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									ETHICS IN A PANDEMIC accessed 2006-0324
Ethicists Offer Guide to Decision-Making in Predicted Flu Pandemic; Quarantine, Duty to Care, Resource Allocation
among Key Issues

Embargo: 6:00 pm EST, Sun Nov. 27, 2005

Contacts: Terry Collins, +1-416-538-8712 or +1-416-878-8712
Juliet Heller, +44 (0)1601-868083 or +44 (0)7946-616150

Stand on Guard for Thee - Full Study

JCB Flu Pandemic Working Group Members (Ross E.G. Upshur, Karen Faith, Jennifer L. Gibson, Alison K. Thompson,
C. Shawn Tracy, Kumanan Wilson, Peter A. Singer) are available for advance interviews Weds-Fri Nov. 23-25. Please
call to schedule a time. Media can preview the study, "Stand on Guard for Thee," to be released Nov. 28, online at

Coping effectively with a predicted influenza pandemic that threatens to affect the health of millions worldwide,
hobble economies and overwhelm health care systems will require more than new drugs and good infection control.

An international medical ethics think-tank says that all-important public cooperation and the coordination of public
officials at all levels requires open and ethical decision making.

The Influenza Pandemic Working Group at the University of Toronto Joint Centre for Bioethics today recommended a
15-point ethical guide for pandemic planning, based in part on experiences and study of the Severe Acute
Respiratory Syndrome (SARS) crisis of 2003.

The report says pans to deal with a flu pandemic need to be founded on commonly held ethical values. People need
to subscribe in advance to the rationale behind such choices as: the priority recipients of resources, including hospital
services and medicine; how much risk front line health care workers should take; and support given to people under
restrictions such as quarantine. Decision makers and the public need to be engaged so plans reflect what most
people will accept as fair, and good for public health.

"A shared set of ethical values is the glue that can hold us together during an intense crisis," says Peter Singer, M.D.,
Director of the University of Toronto Joint Centre for Bioethics (JCB), which undertook the advisory report. "A key
lesson from the SARS outbreak is that fairness becomes more important during a time of crisis and confusion. And
the time to consider these questions and processes in relation to a threatened major pandemic is now."

The report concludes that flu pandemic plans universally need an ethical component that addresses four key issues:
     1.   Health workers' duty to provide care during a communicable disease outbreak;
     2.   Restricting liberty in the interest of public health by measures such as quarantine;
     3.   Priority setting, including the allocation of scarce resources such as medicines;
     4.   Global governance implications, such as travel advisories.

Health Care Workers Duty to Care

The SARS crisis exposed health care systems to hard ethical choices that rapidly arose. Dozens of health care
workers, for example, were infected through their work and some died. Other failed to report for duty to treat SARS
patients out of fear for their own health or that of their family. A flu pandemic, where there may be no absolute
protection or cure, would put far greater pressures on health care systems around the world.

"Workers will face competing obligations, such as their duty to care for patients and to protect their own health and
that of families and friends," says JCB member Ross Upshur, M.D., Director, Primary Care Research Unit, Sunnybrook
and Women's College Health Sciences Centre. "Medical codes of ethics in various countries provide little specific
guidance on how to cope with this very real dilemma. Professional colleges and associations need to provide this kind
of particular guidance in advance of an infectious disease outbreak crisis."

Governments and hospitals also need to provide for the health and safety of workers, and for the care of those who
fall ill on duty. This might include and insurance fund for life and disability to cover health care workers who become
sick or die as they place themselves in harm's way.

The Human Costs of Restrictive Measures

Officials need to provide support for those in quarantine, cut off from family, friends, work, shopping and possibly
medical care for other aliments, the report says. The public should also be made aware of the need for quarantine
and the consequences of non-compliance.

"Decisions to use restrictive measures need to be made in an open, fair and legitimate manner. The public has a
right to know the compelling public health reasons for curtailing rights and restricting normal activities. If
quarantines are used, those affected need adequate care and job protection. Preventing financial hardship is
important to obtaining full compliance from the public," says Dr. Upshur.

Measures to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected
by quarantine also should be part of pandemic preparedness plans the report recommends.

Allocating Scarce Resources, Medicines

All countries will face scarcities of medicines, equipment and health care workers during a pandemic, according to the
group. Governments, hospitals and health regions should publicize a clear rationale for giving priority access to anti-
viral medicines and vaccines to particular groups (e.g., front line workers, children, decision-makers).

