Ethics and the H1N1 flu: A wake-up call for policy makers?
Ethics and the H1N1 flu: A wake-up call for policy makers?
Employers also need to have preparedness plans
The overriding ethical issue of a pandemic influenza — or any other health crisis involving a contagious disease — appears to be the dilemma of balancing public health vs. individual liberties. This recent outbreak, which can correctly be termed a pandemic due to its global presence, has likely heightened the concerns of public health officials at all levels of government — and in multiple countries — regarding how good the plans are that they have in place to respond to such a crisis.
As history has shown with other influenza pandemics, there looms the possibility of even more severe waves of this particular outbreak with the arrival of the usual fall and winter flu season.
"What I would say is we are very lucky that it seems that at least so far, this [outbreak] has not been as severe as some people feared it would be," says Nancy Kass, PhD, deputy director of the Johns Hopkins Berman Institute of Bioethics in Baltimore, and co-author of "Ethics and Severe Pandemic Influenza: Maintaining Essential Functions Through a Fair and Considered Response."1
"It's always an excuse when you get a scare like this . . . It's always — and should be — a wake-up call to make sure that your preparedness plans are as detailed as they could be, because, first of all, one never knows what might happen in the future."
With some schools in the United States having closed at the request of local authorities, who were acting on recommendations from the Centers for Disease Control and Prevention (CDC) in Atlanta, one of the so-called "predictable" ethics questions did arise in this outbreak, according to Kass: "When do you start to limit ordinary activities for the sake of protecting the public's health, or for the sake of what you hope will be protecting the public's health. Obviously, you work in some context of uncertainty."
The second predictable ethics question that "fortunately did not arise" — or hasn't to date — is the question of allocation challenges with scarce resources.
"If it were to turn out that there were insufficient antiviral medication; if there were insufficient vaccine; if there were insufficient ventilators; if there were insufficient numbers of masks, you would be up against a resource allocation problem, where you would have to make some very tough decisions," Kass says.
How well did public officials do?
According to Ruth Faden, PhD, MPH, director of the Berman Institute of Bioethics at Johns Hopkins in Baltimore, one of the most difficult decisions to deal with, not only in terms of pandemic preparedness but in public health generally is, "When do you have enough evidence to call it — either to move it up to the next stage, as did [the World Health Organization], but also at the local level to start making determinations about when you're going to start implementing whatever preparedness — hopefully planned…that your health care center, your hospital, your private practice, or your community have put together."
Another ethical dilemma for public officials is the balancing act of providing sufficient information without contributing to panic.
"So, this is that challenge between how far do you go in, for example, making analogies to [the Spanish flu pandemic of] 1918, which could be quite terrifying, or making analogies to seasonal flu," Faden says. "What is the right way of framing this for your colleagues, if you are the local pandemic coordinator, or if you're an expert and you're talking to representatives of the press or a public information organization more broadly."
But as far as the public face of what ultimately was termed a pandemic, how did officials in the United States fare under what was also public and professional scrutiny?
Nancy Berlinger, PhD, MDiv, deputy director and scholar at The Hastings Center in Garrison, NY, gives high marks to public officials on the handling of the H1N1 outbreak.
"As far as I could tell, I was quite impressed by both the quality and the rapidity of the information that was coming out of the CDC; and this was the case, obviously, while this was going on in other parts of the world — that this was, in particular, a North American story," Berlinger notes.
"You heard about other cases in other parts of the world, but especially you heard about Mexico and the United States. So, the CDC had to work in cooperation with the health authorities in another country, a bordering country, and of course, the World Health Organization was involved, as well," she says.
Berlinger says the acting director of the CDC, Richard Besser, MD, who was the public face of the CDC's issuing updates to the media and the public, did "a wonderful job."
"I thought he was very comfortable in front of the cameras, and I thought that really helped," she says.
Berlinger is a co-author of bioethics backgrounder on ethical considerations during an influenza pandemic.2
She says President Obama also became a voice of calm to the public, with the administration's decision to lead off an evening televised national press conference in which he urged the public to take precautions, such as hand-washing and covering coughs — something that anyone could do.
"I thought that was sort of a [President Franklin Delano Roosevelt] touch, the Fireside Chats, by saying, 'I know what you're thinking about, so let me give it to you right off the bat — wash your hands,'" Berlinger says.
Berlinger says that President Obama addressed the public in "very no-nonsense language" and offered them direct advice, which is a plus in a situation such as the one the United States is experiencing.
