Ethical considerations found lacking in preparedness plans for bird flu outbreaks

International planning to control a potential avian influenza pandemic should include an explicit ethics component, according to a report the University of Toronto's Joint Centre for Bioethics released in November 2005.

The Congressional Budget Office has estimated that as many as 90 million Americans could get sick, and 2 million could die within months of a potential outbreak of the H5N1 flu strain that has killed at least 69 people in Asia.

While the White House and the Dept. of Health and Human Services have issued pandemic flu plans, neither plan deals explicitly with ethical issues that would arise should a pandemic hit.

Toronto's experience with the severe acute respiratory syndrome outbreak in 2003 that infected 375 people, killed 44 and practically shut down the city made it clear that ethical issues such as prioritizing medical treatment, instituting a quarantine and helping physicians meet ethical obligations should be examined before the emergency strikes, according to the report, "Stand on Guard for Thee."

"There's about 200 countries in the world. Zero have an explicit ethics framework in their pandemic plans," said Peter A. Singer, MD, MPH, one of the report's authors and director of the Joint Centre for Bioethics. "The lesson from SARS is that the ethical values framework is the foundation of the house in those plans."

Toronto political and health officials, with no ethics plan in place, rushed to justify decisions about prioritizing access to care, implementing a quarantine and defining health care workers' duty to care for the sick even at personal risk.

SARS ultimately proved to be less infectious than originally feared, requiring close personal contact for it to be spread. The avian flu, on the other hand, could be spread widely through ordinary social or indirect contact, leaving officials with less time to act.

"There's an opportunity now to engage the public in how resources are going to be distributed and where individuals will be situated in that process," said Ross E.G. Upshur, MD, director of the primary care research unit at Toronto's Sunnybrook and Women's College Health Sciences Centre and a member of the Joint Centre for Bioethics. "We need to have the discussion now rather than when people are sick and scrambling around not knowing what will happen."

Make tough choices now

Based on Canada's experience, report authors say the public will be more likely to accept the hard choices made to protect public health if those choices are discussed before a crisis hits. These choices could include quarantining the sick and prioritizing whom should receive antiviral medications and, eventually, a vaccine.

The ethical challenge of prioritizing antiviral and vaccine distribution is "very serious," according to Yanzhong Huang, PhD, director of the Center for Global Health Studies at Seton Hall University in New Jersey.

"Even at normal times, demand and supply is always a problem in distributing vaccines," Dr. Huang said. "When speaking of a pandemic, it hits not just the weak or the elderly or the very young but also people in their most productive age."

Hospitals and other health care organizations also should do everything possible to prevent physicians from having to choose between caring for their patients and protecting themselves and their families, according to the Toronto report.

"We know that most health care professionals have an innate desire to care for patients in times of crisis," Dr. Upshur said. "But this also poses risks for them as individuals. There are competing obligations." Hospitals should make sure physicians, nurses and medical staff have adequate protective gear and that proper ventilation systems are in place, he said.

Priscilla Ray, MD, a Houston psychiatrist and chair of the AMA's Council on Ethical and Judicial Affairs, said physicians' first duty was to take care of themselves, so they are able to help others.

"We have a responsibility to protect ourselves in advance, and that means getting the vaccine," Dr. Ray said. "We could easily become a vector of the flu. We also need to prepare ourselves with knowledge about what the requirements will be."

Some discussions under way

In November 2005, the AMA adopted a CEJA opinion on the use of quarantine, outlining physicians' obligations to protect public health by advising patients to comply with any restrictions.

And doctors have had to deal with the question of when it is appropriate to prescribe the antiviral flu medicine oseltamivir, marketed as Tamiflu.

The AMA has said individuals should not stockpile Tamiflu or other antivirals because the drugs are needed to treat flu cases in the elderly and high-risk individuals.

Even those who should know better are guilty of hoarding, according to Luther Rhodes III, MD, chief of infectious disease for Lehigh Valley Hospital and Health Network in Allentown, Pa.

Dr. Rhodes attended the Infectious Disease Society of America's October 2005 annual meeting in San Francisco and said that when asked by a speaker if they were stocking up on Tamiflu for themselves, a roomful of experts' hands shot up.

"That's exactly the wrong thing to do and the wrong message to send," Dr. Rhodes said.

About 36,000 people die during a typical flu season, according to Robert Belshe, MD, director of the infectious diseases division at Saint Louis University in St. Louis, Mo.

"If people start hoarding Tamiflu, then more people are going to die from ordinary influenza," Dr. Belshe said. "It needs to be available in the pharmacy."

HHS did not respond to a request to discuss ethics planning.

The Centers for Disease Control Centers for Disease Control and Prevention has produced a document on prioritized use of vaccine, called "Tiered Use of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage." The document is available on the CDC's Web site (link)