Pandemic Influenza

Below is a series of questions to each about each of the three (3) scenarios, and well as a final set related to ethical issues during pandemics. Each requires some thoughtful reading and responding.
Scenario 1: First Set of Questions
1.    What are your initial thoughts and feelings about this scenario?
2.    What do you think are the most important considerations for Maria in making her decision?
3.    Would your opinion change if the day care center was dosed? Why?
Scenario 1: Second Set of Questions
1.    What do you think of the clinical group’s decision?
2.    Do you think society has an obligation to health care workers in the event of a pandemic outbreak?
3.    In your view, is the health status of a health care worker an acceptable reason for that individual to not respond to a pandemic virus?
4.    Should health care providers face consequences for refusing to show up for work?
5.    If no, why? If yes, what sorts of penalties do you think would be fair?
Scenario 2: First Set of Questions
1.    What are your initial responses to this situation? What is your gut reaction?
2.    What are the most important considerations in this scenario?
3.    What are the features of this case that you find the most compelling?
Scenario 2: Second Set of Questions
1.    Have your initial responses to the situation changed in light of this added information?
2.    Are there any considerations that you find significant in this additional information?
3.    Is there anything compelling about this development?
4.    Do these personal details about the two patients’ lives affect your perspective?
Scenario 3: First Set of Questions
1.    What are your initial thoughts and feelings about this situation?
2.    What do you think were the most important considerations for the family in making their decision?
3.    What features of this case do you find most compelling?
Scenario 3: Second Set of Questions
1.    What do you think of Diana’s decision?
2.    Do you think people should face consequences if they don’t follow an order of quarantine? If yes, what sort of penalties do you think would be fair?
3.    Is there anything compelling about this development? The US government has now declared a state of emergency.
Scenario 3: Third Set of Questions
1.    Have your responses to the situation changed in light of this new information?
2.    What do you think of the public health authority’s decision to detain Diana?
3.    Do you think society has obligations to those ordered into quarantine?
4.    Is there anything compelling about this development?
Ethical Discussion Questions
1.    What are the ethical problems for health professionals, public administrators, and community members presented in each of the three cases?
2.    What were the competing or conflicting ethical principles or values in each case?
3.    What are the possible negative or positive consequences of the actions taken by those involved in each case?
4.    Review the ethical guidelines above. Which of these do you think are most important? Explain.

Fourteen-year-old Jacob Moya was busing tables at the Texas Bible Institute in Columbus on July 8, 2009, when he felt run-down and called his dad in Pflugerville. He resisted his father’s offer to come get him, saying he would tough it out, said his father, Henry Moya, later. Jacob continued to work despite feeling ill. Within a few days, Jacob had become so ill with severe flu symptoms, including fever, cough, and fatigue, that he had to be taken to the emergency room in Round Rock, Texas. In the ER, the doctor advised Jacob to see his family doctor if he did not feel better and was released. A day later, Jacob had problems breathing and was back in the ER, where he was sent to a San Antonio Hospital that had the nearest heart-lung machine. Within one month of exhibiting the first symptoms of H1N1 flu, Jacob was dead of respiratory failure and a brain hemorrhage. What surprised health officials was that Jacob died from the H1N1 virus though he had no underlying health conditions. In fact, 20 to 30 percent of the children who died from H1N1 in 2009 would be like Jacob—perfectly healthy until they fell ill.

The H1N1 influenza virus that killed Jacob was not the normal seasonal flu that we experience each year, but rather a new influenza flu virus of swine origin that was first detected in Mexico in April 2009, when it began infecting people throughout the world. Within a few weeks, the virus had infected thousands of people around the world through person-to-person contact. The Centers for Disease Control and Prevention (CDC) estimated that from April 2009 to April 2010, between 43 million and 61 million cases of H1N1 occurred in the United States alone. Furthermore, the CDC estimated that between 195,000 and 403,000 H1N1-related hospitalizations and between 8,870 and 18,300 H1N1-related deaths occurred between April 2009 and April 2010. The CDC considered the H1N1 pandemic, unlike the devastating pandemic in 1918, moderate in severity, but cautioned that we should plan for more severe pandemics in the future.

