are developing pandemic plans. However, there has been precious little public discussion and debate about the planning process. The values underlying pandemic plans must be made public. Decision-makers should discuss the values with people who could be affected, ranging from health care workers, who will find themselves on the front lines, to hospital administrators who will make decisions about the allocation of limited resources, to the public at large, who will be affected in many ways. This discussion should take place in advance of a health crisis, not when patients are lining up at emergency wards. Openly discussing the choices and confirming that they are based on ethical values that are shared by members of a society brings important benefits. If ethical values are clearly built into pandemic plans in an open and transparent manner, and with buy-in from multiple sectors of society, the plans carry greater trust, authority, and legitimacy. (7) Advance discussions of such issues can help address fears of the unknown. People will be more likely to cooperate, and accept difficult decisions made by their leaders for the common good. The need for a clearly understood and widely accepted ethics approach to dealing with serious communicable disease outbreaks was underscored during the outbreak of severe acute respiratory syndrome [SARS] in early 2003. SARS showed the universal vulnerability of humans to communicable diseases, and the need for coordinated and cooperative responses across national borders. It also found that health care systems had generally not prepared themselves to deal with the hard ethical choices that rapidly arose. (8) Research in the aftermath of SARS found that as the crisis became more severe and restrictions were imposed, there were concerns over access to care, the allocation of medicines, the availability of safety equipment, and the sharing of vital information. (9) Debate arose as to whose values should prevail during a public health emergency. Leaders in governments and health care systems had not previously developed an ethical framework or held prior consultations to deal with the suite of ethical issues forced on them by SARS. Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat the sick, and economic losses against the need to contain the spread of a deadly disease. Information and conditions changed constantly and decisions had to be rapid. …

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