Pandemic ethics

The H1N1 influenza pandemic brings up a lot of medical ethics issues that should be considered before the onset of another wave, according to the University of Toronto Joint Centre for Bioethics (JCB).

Some of these ethics issues are: the duty of health care workers to work during a serious flu pandemic; government restrictions on individual freedoms and privacy and their responsibilities administering vaccination programs; how to allocate limited medical resources; and the obligation of rich countries to share such resources with those less fortunate.

Duty to care

Should health care workers (HCWs) be obligated to treat patients when there is a risk of infection? Are there any limits to the duty to care? Should HCWs receive institutional support during a pandemic?

The Joint Centre for Bioethics (JCB) conducted a survey among its members. 90% think that HCWs should go to work even with the risks, as long as safety precautions are provided. 85% think that HCWs should get free disability insurance and death benefits during a flu crisis, and 84% think that a HCW who feels unsafe at work should have the right to file a grievance.

However, when members of the public were surveyed, the results were not as decided. 48% said that HCWs who miss work without a legitimate reason should lose their job or their license, but 38% disagree. 47% think that the government should conscript HCWs during a pandemic, but 43% disagree.

The people who participated in the study said that, "like soldiers, HCWs should be expected to uphold their duties no matter how challenging and frightening the situation. On the other hand, the government and health care organizations have reciprocal obligations to protect health care professionals from elevated risks in all ways possible, including policies to ensure a safe working environment."

When survey participants were asked what they considered a legitimate reason to miss work, 89% said that a serious health problem that could increase vulnerability to the flu is a legitimate reason.

There is also the issue of competing care obligations; some HCW might have young children or elderly relatives to care for. When asked if HCW should be able to miss work in order to care for their family, only 57% of the public thought that that's a legitimate reason to not work.

Priority setting

If there are not enough resources to treat everyone, who should get priority? This is a difficult choice to make. According to members of the JCB, the ethical goals of priority-setting are legitimacy, fairness and equity. Member of the public, however, said that priority should depend on need, survivability, and social value.

Need means treating those most sick or those who are responsible for the care of others. Survivability means giving scarce resources to those who are most likely to survive. Social value refers to health care workers, police officers and others that are needed for society to function in a pandemic crisis.

With regards to the allocation of medicine, 59% said that every Canadian should have an equal chance of getting antivirals, while 94% said that HCWs should get priority in a pandemic, and 89% said that children should get second priority. Also, people who were denied resources should have the option to appeal the decision.

Members of the public are skeptical of the Canadian health care system's ability to respond effectively to a pandemic. They think that Canadian health care is not good at prioritizing.

H1N1 vaccinations

There are also ethics issues regarding coercion in vaccination policy. To justify using coercion, like making vaccination mandatory, health officials must have scientific evidence that the vaccination program has obvious health benefits.

The ethics of coercion also depend on the purpose of the vaccination program. If the purpose is to give the vaccine to individuals for their own protection, then individual liberty would overrule the government's power to enforce vaccination, so coercion cannot be justified. On the other hand, if the goal is to protect the entire population, then the protection of the public could overrule individual liberty, and coercion can be justified.

However, if individual liberties are taken away, the government must take responsibility for the wellbeing of vaccine recipients. First of all, the government has to make sure that the vaccine is as safe and effective as possible. Also, it is possible that some people might be harmed by a mass vaccination program. Because of this, the government should have a no-fault compensation program.

Restrictive measures

To protect the public, the government may have to limit some personal freedoms: mobility, freedom of assembly, and privacy. According to JCB research, after the SARS outbreak, members of the public understood the need to control the spread of infection, and they accepted that restrictive measures may be used.

According to the survey, 85% of participants said that when there is a pandemic, the government should be able to suspend some individual rights, like traveling and the right to assemble.

However, 95% said that if individual liberties are suspended, the government should be obligated to provide food, shelter, social support and other basic needs to restricted individuals. They also said that "restricted individuals should not be penalized by an employer for following a quarantine order."

Global ethics

Are rich countries obligated to help poorer countries experiencing a pandemic? 70% of survey participants thought that Canada should help poorer countries facing a pandemic, even if it leaves fewer resources for Canada.

Canadians care about global equality, reciprocity and justice. 54% said that saving lives globally should be a priority; 36% said that saving lives of Canadians should come first.

Some suggestions from the JBC: Canada should share at least 10% of its stockpile of antiviral medications and outbreak management kits with poor countries. Canada should also ask that vaccine priority will be given to health care workers, and those who are most vulnerable. Also, Canada's vaccine producers should keep production going at full capacity for as long as there is need in other countries, even if all Canadians have already received vaccines.

Risk communication

According to the JCB, "For people to accept public health measures that may limit their individual liberty and potentially cause them to be stigmatized, they must trust the information they receive as well as the authorities who provide the information."

It is imperative to have information made available to both professionals and the public. Also, people should know that the information is coming from a reliable source. Being transparent is also important; health officials must be open about what is known and what is not known about the situation.

For citizens to be honest about their health, the government has to promise that they will not be penalized. For example, someone who accepts voluntarily quarantine should be assured that they will not lose their job.

Source: University of Toronto Joint Center for Bioethics. "Ethics Issues in H1N1 Swine Flu Pandemic." 24 Sep 2009.