Pandemics pose unique challenges to organizations, communities, and nation-states, not only because of their capacity to cause a large number of people to become ill or die, but also because of the severe social and economic disruptions that are likely to occur. According to the US Department of Health and Human Services (HHS), it is estimated that if a pandemic influenza virus similar to the 1918 strain in virulence emerged today, in the absence of intervention, 1.9 million Americans could die and almost 10 million could be hospitalized over the course of the pandemic, which might evolve over a year or more. This extraordinary number of sick people over a large geographic area, all requiring care at the same time, would overwhelm the health care system, strain local, state, and federal resources, and lead to critical shortages in vaccines, medications, medical supplies, hospital beds, and food, water, and health care workers. The economic impact on the United States of even a mild pandemic is estimated at $71.3 billion to $166.5 billion in direct health care costs, lost productivity for those affected, and lost expected future earnings for those who die, with the loss of life accounting for the majority of the economic impact.

A pandemic of highly pathogenic influenza would threaten the lives of hundreds of thousands of people in the United States and confront governments and public health organizations with ethical issues that would have wide-ranging implications and consequences. Public officials and health care professionals would face difficult ethical dilemmas in trying to choose among potentially conflicting priorities, particularly if no clear ethical guidelines are developed in advance. During a severe influenza pandemic, there would not be enough time to engage in a public discussion of the ethical trade-offs in many of the critical decisions that would need to be made.

To facilitate such a discussion, this case will first provide a worst-case scenario in the United States in the near future that would be much like the 1918 pandemic. Next, three short scenarios are presented that each illustrate a particular aspect of a pandemic that is sure to challenge the ethical fitness of health care professionals, public officials, and ordinary individuals. These scenarios are based on the cases developed by the National Collaborating Centre for Healthy Public Policy in Quebec, Canada. Each scenario aims to assist in the development and application of moral reasoning through concrete examples. In addition, each is meant to stimulate discussion within a group of individuals (perhaps from multiple disciplines and/or with dissimilar points of view) in order to gain a deeper understanding of the issues from different perspectives and in both general and specific contexts.

The Worst Case: A Worldwide Outbreak of a Severe Influenza Pandemic

The pandemic catastrophe begins on January 3, 2018, after billions of people around the world have celebrated the start of the new year. That is when HSN1 (avian influenza) virus goes global, mutating so that it can be passed from one human to the next. The avian influenza virus refers to influenza A virus, which was found in 2009 chiefly in birds; thus, the risk from avian influenza was believed to be generally low to most people because these viruses did not usually infect humans. Nonetheless, because all influenza viruses have the ability to change, scientists have been concerned that HSN1 virus could one day infect humans and spread easily from one person to another. The Centers for Disease Control and Prevention has warned Americans, “Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population. If HSN1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin.” On January 10, 2018, a cluster of thirty unusual flu cases appears in the state of Perak in Malaysia. Clinical rests confirm that a new strain of the HSN1 virus has infected all thirty of these people. The population in Perak, as well as the rest of the world, has no innate immunity to this new strain. By the end of the month, at least fifteen people are dead across Malaysia, two hundred are hospitalized, and more than one thousand cases have been confirmed. Then another suspected case is discovered in Singapore.

Not knowing how bad the pandemic will be, the experts at the World Health Organization (WHO) are making every effort to stop the spread of the disease and to understand how fast this new virus can spread. Teams from the WHO are deployed to Perak and elsewhere in Malaysia to issue antiviral drugs and collect samples for testing. Despite these initial efforts, within one month cases are being reported in Singapore, Hong Kong, and mainland China. Experts realize at this point that the virus’s seven-day incubation period is allowing people carrying the virus to travel before they become symptomatic. With an incubation period significantly longer than that of any other flu strain, the virus has become capable of global spread. By March 2018, the flu has made its way around the world. By the middle of the month, about 700,000 people are already hospitalized in Japan, despite the distribution of four million doses of Tamiflu over the first week of the month to health care workers and those older than seventy-five and younger than fifteen. Although Tamiflu has not stopped the spread of the virus, it has lowered the death rate of severe cases significantly.

