Ethical Issues in a Pandemic: Social Justice

Welcome to ReachMD’s Medical Focus Series. This month ReachMD explores our nation’s progress in disaster medicine and public health preparedness.

When resources needed to be rationed in a pandemic, who will make the decisions and why? You are listening to ReachMD XM 157, the channel for medical professionals. Welcome to the clinician’s roundtable. I am Dr. Maurice Pickard, your host, and with me today is Dr. Nancy Berlinger. Dr. Berlinger is a Deputy Director and Research Associate at Hastings Center. She has been the Co-Director of Addressing Pandemic Planning in Clinical Ethics Education and is the Author of After Harm: Medical Error and the Ethics of Forgiveness.

DR. MAURICE PICKARD:

Thank you very much Dr. Berlinger for joining us.

DR. NANCY BERLINGER:

Delighted to be here.

DR. MAURICE PICKARD:

To begin with, could you just tell me what the National Pandemic Influenza Preparedness and Response Plan is?

DR. NANCY BERLINGER:

The National Pandemic Influenza Preparedness and Response Plan is the US Government's overall strategy for dealing with the threat posed by pandemic influenza. Also sometimes called bird flu, avian flu, H5N1 influenza A; there are number of different terms that might be used to describe this threat and I should add that there are many potential strains that the World Health Organization is keeping their eye on, but we tend to hear about one called H5N1 the most (01:30). Now, under the National Plan, there are duties of the Federal Government and there are duties of state governments. What the Federal Government would be responsible for in a pandemic situation is surveillance, investigation of reported outbreaks, the development of lab test to determine which strain of flu was responsible for an outbreak, the vaccine development in response to the strain that has been identified because the stockpiled vaccine that we have stockpiled now may not actually work against the pandemic strain, which would be a mutated strain, the enactment of travel restrictions or quarantines in Federal air space or on interstate highways, and facilitating communications, and many of these activities would be coordinated by the Centers for Disease Control and the Department of Health and Human Services. Now, the Department of Health and Human Services gave each of the states an assignment about a year ago to submit a plan for fulfilling the state's duties. Now the state's duties are the identification of public and private sector partners for local planning and response, coordination with federal surveillance and infection control efforts, the integration of state and federal efforts so people aren’t working at cross-purposes to one another, the coordination of local health authorities because, of course, that is the level which care is actually delivered, data management, and coordination with adjacent states and other jurisdiction such as (03:00) Mexico and Canada, but also bordering states because viruses don’t care what state they enter and they are going to just keep moving, so that is very important that states don’t work in isolation from one another as well. Now, when the states filed their plan, there were some researchers who took a look at the plans and they published their findings in the June 2007 issue of the American Journal of Public Health and they were looked at the extent to which these state plans described ethics. Now, when we talk about ethics, we can mean many many different things, but my quick definition of ethics is the consequences of our decisions if they affect other people. So what these researchers found is that these plans actually said very little about ethics. They would say, well rationing will be necessary, but they did not actually say how you would ration or what is the fair way to ration; fairness is a very big term in ethics. So what is pretty clear is that while there are lot of plans on the file and there is plenty of information up for anyone who cares to look at www.pandemicflu.gov, which is the government web site on pandemic flu, there is not necessarily a great deal of information on how to carry out pandemic planning, pandemic preparedness, and to actually respond in the middle of the crisis in a fair manner. So that is the big conversation that is going on in the states right now.

DR. MAURICE PICKARD:

You touched on an interesting subject. Most of us in medical school (04:30) and at the bedside deal with the clinical ethics as it applies to an individual. Now we are beginning to talk about possibly altered standards of care for a larger community. Can you tell me some of the ethical conflicts that we are likely to see and that the practicing physician is really not prepared for?

DR. NANCY BERLINGER:

Certainly. Clinical ethics often talks a great deal about the individual patient and the individual patient's values and preferences. So we talk about saying what does the patient want in his or her care, what are their choices near the end of life? We talk about informed consent saying before someone makes a decision about something, they need information about all of their choices, they have the right to say yes, they have the right to say no, and many many other situations in healthcare that talk about the individual patient. In the public health context, we talk about population, we talk about communities, and we assume given a threat to the entire community, given the likelihood of severely limited resources, severe pressure for every single resource we can imagine. So not just vaccine and antivirals, but beds, masks, food, money, everything, how do we decide how we will do the most good for the largest number of people? While at the same time not harming (06:00) if we can avoid harm. There are situations where it is going to be difficult to avoid harm because, for example, we cannot maintain normal standards of infection control. We are trying to contain pandemic outbreaks, but we are doing so in a hospital where we may be down to a skeleton janitorial staff, for example. So there are many many aspects of healthcare that will not be business as usual. So it is very important when we talk about ethics that we do not transplant our normal way of thinking about ethics, which is honoring individual patient's values and preferences, which is enormously important as the framework for ethics under ordinary circumstances when we are able to think patient to patient. When we think about the public health consequences, we have to think about everyone at once and so it can be a little awkward sometimes when public health planners try to talk about ethics that may be they have invited someone to come in and that person starts talking about patient autonomy and public health professionals around the table say, but how are we going to do that when we are dealing with thousands of people. So when we talk about public health ethics, we tend to put justice first. You can say justice means fairness, it means equity, it means access, and so that tends to be the very first thing we talk about.

