1. 1 Pandemics: Policy and Resource Allocation Jan C. Heller, Ph.D. Ethics and Theology Providence Health & Services

2. 2 Presentation Outline Introduction –A disclaimer…allocation issues will be discussed, not resolved A preliminary distinction –Ethics of disasters and ethics in disasters Quick overview of likely concerns –Liberty restrictions –Capacity Issues –Practice guideline issues –Coordination issues Ethical principles to guide decision making and policy development

3. 3 A Preliminary Distinction Ethics of disasters vs. ethics in disasters –Distinction introduced by N B King, who discusses the potential to misallocate public health funds in the name of disaster preparation –N B King, “The Ethics of Biodefense,” Bioethics 19 2005: 432- 446. Ethics of disasters considers the allocation of disasters themselves –In fact, disasters are not visited equally on all humans, and their occurrence is more under human control (and, hence, subject to moral analysis) than is commonly thought

4. 4 A Preliminary Distinction But, our focus today is on ethics in disasters –I.e., those allocation issues one encounters during disasters And, our focus today is on one kind of disaster: pandemic influenza –“An epidemic (a sudden outbreak) that becomes very widespread and affects a whole region, a continent, or the world.” –http://www.medterms.com/script/main/art.asp?articlekey=4751 –Estimated that a pandemic today, like the 1918 flu, would kill ~62 million people worldwide, the vast majority of whom would probably live in poor countries and also be disproportionately young (teenage and young adult) –http://www.medicinenet.com/script/main/art.asp?articlekey=78717

5. 5 Overview of Issues/Concerns No surprises here, but a debate is raging about how many resources should be expended in preparation for pandemics (which leaves fewer resources for other goods) –Liberty restrictions –Capacity Issues –Practice guideline issues –Coordination issues

6. 6 Overview: Liberty Restrictions Communication and implementation of restrictions should follow UN’s Siracusa Principles (re: isolation, quarantine, etc.) –Limits in accord with the law –Based on a legitimate objective –Strictly necessary –Use least restrictive means –Not arbitrary, unreasonable, or discriminatory –http://www1.umn.edu/humanrts/instree/siracusaprinciples.html

7. 7 Overview: Liberty Restrictions Special attention should be given to populations who are already socially vulnerable Try to limit economic hardships, especially for lower wage personnel (workplace closings, distribution of food and other necessities) Consider what is owed by way of compensation to those adversely affected by public health measures, either economically or by status as “essential personnel”

8. 8 Overview: Capacity Issues On what basis should we allocate vaccines to prevent and antiviral medications to combat infection –Save the most lives principle –Life cycle allocation principle –Investment refinement, public order principle –E J Emanuel and A Wertheimer, “Who Should Get Influenza Vaccine When Not All Can?” Science, 312 (12 May 2006): 854-5. Hospital space Space for care outside of hospitals Morgue space

9. 9 Overview: Practice Guidelines Legal protection for physicians –Required breaching of patient confidentiality –Working outside of training and licensing limits Infection control measures –Isolation and quarantine –Voluntary vs. non-voluntary Providing care outside hospitals Safety of health care workers Conflicting duties for health care workers

10. 10 Overview: Coordination Issues Vertical –E.g., between decision makers (with resources to allocate) and caregivers (who need those resources and have info on where they should be deployed) Horizontal –E.g., between caregivers

11. 11 Relevant Ethical Principles Substantive Principles Individual liberty Protection of the public from harm Proportionality Privacy Duty of provide care Reciprocity Equity U of Toronto Joint Centre for Bioethics, Stand on Guard for Thee Trust Solidarity Stewardship Procedural Principles Reasonable Open and transparent Inclusive Responsive Accountable

12. 12 Selected Principles: Proportionality “Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community.”

13. 13 Selected Principles: Reciprocity Reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible…[, especially for]…health care workers, patients, and their families.”

14. 14 Selected Principles: Equity “All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of the health crisis, this could curtail not only elective surgeries, but could also limit the provision of emergency or necessary services.”

15. 15 Selected Principles: Solidarity “…A pandemic can challenge conventional ideas of national sovereignty, security or territoriality…It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services, or institutions.”

16. 16 Selected Principles: Transparency “The process by which decisions are made must be open to scrutiny, and the basis upon which decisions are made should be publicly accessible.”

17. 17 Selected Principles: Accountable There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of the actions and inactions should be grounded in the 14 other ethical values proposed [here].”

18. 18 Questions and Discussion