In the United States, the first cases are reported in Los Angeles on March 10 and in New York on March 12, despite the nation’s efforts to do health screenings of those entering the country from overseas. Despite the rapid spread of the virus, there is hope as CDC scientists in the United States isolate the H5N1 “Killer Malaysian Flu” strain that is needed to make a vaccine. They also determine that the death rate is less than 5 percent of those infected. Recently, experts have discovered that this H5Nl virus is behaving like the 1918 influenza pandemic, which killed 50 million to 100 million people around the globe. One study that extrapolates from the severe 1918 pandemic finds that, in the absence of intervention, an influenza pandemic could lead to 1.9 million deaths in the United States and 180 million to 369 million deaths globally. Like the 1918 virus, this new H5N1 virus is disproportionately killing healthy adults between the ages of eighteen and forty-four-not seniors or children. The virus seems to cause a “cytokine storm,” or an excessive amount of immune system proteins that trigger the body’s inflammation response and harm the patient in the process. As a result, the healthier the individual is before being infected, the worse off he or she may become when taken ill.

To better imagine the impact such a pandemic might have in today’s society, consider the following hypothetical. The American people are feeling the full brunt of the pandemic by April, 2018. More than 2 million people have sought hospital care. In 2011 the United States had approximately 970,000 staffed hospital beds and 100,000 ventilators, with three-quarters of them in use on any given day. Thus, in a pandemic most patients with influenza who need ventilation will not have access to it. In fact, according to recent pandemic planning models, it is estimated that in a pandemic the US health care system would be overwhelmed in seven to ten weeks and as such would need to turn away 3 to 4 million patients. In April 2018, when many of the sick find that hospitals are crowded and unable to accommodate them, they return home to be cared for by family and friends. Many people avoid public places, quarantining themselves, and are generally unable to work. Schools and other civic buildings become infirmaries, but these too become crowded in short order. Ultimately, a depression of economic activity and general slowdown of the federal government ensue. Not only is space an issue, but supplies of the antiviral drug Tamiflu are running low after an early rush of prescriptions. Even with the stockpiling of vaccines, supplies dwindle quickly. This is problematic given that production of a new vaccine takes a minimum of six months after isolation of the circulating strain. In addition, given the capacity of all the current international vaccine manufacturers, supplies during those next six months are limited to fewer than 1 billion doses worldwide. Since two doses are required for protection in this case, fewer than 500 million people-approximately 14 percent of the world’s population-can be vaccinated.

Owing to our “just-in-time delivery” economy, the United States has no surge capacity for health care, some food supplies, and many other products and services. Consequently, the global health impact of this sort of influenza pandemic can be expected to affect workforces, transportation systems, and supply chains. Critical supplies such as food, water, decongestant drugs, and other cold/flu medications are scarce in some regions, particularly urban areas. Doctors and nurses, emergency medical personnel, teachers, and police and fire personnel are among the many who are getting sick themselves or staying home to care for sick family members. Businesses throughout the country are reporting significant increases in absenteeism, and absentee rates are expected to be between 20 and 40 percent across all sectors. A CDC model has predicted that at the peak of a pandemic about 10 percent of the workforce will be absent owing to illness or the need to care for an ill family member. By the end of April 2018, about 250,000 Americans are dead from the flu. In the worst-case scenario, it is assumed that with an attack rate of 30 percent and a case fatality rate of2.5 percent, a severe pandemic would cause the death of more than 1 million labor force participants. The Killer Malaysian Flu rages on in the West through May and June. The pandemic circles the globe in three distinct waves through the winter of 2018-2019. By the end of the pandemic in June 2019, almost one-third of all Americans (about 90 million people) have been infected. Of those infected, 50 percent (about 45 million) have required outpatient medical care, 9.9 million have been hospitalized, about 1.5 million have been in an ICU, 740,000 have required mechanical ventilation, and about 2 million have died.

Although a vaccine has finally been produced by the end of  June 2018,  it is a race at this point to produce enough vaccine to stop a second wave at the start of the traditional flu season later in the year. If all goes well, sufficient quantities of vaccine should be available by midsummer-about six months after the start of the pandemic. Soon 40 million doses of the vaccine are being produced every month, but there continue to be shortages owing to the fact that more than one dose is necessary per person for adequate protection. Governments must decide who should get the vaccines first: The young? The workforce? Health care employees? In developing countries, where the vaccine is in even shorter supply, only the rich receive doses. Those who are not given first shot at the vaccines are left to rage at the inequity and fear the coming winter. Some people hunt desperately for doses of the vaccine on the black market or across international borders.