Advance planning ought to include criteria for resource allocation decisions, created in consultation with the general
Travel Bans

The World Health Organization (WHO) has warned that if the H5N1 strain of bird flu mutates and infects people it
could reach all continents in less than three months. The WHO would likely impose regional travel restrictions in
hopes of slowing the spread of the disease.

However, such decisions can have major economic impacts. Canada, and Toronto in particular, suffered millions in
economic losses when the WHO advised international travelers against all nonessential travel because of SARS.

Descriptions about travel restrictions need to be clearly justified and the process must be transparent the report

At the same time, the WHO relies on individual countries for report disease outbreaks. Such surveillance may be
beyond the capacity of many developing countries. The developed world should continue to invest in the surveillance
capacity and the overall public health infrastructures of developing countries.


The WHO recommends that ethical issues be a consideration in the planning process for an influenza pandemic.
Canada's province of Ontario has incorporated this framework into its plan.

"We encourage all jurisdictions and nations to assess their pandemic plan against the ethical framework we have
proposed," says Dr. Singer.

"Looking ahead, we can say that if the pandemic strikes it will cause great hardship, but societies will struggle
through. They will be better able to do so if they have general agreement on an ethical approach. Afterwards, history
will judge today's leaders on how well they took decision on the ethical challenges they faced in the midst of the


Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak


 Individual liberty   In a public health crisis, restrictions to individual liberty may be necessary to protect the public
                      from serious harm. Restrictions to individual liberty should:

                               Be proportional, necessary and relevant.
                               Employ the least restrictive means.
                               Be applied equitably.

 Protection of the    To protect the public from harm, health care organizations and public health authorities may
 public from harm     be required to take actions that impinge on individual liberty. Decision makers should:
                             Weigh the imperative for compliance.
                             Provide reasons for public health measures to encourage compliance.
                             Establish mechanisms to review decisions.

Proportionality   Proportionality requires that restrictions to individual liberty and measures taken to protect the
                  public from harm should not exceed what is necessary to address the actual level of risk to or
                  critical needs of the community.

Privacy           Individuals have a right to privacy in health care. In a public health crisis, it may be necessary
                  to override this right to protect the public from serious harm.

Duty to provide   Inherent to all codes of ethics for health care professionals is the duty to provide care and to
care              respond to suffering. Health care providers will have to weigh demands of their professional
                  roles against other competing obligations to their own health, and to family and friends.
                  Moreover, health care workers will face significant challenges related to resource allocation,
                  scope of practice, professional liability and workplace conditions.

Reciprocity       Reciprocity requires that society support those who face a disproportionate burden in
                  protecting the public good, and take steps to minimize burdens as much as possible. Measures
                  to protect the public good are likely to impose a disproportionate burden on health care
                  workers, patients and their families.

Equity            All patients have an equal claim to receive the health care they need under normal conditions.
                  During a pandemic, difficult decisions will need to be made about which health services to
                  maintain and which to defer. Depending on the severity of the health crisis, this could curtail
                  not only elective surgeries, but could also limit the provision of emergency or necessary

Trust             Trust is an essential component of the relationships among clinicians and patients, staff and
                  their organizations, the public and health care providers or organizations, and among
                  organizations within a health system. Decision makers will be confronted with the challenge of
                  maintaining stakeholder trust while simultaneously implementing various control measures
                  during an evolving health crisis. Trust is enhanced by upholding such process values as

Solidarity        As the world learned from SARS, a pandemic influenza outbreak will require a new vision of
                  global solidarity and a vision of solidarity among nations. A pandemic can challenge
                  conventional ideas of national sovereignty, security or territoriality. It also requires solidarity
                  within and among health care institutions. It calls for collaborative approaches that set aside
                  traditional values of self-interest or territoriality among health care professionals, services or

Stewardship       Those entrusted with governance roles should be guided by the notion of stewardship.
                  Inherent in stewardship are the notions of trust, ethical behaviour and good decision-making.
                  This implies that decisions regarding resources are intended to achieve the best patient health
                  and public health outcomes given the unique circumstances of the influenza crisis.
Five procedural values to guide ethical decision-making for a pandemic influenza outbreak


Reasonable           Decisions should be based on reasons (i.e., evidence, principles and values) that stakeholders
                     can agree are relevant to meeting health needs in a pandemic influenza crisis. The decisions
                     should be made by people who are credible and accountable.

Open and             The process by which decisions are made must be open to scrutiny, and the basis upon which
transparent          decisions are made should be publicly accessible.

