Ethical Issues in Pandemic Influenza Planning

1. Ethical Issues in Pandemic Influenza Planning CDC Avian Influenza Training

2. Learning Objective • Understand ethical considerations pertaining to pandemic influenza preparedness and response

3. Session Overview • General and specific ethical considerations in public health • Public engagement • Planning and resources

4. General and Specific Ethical Considerations in Public Health http://www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf

5. What are Public Health Ethics? • A set of principles based on values and beliefs which underlie the principles of public health ethics • A guide to actions to promote health and prevent injury and disease in the population • Processes to clarify, prioritize, and justify possible courses of public health action based on ethical principles

6. Values and Beliefs “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.” Universal Declaration for Human Rights, Article 25

7. 12 Principles of the Ethical Practice of Public Health • Address the fundamental causes of disease and requirements for health • Respect individual rights in the community • Ensure an opportunity for community input • Empowerment of disenfranchised • Seek information for effective policies and programs • Provide community with information

8. 12 Principles of the Ethical Practice of Public Health • Act in a timely manner • Incorporate a variety of approaches and respect diversity • Enhance physical and social environment • Protect confidentiality • Ensure professional competence • Collaborate to build trust and effectiveness

9. Benefits of Public Health Ethics • Build and maintain credibility and public trust in your agency • Foster consensus and resolve value conflicts in an atmosphere of respect • Guide decisions when there is scientific uncertainty and varying opinions on how to proceed • Increase awareness of the rights of participants and communities in public health activities

10. General Ethical Considerations • Identification of overall goals • Planning • Decision-making • Preparedness • Use of scientific information • Global preparedness • Balance of individual liberty and community interests • Proceduraljudicial mechanism

11. Question 1 Fill in the missing words in the following definition of public health ethics: “Processes to _____, _____, and _____ possible courses of public health action based on ethical principles, stakeholder values, and scientific information” • Initiate, carry through, complete • Clarify, prioritize, justify • Examine, accept, publicize • Identify, change, promote Answer: B. Clarify, prioritize, justify

12. Question 2 Which of the following is NOT one of the 12 principles of public health ethics? • Act in a timely manner • Provide community with information • Protect individual rights over the community • Enhance physical and social environment Answer: c. Protecting individual rights over the community is NOT one of the 12 principles.

13. Identification of Overall Goals • Minimize serious influenza-associated complications • Preservation of the functioning of society Priorities favor those who are responsible for provision of health care, public safety and functioning of key aspects of society • Centralization of decision making authority To ensure equity in decision making and address need to preserve functioning of society across communities

14. Planning and Decision-Making • Planning • A commitment to transparencythroughout the pandemic influenza planning and response processes • Decision-making • Public engagement and involvement • Public as partner throughout planning and decision-making • Particular attention to vulnerable or marginalized members of society

15. Preparedness Responsibility to maximize preparedness to minimize the need for allocation decisions later • Proactive planning • Develop response strategies • Training of staff • Development of decision making rules in advance of pandemic

16. Use of Scientific Information and Global Preparedness • Sound guidelines should be based on the best available scientific information • Importance of working with and learning from global preparedness efforts • Not merely to benefit U.S. citizens • Recognition of common good and global interdependence

17. Balance of Individual Liberty and Community Interests • Follow three guiding principles: • Adopt least restrictive practices • Ensure that restrictions are necessary and proportional to need • Ensure that those affected receive support from the community • Involve diverse public representation in defining restrictions and articulating justification for these restrictions

18. ProceduralJudicial Mechanism Elements of an ideal procedural justice approach: • Consistency of standardsacross people and time • Impartialand neutral decision makers • Adequately reasoned decisions based on accurate information • Assurance that those affected by decisions have a voice in decision-making and agree to the proposed process • Clear communications with no hidden agendas • Revision process whennew information is available • Process for appeals • Procedures that are sustainable and enforceable

19. Question 3 What important ethical balance needs to be maintained during a pandemic? • Prevention vs intervention • Individual liberty vs community interests • State vs. Federal powers • Vaccination vs quarantine Answer: B. Individual liberty (personal freedoms) vs. community interests (public health)

20. Specific Ethical Issues • Allocation of scarce resources • Community mitigation measures

21. Allocation of Scarce Resources Distribution plans should specify: • What scarce goods are involved? • Who (or what agency) will decide about prioritization and distribution ? • What mechanism will be used for disputes or appeals? • Who is eligible to be a recipient ? • What criteria will be used to assign higher or lower priorities to groups of individuals ?

22. Community Mitigation Measures Social Distancing • Isolation of ill individuals • Quarantine of personsexposed to ill individuals • Closure of schools, day care centers, businesses, public venues, and cancellation of large public events • Alternative work practices/schedules • Limiting travel

23. Community Mitigation Measures (cont.) Liberty limiting measures should be voluntary and balanced with protection of individual rights: • No unwarranted invasions of privacy • Maintain confidentiality of private information • Restriction on personal freedom should be equitably applied • Avoid an unequal burden being placed on specific individuals or groups • Protect against stigmatization

24. Community Mitigation Measures(cont.) • Ensure that necessary support services (e.g., food, water and other essential services) are provided to the impacted population • Take into account needs of vulnerable populations (e.g., the elderly, handicapped) • Establish appeals process for those affected by the liberty limiting measures