Ethical Issues to Consider in a Pandemic

In the worst-case scenario imagined above, hundreds of thousands of people in the United States could die in a period of months during a pandemic of highly pathogenic influenza. The circumstances anticipated during a severe influenza pandemic highlight the shortage of health care personnel, equipment, and vaccines necessary to meet the needs of all the critically ill patients. It is highly likely that in such a scenario the entire country would face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. As mentioned earlier, a severe pandemic will challenge almost every sector of society-the health care sector, the labor force, transportation, banking, and law enforcement, to name a few.

In addition, disasters as intense as a pandemic are sure to present many ethical dilemmas that affect decisions by federal, state, and local officials, even those who have pandemic influenza response plans and guidance documents. The most critical ethical issues that will arise during a severe influenza pandemic include: health workers’ duty to provide care during a communicable disease outbreak; allocation of scarce resources; and conceivable restrictions on individual autonomy and liberty in the interest of public health through public health management measures such as quarantine and border closures. These issues are the subjects of the following
three short scenarios.

A successful response to an influenza pandemic will depend in large part on the skills, attitudes, and efforts of health care workers. Faced with a very serious disease for which there may be no absolute protection or cure, health care workers will find themselves facing potentially overwhelming demands: that they work in a more hazardous environment with greater exposure to disease and the risk of infection; that they put in extra hours to care for the increasing number of patients; that they cover for workers who are ill; that they work outside their normal scope of practice; and that they be prepared to move their services to where they are most needed, including temporary facilities.  Health care workers will be forced to weigh their duty to provide care against competing obligations, such as their duty to protect their own health and that of their families and friends. Initially, primary care and emergency service workers will take the brunt of the demands posed by a pandemic flu and therefore will bear a disproportionate risk compared to more specialized care providers. Given the high risks to which health care workers and their families are exposed, is it reasonable to demand that they put their lives on the line in the case of a pandemic, or must they provide care because they have an ethical and professional duty to care for the sick regardless of the environment or risk?

Inherent in all codes of ethics for health care professionals is the duty to provide care, to respond to suffering, and to do no harm. It is assumed by society that health care professionals, because of their training, knowledge, and commitment to care for the sick and injured, have a moral and professional obligation to provide health care at all times, even during an influenza pandemic. Bioethicists argue that if health care workers are expected to take on these higher risks, there is an equally strong, reciprocal obligation by society (in particular, health care organizations) to protect and support these workers by giving them the highest priority for vaccinations, providing personal protection equipment, and making disability insurance and death benefits available to workers and their families. What is critical is that pandemic preparedness plans provide clear guidance for health care workers on such issues as their rights and responsibilities in the event of a pandemic influenza. The first scenario addresses this issue of health care professionals’ duty to care.

Scenario 1: Duty to Care

Media outlets are reporting that the World Health Organization has officially determined that a pandemic influenza is now under way. The Centers for Disease Control and Prevention has confirmed person-to-person spread in several US cities. Local media are reporting increased demand for emergency room and family physician office visits. Some deaths have been reported, but no one is really certain how serious the problem may be. Little is known about the actual virus at this point. Maria is a thirty-five-year-old family physician and the mother of three children ages four to eight. She is one of twelve doctors practicing in a primary care clinic in El Paso, Texas. Her husband works in an accounting firm. When her husband hears the media reports, he becomes concerned that Maria may become ill or bring illness home to her family because of her increased exposure at work. He encourages her not to go to work. Maria is concerned about how to care for her children, who attend a local day care center. She is also worried about abandoning her patients and increasing the workload of her colleagues, many of whom, like her, have young families.

Please complete Scenario 1: First Set of Questions

Maria decides she will go to work, though she is concerned that her clinic lacks the appropriate amount of protective equipment. The clinical group meets and decides that they are committed to providing care to people with influenza, but will only do so if appropriate protective equipment is provided by the clinic or the state department of health. One of Maria’s colleagues is close to retirement and also has diabetes and heart disease. He tells the clinic that he will not come to work, as he feels the risk to his own health is too great. Within two weeks, the influenza pandemic is well advanced, and many people are sick, including a large number of health care workers. Many health care providers in hospitals and clinics are refusing to show up for work because they fear infection.

