Ethical Challenges in Pandemic Influenza

Ethical Issues in Pandemic Influenza Planning

Dr. Ross Upshur for the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group

Coping effectively with a predicted influenza pandemic that threatens to affect the health of millions worldwide, hobble economies and overwhelm health care systems will require more than new drugs and good infection control.

An effective response to pandemic influenza needs to be founded on commonly held ethical values. People need to subscribe in advance to the rationale behind such choices as: the priority recipients of resources, including hospital services and medicine; how much risk front line health care workers should take; and support given to people under restrictions such as quarantine. Decision makers and the public need to be engaged so plans reflect what most people will accept as fair, and good for public health. Five key issues require attention:

1. Health workers' duty to provide care during a communicable disease outbreak;
2. Restricting liberty in the interest of public health by measures such as quarantine;
3. Priority setting, including the allocation of scarce resources such as medicines;
4. Global governance implications, such as travel advisories.
5. How to best expedite ethics review of research proposals during infectious disease outbreaks.

An interdisciplinary group of scholars, in response to these challenges, has created an ethical framework to assist healthcare organizations and ministries of health in meeting these challenges. Full details of the report can be found at: http://www.utoronto.ca/jcb/home/documents/pandemic.pdf

Health Care Workers Duty to Care

The SARS crisis exposed health care systems to hard ethical choices that rapidly arose. Dozens of health care workers, for example, were infected through their work and some died. Other failed to report for duty to treat SARS patients out of fear for their own health or that of their family. A flu pandemic, where there may be no absolute protection or cure, would put far greater pressures on health care systems around the world.

Governments and hospitals need to provide for the health and safety of workers, and for the care of those who fall ill on duty. This might include and insurance fund for life and disability to cover health care workers who become sick or die as they place themselves in harm's way.

The Human Costs of Restrictive Measures

Restrictive measures such as quarantine may play only a temporizing role in an influenza pandemic. Officials need to provide support for those in quarantine, cut off from family, friends, work, shopping and possibly medical care for other aliments. The public should also be made aware of the need for restrictive measures and the consequences of non-compliance.

Measures to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by restrictive measures also should be part of pandemic preparedness plans.

Allocating Scarce Resources, Medicines

All countries will face scarcities of medicines, equipment and health care workers during a pandemic, according to the group. Governments, hospitals and health regions should publicize a clear rationale for giving priority access to anti-viral medicines and vaccines to particular groups (e.g., front line workers, children, decision-makers).

Advance planning ought to include criteria for resource allocation decisions, created in consultation with the general public.

Travel Bans

The World Health Organization (WHO) has warned that if the H5N1 strain of bird flu mutates and infects people it could reach all continents in less than three months. The WHO would likely impose regional travel restrictions in hopes of slowing the spread of the disease.

However, such decisions can have major economic impacts. Canada, and Toronto in particular, suffered millions in economic losses when the WHO advised international travelers against all nonessential travel because of SARS.

Descriptions about travel restrictions need to be clearly justified and the process must be transparent the report says.

At the same time, the WHO relies on individual countries for report disease outbreaks. Such surveillance may be beyond the capacity of many developing countries. The developed world should continue to invest in the surveillance capacity and the overall public health infrastructures of developing countries.

Research Ethics

A novel strain of influenza spreading through populations globally will require a vigorous response from researchers to determine the effectiveness of newly created vaccines and therapeutic agents. The rapid introduction of new agents will stress usual means of approving human subjects research. Innovative methods of expedited ethical review will be required for a pandemic.