PoPulationand Public HealtH etHics

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practice Decision making While the philosophical doctrines discussed above may inform public health decision making, they are not the only criteria against which to evaluate possible responses to the conditions described in this case. A recent review of resource allocation during an H1N1 pandemic noted that, “it is especially important for there to be dialogue between the general public, government and healthcare decision-makers since having the public abide by recommendations requires trust among all interested parties. And in the case of pandemic influenza, everyone is an interested party.” 6 This observation raises two key questions about future pandemic planning in Canada: which stakeholders must be represented and what role should they play in the planning process? While the quotation above suggests that “everyone” is a stakeholder, this case illustrates how different communities may have very different stakes and interests in pandemic planning. In this case, it is clear that representatives of First Nations communities must play a significant role in pandemic planning. In a practical sense, they can improve planning by alerting public health organizations about the particular resource constraints their communities face, thus preventing future problems such as the recommendation of frequent hand washing in a community without running water. From the point of view of justice, they can advocate for increased attention to health inequalities that may disadvantage their communities, including placing the alleviation of these resource constraints on the public health agenda. Given that First Nations communities have a clear stake in future pandemic planning, what might their actual participation entail? In a limited sense, they must obviously play a role in selecting, designing and implementing interventions targeted at First Nations communities. But what about the distribution of pandemic planning resources more generally? Does the fact that First Nations communities suffered health inequalities during the last pandemic justify a seat at the table in pandemic planning? As a comparison, we might note that women suffered disproportionate morbidity and mortality in the H1N1 pandemic. The 2009 study notes that females comprised 67.3% of hospital admissions and 72% of deaths, despite only making up roughly 50% of the Canadian population. If First Nations communities deserve representation in pandemic planning by virtue of their greater vulnerability to H1N1, then it stands to reason that women — who make up a much larger PoPulation anD Public HealtH etHics 162
proportion of the population — deserve even greater representation. And how might the needs of these populations be weighed against one another? Conclusion We have seen that our interpretation of the ethical questions raised by this case depends in large part on the philosophical doctrine that one employs to evaluate the available evidence base. To conclude, let us briefly consider the second “scenario shift,” which asks whether the implementation of a tertiary care facility accessible to First Nations communities would be an improvement. From the point of view of liberalism, the answer would likely be ‘no,’ because it does not address the underlying violation of basic rights. From a utilitarian point of view, the answer may well be ‘yes’ if, as expected, this improves the health of First Nations communities more generally, and thus makes them less susceptible to serious H1N1 outcomes. Finally, from an egalitarian point of view, the situation is complicated. In a strict sense, this is hardly an improvement if First Nations communities still lack access to adequate housing and drinking water. However, from a broader perspective, the addition of a new health care facility increases First Nations communities’ overall health resources, and is thus clearly an improvement. reFerences 1 Roberts, M. J. & Reich, M. R. (2002). Ethical analysis in public health. Lancet; 359(9311):1055–1059. 2 Braveman, P. & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health;57:254–258. 3 Morgan, O. W., Bramley, A., Fowlkes, A., et al. (2010). Morbid Obesity as a Risk Factor for Hospitalization and Death Due to 2009 Pandemic Influenza A(H1N1) Disease. PLoS ONE;5(3):e9694. 4 Campbell, A., Rodin, R., Kropp, R., et al. (2010). Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza. Canadian Medical Association Journal;182(4):349–355. 5 Zarychanski, R., Stuart, T. L., Kumar, A., et al. (2010). Correlates of severe disease in patients with 2009 pandemic influenza (H1N1) virus infection. Canadian Medical Association Journal;182(3):257–264. 6 Silva, D., Nie, J., Rossiter, K., et al. (2010). Contextualizing ethics: Ventilators, H1N1 and marginalized populations. Healthcare Quarterly;13(1):32–36. Retrieved from: http://www.jointcentreforbioethics.ca/people/publications/hq2010.pdf Health Inequities in First Nations Communities and Canada’s Response to the H1N1 Influenza Pandemic 163
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
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esearch Many different parties have
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esearch of his concern for people w
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esearcH etHics anD conFlicts oF int
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esearch and non-public information
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esearch reFerences 1 Public Health
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esearch Key ethical dimensions Perh
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esearch such support, seen across t
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esearch Proposed resolution Enablin
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a tool For etHical analysis oF Publ
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esearch are explicit. In Quebec, su
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esearch reFerences 1 Bayer, R. and
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Part two Policy
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policy being increasingly introduce
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policy behaviour. Therefore, the et
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policy 18 Chapman, S. and Freeman,
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policy through outdoor smoking, any
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policy that this is an injustice. W
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DeFerring blooD Donation FroM Men w
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policy 26 per cent of new infection
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policy 6 NHS Blood and Transplant.
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policy public trust might also incl
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policy lived in certain regions in
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policy 4 Zou, S., Musavi, F., Notar
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policy Case description For nearly
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policy 3 Economic conditions could
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policy essential to examine the his
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policy lMICs. Evidence-based introd
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policy governments, regional develo
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First nations Drinking water Polici
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policy federal government was aware
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policy reFerences 1 Health Canada.
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policy Core issue Case study author
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policy Additional issues It may be
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policy Arguably, an exception might
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policy Case Following the pharmaceu
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policy 3 What potential harms may b
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policy in the “anti-cancer vaccin
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policy adults may choose for themse
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