JCB Flu Pandemic Working Group Members (Ross E.G. Upshur, Karen Faith, Jennifer L. Gibson, Alison K. Thompson, C. Shawn Tracy, Kumanan Wilson, Peter A. Singer) are available for advance interviews Weds-Fri Nov. 23-25. Please call to schedule a time. Media can preview the study, "Stand on Guard for Thee," to be released Nov. 28, online at http://www.utoronto.ca/jcb/home/documents/pandemic.pdf.
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 international medical ethics think-tank says that all-important public cooperation and the coordination of public officials at all levels requires open and ethical decision making.
Protection of the public from harm: To protect the public from harm, health care organizations and public health authorities may be required to take actions that impinge on individual liberty. Decision makers should:
Proportionality: Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community.
Privacy: Individuals have a right to privacy in health care. In a public health crisis, it may be necessary to override this right to protect the public from serious harm.
Duty to provide care: Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability and workplace conditions.
Reciprocity: Reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families.
Equity: All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of the health crisis, this could curtail not only elective surgeries, but could also limit the provision of emergency or necessary services.
Trust: Trust is an essential component of the relationships among clinicians and patients, staff and their organizations, the public and health care providers or organizations, and among organizations within a health system. Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during an evolving health crisis. Trust is enhanced by upholding such process values as transparency.
Solidarity: As the world learned from SARS, a pandemic influenza outbreak will require a new vision of global solidarity and a vision of solidarity among nations. A pandemic can challenge conventional ideas of national sovereignty, security or territoriality. It also requires solidarity within and among health care institutions. It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services or institutions.
Stewardship: Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour and good decision-making. This implies that decisions regarding resources are intended to achieve the best patient health and public health outcomes given the unique circumstances of the influenza crisis.
Five procedural values to guide ethical decision-making for a pandemic influenza outbreak
Reasonable: Decisions should be based on reasons (i.e., evidence, principles and values) that stakeholders can agree are relevant to meeting health needs in a pandemic influenza crisis. The decisions should be made by people who are credible and accountable.
Open and transparent: The process by which decisions are made must be open to scrutiny, and the basis upon which decisions are made should be publicly accessible.
Inclusive: Decisions should be made explicitly with stakeholder views in mind, and there should be opportunities to engage stakeholders in the decision-making process.
Responsive: There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis. There should be mechanisms to address disputes and complaints.
Accountable: There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of actions and inactions should be grounded in the 14 other ethical values proposed above.
Summary of Recommendations
An ethical guide for pandemic planning:
1. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should ensure that their pandemic plans include an ethical component.
2. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should consider incorporating both substantive and procedural values in the ethical component of their pandemic plans.
Four key ethical issues:
Health workers’ duty to provide care during a communicable disease outbreak
1. Professional colleges and associations should provide, by way of their codes of ethics, clear guidance to members in advance of a major communicable disease outbreak, such as pandemic flu. Existing mechanisms should be identified, or means should be developed, to inform college members as to expectations and obligations regarding the duty to provide care during a communicable disease outbreak.
2. Governments and the health care sector should ensure that:
a. care providers’ safety is protected at all times, and providers are able to discharge duties and receive sufficient support throughout a period of extraordinary demands; and
b. disability insurance and death benefits are available to staff and their families adversely affected while performing their duties.
3. Governments, hospitals and health regions should develop human resource strategies for communicable disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution of risk among individuals and occupational categories.
Restricting liberty in the interest of public health by measures such as quarantine
1. Governments and the health care sector should ensure that pandemic influenza response plans include a comprehensive and transparent protocol for the implementation of restrictive measures. The protocol should be founded upon the principles of proportionality and least restrictive means, should balance individual liberties with protection of public from harm and should build in safeguards such as the right of appeal.
2. Governments and the health care sector should ensure that the public is aware of:
a. the rationale for restrictive measures;
b. the benefits of compliance; and
c. the consequences of non-compliance.
3. Governments and the health care sector should include measures in their pandemic influenza preparedness plans to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by quarantine or other restrictive measures.
4. Governments and the health care sector should institute measures and processes to guarantee provisions and support services to individuals and/or communities affected by restrictive measures, such as quarantine orders, implemented during a pandemic influenza emergency. Plans should state in advance what backup support will be available to help those who are quarantined (e.g., who will do their shopping, pay the bills and provide financial support in lieu of lost income). Governments should have public discussions of appropriate levels of compensation in advance, including who is responsible for compensation.
Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines
1. Governments and the health care sector should publicize a clear rationale for giving priority access to health care services, including antivirals and vaccines, to particular groups, such as front line health workers and those in emergency services. The decision makers should initiate and facilitate constructive public discussion about these choices.
2. Governments and the health care sector should engage stakeholders (including staff, the public and partners) in determining what criteria should be used to make resource allocation decisions (e.g., access to ventilators during the crisis, and access to health services for other illnesses), should ensure that clear rationales for allocation decisions are publicly accessible and should provide a justification for any deviation from the pre-determined criteria.
3. Governments and the health care sector should ensure that there are formal mechanisms in place for stakeholders to bring forward new information, to appeal or raise concerns about particular allocation decisions and to resolve disputes.
Global governance implications, such as travel advisories
1. The World Health Organization should remain aware of the impact of travel recommendations on affected countries, and should make every effort to be as transparent and equitable as possible when issuing such recommendations.
2. Federal countries should utilize whatever mechanisms are available within their system of government to ensure that relationships within the country are adequate to ensure compliance with the new International Health Regulations.
3. The developed world should continue to invest in the surveillance capacity of developing countries, and should also make investments to further improve the overall public health infrastructure of developing countries.
University of Toronto Joint Centre for Bioethics
Innovative. Interdisciplinary. International. Improving health care through bioethics.
The JCB is a partnership among the University of Toronto and 15 health care organizations. It provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.
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