Inclusive            Decisions should be made explicitly with stakeholder views in mind, and there should be
                     opportunities to engage stakeholders in the decision-making process.

Responsive           There should be opportunities to revisit and revise decisions as new information emerges
                     throughout the crisis. There should be mechanisms to address disputes and complaints.

Accountable          There should be mechanisms in place to ensure that decision makers are answerable for their
                     actions and inactions. Defence of actions and inactions should be grounded in the 14 other
                     ethical values proposed above.

Summary of Recommendations

An ethical guide for pandemic planning:

    1.      National, provincial/state/territorial, and municipal governments, as well as the health care sector, should
            ensure that their pandemic plans include an ethical component.
    2.      National, provincial/state/territorial, and municipal governments, as well as the health care sector, should
            consider incorporating both substantive and procedural values in the ethical component of their pandemic

Four key ethical issues:

Issue 1
Health workers' duty to provide care during a communicable disease outbreak

    1.      Professional colleges and associations should provide, by way of their codes of ethics, clear guidance to
            members in advance of a major communicable disease outbreak, such as pandemic flu. Existing
            mechanisms should be identified, or means should be developed, to inform college members as to
            expectations and obligations regarding the duty to provide care during a communicable disease outbreak.
    2.      Governments and the health care sector should ensure that:
            a. care providers' safety is protected at all times, and providers are able to discharge duties and receive
            sufficient support throughout a period of extraordinary demands; and
            b. disability insurance and death benefits are available to staff and their families adversely affected while
            performing their duties.
    3.      Governments, hospitals and health regions should develop human resource strategies for communicable
          disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are
          assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution
          of risk among individuals and occupational categories.

Issue 2
Restricting liberty in the interest of public health by measures such as quarantine

    1.    Governments and the health care sector should ensure that pandemic influenza response plans include a
          comprehensive and transparent protocol for the implementation of restrictive measures. The protocol
          should be founded upon the principles of proportionality and least restrictive means, should balance
          individual liberties with protection of public from harm and should build in safeguards such as the right of
    2.    Governments and the health care sector should ensure that the public is aware of:
          a. the rationale for restrictive measures;
          b. the benefits of compliance; and
          c. the consequences of non-compliance.
    3.    Governments and the health care sector should include measures in their pandemic influenza preparedness
          plans to protect against stigmatization and to safeguard the privacy of individuals and/or communities
          affected by quarantine or other restrictive measures.
    4.    Governments and the health care sector should institute measures and processes to guarantee provisions
          and support services to individuals and/or communities affected by restrictive measures, such as
          quarantine orders, implemented during a pandemic influenza emergency. Plans should state in advance
          what backup support will be available to help those who are quarantined (e.g., who will do their shopping,
          pay the bills and provide financial support in lieu of lost income). Governments should have public
          discussions of appropriate levels of compensation in advance, including who is responsible for

Issue 3
Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines

    1.    Governments and the health care sector should publicize a clear rationale for giving priority access to
          health care services, including antivirals and vaccines, to particular groups, such as front line health
          workers and those in emergency services. The decision makers should initiate and facilitate constructive
          public discussion about these choices.
    2.    Governments and the health care sector should engage stakeholders (including staff, the public and
          partners) in determining what criteria should be used to make resource allocation decisions (e.g., access to
          ventilators during the crisis, and access to health services for other illnesses), should ensure that clear
          rationales for allocation decisions are publicly accessible and should provide a justification for any deviation
          from the pre-determined criteria.
    3.    Governments and the health care sector should ensure that there are formal mechanisms in place for
          stakeholders to bring forward new information, to appeal or raise concerns about particular allocation
          decisions and to resolve disputes.

Issue 4
Global governance implications, such as travel advisories
     1.   The World Health Organization should remain aware of the impact of travel recommendations on affected
          countries, and should make every effort to be as transparent and equitable as possible when issuing such
     2.   Federal countries should utilize whatever mechanisms are available within their system of government to
          ensure that relationships within the country are adequate to ensure compliance with the new International
          Health Regulations.
     3.   The developed world should continue to invest in the surveillance capacity of developing countries, and
          should also make investments to further improve the overall public health infrastructure of developing


University of Toronto Joint Centre for Bioethics
Innovative. Interdisciplinary. International. Improving health care through bioethics.

The JCB is a partnership among the University of Toronto and 15 health care organizations. It provides leadership in
bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in
order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions
on specific issues, although its individual members may do so.

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