Addressing ethical issues in pandemic influenza planning

WHO/HSE/EPR/GIP/2008.2
WHO/IER/ETH/2008.1
Addressing ethical issues
in pandemic in?uenza planning
DISCUSSION PAPERS
EPIDEMIC AND PANDEMIC
ALERT AND RESPONSE

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WHO/HSE/EPR/GIP/2008.2
WHO/IER/ETH/2008.1
Addressing ethical issues
in pandemic in?uenza planning
DISCUSSION PAPERS

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Contents
Acknowledgements
iv
Introduction
v
I
Equitable access to therapeutic and prophylactic measures
1
II
Isolation, quarantine, border control and social-distancing measures
29
III
The role and obligations of health-care workers during an outbreak of
pandemic in?uenza
67
IV
Pandemic in?uenza planning and response – transnational issues for governments
87
iii

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Acknowledgements
This document grew out of the WHO project on
First and foremost, we would like to thank the
“Addressing ethical issues in pandemic prepared-
chairs of the WHO working groups on ethical issues
ness and response”, jointly led by the Department
in pandemic in?uenza, Robert Archer, Larry Gostin,
of Ethics, Equity, Trade, and Human Rights and
Ross Upshur, and Marcel Verweij, who prepared
the Department of Epidemic and Pandemic Alert
the reports. Further, we would like to acknowledge
and Response. It was edited by Carl Coleman,
the essential contributions of the members of the
Alice Croisier, and Andreas Reis, under the overall
working groups to this project (see Annexes).
guidance of Marie-Charlotte Bouësseau and Keiji
The editorial guidance of Ana Estrela and
Fukuda.
Rosamund Williams are gratefully acknowledged.
The creation of this volume would not have
Finally, WHO thanks the Swiss Federal Of?ce
been possible without the participation of numer-
of Public Health for their generous support in this
ous individuals.
project.
iv

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Introduction
In March 2006, the World Health Organization
(United States of America). This chapter explores a
(WHO) convened four working groups to review
broad range of non-pharmaceutical public health
the literature and develop preliminary conclusions
interventions, including surveillance, personal and
on key ethical issues in pandemic preparedness and
community hygiene, health facility infection con-
response. The working groups included experts
trol, isolation and quarantine, social distancing,
in ethics, law, and public health, WHO staff, and
and international travel and border controls. The
country representatives. This volume includes the
authors emphasize that these interventions must be
background papers prepared by the chairpersons in
implemented within the context of internationally-
consultation with their working group members.
recognized human rights principles, including those
In chapter I, Marcel Verweij of Utrecht Univer-
protecting freedom from arbitrary arrest, the right
sity (Netherlands), chairperson of the working
to movement, right to nondiscrimination, and the
group on “Equitable access to therapeutic and
right to health. According to the Siracusa Principles,
prophylactic measures”, explores the challenge
interventions that interfere with human rights must
of allocating vaccines, antiviral medications, ven-
be in accordance with the law; based on a legiti-
tilators, and other scarce resources during a pan-
mate objective; strictly necessary in a democratic
demic. He identi?es three key ethical principles to
society; the least restrictive and intrusive means
guide such allocation decisions: ef?ciency, equity,
available; and not arbitrary, unreasonable, or dis-
and procedural fairness. While the principle of ef?-
criminatory. In addition, principles of public health
ciency can be interpreted in multiple ways, Dr Ver-
ethics emphasize the importance of distributive
weij argues that the most defensible approach to
justice, transparency, and promoting public trust.
ef?ciency in the context of a pandemic is to focus
The authors highlight the importance of mitigat-
on saving the greatest number of lives. The princi-
ing the privacy and autonomy risks of public health
ple of equity requires efforts to avoid discrimina-
interventions, providing due process protections to
tion, minimize unfairness, and prioritize individuals
individuals whose liberty is restricted, and favour-
who are most likely to die without intervention. In
ing voluntary compliance over coercion as much as
addition, the “fair innings” approach to equity sug-
possible.
gests that it might be appropriate to give priority
In chapter III, Ross Upshur of the University of
to younger persons over older persons, although
Toronto (Canada), who served as chairperson of
such an approach is likely to be controversial in
the working group on “Role and obligations
many countries. Finally, procedural fairness requires
of health-care workers during an in?uenza
policy-makers to ensure that prioritization deci-
pandemic”, discusses the importance of ensuring
sions are made pursuant to impartial procedural
adequate numbers of health-care workers during
mechanisms, that decision-makers are publicly
a pandemic. He notes that, while most health-care
accountable, and that the decision-making process
workers provided exemplary service during the
is designed to promote public trust.
severe acute respiratory syndrome (SARS) crisis of
Chapter II is written by Larry Gostin, chairper-
2003, some failed to report for duty. In addition,
son of the working group on “Isolation, quar-
surveys of health-care workers’ attitudes re?ect
antine, border control, and social distancing”
a substantial reluctance among many workers to
and Ben Berkman, both of Georgetown University
provide care for patients during infectious disease
v

