Ethical Issues in Pandemic Influenza Planning

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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
http//www.cdc.gov/od/science/phec/panFlu_Ethic_Gu
idelines.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

• Address the fundamental causes of disease and
  requirements for health
• Respect individual rights in the community
• Ensure an opportunity for community input
• Empowerment of disenfranchised
• Seek information for effective policies and
  programs
• Provide community with information

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12 Principles of the Ethical Practice of Public
Health

• Act in a timely manner
• Incorporate a variety of approaches and respect
  diversity
• Enhance physical and social environment
• Protect confidentiality
• Ensure professional competence
• 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
• Initiate, carry through, complete
• Clarify, prioritize, justify
• Examine, accept, publicize
• Identify, change, promote
• Answer B. Clarify, prioritize, justify

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Question 2

• Which of the following is NOT one of the 12
  principles of public health ethics?
• Act in a timely manner
• Provide community with information
• Protect individual rights over the community
• 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

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Planning and Decision-Making

• Planning
• A commitment to transparency throughout the
  pandemic influenza planning and response
  processes
• Decision-making
• Public 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 strategies
• Training of staff
• Development 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 efforts
• Not merely to benefit U.S. citizens
• Recognition of common good and global
  interdependence

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Balance of Individual Liberty and Community
Interests

• Follow three guiding principles
• Adopt least restrictive practices
• Ensure that restrictions are necessary and
  proportional to need
• Ensure 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 makers
• Adequately reasoned decisions based on accurate
  information
• Assurance that those affected by decisions have a
  voice in decision-making and agree to the
  proposed process
• Clear communications with no hidden agendas
• Revision process when new information is
  available
• Process for appeals
• Procedures that are sustainable and enforceable

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Question 3

• What important ethical balance needs to be
  maintained during a pandemic?
• Prevention vs intervention
• Individual liberty vs community interests
• State vs. Federal powers
• 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 stigmatization

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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)
• No unwarranted invasions of privacy
• Restriction on personal freedom
• Maintain confidentiality of private information
• 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 publics trust
• Transparent decision making
• Seek publics input
• Early 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 world

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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 measures
• Encouraging sick persons to stay home
• Canceling large public gatherings
• Challenges identified
• Ensuring soundness of planning
• Minimizing potential economic impacts
• Addressing information needs of the population
• Recognizing 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 5

• Fill 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.
• Food, water, essential services
• Advance communication
• Vulnerable populations
• Appeals process
• Sanctuary
• Answer (1) a (2) c (3)d (4)b

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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 security
• Health care and community support services
• Critical infrastructure
• General population

Available at http//www.pandemicflu.gov/vaccine
/prioritization.html
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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?
• National security
• Healthcare and community support services
• Critical infrastructure
• General population
• 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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Public Health Ethics Resources for Pandemic
Influenza
Fact Sheet
Checklist
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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.htmlc
  ommunity
• CDCs 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-418
  5-9CBD-BD405FC60856/0/ethicsbrochure.pdf
• James Thomas, Skills for the Practice of Public
  Health
• http//209.9.235.208/CMSuploads/EthicalPracticePub
  licHealth-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