Please complete Scenario 1: Second Set of Questions

If a flu pandemic is as severe as some fear it could be, an extraordinarily high number of sick people around the world will require care, all at the same time and on top of the “normal” demands for health care that often strain medical systems at the best of times. During a pandemic, the human and material resources of health care will be rapidly overwhelmed. There will be scarcities of medicines, equipment, and health care workers in all countries, and less-developed nations will face some of the greatest scarcities. Many of the sick are likely to recover with minimal assistance, but others will be seriously ill and unable to survive without prolonged hospitalization, diagnostic facilities, multiple drugs, access to scarce resources such as mechanical ventilators, and well-trained staff.

During a severe influenza pandemic, there will be a critical shortage of mechanical ventilators, or breathing machines. The US National Vaccine Program Office stated that in a future severe pandemic, “intensive care
units at local hospitals will become overwhelmed, and soon there will be widespread shortages of mechanical ventilators for treatment of patients with pneumonia.” According to one estimate, a pandemic will require 198 percent of the current supply of ventilators. If this happens, many people in respiratory failure due to influenza or other injury or illness who need mechanical ventilation in order to survive will not receive it. This grave shortage of ventilators will raise unprecedented allocation dilemmas for health care professionals and have a significant impact on individuals and families.

As such, once the federal government declares a public health emergency, the individual disease management decisions of physicians and patients would be subordinated to the larger public health goals of reducing infection, illnesses, and deaths. Decision-makers will need to consider the well-being of the community as a whole while balancing obligations to individuals and individual needs. They will need to decide who will receive vaccines, antiviral drugs, ventilators, and other forms of care, and who will not. It is expected that decision-makers will use priority-setting processes, also known as rationing or resource allocation, with guidance from federal, state, or local pandemic planning documents and guidelines. Consequently, current societal expectations about access to health care will have to change in light of a public health crisis of such major proportions.

Already there are signs of a public debate over choices. For example, when there are shortages of equipment like ventilators and beds in intensive care units, health providers typically ration on a first-come, first-served basis; however, during a pandemic such rationing will likely be done on a different basis-that of saving the greatest number of lives. In most emergency rooms, medical need-those patients who are the worst off and in greatest need-determines which patients are treated first. During a pandemic, saving the greatest number of lives may take priority over patient autonomy. The goal of helping those most in need will clash with the goal of minimizing deaths. Patients with respiratory and multi-organ failure and those whose condition deteriorates over the first few days of treatment have a poor prognosis, so they are most in need. But treating these patients will increase the total number of deaths because their use of a ventilator for many days will preclude the
treatment of other patients who need a ventilator for a few days and have a greater chance of survival. Although such choices are justifiable, it would help to build public support by discussing these issues in an open and transparent manner before a pandemic occurs. The second scenario highlights some of the ethical challenges in the allocation of scarce resources during a pandemic.

Scenario 2: Priority-Setting in an Intensive Care Unit

The Regional Hospital is a major trauma center with a large emergency department and intensive care unit (ICU).  During a pandemic influenza crisis, Regional’s ICU is filled to capacity with patients suffering from life-threatening medical conditions, including complications from influenza-like bacterial pneumonia. The emergency department calls the ICU seeking to admit Mr. Smith, who has been brought to the emergency room with a severe but potentially reversible brain injury after an automobile accident. One alternative is to move one of the current ICU patients to a medical unit in order to make room for Mr. Smith. However, the ICU staff report that all of their patients need ventilator support, and there are no other ventilated beds available in the hospital. Another alternative is to send Mr. Smith to another unit in the hospital. However, given Mr. Smith’s injuries, it is clear that this would overtax the clinical capabilities of the hospital staff who are not trained in critical care and most of whom are already struggling to care for other patients. The final alternative is to transfer Mr. Smith to another health care facility. However, the influenza pandemic has overwhelmed all hospitals in the region, and no ICU beds are available anywhere else.

Please complete Scenario 2: First Set of Questions

An ICU patient passes away. A bed is now available in the ICU for Mr. Smith. Just as his transfer is about to be made, an ICU nurse named Ms. Brown is admitted with severe difficulty breathing. It is determined that she
has been infected with the influenza virus, which she may have contracted while caring for patients in the hospital’s ICU. She needs immediate ventilation support, which is only available in the ICU bed designated for, but not yet occupied by, Mr. Smith. It comes to light that Mr. Smith has aging parents at home who rely on him for help with activities of daily living. Though not a long-standing employee of the hospital, Ms. Brown is well respected by her coworkers.

