Chripkova pandemie: eticke problemy Jihoceska universita v Ceskych Budejovicich Katedra filosofie a etiky v p.p. Jaro Kotalik, MD,MA,FRCPC

Some basic facts about the flu pandemic Certainty Unpredictability Our vulnerability Enormous potential impact Everyone affected

Influenza Pandemics Pandemics: 3 in 20 th century 1918 : million deaths worldwide Next pandemic: when? how severe? in USA million will get ill will be hospitalized will die How to avoid severe shortage of health care staff? Vaccination acceptance?

Public health system obligations? Provide a level of protection against a threat of an event like a flu pandemic that is compatible with existing system resources? Provide the best possible level of protection achievable by the best science and technology, within acceptable social parameters?

Ethical Framework of the Ontario Plan for Influenza Pandemic Protection of public from harm Duty to provide care Reciprocity Stewardship Proportionality Individual liberty Privacy Solidarity Equity Trust

Some cardinal issues A. What kind of process was used and will continue be used for preparedness planning B.How much material resources will go into preparedness work C. How are we going to deal with human resources D. How to balance various elements of prevention and treatment E. How to communicate about pandemic plans

Bioethicists facing the influenza pandemic issue The event: time severity impact The response: international national pandemic plans – (war plans) macro meso micro levels regional, local, institutional plans

Tools of bioethics : Public Health Ethics Principles Principle of beneficence Principle of nonmaleficence Principle of respect for autonomy Principle of justice Principle of proportionate response Principle of the least possible interference Principle of transparency Principle of subsidiarity Precautionary principle

Working in health care during pandemic Enormous workload Demands for expansion of scope of practice Working in temporary facilities Lack of supplies, drugs, equipment Working in distant locations RISK OF INFECTION, ILLNESS, DEATH

Do health care professionals have an ethical obligation to serve in an outbreak? YES, the obligation is strong, but not absolute and it can be balanced against: Other professional and personal obligations The level of risk of illness & death The level of training received and protection available

What could be done to enhance the ethical commitment to serve during an outbreak ? i The fulfillment of reciprocal ethical obligations of institutions to: Provide full available information about the needs, the risk & the means of protection. Provide assurance that all effective protective measures will be available, proportionate to the risks (training, antivirals, vaccination) Remove all legal, financial, and other barriers to the service (e.g. assume legal liability, life & disability insurance).

What could be done to enhance the ethical commitment to serve during an outbreak ? ii Most importantly, Initiate a well informed, robust discussion about practical expectations and ethical responsibilities of all health care workers during the pandemic by sharing pandemic plans with all relevant professional organizations and the trade unions of health care workers

Balanced approach to vaccination of h.c. workers Example: adopt the notion of mandatory vaccination of health care workers - but use the strongest arguments that can be made against the mandatory approach to construct limiting conditions or pre- conditions for an implementation of such a program

Could mandatory vaccination of health care workers during influenza pandemic be ever justified? Yes, if and when all following assertions are true: The pandemic is of serious nature Vaccine is reasonably safe Vaccine is reasonably effective Unvaccinated h.c. workers definitely represents a risk to patients Voluntary vaccination will not meet objectives of the vaccination program

How to avoid the need for mandatory vaccination of h.c.workers? Initiate a through discussion among h.c. professionals about the pandemic and about ethical aspects of vaccination & other measures they will be asked to undeertake Promote an articulation of their moral commitment to engage wholeheartedly in preparing for and later responding to this most serious threat.

Ethical Framework of the Ontario Plan for Influenza Pandemic Decision-making process to be Open & transparent Reasonable (evidence, principles, values) Inclusive Responsive Accountable

Arguments in favor of ethical acceptability of mandatory vaccination Notion of professionalism: duty to be available, heightened in pandemic, duty to take care of herself or himself, incl. protection against infection Principle of nonmaleficence: unvaccinated workers pose a risk & could cause harm to patients they care for….this would be contrary to this principle

Arguments against ethical acceptability of mandatory vaccination Principle of respect for autonomy: mandatory vaccination is an affront to personal autonomy and liberty Principle of least infringement: when several interventions could achieve a goal, always use such public health intervention that will least infringe on personal liberties ……voluntary vaccination is such an intervention

Do health care professionals have an ethical obligation to serve in an outbreak? YES, because: To be a professional means to profess the willingness to serve others, putting a patient's interest above one’s self-interest An unwritten social contract. History of professions shows that a doctor, nurse, therapist, pharmacist always accepted a degree of risk of infection – generates trust and esteem from society.

Do health care professionals have an ethical obligation to serve in an outbreak? YES, BUT, the duty is not absolute and it will have be balanced with: Other professional and personal obligations The level of risk of illness & death The level of training received and protection available

Thank you. Any questions or comments ?