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Ethical Issues in Pandemic Influenza Planning

CDC Avian Influenza Training

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Learning Objective

• Understand ethical considerations pertaining to pandemic influenza preparedness and response

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Session Overview

• General and specific ethical considerations in public health

• Public engagement

• Planning and resources

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General and Specific Ethical Considerations in Public Health

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http://www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf

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What are Public Health Ethics?

• A set of principles based on values and beliefs which underlie the principles of public health ethics

• A guide to actions to promote health and prevent injury and disease in the population

• Processes to clarify, prioritize, and justify possible courses of public health action based on ethical principles

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Values and Beliefs

“Everyone has the right to a standard of living adequate for the health and well-being of himself

and of his family.”

Universal Declaration for Human Rights, Article 25

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12 Principles of the Ethical Practice of Public Health

1. Address the fundamental causes of disease and requirements for health

2. Respect individual rights in the community

3. Ensure an opportunity for community input

4. Empowerment of disenfranchised

5. Seek information for effective policies and programs

6. Provide community with information

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12 Principles of the Ethical Practice of Public Health

7. Act in a timely manner8. Incorporate a variety of approaches and

respect diversity9. Enhance physical and social environment10. Protect confidentiality 11. Ensure professional competence12. Collaborate to build trust and effectiveness

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Benefits of Public Health Ethics

• Build and maintain credibility and public trust in your agency

• Foster consensus and resolve value conflicts in an atmosphere of respect

• Guide decisions when there is scientific uncertainty and varying opinions on how to proceed

• Increase awareness of the rights of participants and communities in public health activities

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General Ethical Considerations

• Identification of overall goals

• Planning

• Decision-making

• Preparedness

• Use of scientific information

• Global preparedness

• Balance of individual liberty and community interests

• Procedural judicial mechanism

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Question 1

Fill in the missing words in the following definition of public health ethics:

“Processes to _____, _____, and _____ possible courses of public health action based on ethical principles, stakeholder values, and scientific information”

A. Initiate, carry through, complete B. Clarify, prioritize, justify C. Examine, accept, publicize D. Identify, change, promote

Answer: B. Clarify, prioritize, justify11

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Question 2

Which of the following is NOT one of the 12 principles of public health ethics?

a. Act in a timely mannerb. Provide community with informationc. Protect individual rights over the communityd. Enhance physical and social environment

Answer: c. Protecting individual rights over the community is NOT one of the 12 principles.

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Identification of Overall Goals

• Minimize serious influenza-associated complications

• Preservation of the functioning of society

Priorities favor those who are responsible for provision of health care, public safety and functioning of key aspects of society

• Centralization of decision making authority

To ensure equity in decision making and address need to preserve functioning of society across communities 13

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Planning and Decision-Making

• PlanningA commitment to transparency throughout the

pandemic influenza planning and response processes

• Decision-makingPublic engagement and involvement

Public as partner throughout planning and decision-making

Particular attention to vulnerable or marginalized members of society

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Preparedness

Responsibility to maximize preparedness to minimize the need for allocation decisions later

•Proactive planning

•Develop response strategiesTraining of staffDevelopment of decision making rules in advance

of pandemic

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Use of Scientific Information and Global Preparedness

• Sound guidelines should be based on the best available scientific information

• Importance of working with and learning from global preparedness effortsNot merely to benefit U.S. citizensRecognition of common good and global

interdependence

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Balance of Individual Liberty and Community Interests

• Follow three guiding principles:Adopt least restrictive practicesEnsure that restrictions are necessary and proportional to

needEnsure that those affected receive support from the

community

• Involve diverse public representation in defining restrictions and articulating justification for these restrictions

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Procedural Judicial Mechanism

Elements of an ideal procedural justice approach:Consistency of standards across people and time Impartial and neutral decision makersAdequately reasoned decisions based on accurate informationAssurance that those affected by decisions have a voice in

decision-making and agree to the proposed processClear communications with no hidden agendas Revision process when new information is availableProcess for appealsProcedures that are sustainable and enforceable

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Question 3

What important ethical balance needs to be maintained during a pandemic?

a. Prevention vs intervention

b. Individual liberty vs community interests

c. State vs. Federal powers

d. Vaccination vs quarantine

Answer: B. Individual liberty (personal freedoms) vs. community interests (public health)

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Specific Ethical Issues

• Allocation of scarce resources

• Community mitigation measures

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Allocation of Scarce Resources

Distribution plans should specify:What scarce goods are involved?Who (or what agency) will decide about

prioritization and distribution ?What mechanism will be used for disputes or

appeals?Who is eligible to be a recipient ?What criteria will be used to assign higher or lower

priorities to groups of individuals ?