Please complete Scenario 2: Second Set of Questions

Until a new flu vaccine is developed or other medications are found that can abate the severity and spread of pandemic flu, restrictive measures may be one of the important public health tools to reduce the spread of this
communicable disease. Governments may need to limit three basic personal freedoms that we take for granted: (1) mobility, (2) freedom of assembly, and (3) privacy. For example, public health officials may close schools, cancel public gatherings and sporting events, and impose quarantine, isolation, and even detention where needed in order to manage the spread of the disease. A major flu pandemic could result in very large numbers of people being subjected to such measures, which would impose a heavy burden on those most directly affected. People might be cut off from family, friends, work, shopping, entertainment, travel, and most other activities, including some forms of medical care. People might feel stigmatized if they are put into quarantine or identified as being affected by pandemic flu.

Research conducted in the aftermath of the 2002-2003 SARS epidemic showed that people understood and accepted the need for restrictive measures to control the spread of a communicable disease. However, the research also indicated that if decision-makers expect full compliance with restrictive measures, they need to make their decisions in a fair manner, and those affected by such measures need to support the decisions and conditions. Reciprocity requires that society ensure that those affected receive adequate care and do not suffer unfair economic penalties. The University of Toronto Joint Centre for Bioethics provides the following
recommendations to decision-makers: If leaders expect people exposed to or suffering from communicable diseases to act in a manner that does not put others at risk, it is important that they create a social environment that does not leave people without supports. For example, if quarantine is implemented, governments should ensure that people have adequate food supplies and are able to carry out essential functions. Their jobs should be protected, and they should not suffer an undue financial burden. In the event of a severe pandemic influenza, people in the United States can expect quarantines, but they may also face the possibility of other measures to contain the disease, including mandatory vaccination, surveillance cameras, monitoring devices, and even imprisonment for people who fail to comply with quarantine orders.

Scenario 3 discusses the ethical dilemmas that arise when a quarantine is imposed.

Scenario 3: Measure that Restrict Liberty and Freedom

With the WHO’s official determination that an influenza pandemic is under way, the Department of Health and Human Services reports that influenza is confirmed to be spreading in the United States and that several deaths have occurred; further, with large-scale public vaccination programs remaining weeks away, public health officials are strongly recommending the immediate implementation of some restrictive measures to help slow the spread of the infection. Soon many localities have closed community centers and schools and canceled all large public gatherings and events.

One family does not receive this information, which is released just when their daughter, sixteen-year-old Maria, has been killed in a car accident. Information about the closings is disseminated in the English media, and this family does not ordinarily watch TV or listen to the radio in English. Sponsored by her twenty-four-year-old sister Diana to come to the United States, Maria, her brothers Raul and Marcos, and her parents arrived from Colombia less than a year ago, and they all speak little English. The family holds a large memorial service for family and friends the following day. Few people fail to show up because most of them, although they have heard the order by authorities, think that the cancellation of large public gatherings applies to social events, not to a funeral, which is a sacred rite to honor the passing of a loved one. Moreover, the tragedy of this untimely loss overshadows everyone’s concern about a disease outbreak whose seriousness remains unknown. There have been no reported deaths from influenza in their immediate community. Over two hundred people attend the funeral for the young woman.

Please complete Scenario 3: First Set of Questions

Immediately following the funeral, state public health authorities issue an order requiring everyone who attended the funeral to stay home for a period of seven days, even though there is still little information about the virus or the extent of the outbreak. Diana wonders whether this is feasible, as her family depends on her income as a sales associate at a local box retailer. Diana started this position as a part-time job and was promoted in the last month to a full-time position, which has enabled her to start receiving health care benefits. Thus, she has no sick leave accrued and cannot take time off from work without losing income. She decides to go to work, where she will be checking out customers, in spite of the order, while the rest of her family stays home.

Please complete Scenario 3: Second Set of Questions

Three people who attended the funeral are showing symptoms of influenza, and one person has died from it. Although Diana is aware that the outbreak has now hit close to home, she can’t see how it would be possible for her not to go to work. After she continues to ignore the order, public health officials detain Diana. Her family is left with no income and stranded at home with little food.

