INTRODUCTION

 

What is the threat of a pandemic?

The devastation of a global pandemic is best illustrated by the Spanish Flu of 1918-1919, when perhaps a third of the world's population became infected, and estimates of deaths tend to exceed 50,000,000, including over 675,000 Americans. The virus in the Spanish Flu pandemic was an H1N1 strain of "Bird Flu" that spread to humans and then was quickly transmitted human-to-human. Today, another "Bird Flu" virus--H5N1--shows potential for becoming highly transmissible and lethal on a pandemic scale. It has already developed the capacity for "relay transmission" between poultry and wild birds, and has moved from South-East Asia to Central Asia, the Middle East, Africa, and Europe (including Great Britain). Humans in close contact with birds have contracted the virus, and human-to-human transmission appears already to be possible, though cases have so far been rare and unsustained. The virus may weaken as it mutates, but if and by how much it may do so is unclear. As of June 2009, the World Health Organization had recorded 433 human infections, with 262 of those people having died, for a death rate of 60.5%. The death rate for the Spanish Flu was approximately 2.5%.

A pandemic would not need to reach the level of the Spanish Flu in order to cause massive social and economic disorder in the US. The flow of goods, from manufacture to distribution, would be disrupted by shortages of raw materials, worker illness, and travel restrictions. With goods scarce, employees out, and travel limited, services of all sorts would be affected, especially health care, for which there would be clamorous demand. To this, add the problem of public panic and the possibility of civil disorder. The event would moreover not be contained within a single geographic area, and it would escalate over a number of weeks and continue for months. Through it all, questions of the rights and responsibilities of individuals and institutions, and of the justness of actions in response to the pandemic--questions of values, questions of ethics--would be key to the process of emergency management. For health care providers in particular, a pandemic would present not only a health crisis at the center of a societal crisis, but the practical and ethical problem of how to help in spite of insufficient resources to meet the standards of modern medical care.

 

What major ethical problems would confront health care providers?

At the onset of an influenza pandemic, providers would face a very personal ethical decision about their duty to serve contagious patients verses the ways that concerns for personal safety play into duties to their own families and others to whom they have responsibility. While most health care workers would probably rush to a crisis as a function of their professionalism, some would not (perhaps especially if they have doubts about their institution's pandemic plan), yet virtually all would surely be aware of the ethical and emotional significance of the decision.

The most glaring ethical decisions, however, would be those of how to treat overwhelming numbers of patients with scarce and diminishing medical resources. Two shortages would likely stand out: antiviral drugs and mechanical ventilators. These potentially life-saving treatments would have to be allocated to fewer than the number of patients who would need them, and that fundamental fact poses a number of ethical questions. The problem can be conceived broadly in terms of distributive justice: What is the just--or the most just--way to distribute scarce resources?

Distribution of an antiviral drug like Tamiflu (oseltamivir) has received much attention in hospital and government planning aimed at saving the most number lives with the limited amount of drugs available. Such a drug could potentially be used for prevention as well as for cure (though tests have raised questions of effectiveness), so the two groups that typically are assigned highest priority to receive the drug are patients with the greatest clinical need and providers with the greatest risk of exposure. This scheme seeks to balance two connected ethical imperatives: to treat the sick and to secure the ability to offer that treatment; and it puts forward the ethics of the "common good" (of maximizing the saving of life) over the "individual good" (of persons in lower priority groups).

Providers may feel an ethical tension in following drug distribution plans, since the prioritization of recipients rests on debatable assessments of risk and therapeutic efficacy; also the "common good" is often perceived as a relatively weak abstraction compared to the "real" concerns of specific people at hand. Some providers may choose to challenge or defy official plans out of a differing assessment of risk and resources and out of their own pressing sense of duty to individuals. Moreover, the stockpiling of drugs, even in small amounts, raises the question of when maintaining an inventory becomes hoarding.

Much more ethically troublesome questions than those about the distribution of antiviral drugs would grow out of the shortage of mechanical ventilators --in part because Tamiflu has shown only limited efficacy against the H5N1 virus, but the withholding or withdrawing of a ventilator usually indicates a decision with immediate life-and-death consequences. The ethical gravity of assessment and prioritization, and of the weighing of individual need against the "common good," is intensified here.

There are a little over 100,000 ventilators currently in the US, with more than 85% of them regularly in use; but estimates of the number of patients who would require ventilatory support in an H5N1 pandemic range upwards of 700,000. It would be ethically wrenching for any physician to choose which critically ill patients would be given a chance for survival on a ventilator and which would be consigned to a high likelihood of dying in a very short time. Even that decision, however, pales in comparison to the prospect of removing a patient from a ventilator--perhaps against the patient's or the family's wishes--merely because he or she is not improving rapidly enough to justify continued use of a scarce resource. Providers will likely try to expand ventilator availability by such means as having patients share machines, arguing ethically that the possibility of increased risks (e.g., of infections) from "cutting corners" is outweighed by the more certain risk in denying a patient a ventilator. Resources would be stretched by such "altered standards of care" that would never be justifiable under normal circumstances. Still, though, the lack of ventilators would require some of the hardest clinical decisions in a pandemic.