DR. MAURICE PICKARD:

When we talk about a pandemic in our recent experiences in Katrina, is the public really sensitized that we have to be prepared this time (07:30).

DR. NANCY BERLINGER:

At the moment, I would say no. I mean there are probably some individuals who are very aware of this. I get asked about it a lot, you know, just among my friends is this really going to happen, but people who track media interest in the topic have noted that it peaked a few years ago even though scientists and epidemiologists and clinicians continue to be very very much interested in pandemics flu because they see the continuing statistics about it coming from the World Health Organization, but the public has probably moved on to other things to be worried about and it can be difficult to get people to focus on something that seems on the one hand unreal and on the other hand so scary. There is not a lot of collective memory left of community-wide, state-wide national pandemics. I had a great aunt who died in the 1819 world flu, I should say Spanish influenza, but of course I never knew her and those were stories from family members who are themselves no longer living. So we do not have a lot of collective memory of this. What we do have collective memory of are cases like Hurricane Katrina and I know one clinical ethicist who said those televised images did have an effect on her community because they crystalized in their mind (09:00) the idea of healthcare disparities and she said, you know, when you saw who was able to evacuate from the city, the people with cars and who stayed behind, the people without cars. If you serve a low-income community, they will be crystalizing your mind the idea that if there is a pandemic, I am not going to get what I need where someone in a wealthier community may feel, Oh I am going to get what I need, there will be a way that I can go on the open market and get what I want. So people's social location also determines whether or not they think they are at risk.

DR. MAURICE PICKARD:

SARS, 2002 Toronto. Did we learn from that and are we taking their lessons to heart in our planning?

DR. NANCY BERLINGER:

There is a great deal that we can learn from SARS. In fact, in Canada, they put together a publication that is called Stand on Guard for Thee that really came out of the lessons of SARS and gave the Canadian healthcare system in their different provinces a model for developing pandemic plans and other public health tools on an ethical model. Here were the lessons and here is how we can prepare for what might be down the pike. On this side of the borders, here are some of the things that we learnt from SARS. We learned that quarantine is possible in contemporary North America, the Toronto health authorities identified several thousand individuals who might have been exposed to a person who did have SARS. They identified 23,000 individuals who needed to be under quarantine. They were put under isolation at home for 10 days. They checked in by phone with these individuals to make sure (10:30) that they were staying home and were not going out. So it is possible to do this. We also learned that there were 2 waves of the SARS epidemic, the second wave happened in a hospital because of improper use of protective gear, literally when people were changing mask they were actually taking a viral agent from the front of the mask into their mucous membranes and were getting infected that way, so things were learned about how to keep yourself safe when you do have protective gear. We learned that healthcare providers who are on duty in long-term public health emergencies can suffer tremendous isolation. They are isolated from there families and there are cases several healthcare providers died. So these individuals felt they were at risk, so that was another lesson. I was recently reading a publication that came out of New Orleans and they also mentioned that it is very important that when you are signing people up for public health triage duty that people sign up being mindful of their home circumstances because if, for example, you have children at home and you are a single parent, you may want to sign up to be on duty, but how will your children be cared for, let us say the schools are closed or your baby sitter cannot get to your house, and so it is very important that the triage officer knows who is going to be on duty so that was a lesson from Katrina as well as SARS that being mindful of who actually is capable of providing healthcare (12:00) during a prolonged emergency is incredibly important.

DR. MAURICE PICKARD:

I would like to thank Dr. Nancy Berlinger who is the Deputy Director of the Hastings Center and we have been talking about pandemic issues and ethical problems that may arise in the very near future.

I am Dr. Maurice Pickard, your host, and you have been listening to the clinician’s roundtable on ReachMD XM 157, the channel for medical professionals. For questions and comments, please send your e-mails to xm@reachmd.com, and visit us at www.reachmd.com. Thank you for listening.

Thank you for listening to ReachMD September medical focus series, Disaster Medicine and Public Health Preparedness. Tune in each hour at this time and hear insights from the nation’s top sought leaders as we explore our nation’s progress since 09/11 and Katrina. Also, for your convenience, all ReachMD XM 157 broadcasts are available on demand at www.reachmd.com.