Apart from the seasonal influenza epidemics caused by antigenic drifts, a significant change in the virus's virulence through antigenic shifts has been a major source of concern for healthcare professionals. These new strains may reach pandemic proportions. Predicting the next outbreak is an impossible task but historically, the longest period between two outbreaks has been forty one years and it usually occurs every 30-40 years. An outbreak can reach pandemic proportions in as little as 6-month's time, or even lesser. This fast spread can be attributed to globalization and urbanization. Countries, such as Bangladesh or Indonesia, where overcrowding is common, can prove to be a haven for the emergence of new strains, but it may still be irrational to predict where the next pandemic may originate from. Two out of the last four strains originated from Southeast Asia and the most recent outbreak of 2009 was from Mexico. (Tam & AW, 2003)
The possibility of a pandemic flu outbreak is a very scary thought for everyone, but especially the members of the healthcare team that will be put in the frontlines to care for the infected. Previous flu pandemics have raised several questions regarding humanitarian laws and equality. The possibility of such an occurrence again has been followed by an ethical debate: what are the duties of a healthcare worker responsible for care during a flu outbreak, how will the healthcare team respond if resources are scarce, and who will make these decisions. (Lewis, 2009) The aim of this article is to discuss the ethical and legal issues regarding such a scenario.
A pandemic is a state of a world wide emergency, which should allow every individual an equal access to the different modes of healthcare, such as vaccines, drugs and other supportive measures. In March 2006, the World Health Organization allocated staff members to develop preliminary conclusions on key issues regarding pandemic preparedness and response measures. The members of the board consisted of experts in ethics, WHO staff, country representatives, and law and public health members. The conclusions were published and distributed to health professionals. The first and foremost issue discussed in this panel is regarding equity and the handling of resources, which includes vaccines, antiviral medications, ventilators and other scarce materials. (Addressing ethical issues, 2008)
With the production of a vaccine, there is always an initial period of scarcity after which its production may meet demands. Vaccines are preventive and therefore it would be fair to say that the first and second line healthcare professionals should be the first to receive it. (Addressing ethical issues, 2008) Who should be the second group of people to receive the vaccine is an ethical dilemma. If an immune-compromised patient without exposure has the same risk of developing the flu as an immune-competent subject who has been exposed, who should receive it first. In an efficient system, isolation of high risk subjects and educated decisions about who will benefit most can answer these questions.
However, the con side of the argument focuses on the few people who will be refused the vaccine due to the low possibility of benefit. This may also present as a legal issue that concerns the surviving family member of a sick patient who was refused care because of their low chance of survival. This family member may think they have a basis to sue the facility that refused care. (Lewis, 2009)
When discussing vaccines in particular, during the initial phase of an epidemic, there may also be a disparity between rural and urban health care centers. Tertiary care facilities in urban set-ups are more likely to receive the vaccines first. Such an inclination may be based on the focus of saving as many lives as possible, which can be unfair to patients who do not have access to such facilities, either because they are too sick to reach it or can not reach it on time. (Addressing ethical issues, 2008)
A vaccine being a preventive measure takes time to be produced. During this time lag, antiviral drugs maybe the only specific treatment and prophylactic. Even though such drugs may not be completely curative, they do decrease the possibility of developing complications. Current guidelines recommend the use of Oseltamivir for up to 8 weeks as a prophylactic measure during pandemics of Influenza. Post-exposure use of this drug should be started immediately, following exposure, for 7-10 days. Apart from a few diseases, viral illnesses are usually self-abortive and so the use of antiviral drugs is not a routine practice. Therefore, during a pandemic, production of these drugs may not meet consumption demands. The only option in this case is to stockpile them in advance. However, this may not be feasible in most cases because when pandemics do occur after 30-40-year periods; most of these stored supplies will be expired and unfit for use. (Addressing ethical issues, 2008)
There are also discrepancies between high and low income countries regarding resources. Most high income countries have signed contracts with pharmaceutical companies for reservation of drugs and vaccines, so that they may receive it as soon as they are produced. Low income countries have no such contracts. This raises the issue of international aid and justice. In case of scarce resources, most high income countries may be unwilling to help lower income countries due to preference of their own citizens. (Addressing ethical issues, 2008)
Another major ethical concern, when discussing scarce resources, is the issue of limited critical care facilities. During outbreaks of serious contagious illnesses, hospitals flood with a great number of patients, most of which require critical care support. With limited beds in the Intensive Care Unit and only a few ventilators, the question of who to save comes into play. Patients that are immune-compromised, such as the elderly and those already suffering from an underlying chronic disease have a higher possibility of complications and a greater mortality rate. These patients usually need longer hospital stays and the greatest amount of intervention. In the face of an outbreak, most of these patients are refused care due to their low chances of survival. Apparently healthier subjects need lesser hospital stays and therefore, the resources utilized by these patients are mobilized earlier. (Addressing ethical issues, 2008)
This raises a great public concern on who will benefit from policies regarding prioritization and who will not. In a study conducted on the general public's opinion regarding such an ethical concern, a great majority expressed the opinion that every individual has the right to appropriate health care from a healthcare professional. Another starring point made by some respondents was that scarcity should be taken as a 'given', and that even though some participants will not receive the critical care they need, the responsibility would be to provide them the next best healthcare facility. Considering the issue of prioritization, most participants displayed a similar view, "do the best good for the most people." (Silva et al., 2012)
Priority settings in healthcare have been a controversial issue for centuries. This problem has caused unease amongst the general population, especially when the possibility of a pandemic illness is in question. Three core ethical principles need to be discussed when arguing on how to handle scarce resources. These principles include: efficiency, equity, and procedural fairness. Efficiency can be simply defined as making the greatest use or saving the greatest number of lives out of a given set of reserves. Healthcare workers, medicines and other raw materials are all predictors of efficiency. On the other hand, caring according to need is equity. This means that sicker patients should be provided greater care. By prioritizing individuals, unfairness and discrimination is minimized. Lastly, procedural fairness is based on the principle that all healthcare workers are publically accountable. These three principles help to rationalize many ethical decisions and promote transparency. (Addressing ethical issues, 2008)
Policies regarding mobilization of the healthcare team and resources cannot wait for the next pandemic. These ethical and legal dilemmas also need to be discussed with the general population in order to gain public trust. While it is often accepted that such ethical issues be dealt by experts on the matter, collecting public opinion through surveys, like the one mentioned above, and maintaining transparency can help build trust and thus, enhance compliance. Policy makers may argue that such openness may produce unnecessary anxiety, but according to Kotalik (2005, p 430), it does not justify a lack of transparency. When preparing to develop policies, it is important to address to the methods that may be taken to promote transparency, such as allowing public opinion.
Measures taken to allow public engagement may occur along a spectrum. At one end, the public is simply informed of the policy, either before or after they come into play. At the other end of the spectrum, the public is given the power to allow or withhold permission for the policies to be implemented. At this extreme, the public is a "partner" in the development of a legal framework. Another idea would be to…