Ethics guidelines for pandemics

According to a follow-up study1 in the American Journal of Public Health, few states in the United States have properly addressed ethical issues surrounding pandemic flu preparedness in recent years.

The original study2 was conducted in 2007 and published in the same journal. Researchers James C. Thomas, PhD, MPH, and Siobhan Young, MPH, from the Gillings School of Global Public Health at the University of North Carolina, Chapel Hill, NC, were assessing the progress made after the 2007 survey. Their current study was funded by the Centers for Disease Control and Prevention (CDC).

The researchers analyzed the federal and state plans, available on the Internet, for evidence of ethical guidance as judged by the presence of ethical terms. The most striking finding, the researchers reported, was an absence of ethical language. Although some states acknowledged the need for ethical decision-making, few prescribed how it should happen. If a particular state did have recommendations on ethics preparedness, Thomas and Young followed up with phone calls to gather more specifics. Thomas and Young also found that states who have addressed the ethical issues that arise from any pandemic have focused primarily on allocating scarce hospital resources, while somewhat ignoring such issues as community engagement surrounding isolation and quarantine plans.

The new study found that six states (Iowa, Indiana, New Mexico, North Carolina, South Carolina, and Tennessee) had their own guidelines for ethical decision making, and three others referred visitors to CDC guidelines: Utah, West Virginia, and Wisconsin.

Additionally, four states web sites linked to presentations on ethics and pandemic flu: Iowa, Idaho, Minnesota, and North Carolina. Idaho's site linked to North Carolina's presentation, and the Minnesota health department's site linked to materials on the pandemic flu web site of the University of Minnesota School of Public Health, Minneapolis. (For more information, see Resources, below.) The researchers also noted that only one of 21 recent state-sponsored pandemic flu summits had an ethics discussion on the agenda, and that was North Carolina.

The study also found that seven states made recommendations to further develop ethics-related policies or capacities following this summit. Of these, six states (Iowa, Indiana, Minnesota, North Carolina, New York, and South Carolina) created a task force to make recommendations. The most common recommendations made were related to allocating scarce resources in hospitals. The seventh state, California, listed eight legal and ethical recommendations but had not acted on implementing them and had not designated anyone to follow through on them.

In Minnesota and New York, state health department were reviewing the recommendations, while officials in North Carolina and South Carolina were working with medical and hospital boards to implement them. In Indiana, the state health department was nearly finished implementing one of 15 recommendations.

After Iowa's task force developed an ethical framework, the state's epidemiologists were trained in the new policies and then conducted half-day regional workshops for hospital administrators and public health professionals. They also provided follow-up support, such as help creating ethics panels.

The authors found that the key factor in promoting progress on ethics steps was "unambiguous" support from the top. The main barrier to progress in California, they said, was "a lack of appreciation for, or priority given to, public health ethics among those receiving the recommendations."

In contrast, the authors said that strong cultures of community involvement in Iowa and corporate citizenship in Minnesota fostered advancement on these issues.

The authors conclude, "The sense of urgency for pandemic influenza preparation, including ethical considerations, seems to have passed." However, they warn, "in a pandemic of highly pathogenic influenza, there will be little time to sort out complicated issues such as the particular values or needs of minority populations."

The researchers encourage national organizations such as the CDC and Association of State and Territorial Health Officials (ASTHO) to disseminate best ethics-related practices, coach state health departments on implementing best practices, and help identify gaps and address, with funds and expertise, how to fill those gaps with comprehensive guidelines.


  1. Thomas J, Young S. Wake me up when there's a crisis: Progress on state pandemic influenza ethics preparedness. Am J Public Health 2011; Published online ahead of print Sept. 22, 2011: e1-e3. Doi:10.2105/AJPH.2011.300293.
  2. Thomas J, Dasgupta N, Martinot A. Ethics in a pandemic: A survey of the state pandemic influenza plans. Am J Public Health 2007; 97:S26–S31.