Ethical issues in rapid containment strategies Ethical issues in rapid ...

Ethical issues in rapidcontainment strategiesPandemic Influenza – Rapid Containment

Overview of the session1) Ethical issues in pandemic influenza (PI) preparedness andresponse2) WHO project on addressing ethical issues in PI planning3) Ethical issues in rapid containment strategiesPandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseWhat is Ethics ?A discipline dealing withwhat is right and wrongand with moral duties,obligations, and rights.A process for reachingagreement when valuesare in conflict.Pandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseA) Ethical and human rights issues in public health measures– Surveillance & information dissemination– Measures to prevent animal-to-human transmission(culling, etc.)– Quarantine, isolation and social distancing– International travel and border control(International Health Regulations)Pandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseB) Equitable access to health care in a pandemic– How to allocate vaccines, antivirals and hospital care– Should some population groups have priority?– For example, should health care workers be prioritized to receiveOseltamivir or a vaccine?– How to allocate resources (in advance and during the pandemic)between pandemic influenza and other health needsPandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseC) Obligations of (and to) healthcare workers in a pandemic– Do health care workers (HCWs) have a duty to care in the event ofa pandemic? If so, is it unlimited?– Are obligations of healthcare workers dependent on their receivingspecial protections or on direct or implied commitments madewhen they entered the profession?– Should HCWs receive priority treatment, prophylaxis or vaccine?– Which persons are included ( "professionals" or others?)– How and by whom should obligations be formulated and enforced?Pandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseD) Obligations among countries & international organizations– How should governments balance their duties to their ownpopulation versus to other countries and populations?– Is there a reciprocal obligation between developing countriesproviding surveillance and specimen and developed countriesproviding treatment and vaccines?– What role can and should international organizations (such asWHO) play in addressing cross-border risks and obligations?Pandemic Influenza – Rapid Containment

Ethical issues in pandemic preparedness and responseImportance of Planning and PreparednessSince many of these questions are difficult to answer, countriesshould prepare and discuss them ahead of time, and make sure thatthe public has been engaged in the decision-making process.Pandemic Influenza – Rapid Containment

WHO project on ethical issues in pandemic planningObjectiveFormulation of guidance for Member States onhow to address the ethical issues that arisein the preparation and response toa potential influenza pandemic.Pandemic Influenza – Rapid Containment

WHO project on ethical issues in pandemic planning• Publication a of document on Ethical Considerationsfor Pandemic Influenza Planning• Dissemination through various channels:– WHO, MoH, NGOs– UN Interagency Committee on Bioethics– Global Summit of National Bioethics AdvisoryBodies– Conferences• Regional and country support activities:contextualisationPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentPublic Health Ethics: Principles• Public Health Necessity• Reasonable and effective means• Proportionality• Distributive Justice• Trust and Transparency• Siracusa Principles (Human Rights): Limitations on human rights mustbe based on a legitimate objective, be the least restrictive andintrusive means; and not be arbitrary, unreasonable or discriminatoryPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentProphylaxis/treatment with neuraminidase inhibitors• During rapid containment, antivirals will be available for everyonewho requires them• Informed consent:• Language• Risks & benefits• Right to refuse prophylaxis/treatment• Special care with pregnant women and infants• However, other types of care, such as hospital beds andmechanically-assisted ventilation, may be in short supplyinclude prioritization criteria in country-level planningPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancingEmployees of Stewart & Holmes Wholesale Drug Co. Seattle, 1918Courtesy of Grace Loudon Mc AdamPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancing – basic concepts• Tension between the interests of society in protecting and promotingthe health of its citizens and the freedom of the individual• Social separation can infringe individual rights anddisrupt social and economic life;• In order to justify a restriction of civil liberties, the means used shouldbe considered to be effective in combating the public health threat• In order to pass the balancing test, the expected benefits for publichealth should outweigh the burdens or harms for individualsPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancing- Decision-making• Decision to use restrictive measures needs to be made in anopen, fair, and legitimate manner.• Transparency and community participation will enhance public trust andacceptance of the proposed containment measures.• Governments should explicitly define who has the power to order publichealth interventions, for what period of time, and what the criteria will befor making the decision.Pandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancing- Implementation (1)• Measures should be voluntary whenever possible• If necessary and justified, public health officials should be allowed toenforce containment measures by least intrusive means• Penalties for non-compliance should be proportional• Privacy and confidentiality: Personal information should be keptconfidential as much as possible (stigma/discrimination)Pandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancing – Implementation (2)• Implementation in a humane, sensitive manner(for ex., IHR's provisions include the need for special concernsregarding gender, religious, and ethnic issues)• When protection of public health requires limits on individual liberty,the principle of reciprocity obliges society to provide those affectedwith necessities of life• Distributive justice:special care should be taken for the most vulnerable(food, water, clothing, medical care etc.)• Social distancing should not be used in a discriminatory fashion, as apretext to persecute ethnic or religious minorities or dissidentsPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIsolation, quarantine, and social distancing – a survey• Source: Attitudes towards the use of quarantine – a multisite research survey(Blendon RJ et al. Health Affairs, 2006, 25(2):w15–25.)• China/Hong Kong SAR; China/Taiwan; Singapore; and the USA• In all locations, a majority of respondents supported quarantine measures• Support was lower in all locations if refusal to comply with a quarantine ordercould lead to arrest• Main worries about quarantine in a health-care facility: exposure to contagiousdisease, overcrowding, and difficulty communicating with family• Authors' conclusion: policy-makers need specific plans to deal with the public’sconcerns about compulsory quarantine policies.Pandemic Influenza – Rapid Containment

Ethical issues in rapid containmentIowa State gymnasium, converted into hospital,1918 flu epidemicPandemic Influenza – Rapid Containment

Ethical issues in rapid containmentInternational travel and border controls• Freedom of movement is a basic right protected by national laws andinternational treaties• Containment measures may require the travel industry to collect and disclosepassenger data• As part of perimeter control, obtain informed consent from travellers forscreening, prophylaxis, and treatment• Burdens on privacy are justified only if necessary to obtain high-qualitysurveillance data• IHR: specific provisionsPandemic Influenza – Rapid Containment