"People, if they feel nervous about something, it's better if you give [them] something concrete to do, and one of those things you can do is wash your hands more frequently than you normally do," she notes. "But also just addressing that dimension of, 'Yes, if you have to close the school after talking to public officials, go ahead and do it.'"
Marc Hiller, DrPH, of the Department of Health and Management and Policy in the College of Health and Human Services at the University of New Hampshire in Durham, NH, points out that when the news of the outbreak first broke, there was no secretary of Health and Human Services — and no surgeon general. That meant that the secretary of Homeland Security was the initial public voice for the outbreak.
"While I'm not suggesting that in any way, shape, or form that [Homeland Security Secretary Janet Napolitano] is not competent to address the issue, from a public health point of view, I would have expected that the word would have come — if we had had the appropriate officials in place — either from the secretary of Health and Human Services, potentially the surgeon general, or the director of the CDC, which we've been implicitly hearing from via the acting director of CDC," Hiller notes.
"You know, I think one of the lessons [from this experience] that at least I've sensed to some degree — if this were to be viewed as an exercise — is that I think we need a more effective line of communication in the context of who is the primary spokesperson."
Hiller says while the outbreak was a matter of homeland security "to the extent that if there were a major outbreak it could impact our overall security, but I'm sensitive to the need to view it first and foremost from a public health point of view," Hiller maintains.
Public and business interests intertwined
According to the Berman Institute's Faden, business interests and the economy "play hugely" into the decision making by public health officials.
"One thing we have to understand in all of this — and again, this is a general challenge for public health — is that health is very important to all of us. In my own work, I always refer to it as an essential dimension of well-being . . . ," Faden says. "But health is not the only thing that makes life go well. And it's not the only dimension of what makes a society functional and capable of allowing people to have decent lives. The economic functioning of a society is also key to how well people's lives go, including how well their health goes.
"To pretend as if the only outcome of concern here has to do with reducing the burden of the pandemic in terms of mortality or morbidity is just not" the reality at all, Faden maintains.
In light of that interconnectedness, it is essential with this wake-up call with the recent H1N1 outbreak for businesses, health care institutions, and public policy makers to re-examine whatever plans they have in place — and Faden says she "suspects" that most are doing just that.
Kass notes that many large corporations in the United States are "models" of disaster preparedness. But both Faden and Kass say rather than having general plans — all developers of preparedness plans need to "drill down" to specifics. In a corporation or even a small business, that means determining sometimes thorny issues such as who comes to work and who doesn't during a pandemic, as well as who gets paid during a pandemic.
Every outbreak, or incident, such as the SARS outbreak at the beginning of this decade, offers lessons to be learned for future pandemics.
The SARS outbreak showed the United States two things, according to these experts: First, it revealed how the transmission of disease occurred, Berlinger says, from a clinical perspective — ultimately showing, in the case of the Toronto outbreak, that infections were occurring from inside the health care system where infected patients were being treated. As a result, several health care workers died.
Second, according to Faden, the United States and public health officials everywhere learned about the economic costs of disease outbreaks.
"For example, we know that there are tremendous economic costs," she says. "We know this from the SARS epidemic, and we know it more generally from how the world has responded to and experienced major pandemics.
"There are huge implications for the economic health of, especially poor communities in terrible pandemics . . . and we have to make sure that we keep the totality of what it is we are committed to, as a society, in mind when we make these decisions," Faden says.
References
- Kass Nancy E., et al., "Ethics and Severe Pandemic Influenza: Maintaining Essential Functions Through A Fair and Considered Response." Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 6; 3 pp. 227236.
- Berlinger N, Moses J. Bioethics Backgrounder: The Five People You Meet in a Pandemic — and What They Need from You Today. November 2007.
Sources
- Nancy Berlinger, PhD, MDiv, Deputy Director and Research Associate, The Hastings Center, Garrison, NY. E-mail: [email protected].
- Ruth Faden, Director, Johns Hopkins Berman Institute of Bioethics, Baltimore. Philip Franklin Wagley Professor of Biomedical Ethics; Professor, Department of Health Policy & Management, Johns Hopkins School of Public Health; Professor, Department of Medicine, Johns Hopkins School of Medicine.
- Marc Hiller, MPH, DPh, Associate Professor, Department of Health Management and Policy, College of Health and Human Services, University of New Hampshire, Durham, NH. E-mail: [email protected].
- Nancy Kass, PhD, Deputy Director for Public Health, Johns Hopkins Berman Institute of Bioethics, Baltimore; Phoebe R. Berman Professor of Bioethics and Public Health; Professor, Johns Hopkins Bloomberg School of Public Health.
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