Pandemics

At the time of writing (mid-May), the early experience with H1N1 (swine derived) influenza A virus has not lived up to the initial predictions of widespread morbidity and mortality, with most infections being self-limited. However, this novel influenza virus may eventually cause infection in up to a third of the earth’s population. With a case fatality rate around 0.4 percent, it will likely contribute to the death of millions of people worldwide (1). Recent concern about the spread of another influenza virus (H5N1 avian influenza with a case fatality rate of over 50 percent) had led to discussion about the ethical principles involved in pandemic planning and response.

There are many ethical issues involved in the delivery of medical care during an infectious disease pandemic, and this paper can only address a few. Issues of distributive justice — that is, who should be treated when not all can be treated — will likely be most important in the public mind. To be discussed here include the ethical aspects of delivery of medical care when the demand for treatment overwhelms the ability to provide such treatment (because of a lack of staff, space, equipment, or medication), public perception of medical care delivery when treatments may be refused to patients based on scarcity, and the obligations of medical personnel to work during an infectious disease outbreak with its inherent danger of disease contraction.

It is becoming increasingly acknowledged that our hospitals, clinics, and emergency departments may lack the surge capacity to effectively treat all patients during a pandemic. Additionally, scarcity of medications or equipment (e.g., ventilators) will surely reduce the ability to provide treatment to all. One intuitive model summarizing the likely progression of the pandemic response in the setting of scarce resources is that developed in the Swiss influenza pandemic plan:

1. Phase 1: During the first phase, everyone who needs treatment will receive it. This phase will continue until the number of those requiring treatment exceeds the capacity of the enhanced treatment facilities. In this phase treatment is administered to individuals on a “first come, first served” basis or to those who are already being treated for another illness.
2. Phase 2: The second phase begins when it is no longer possible to treat everyone because the therapeutic capacity is exhausted, and some have to be turned away. In this phase, the scarce therapeutic resources are reserved for those whose condition is most threatening.
3. Phase 3: Finally, there is the third phase, which corresponds to the triage used in war or disaster situations. Right from the outset of this phase, the scarce resources should be reserved for influenza patients in a life-threatening condition. When all those who are in a life-threatening condition can no longer be treated, priority will be given to those who are expected to have the best chance of survival as a result of treatment. Conversely, treatment in this phase will, if possible, be withheld only from those who are unlikely to benefit from it. Individuals with a poor prognosis will only be treated palliatively in this phase; intensive treatment, for example, will not be initiated (2). (emphasis original)

Putting this model into classic ethics language, in the setting of scarce resources, the utilitarian principle of maximizing the most good for the most people will be employed. However, because of changing of local and regional capabilities in relation to number of patients, difficult decisions to treat or not treat will also be in flux, based on current information and imperfect predictions. For instance, because of the current prediction of a future scarcity of antiviral medications, these drugs have been withheld in “mild” H1N1 disease (perhaps unjustifiably), putting the current response, in a certain sense, already in phase 2 of the Swiss model.

Medical professionals generally understand that in a pandemic with a highly virulent organism not all patients needing it will necessarily receive maximal treatment (especially critical care). Although most people may agree that scarce treatment is best provided to those most likely to benefit, the difficulty lies in determining which patients may best benefit. Without prior public notification and involvement in pandemic planning, medical decisions to withhold medical treatment based on scarcity of resources may appear arbitrary at best or discriminatory at worst, unless grounded in previously developed guidelines. The World Health Organization emphasizes transparency, public engagement, and mobilization in order to “contribute to the development of adequate and effective plans and increase public confidence that policies are reasonable, responsive, non-discriminatory, and in line with local circumstances and values” (3). National, state, and local health agencies and policymakers must ensure public participation in the planning, implementation, and evaluation of a pandemic response. It is only through this process of lay public involvement that the medical profession will prevent public concerns of “unethical behavior” when the reports of prioritization of treatment (described, of course, as the withholding of treatment) begin to circulate.

There are ethical issues involving healthcare workers’ obligation to provide care during an infectious disease pandemic. Providing medical care is, of course, not without risk, infectious pandemic or not. Healthcare professionals possess unique skills that are essential to the treatment of disease, and a moral obligation to provide care should be argued. However, this obligation cannot be considered absolute. Situational factors of the provider (for instance, personal, high-risk factors for severe disease, pregnancy, or family care requirements) may provide justification to decline or limit provision of care. Although there may be moral, professional, or legal obligations to provide care during a pandemic, governmental and professional bodies need to define such obligations and any potential sanctions if such obligations are not met. Furthermore, government and other regulatory agencies must ensure the reciprocating obligation of providing safe practice environments and protections for providers, such as priority to vaccines or treatment and legal protections, or support to those who become ill while providing care.

There are many other issues involved in pandemic planning and response that have ethical implications that are not discussed here. To list a few: individual civil rights in the setting of involuntary quarantine, triage guidelines in a mass casualty setting, mutual aid, vaccine allocation schemes, and the obligation of regions or countries with more resources to those with less. The current H1N1 outbreak provides a perfect setting to investigate or reflect upon our understanding of resources, regulations, and obligations, and our individual readiness to provide care during this looming pandemic.

References:

1. Fraser C, Donnelly CA, Cauchemez S, et al. Pandemic Potential of a Strain of Influenza A (H1N1): Early Findings. Science. Electronically published May 11, 2009.
2. Federal Office of Public Health, Switzerland. Swiss influenza pandemic plan version 2007. page 250.
3. World Health Organization. Ethical considerations in developing a public health response to pandemic influenza, 2007. page 3.