Of course, competition for ventilators would come not only from among influenza patients, but from a variety of patient groups for whom mechanical ventilation is part of best medical practices. For many patients with an immediate need for a ventilator following a cardiac arrest, for instance, machines simply would be unavailable -- the protocol for providing Advanced Cardiac Life Support could be impossible to accomplish, and some hospitals might even impose a moratorium on resource-intensive procedures like cardio-pulmonary resuscitation as a conservation strategy at the height of a pandemic. Weeks into the crisis, supplies of all sorts would become depleted, and health care providers would be hard-pressed to work in ways that resembled the normal ethical practice of their professions. What is more, many providers will find themselves practicing outside of their fields of expertise, as fewer and fewer staff attempt to provide coverage across the spectrum of medical care. With standards for care altered, values under stress, and physical exhaustion mounting, even veteran clinicians may have trouble remaining clear about ethical courses of action.

 

How might ethical questions about resource allocation hinder the medical response to a pandemic?

Mass casualty emergencies, by their nature, overwhelm medical resources; so the goal of mass casualty response plans is to save the largest number of lives with the resources available. These plans are based upon utilitarian ethics and focus on the "big picture," on serving a "greater good," which may not be in the best interests of any one person. Individual needs and patient autonomy become subordinated to an intense application of the ethical principle of distributive justice in order to wring the greatest life-saving benefit from a scarcity of both materials and time for treatment. The plans are based upon military models of triage and grew from the exigencies of battlefields. While it makes some sense that they should be a means of saving the most lives in any mass casualty disaster, including pandemic flu, these plans require health care providers (and patients and families) to make a dramatic shift in ethical thinking--in the rules for assessing what is the ethically "right" and "wrong" course of action in the midst of a crisis.

So, for instance, the ethical perspective of mass casualty plans characteristically allows for patients who either demand an excess of precious resources, or who will likely die regardless of the resources devoted to their care, to be given low priority for treatment or even set aside to die. Yet, this course of action would be morally reprehensible to any clinician (or patient or family) in the mindset of normal standard-of-care circumstances. If care providers do not well understand the ethics behind mass casualty plans, if they become unclear in a disaster about the ethical rules by which life and death decisions are determined to be "right" or "wrong," or if they come to feel that they are involved in ethically/morally "wrong" actions, the result may be a slowdown or partial breakdown of the mass casualty response itself. Ultimately, if a mass casualty response plan gets caught up in ethical conflicts at the bedside, it risks losing the very efficiency for saving lives that is the reason for altering triage and care practices in the first place.

Medical first responders and emergency room personnel are typically practiced in the operational and ethical shifts involved in mass casualty plans, but many people who work in health care have very little familiarity. During an influenza pandemic, which would last for weeks to months, triage and resource allocation decisions will need to be made beyond the point of initial patient intake; they will come to affect daily the work of doctors, nurses, and allied providers throughout a hospital --many of whom may know the general principles of mass-casualty triage but have insufficient experience in applying the underlying ethical reasoning to clinical situations or in explaining the values-basis for extraordinary decisions to colleagues, patients, or families.

For example, in an Intensive Care Unit, days into a pandemic, would there be sufficient ethical clarity among staff to address questions about a shortage of respirators and which patients should receive mechanical ventilation and for how long? Such issues are so complex that they cannot be entirely managed by clinical parameters and protocols. Would it be ethical (and/or legal) to withdraw a respirator simply because of an assessment that a patient who was benefiting from the therapy was not benefiting enough to justify the continued use of a machine that might be used more efficiently on other patients in respiratory crises? Would physicians, nurses, or respiratory therapists feel "right" in looking such a patient in the eyes and saying that the respirator needed to be disconnected for the "greater good?" How effectively could clinicians interact with family members around this? And, how might the ethical quandary of such a case affect teamwork, order, and other decision-making processes on the ICU or between the ICU and other hospital units or an Incident Command Center? How might such situations increase personal fatigue among care givers? Moreover, what if a plan stretched ethical justifications further by adding special provisos to the triage protocol, such as giving priority to some patients purely because they were fellow health care workers, incident-critical personnel, or other types of VIPs? Would there be any recourse for challenging perceived injustice during the emergency?

It is with these sorts of questions in mind that many authors on pandemic ethics have called for broad, advance discussion of pandemic response. There may not be any simple answers here, but there is certainly a best course that can emerge through the discussion of values, consensus-building around ideas, and fine-tuning of plans in order to achieve the greatest good in the worst of times.

 

NOTE: The ethics of pandemic response planning often tends toward the abstract, and even though some publications on the subject may be clearly written, tracing the direct connections between ethical issues and practical action can often be difficult. One strategy to concretize the implications of ethical reasoning is to construct algorithms that present the flow of decision-making processes. (For one example, click HERE.) Graphic representations such as algorithms may be particularly helpful to constructive discussions of ethical decision-making.
 

--JWE, 6/9/09
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