Please complete Scenario 3: Third Set of Questions
Ethical Principles

Ethical Principles: Individual liberty includes some of the basic rights that we value in our society, such as freedom of movement. In an influenza pandemic, restrictions on individual liberty, such as isolation or quarantine, may be necessary to protect the public from serious harm. In addition, some taking of private property may be necessary. Restrictions and takings should:
•    Be necessary given the nature of the influenza pandemic;
•    Employ the least restrictive means needed to protect the public; and
•    Be applied equitably to similarly situated individuals irrespective of race, color, religion, nationality, ethnicity, gender, age, disability, sexual orientation, geography, economic status, or insurance status, unless there are specific clinical reasons why different groups should be treated differently.

Protection of the public from harm: Protecting the public is a fundamental social value. To protect the public from harm and to protect public health, governmental authorities may be required to take actions that impinge on individual liberty, such as quarantine or isolation. In making these determinations, decision-makers should:
•    Balance the harm to the public that could arise if no action is taken with the harm to the individual(s) that could result if action is taken;
•    Provide reasons and/or incentives to encourage voluntary compliance;
•    Employ the least intrusive means needed to protect the public and ensure that the basic necessities of the people subject to quarantine or isolation are being met;
•    Discontinue protections as soon as circumstances permit; and
•    Specify penalties that will be used to address noncompliance (e.g., jail or fines); and

Proportionality: Restrictions to individual liberty, or other measures taken to protect the public from harm, should not exceed what is necessary to address the actual level of risk to or critical needs of the community. Inherent to all codes of ethics for health care professionals

Duty to provide: Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care professionals, because of their training, knowledge, and commitment to care for the sick and injured, have a heightened obligation to provide health care during an influenza pandemic. Licensed health care professionals have a heightened responsibility to care for the ill because of the special privileges and monopoly conferred on licensed health care professionals. This obligation exists even in the face of increased risk to the health care professional’s health or safety. However, health care professionals need to balance their ability to meet the health care needs of individual patients during an influenza pandemic with their ability to care for patients in the future. Health care organizations, and society at large, owe support (reciprocity) to health care workers who may be putting themselves or their families at increased risk during an influenza pandemic.

Reciprocity: Certain individuals will be called upon to bear a disproportionate risk to their health or life in the response to an influenza pandemic, including health care professionals and other health care workers, emergency management workers and other first responders, and workers in other critical industries or key professions. Reciprocity requires that society support those who face a disproportionate burden in protecting the public and rake steps to minimize this burden as much as possible. In some instances, reciprocity may require additional compensation, services, care, or special considerations for disproportionately burdened individuals.

Equity: Values of distributive justice and equity stare that all people have equal moral worth. However, during an influenza pandemic, it may be the case that not all individuals are able to receive all of the health care services they need. Difficult decisions will have to be made about whom to treat and about which health care services to provide and which to defer. Depending on the severity of the health crisis, some individuals may not be able to receive all the health care services needed to treat the flu (such as ventilators). Others may not be able to receive elective surgeries, emergency care, or other necessary services. Decisions about whom to treat and access to needed health care services during an influenza pandemic should not be based on an individual’s race, color, religion, nationality, ethnicity, gender, age, disability, sexual orientation, geography, economic status, or insurance status, unless there are specific clinical reasons why different groups should be treated differently. Furthermore, equity concerns may arise in decisions orher than treatment. For example, equity issues may arise if certain health care workers are not required to work during a pandemic (e.g., pregnant women or single parents) or if cerrain workers are required to work longer hours or remain at the worksite.

Trust: Trust is an essential component of the relationships between clinicians and patients, staff and their organizations, and the public and governmental organizations. Decision-makers will be confronted with the challenge of maintaining the public’s trust while simultaneously implementing various control measures during an evolving health crisis. Trust is indispensable for expectations of compliance. Trust is enhanced by transparency in decision-making, equity in the application of restrictions and/or allocation of limited resources, and reciprocity toward those with an increased burden.

Collaboration Response to an influenza pandemic requires collaboration and cooperation within and between governmental officials and organizations, government, public and private health care institutions, health care professionals, other public and private organizations, and individuals. It calls for approaches that set aside narrow self-interest or territoriality.

Please complete the Ethical Discussion Questions

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