Confronting the Ethics of Pandemic Planning Indianapolis, Indiana July 14, 2008 Janelle A. Rhyne, MD, FACP Physician Epidemiologist Public Health Regional Surveillance Team 2 President, North Carolina Medical Board

Process  Panel convened by North Carolina Division of Public Health and The North Carolina Institute of Medicine.  Diverse membership representatives from:  Ethicists  Physicians  Persons with disabilities (physical & mental)  Policy makers  Private industry  Legal  Faith-based groups  Hospitals  Nursing Board  Medical Board  Health Directors  American Association of Retired Persons  Law Enforcement  Minority populations  Schools  Department of Agriculture  Respiratory Therapy

 Series of Testimonies, Scientific Presentations  Development of Recommendations

Followed with community focus groups discussing Pandemic Influenza overview Critical Workers Balance Rights Limited Resources

Ethical Principles Individual liberty Protections of the public from harm Proportionality Privacy Reciprocity Duty to provide: health care workers and other critical infrastructure Equity Trust Collaboration Stewardship

Procedural Values Reasonableness Transparency Truth telling Inclusiveness Responsiveness Timeliness Accountability

Hurricane Katrina Hit the Gulf Coast in PHYSICIANS LEFT THE AREA

43% OF THOSE FALLING PREY TO SARS WERE HEALTH CARE WORKERS WITH A CASE FATALITY RATE OF ABOUT 15% 2003 Severe Acute Respiratory Syndrome (SARS) Outbreak in Canada

49% OF SARS HEALTH CARE WORKERS REPORTED SOCIAL STIGMATIZATION 31% REPORTED OSTRACISM BY FAMILY MEMBERS

Many health care professionals left the profession for new careers rather than expose themselves and their families to risks associated with caring for patients with potentially lethal infectious disease. DURING THE SARS EPIDEMIC FAILURE TO REPORT TO WORK RESULTED IN PERMAMENT DISMISSAL OF HOSPITAL STAFF

National, regional and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. American Medical Association Policy Statement Professional’s Duty to Care in a Public Health Emergency

...The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future. …continued

Physicians should evaluate their risk for becoming infected with pathogens, both in their personal lives and in the workplace, and implement appropriate precautions....Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous application of infection control methods. The denial of appropriate care to a class of patients for any reason, including disease state is unethical. The American College of Physicians (ACP) Ethics Statement

Appeal to Professionalism Professionalism is the basis of medicine’s contract with Society. It - places the interests of patients above those of the physician - sets and maintains standards of competence and integrity - provides expert advise to society on matters of health

Professional Obligation Licensed and nonlicensed healthcare professionals have an ethical obligation to provide care because: 1. The ability of physicians and other licensed healthcare professionals to provide care is greater than that of the public, thus increasing their obligation to provide care. 2. The licensed professions have a social contract, resulting from the privilege of self-regulation and self-licensure, that calls on members to be available in times of emergency. 3. By freely choosing a profession or job devoted to caring for the ill, healthcare personnel have assumed an ethical obligation to act in the best interests of the ill and to assume a proportional share of the risks to which their professions and/or employment setting expose them.

Reciprocal Obligation Government and healthcare organizations have reciprocal duties to healthcare personnel: 1. Healthcare organizations have reciprocal obligations to ensure that the work asked of healthcare personnel does not exceed their professional capabilities, and that the tasks assigned are targeted to addressing the existing emergency. May involve “Just in Time” training. 2. Government and healthcare organizations have reciprocal duties to ensure that healthcare workers are suitably protected, compensated, and supported. 3. Government should provide healthcare personnel and organizations with qualified immunity from liability from malpractice or other suits if they act in good faith to provide needed health services during the pandemic.

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