25. Question 4 What are two individual rights which must be protected when liberty limiting measures are put into place? (choose two) • No unwarranted invasions of privacy • Restriction on personal freedom • Maintain confidentiality of private information • Stigmatization Answer: a and c

26. Public Engagement

27. Pandemic Vaccination Program Goals July-Dec 2005 Purpose: • Rank goals for pandemic influenza vaccination program • Weigh tradeoffs between competing goals • Select goals considered most important to achieve

28. Pandemic Vaccination Program Public Engagement Results Highest goals: • Assuring the functioning of society • Reducing deaths and hospitalizations due to influenza

29. Other Pandemic Vaccination Program Goals • Build and maintain the public’s trust • Transparent decision making • Seek public’s input • Early and clear communication and education • Flexible implementation of policy • Increase vaccine production capacity • Develop other public health measures to protect the public from illness • Provide resources to other regions of the world

30. Community Mitigation MeasuresOct-Nov 2006 Purpose: • Discuss economic and social tradeoffs associated with community mitigation measures • Identify challenges with implementing these measures • Offer solutions to the challenges

31. Community Mitigation Measures Public Engagement Results • Support for early implementation of community mitigation measures • Encouraging sick persons to stay home • Canceling large public gatherings • Challenges identified • Ensuring soundness of planning • Minimizing potential economic impacts • Addressing information needs of the population • Recognizing that social stresses that will be created

32. Solutions to Community Mitigation Challenges • Full engagement of all key sectors in development of detailed, fully-coordinated plan • Transparency of planning process • Training for leadership roles • Public education campaigns prior to pandemic • Connecting community organizations into social networks • Linking providers with people in need prior to pandemic

33. Question 5 Fill in the blank from the selections given below the question. When imposing Community Mitigation Measures (e.g. quarantine), your agency must provide support services such as (1) ____________, take into account the needs of (2)______________, establish (3)_______________ for those affected by liberty limiting measures, and provide (4)________________ about the rationale for these measures. • Food, water, essential services • Advance communication • Vulnerable populations • Appeals process • Sanctuary Answer: (1) a (2) c (3)d (4)b

34. Pandemic Influenza Vaccine Prioritization Dec 2006 – present Purpose: • Discuss prioritization and allocation of pandemic influenza vaccine • Feedback on vaccine guidance* Categories of persons who should receive vaccine • National security • Health care and community support services • Critical infrastructure • General population * Available at: http://www.pandemicflu.gov/vaccine/prioritization.html

35. Pandemic Influenza Vaccine Prioritization Public Engagement Results U.S. Example Highest Vaccination Priority (Tier 1): • Deployed and mission critical personnel • Critical public health and healthcare personnel • Critical infrastructure personnel (i.e., EMS, police, fire, vaccine and antiviral manufactures, key government leaders) • Pregnant women • Infants and toddlers (6-35 months old) Prioritization will need to be reconsidered once specifics of new pandemic virus are known.

36. Question 6 Which category of persons who may be considered during prioritization decisions for vaccination during a pandemic? • National security • Healthcare and community support services • Critical infrastructure • General population • All of the above Answer: • E. All of the above

37. Planning and Resources

38. Questions to Consider in Planning • Have public health decisions been made in a clear, open, and transparent manner? • Have those who will be affected by the public health measures been given the opportunity to provide input into decision making? • Are decisions being made on the best available scientific information? • Have the least restrictive public health measures necessary to protect the common good been used? • Are decisions about protecting the common good being balanced with protection of individual rights?

39. Questions to Consider in Planning (cont.) • Have efforts been made to minimize the negative impact of the public health measures? • Have the public health measures anticipated and respected the diverse values, beliefs, and cultures in the community? • Has a process been established to revise or correct decisions to address new information? • Have efforts been made to acknowledge and respond to public suspicion and distrust of local, state or federal government decisions?

40. Public Health Ethics Resources for Pandemic Influenza Checklist Fact Sheet

41. Summary • Public health ethics foster awareness of the rights of participants and communities in public health activities • Public health ethics build credibility and public trust in your agency, aid in resolving value conflicts, and guide decisions when there is uncertainty • General considerations in public health ethics involve transparency, good practice, and public engagement • Specific challenges in pandemic influenza ethics include prioritizing some groups over others in prevention planning, and allocation of scares resources locally, nationally, and internationally.

42. Resources • Ethics Guidance for Pandemic Influenza • http://www.cdc.gov/od/science/phec/ guidelinesPanFlu.htm • Public Engagement Process • http://www.keystone.org/spp/health-pandemic.html#community • CDC’s Public Health Ethics Activities • http://www.cdc.gov/od/science/phec/ • James Thomas, Principles of the Ethical Practice of Public Health • http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-BD405FC60856/0/ethicsbrochure.pdf • James Thomas, Skills for the Practice of Public Health • http://209.9.235.208/CMSuploads/EthicalPracticePublicHealth-40199.pdf

43. Glossary Public engagement: The process of listening to, interacting with, and gaining greater understanding of a group in order to inform the decision making process Public health ethics: Principles and values that guide actions to promote health and prevent injury and disease in the population Procedural judicial mechanism: An established fair process by which individuals or groups who feel their rights have been violated can be heard in court

44. Glossary Social distancing: Targeted efforts to reduce interaction between persons at specific or general venues, in order to reduce the probability of disease transmission Transparency: Providing for openness, communication, and accountability during a process or decision