Human rights, ethics, and pandemic influenza

1. Human rights, ethics, and pandemic influenza Alan Hinman and AunLor July 2011

2. Outline of presentation • Definitions • Concepts of human rights • Public health impact on human rights • Principles of ethics • Principles of ethical practice of public health • Human rights/ethical issues in pandemic influenza

3. What is health? “Health is a complete state of mental and physical well-being, not merely the absence of disease” WHO charter

4. What is public health? The mission of public health is “fulfilling society’s interest in assuring conditions in which people can be healthy.” Institute of Medicine

5. Fundamental characteristics of human rights • Set of beliefs about societal basis of human well-being • Series of non-provable statements about what people need to maintain their human dignity • Rights of individuals • Inhere to individuals because they are human • Apply to all people around the world • Principally involve the relationship between the state and the individual

6. Pubic Health and Human Rights-1 • Both PH and HR are vitally concerned with social justice • However, many PH workers do not view what they do as human rights activities • Many HR workers do not consider PH indices as important indicators of HR • Working together, PH and HR workers can have much greater impact

7. Pubic Health and Human Rights-2 • HR workers tend to focus on denial of HR • PH workers tend to focus on achieving health (a human right) • How can we bring them to common understanding?

8. Preamble to WHO Constitution "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

9. Human Rights Documentsciting Health Rights - 1 • Universal Declaration of Human Rights • International Covenant on Economic, Social and Cultural Rights • International Covenant on Civil and Political Rights • International Convention on the Elimination of All Forms of Racial Discrimination

10. Human Rights Documentsciting Health Rights - 2 • Convention on the Elimination of All Forms of Discrimination Against Women • Convention on the Rights of the Child • Declaration on the Elimination of all Forms of Intolerance and of Discrimination Based on Religion or Belief • ILO Convention Concerning Indigenous and Tribal Peoples in Independent Countries

11. Human Rights Documentsciting Health Rights - 3 • Standard Minimum Rules for the Treatment of Prisoners • African (Banjul) Charter on Human and Peoples' Rights • European Social Charter • Cairo Declaration on Human Rights in Islam • American Declaration of the Rights and Duties of Man

12. Universal Declaration of Human Rights - 1 • Article 23 (1) - Everyone has the right to…favorable conditions of work • Article 25 (1) - Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food,…medical care…and the right to security in the event of…sickness…widowhood, old age or other lack of livelihood in circumstances beyond his control

13. UDHR - 2 • Article 25(2) - Motherhood and childhood are entitled to special care and assistance • Article 26 (1) - Everyone has the right to education

14. International Covenant on Civil and Political Rights (ICCPR) • Article 7.…no one shall be subjected without his free consent to medical or scientific experimentation • Article 22 (2)...no restrictions on the exercise of this right [freedom of association] other than those which are prescribed by law and which are necessary…[for]the protection of public health… • Article 24 (2) - Every child shall be registered immediately after birth…

15. International Covenant on Economic, Social, and Cultural Rights - 1 • Article 7 (b)…right of everyone to the enjoyment of just and favourable conditions of work which ensure…safe and healthy working conditions • Article 10 (2) - Special protection should be accorded to mothers during a reasonable period before and after childbirth • Article 10 (3) Special measures of protection and assistance should be taken on behalf of all children and young persons

16. ICESCR - 2 • Article 12 (1)…right of everyone to the enjoyment of the highest attainable standard of physical and mental health • Article 12 (2a)...reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child

17. ICESCR - 3 • Article 12 (2b) …improvement of all aspects of environmental and industrial hygiene • Article 12 (2c) …prevention, treatment and control of epidemic, endemic, occupational and other diseases • Article 12 (2d) …creation of conditions which would assure to all medical service and medical attention in the event of sickness

18. ICESCR & Immunization The core obligation of governments “to ensure access to immunization against the community’s major infectious diseases.” General comment 14

19. American Declaration of the rights and duties of man • Article 7 - All women, during pregnancy and the nursing period, and all children have the right to special protection, care and aid • Article 11 - Every person has the right to the preservation of his health through sanitary and social measures relating to…medical care, to the extent permitted by public and community resources

20. Developing a public health and human rights impact assessment • Define the public health problem • Describe the proposed public health program • Identify the anticipated public health impact (beneficial and adverse effects) • Identify the anticipated human rights impact (beneficial and adverse effects) • Identify alternative approaches • Describe the reasons for decision to select the proposed program or not to implement the program