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Community Mitigation Measures

Social Distancing

• Isolation of ill individuals

• Quarantine of persons exposed to ill individuals

• Closure of schools, day care centers, businesses, public venues, and cancellation of large public events

• Alternative work practices/schedules

• Limiting travel

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Community Mitigation Measures (cont.)

Liberty limiting measures should be voluntary and balanced with protection of individual rights:

•No unwarranted invasions of privacy

•Maintain confidentiality of private information

•Restriction on personal freedom should be equitably applied

•Avoid an unequal burden being placed on specific individuals or groups

•Protect against stigmatization23

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Community Mitigation Measures (cont.)

• Ensure that necessary support services (e.g., food, water and other essential services) are provided to the impacted population

• Take into account needs of vulnerable populations (e.g., the elderly, handicapped)

• Establish appeals process for those affected by the liberty limiting measures

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Question 4

What are two individual rights which must be protected when liberty limiting measures are put into place? (choose two)

a. No unwarranted invasions of privacyb. Restriction on personal freedomc. Maintain confidentiality of private information d. Stigmatization

Answer:a and c

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Public Engagement

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Pandemic Vaccination Program Goals July-Dec 2005

Purpose:

• Rank goals for pandemic influenza vaccination program

• Weigh tradeoffs between competing goals

• Select goals considered most important to achieve

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Pandemic Vaccination Program Public Engagement Results

Highest goals:

• Assuring the functioning of society

• Reducing deaths and hospitalizations due to influenza

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Other Pandemic Vaccination Program Goals

• Build and maintain the public’s trustTransparent decision makingSeek public’s inputEarly and clear communication and education

• Flexible implementation of policy

• Increase vaccine production capacity

• Develop other public health measures to protect the public from illness

• Provide resources to other regions of the world29

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Community Mitigation MeasuresOct-Nov 2006

Purpose:

• Discuss economic and social tradeoffs associated with community mitigation measures

• Identify challenges with implementing these measures

• Offer solutions to the challenges

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Community Mitigation Measures Public Engagement Results

• Support for early implementation of community mitigation measuresEncouraging sick persons to stay home Canceling large public gatherings

• Challenges identified Ensuring soundness of planning Minimizing potential economic impactsAddressing information needs of the populationRecognizing that social stresses that will be created

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Solutions to Community Mitigation Challenges

• Full engagement of all key sectors in development of detailed, fully-coordinated plan

• Transparency of planning process

• Training for leadership roles

• Public education campaigns prior to pandemic

• Connecting community organizations into social networks

• Linking providers with people in need prior to pandemic

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Question 5Fill in the blank from the selections given below the question.

When imposing Community Mitigation Measures (e.g. quarantine), your agency must provide support services such as (1) ____________, take into account the needs of (2)______________, establish (3)_______________ for those affected by liberty limiting measures, and provide (4)________________ about the rationale for these measures.

a.Food, water, essential servicesb.Advance communicationc.Vulnerable populationsd.Appeals processe.Sanctuary

Answer: (1) a (2) c (3)d (4)b33

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Pandemic Influenza Vaccine Prioritization Dec 2006 – present

Purpose:• Discuss prioritization and allocation of

pandemic influenza vaccine

• Feedback on vaccine guidance*Categories of persons who should receive vaccine

National securityHealth care and community support

servicesCritical infrastructureGeneral population

* Available at: http://www.pandemicflu.gov/vaccine/prioritization.html34

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Pandemic Influenza Vaccine Prioritization Public Engagement Results

U.S. Example Highest Vaccination Priority (Tier 1):

• Deployed and mission critical personnel

• Critical public health and healthcare personnel

• Critical infrastructure personnel (i.e., EMS, police, fire, vaccine and antiviral manufactures, key government leaders)

• Pregnant women

• Infants and toddlers (6-35 months old)

Prioritization will need to be reconsidered once specifics of new pandemic virus are known.

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Question 6

Which category of persons who may be considered during prioritization decisions for vaccination during a pandemic?

a. National security

b. Healthcare and community support services

c. Critical infrastructure

d. General population

e. All of the above

Answer: E. All of the above

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Planning and Resources

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Questions to Consider in Planning

• Have public health decisions been made in a clear, open, and transparent manner?

• Have those who will be affected by the public health measures been given the opportunity to provide input into decision making?

• Are decisions being made on the best available scientific information?

• Have the least restrictive public health measures necessary to protect the common good been used?

• Are decisions about protecting the common good being balanced with protection of individual rights?

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Questions to Consider in Planning (cont.)

• Have efforts been made to minimize the negative impact of the public health measures?

