With sporadic deaths reported from avian flu in Asia and the Middle East, public health departments all over the world are preparing for a possible influenza pandemic, an outbreak of a new virus to which humans have little or no immunity. Part of that planning must include ethical preparedness.
Under ideal conditions, all patients have an equal claim to the health care that they need. A pandemic necessarily alters opportunities for access due to the burden of mass illness and limited—perhaps steadily decreasing—resources, from transportation to medication, hospital beds, physicians, etc.
In pandemic planning, as in medicine in general, the allocation of these scarce medical resources is the most difficult ethical issue confronting the current health care system. No one wants to speak of rationing, but it occurs daily and necessarily escalates during a disaster. In a time of pandemic, rationing is inevitable and must be done in a manner that is transparent, respectful of persons, inclusive, accountable, proportional, fair, and minimizes harm.
Drawing on the Canadian experience with the 2003 SARS outbreak, the authors of “SARS and Hospital Priority Setting” (Jennifer AH Bell, et al) argue that a public health crisis demands heightened attention to fairness: “In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.”
It is important on two levels: 1) the process by which decisions are made must be fair (procedural justice); and 2) the distribution of scarce human and material resources must be fair (distributive justice).
On the first level, when resources are scarce, fairness requires that a triage protocol be developed to provide guidance and consistency in resource allocation. In formulating explicit inclusion and exclusion criteria for care, triage guidelines provide clarity and transparency to the medical decision-making process. Like cases are treated the same and unlike cases are treated differently, fulfilling the formal principle of justice.
On the second level, one of the most vexing questions about the just rationing of health care resources is which ethical principle ought to guide decision making—save the most lives (e.g., in fires and floods); save the sickest (e.g., in organ transplant protocols); save the most-likely to recover (e.g., in triage during war); save people who can preserve society (e.g., the Centers for Disease Control (CDC) recommendation during a pandemic).
Deciding who can best preserve society means making “social worth” distinctions, which, because they run counter to the instinct for fairness, would ordinarily be considered inappropriate criteria. In the emergency situation of pandemic flu, however, making distinctions on the basis of social worth may be necessary. The hard truth of the matter is that failure to make these sorts of distinctions (giving priority, for example, to doctors, EMS workers, law enforcement personnel, vaccine scientists, firefighters, bus drivers, and sanitation workers) could translate into a high level of injustice accompanied by social chaos, exacerbating an already complicated situation. Hence, prioritizing certain essential personnel, while unfair during non-pandemic conditions, may be the best way to minimize, and ideally avoid, further social breakdown during a flu pandemic.
This article is an excerpt from a report prepared by Center Director of Biotechnology and Health Care Ethics Margaret R. McLean for the Santa Clara County Public Health Department on Ethical Preparedness for Pandemic Influenza.
July 2007