The Domestic and International Impacts of the 2009-H1N1 Influenza A Pandemic Global Challenges, Global Solutions: Workshop Summary (2010) / Chapter Skim
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A8 Hard Choices in Difficult Situations: Ethical Issues in Public Health Emergencies
A8 Hard Choices in Difficult Situations: Ethical Issues in Public Health Emergencies
Pages 248-268
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From page 248... ...
If the pandemic becomes severe, the number of people with respiratory failure, who require mechanical ventilation to survive, is projected to far exceed the available number of ventilators, critical care beds, personnel, and surge capacity of hospitals. Persons with respiratory failure who are not able to receive mechanical ventilation during a severe pandemic will almost certainly die.
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This section specifies the goals of public health during this pandemic, then discusses how to balance public health powers with individual liberty and fairness. Next, it analyzes how ethical principles for a declared public health emergency should be specified and balanced.
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. During a declared public health emergency, public health officials have the authority take actions that would not be permissible in ordinary clinical care, including mandatory examination, isolation, and quarantine.
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Table A8-1 suggests that there is general agreement on many common ethical considerations regarding public health emergencies. This consensus includes the need to balance individual liberty with public health goals, the importance of fairness, and appropriate procedures for developing and implementing policies.
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c Goals of public Protect public safety, Minimize serious Duty to steward resources health policy health, and well-being influenza-associated complications Preserve the Utilitarian goal of saving functioning of the greatest possible society number of lives Balance Equal liberty and human Balance individual Proportionality -- public individual rights. Respect the equal liberty and and individual liberty with liberty, autonomy, and community interests requirements must be public health dignity of all persons commensurate with the goals scale of the emergency and degree of scarce resources Fairness Distributive justiced Maintaining the trust of patients and the community Process Public accountability and Commitment to Standards recognized as of policy transparency transparency fair by all those affected formation by them Public engagement Transparency and involvement Consistency Accountability Procedural justicee Community and provider engagement, education, and communication Responsibility Recognize the special Responsibility Standards evidence based of public health obligations of some public to maximize and responsive to specific and healthcare health professionals, and preparedness needs of individuals and professionals promote competency of the population and coordination among these professionals Base guidelines on Duty of compassion and the best available care scientific evidence
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Distributive justice requires us to distribute the benefits and burdens of the response to a public health emergency fairly or equitably across different groups in society. Public health emergency measures should not disproportionately disadvantage subgroups that already are vulnerable or disadvantaged and should reduce or eliminate existing public health disparities.
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For each public health intervention and situation, it will need to be determined what characteristics are considered ethically relevant. Procedural justice concerns the process by which public health policies in an emergency are developed and implemented.
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For example, one step toward reducing the disparate impact of policies is to engage vulnerable communities to better understand how they might be disproportionately affected by facially neutral policies. Differences and Continuity Between Clinical Practice and Public Health Emergencies The three reports in Table A8-1 differ in emphasizing the differences or similarities in the ethical principles that guide clinical care and responses to declared public health emergencies.
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From page 256... ...
The IOM committee declared: Recognizing that scarce resources may restrict treatment choices, clinicians must not abandon, and patients should not fear abandonment, when an ethical framework informs healthcare disaster policy. It is important to try to reconcile these apparent disagreements over whether ethical principles differ during a public health emergency.
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Treating physicians will be constrained by public health emergency regulations to follow public health allocation policies. The ethical rationale is that during a public health emergency the aggregate benefit to society assumes paramount importance, and minimizing the number of avoidable deaths takes priority over the core ethical principles that underlie usual clinical care: respect for patient autonomy and the best interests of individual patients.
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From page 258... ...
For ventilators, shortages cannot be avoided because during a severe pandemic the need is projected to far outstrip the supply; the cost of supplying enough ventilators and critical care beds for a worst-case scenario would be prohibitive, diverting resources from more basic public health emergency needs. For allocating scarce resources during a public health emergency, ethical principles will need to be specified -- that is, explained in much greater detail with regard to particular public health interventions and circumstances.
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During a dire shortage of a medical resource in a public health emergency, however, these second-order principles governing usual clinical care would not achieve the public health goals of minimizing avoidable deaths and maintaining essential societal functions. For example, an intensive care unit (ICU)
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Several criteria have been proposed for distributing the benefits of scarce medical resources fairly. Equal access to interventions Whatever prioritization rule is selected, it may exacerbate health disparities because certain groups may lack access to the public health intervention.
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Finally, even if a trustworthy weighted lottery could be set up, it would be difficult to implement during a public health emergency. Patient Challenges to Allocation Priorities During public health emergencies, physicians in clinical practice will encounter patients who request or demand a scarce intervention even though they fall outside public health priorities for receiving it.
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Act in the Best Interests of the Patient Physicians should maintain their usual role of acting in the best interests of the individual patient, insofar as it is possible while respecting emergency public health guidelines (Lo, 2009a)
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As previously discussed, expected prognosis will be a key consideration in prioritizing patients who require mechanical ventilation if there is a dire shortage of ventilators. A second question concerns treatment for patients with 2009-H1N1 influenza A infection and refractory respiratory failure.
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If the design and planning for such studies begins only if and when the pandemic becomes severe, valuable time will be lost. Some investment now in research planning will allow more timely research if a severe pandemic occurs and ultimately more efficient use of scarce public health resources.
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Because these challenges would be difficult to address during a severe pandemic, it might be desirable to discuss them now. Concerns About Emergency Public Health Policies During a declared public health emergency, public acceptance of and trust in emergency measures will be crucial.
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Second, the highest-level public health officials should articulate to the public a vision of what kind of nation we aspire to be in a dire public health emer gency. There should be an appeal to values we hold in common as human beings
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Public health officials will need to articulate the ethical reasoning that supports their policies and to develop a process for setting policy that is regarded as fair and participatory. Officials will need to explain why during a declared public health emergency restrictions on liberty and allocation of scarce health resources is ethically appropriate.
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2005. Clinical decision making during public health emergencies: ethical considerations.
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