• Have the public health measures anticipated and respected the diverse values, beliefs, and cultures in the community?

• Has a process been established to revise or correct decisions to address new information?

• Have efforts been made to acknowledge and respond to public suspicion and distrust of local, state or federal government decisions?

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Fact SheetChecklist

Pandemic Influenza Ethics Checklist

This checklist should be used by public health officials when developing or approving plans that will have a substantive impact on policy, practice or the public. Not every question may be applicable in every situation, but every question should be considered. The checklist is intended to enhance ethical decision making and is not meant to be used for official reporting or accountability purposes. General Ethical Considerations Yes No

Have public health response decisions been made in a clear, open, and transparent manner?

Have those who will be affected by the public health measures been provided with timely information and given the opportunity to provide input into decision making?

Are decisions being made based on the best available scientific evidence?

Have the least restrictive public health measures necessary to protect the common good been used?

Are decisions about protecting the common good being balanced with protecting the rights of individuals?

Have efforts been made to minimize the negative impacts of the public health measures?

Have the public health response measures anticipated and respected the diverse values, beliefs, and cultures in the community?

Has a process been established to revise or correct decisions to address new information?

Have efforts been made to acknowledge and respond to public suspicion and distrust of local, state or federal government decisions?

Have state and local authorities had adequate opportunity to have input into decision making?

Have efforts been made to work with and learn from global preparedness and response efforts?

ETHICAL GUIDELINES for RESPONSE to PANDEMIC INFLUENZA General Ethical Considerations

Transparency and public engagement – commitment to clarity and openness in decision making, sharing of information, and obtaining input from the public.

Sound science – commitment to making decisions based on the best available evidence.

Global community – commitment to working with and learning from global preparedness efforts.

Balancing individual liberty and community interests – commitment to using the least restrictive public health measures necessary to protect the common good and minimizing negative impacts of these measures.

Diversity in ethical decision making – commitment of public health officials to foster the trust of all diverse members of society.

Justice (fair process) – commitment to fair distribution of resources, such as vaccines and antiviral medications and in imposing restrictions, both on a local and global level.

Overall goal of pandemic response – commitment to preserving the functioning of society and protecting the public’s health.

Recommendations Regarding Allocation of Resources The primary goals of the distribution system should be clearly specified. Individuals and groups of persons who are identified as key to maintaining critical

infrastructure should be accorded a high priority for the distribution of vaccines and antiviral drugs.

The distribution criteria should be evaluated according to their ability to contribute:

o Realization of the primary goals. o Maximizing fairness (or equity) in the distribution process.

Balance protecting the common good and individual rights: o Refrain from harming or injuring individuals and communities. o Equal opportunity to access resources should be assured to those within

agreed upon priority groups. o Respect for individual autonomy by, for example, employment of the least

restrictive interventions that are likely to be effective. Distribution plans should specify:

o What scarce goods are involved in the distribution plan. o Who (or what agency) will decide about prioritization and distribution. o What mechanism will be used in the case of a dispute or an appeal. o Who is eligible to be a recipient? o The criteria used to assign higher or lower priorities to groups of

individuals Continued on Back

Public Health Ethics Resourcesfor Pandemic Influenza

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Summary

• Public health ethics foster awareness of the rights of participants and communities in public health activities

• Public health ethics build credibility and public trust in your agency, aid in resolving value conflicts, and guide decisions when there is uncertainty

• General considerations in public health ethics involve transparency, good practice, and public engagement

• Specific challenges in pandemic influenza ethics include prioritizing some groups over others in prevention planning, and allocation of scares resources locally, nationally, and internationally.

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Resources

• Ethics Guidance for Pandemic Influenza http://www.cdc.gov/od/science/phec/ guidelinesPanFlu.htm

• Public Engagement Process http://www.keystone.org/spp/health-pandemic.html#community

• CDC’s Public Health Ethics Activities http://www.cdc.gov/od/science/phec/

• James Thomas, Principles of the Ethical Practice of Public Health http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-

BD405FC60856/0/ethicsbrochure.pdf

• James Thomas, Skills for the Practice of Public Health http://209.9.235.208/CMSuploads/EthicalPracticePublicHealth-

40199.pdf

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Glossary

Public engagement: The process of listening to, interacting with, and gaining greater understanding of a group in order to inform the decision making process

Public health ethics: Principles and values that guide actions to promote health and prevent injury and disease in the population

Procedural judicial mechanism: An established fair process by which individuals or groups who feel their rights have been violated can be heard in court

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Glossary

Social distancing: Targeted efforts to reduce interaction between persons at specific or general venues, in order to reduce the probability of disease transmission

Transparency: Providing for openness, communication, and accountability during a process or decision

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