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ADDRESSING ETHICAL ISSUES IN PANDEMIC INFLUENZA PLANNING
outbreaks. Dr Upshur argues that a duty to work
in pandemic preparedness and response efforts to
during infectious disease outbreaks should be
further their national interests or based on an ethi-
considered an ethical obligation for professional
cal sense of solidarity. Governments must balance
health-care workers. He also emphasizes that gov-
their commitments to the international community
ernments and health-care institutions have recipro-
with their primary obligation to protect the health
cal obligations to make the workplace as safe as
and safety of their own populations. Mr Archer
possible and to provide care and support for work-
explains the importance of international coopera-
ers who become ill. He urges societies to adopt
tion before, during, and after a pandemic.
measures to encourage health-care workers to
Together, these four background papers pro-
work voluntarily during a pandemic, and cautions
vided the framework for the discussion at the
against the imposition of sanctions on health-care
WHO global consultation entitled “Addressing
workers who are unwilling to work.
ethical issues in pandemic in?uenza planning
Finally, in chapter IV, Robert Archer, chairperson
and response” held in October 2006, as well as
of the working group on “Pandemic in?uenza
for the publication that grew out of that consulta-
planning and response – transnational issues
tion, “Ethical considerations in developing a public
for governments”, explores the role of interna-
health response to pandemic in?uenza”.1 This vol-
tional cooperation in pandemic preparedness and
ume is intended to complement that publication
response efforts. He notes that international law
by providing a more comprehensive analysis of the
and human rights principles require countries to
ethical and policy issues which WHO considered in
help one another during public health emergencies.
its deliberations. WHO is grateful for the working
Governments also may be motivated to cooperate
groups’ scholarship and insights.
1
“Ethical considerations in developing a public health
response to pandemic in?uenza”. Geneva, World Health
Organization, 2007, available at: http://www.who.int/csr/
resources/publications/ WHO_CDS_EPR_GIP_2007_2c.pdf
vi

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I
Equitable access to therapeutic
and prophylactic measures
Marcel Verweij, Utrecht University
ON BEHALF OF WORKING GROUP ONE
1

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Contents
1.
Aim and context
5
2.
Ethics and scarcity in a pandemic – general considerations and principles
6
2.1
Circumstances
6
2.2
General principles for priority setting: ef?ciency, equity, and procedural fairness
7
2.3
Ef?ciency
7
2.4
Equity
9
2.5
Accountability: fair procedures, public consultation, and trust
11
3.
Antiviral drugs
13
3.1
Background, circumstances and main questions
13
3.2
The use of antivirals in a pandemic: general objectives
13
3.3
Stockpiles and availability of antiviral drugs
14
3.4
Priority targets and groups
15
4.
Priority setting in therapeutic care
16
4.1
Background, circumstances and main questions
16
4.2
Objectives and principles
16
4.3
Triage of mechanical ventilation
16
4.4
Allocating hospital beds
18
5.
Vaccination
20
5.1
Background, circumstances and main questions
20
5.2
Ethical considerations for vaccination priorities
20
5.3
Research and safety considerations
21
6.
Conclusions
23
References
26
Annex
Members of Working Group One
28
3

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