22. Conditions in which human rights may be restricted - Syracusa principles • Restriction is provided for and carried out in accordance with the law • Restriction is in the interest of a legitimate objective of general interest, e.g., public safety, public order, public health • Restriction is strictly necessary in a democratic society to achieve the objective • There are no less intrusive and restrictive means available to reach the same goal • Restriction is not imposed arbitrarily, i.e., in an unreasonable or otherwise discriminatory manner

23. Civil and political rights that may be limited • Right to liberty • Right to security of persons • Freedom from arbitrary arrest, detention, or exile • Freedom of movement • Freedom from interference of privacy, family, home • Right to peaceful assembly and association • Freedom of opinion and expression

24. Ethics, Morals, and Values • Morality refers to “social conventions about right and wrong human conduct that are so widely shared that they form a stable communal consensus.” – The practice • Ethics is the systematic study of morality, a philosophical account of justified behavior – The theory

25. Values • “…core beliefs or desires which guide or motivate attitudes or actions…values are core beliefs which determine how we will behave in certain situations” – “Making Ethical Decisions” – Josephson Ethical Institute

26. Autonomy • Classic medical ethics definitions – Self-determination - persons must be self- governing, rational, and not coerced – Respecting the wishes and choices of persons who have the capacity to decide – Protecting those who lack this capacity • Public health forms: – Privacy – Freedom of action

27. Beneficence • Providing benefits • Balancing benefits with harms • Protecting persons’ interests and promoting the welfare of others • In public health ethics, must be interpreted broadly – in light of social needs • Example: Overall goal of public health policy

28. Nonmaleficence • First, do no harm • Balancing benefits and harms • Example: Considering the side effect profile of a prescription drug

29. Justice • Fairness • Treating similar cases similarly • Equality of opportunity • Equity in access • At the core of public health • Example: Ensuring equal access to vulnerable populations

30. Veracity • Duty to tell the truth or not to lie • Lies add power to the liar and diminish the power of the deceived

31. Public Health Principles • Public health assumes background principles • Social justice • Pragmatism • Equality • The Common Good • Community • Prevention • Access • Liberty • Privacy

32. Principles of the ethical practice of public health - 1 1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2. Public health should achieve community health in a way that respects the rights of individuals in the community. 3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. Public Health Leadership Society

33. Principles of the ethical practice of public health - 2 4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

34. Principles of the ethical practice of public health - 3 6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

35. Principles of the ethical practice of public health - 4 8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

36. Principles of the ethical practice of public health - 5 10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11. Public health institutions should ensure the professional competence of their employees. 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

37. Human rights/ethical issues in pandemic influenza • Delays and shortages in availability of vaccines and antiviral drugs - need to prioritize • Isolation/quarantine • School closings/social distancing • Disruption of national/community infrastructures including transportation, commerce, utilities and public safety due to widespread illness and death among workers and their families

38. US priority groups for vaccine - 1 1A • Vaccine/antiviral manufacturers and others essential to manufacturing and critical support • Medical workers and public health workers involved in direct patient contact 1B • Persons >65 yr old with > 1 high-risk conditions • Persons >6 mo with history of hospitalization for pneumonia or influenza in past year

39. US priority groups for vaccine - 2 1C • Pregnant women • Household contacts of severely immunocompromised persons • Household contacts of children <6 mo old 1D • Public health emergency response workers critical to pandemic response • Key government leaders

40. US priority groups for vaccine - 3 2A • Healthy persons >65 yr old • Persons 6 mo – 64 yr old with 1 high-risk condition • Persons 6 – 23 mo old, healthy 2B • Other public health emergency responders • Public safety workers • Utility workers • Transportation workers • Telecommunications/IT essential workers

41. US priority groups for vaccine - 4 3 • other key government health decision-makers • Funeral directors/embalmers 4 • Healthy persons 2 – 64 yr old not included in above categories

42. US priority groups for antiviral drugs - 1 • Patients admitted to hospital • Health care workers with direct patient contact and EMS providers • Highest risk outpatients – immunocompromised persons and pregnant women • Pandemic helath responders, public safety, government decision-makers • Increased risk outpatients – children 12 -23 mo old , persons >65 yr old, persons with underlying medical conditions

43. US priority groups for antiviral drugs - 2 • Outbreak response in nursing homes/other residential settings • HCWs in emergency departments, intensive care units, dialysis centers, EMS providers • Pandemic societal responders (critical infrastructure groups), HCW without direct patient contact • Other outpatients

44. Conclusions • Human rights and ethics play an important role in public health programs • Enjoyment of human rights may be restricted in order to achieve legitimate public health goals • We should strive to limit negative human rights impact of public health programs • All decisions should be made according to ethical principles