Ethical issues in rapid containment strategies

1. Ethical issues in rapid containment strategies

2. Learning Objectives • Describe the major ethical issues that must be considered in an RC operation. • Discuss ethical considerations in rapid containment strategies. • Develop ways to address the major ethical issues during an RC operation.

3. Overview of the session 1) Ethical issues in pandemic influenza (PI) preparedness and response 2) WHO project on addressing ethical issues in PI planning 3) Ethical issues in rapid containment strategies

4. Ethical issues in pandemic preparedness and response What is Ethics ? A discipline dealing with what is right and wrong and with moral duties, obligations, and rights. A process for reaching agreement when values are in conflict.

5. Ethical issues in pandemic preparedness and response A) 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)

6. Ethical issues in pandemic preparedness and response B) 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 receive Oseltamivir or a vaccine? • How to allocate resources (in advance and during the pandemic) between pandemic influenza and other health needs

7. Ethical issues in pandemic preparedness and response C) Obligations of (and to) healthcare workers in a pandemic • Do health care workers (HCWs) have a duty to care in the event of a pandemic? If so, is it unlimited? • Are obligations of healthcare workers dependent on their receiving special protections or on direct or implied commitments made when 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?

8. Ethical issues in pandemic preparedness and response • How should governments balance their duties to their own population versus to other countries and populations? • Is there a reciprocal obligation between developing countries providing surveillance and specimen and developed countries providing treatment and vaccines? • What role can and should international organizations (such as WHO) play in addressing cross-border risks and obligations? Obligations among countries & international organizations

9. Ethical issues in pandemic preparedness and response Importance of Planning and Preparedness Since many of these questions are difficult to answer, countries should prepare and discuss them ahead of time, and make sure that the public has been engaged in the decision-making process.

10. WHO project on ethical issues in pandemic planning Objective Formulation of guidance for Member States on how to address the ethical issues that arise in the preparation and response to a potential influenza pandemic.

11. WHO project on ethical issues in pandemic planning • Publication a of document on Ethical Considerations for Pandemic Influenza Planning • Dissemination through various channels: • WHO, MoH, NGOs • UN Interagency Committee on Bioethics • Global Summit of National Bioethics Advisory Bodies • Conferences • Regional and country support activities: contextualisation

12. Ethical issues in rapid containment Public Health Ethics: Principles • Public Health Necessity • Reasonable and effective means • Proportionality • Distributive Justice • Trust and Transparency • Siracusa Principles (Human Rights): Limitations on human rights must be based on a legitimate objective, be the least restrictive and intrusive means; and not be arbitrary, unreasonable or discriminatory

13. Ethical issues in rapid containment Prophylaxis/treatment with neuraminidase inhibitors • During rapid containment, antivirals will be available for everyone who 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 and mechanically-assisted ventilation, may be in short supply include prioritization criteria in country-level planning

14. Ethical issues in rapid containment Isolation, quarantine, and social distancing Employees of Stewart & Holmes Wholesale Drug Co. Seattle, 1918 Courtesy of Grace Loudon Mc Adam

15. Ethical issues in rapid containment Isolation, quarantine, and social distancing – basic concepts • Tension between the interests of society in protecting and promoting the health of its citizens and the freedom of the individual • Social separation can infringe individual rights and disrupt social and economic life; • In order to justify a restriction of civil liberties, the means used should be considered to be effective in combating the public health threat • In order to pass the balancing test, the expected benefits for public health should outweigh the burdens or harms for individuals

16. Ethical issues in rapid containment Isolation, quarantine, and social distancing - Decision-making • Decision to use restrictive measures needs to be made in an open, fair, and legitimate manner. • Transparency and community participation will enhance public trust and acceptance of the proposed containment measures. • Governments should explicitly define who has the power to order public health interventions, for what period of time, and what the criteria will be for making the decision.

17. Ethical issues in rapid containment Isolation, quarantine, and social distancing - Implementation (1) • Measures should be voluntary whenever possible • If necessary and justified, public health officials should be allowed to enforce containment measures by least intrusive means • Penalties for non-compliance should be proportional • Privacy and confidentiality: Personal information should be kept confidential as much as possible (stigma/discrimination)

18. Ethical issues in rapid containment Isolation, quarantine, and social distancing – Implementation (2) • Implementation in a humane, sensitive manner (for ex., IHR's provisions include the need for special concerns regarding gender, religious, and ethnic issues) • When protection of public health requires limits on individual liberty, the principle of reciprocity obliges society to provide those affected with 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 a pretext to persecute ethnic or religious minorities or dissidents

19. Ethical issues in rapid containment Isolation, 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 order could lead to arrest • Main worries about quarantine in a health-care facility: exposure to contagious disease, overcrowding, and difficulty communicating with family • Authors' conclusion: policy-makers need specific plans to deal with the public’s concerns about compulsory quarantine policies.

20. Ethical issues in rapid containment Iowa State gymnasium, converted into hospital, 1918 flu epidemic

21. Ethical issues in rapid containment International travel and border controls • Freedom of movement is a basic right protected by national laws and international treaties • Containment measures may require the travel industry to collect and disclose passenger data • As part of perimeter control, obtain informed consent from travellers for screening, prophylaxis, and treatment • Burdens on privacy are justified only if necessary to obtain high-quality surveillance data • IHR: specific provisions