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Pandemic plans address vaccines but not ethics
Review of plans reveals holes in ethical foresight
Should a pandemic strike the United States, states and local communities are ready with protective equipment and plans for allocating vaccines. But some important ethical questions aren't addressed in state pandemic flu plans, one public health expert says, and those are the issues that might derail the best-laid disaster plans.
James C. Thomas, MPH, PhD, an epidemiologist at the University of North Carolina School of Public Health, Chapel Hill, has researched the pandemic preparedness plans of all 50 states, the District of Columbia, and the federal government, and found some critical weaknesses shared by all.1
"The things that are being addressed most are those having to do with vaccines, antivirals, protective equipment, and those sorts of things," says Thomas. "What's being less well addressed in the plans are how to prepare a state or a local community for the decisions that will have to be made. Right now, the decision-making plans are centralized and limited to a few issues.
"Many of the issues that will be faced are going to be difficult to foresee, so what needs to be happening now is that we need to be preparing local health departments to make difficult ethical decisions."
Thomas found all the preparedness plans lacking in key ethical terminology, including accountability, autonomy, collaboration, confidentiality, and privacy.
'Opaque reasoning' leaves room for error
Some points in the pandemic plans, Thomas reasons, are set out as thoroughly as can be done ahead of time, but sometimes miss some important ethical points.
"On some questions, such as who should get the vaccines when they become available, the guidelines created by the CDC [Centers for Disease Control and Prevention] and others are available, and there have been a lot of very well-informed people who are part of those decisions," he says.
But the thought given to what to do in the time between when a virus is identified and when the antivirals and vaccines are available for it "is disproportionate to the number of issues we'll be facing."
Also, plans that call for immunizing the most vulnerable and most needed — the chronically ill, elderly, and very young, and those responsible for public health and public order — leave out some ethical questions that could prove very troubling.
"What about prison populations?" Thomas asks. "Prisoners are not high on the list of people who are needed to maintain order, nor are many of them on the list of people who are physically vulnerable. But they are in a crowded situation that they can't leave, so if the virus gets into their population, it can sweep through them."
Immigrants, undocumented people living in the country, and those without health care or in extreme poverty are among those who will likely be hit hardest, earliest, and longest by a pandemic, Thomas adds.
"When a crisis happens, it exacerbates disparities, and people who are vulnerable are, by definition, vulnerable, and they need to be given extra vigilance," he says. Working against their favor is the "two-list" model of ensuring vaccines and antivirals for the physically vulnerable and those needed for public order, both of which stand to overlook other vulnerable populations.
Thomas says many of the plans he and his colleagues reviewed employ "opaque ethical reasoning;" they carry the implied messages of "trust us and do as we say" and "ethics are self-evident, just do what is needed to preserve lives."
But many of the ethics are not self evident, Thomas predicts, and state and federal plans should take steps to anticipate them better and train public health providers — and all levels of government — to identify and address the ethical decision making that can be faced during a public health emergency.
Thomas says many plans recognize the need to address ethical questions, but sidestep the issue by simply stating that ethicists would need to be consulted at some point.
Lessons learned from past events
Meanwhile, other ethical questions were seldom addressed, including the diversion of resources from other public needs in order to anticipate or address the pandemic, acceptable compromises in skill levels if retired professionals are recruited to fill in for those struck by the pandemic, and preventing panic in communities and fear mongering by the media. Looking to past events and near-events is one way to anticipate and plan for potential ethical issues, Thomas says.
"The swine flu epidemic — the epidemic that didn't happen — showed us some of the risks of actions you can take if you think you see a pandemic coming your way," he says. "It highlights questions about resource allocation, about how many resources you want to put into anticipation of an epidemic, and how many resources to put into responding to an epidemic."
Communities should consider allocating public health resources ahead of an epidemic toward monitoring and communication — processes that will prove useful even if the pandemic doesn't occur as expected.
"The public needs to understand how things will be handled, so public education about allocation of resources needs to take place ahead of time," he says. "Some information will be available on-line, but how much can the Internet handle and how quickly?"
Private television stations will be a major point of disseminating official releases of information during a health emergency, but there is the potential for fear mongering by media outlets who stand to profit from advertising revenues generated when more people tune in for news on a crisis.
One of the lessons of the 1918 influenza pandemic was a credibility crisis for the government, he points out. Because World War I was drawing to a close, the federal government turned little attention to the pandemic, instead urging the public to ignore the "nuisance" of influenza and to stay focused on the war effort.
"It showed us that communication is vital, that truth and credible information is one of the key elements in maintaining order and helping people cope," he says.
The SARS outbreak four years ago gave two very different pictures of response and results, Thomas points out. Under authoritarian regimes in China and Hong Kong, there was stringent forced screening and isolation of those exposed; police were empowered to hunt down and isolate "superspreaders" of the virus, even to publicize their names; and workers in heavy contact with the public were mandated to be screened on a frequent basis. The control of the virus in those situations, Thomas relates, appeared to have been much more effective than in Canada, a far less restrictive environment.
"What compromises in professional ethics are we willing to incur if the need arises to conscript individuals into various forms of service?" Thomas asks. "One of the things that came out of the SARS analysis, especially in Canada, was the responsibility and rights of those who face risks because they are caring for those who are sick.
"If there is a 'duty to care' that is so often invoked, so too is there a duty to care for those workers, many of whom have divided loyalties between the people they care for and their own families."
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