Ethical Issues in
Pandemic Influenza Planning
CDC Avian Influenza Training
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Learning Objective
• Understand ethical considerations pertaining to
pandemic influenza preparedness and response
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Session Overview
• General and specific ethical considerations in
public health
• Public engagement
• Planning and resources
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General and Specific Ethical
Considerations in Public Health
http://www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf
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What are Public Health Ethics?
• A set of principles based on values and beliefs which
underlie the principles of public health ethics
• A guide to actions to promote health and prevent
injury and disease in the population
• Processes to clarify, prioritize, and justify possible
courses of public health action based on ethical
principles
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Values and Beliefs
“Everyone has the right to a standard of living
adequate for the health and well-being of himself
and of his family.”
Universal Declaration for Human Rights, Article 25
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12 Principles of the Ethical Practice of
Public Health
1. Address the fundamental causes of disease and
requirements for health
2. Respect individual rights in the community
3. Ensure an opportunity for community input
4. Empowerment of disenfranchised
5. Seek information for effective policies and
programs
6. Provide community with information
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12 Principles of the Ethical Practice of
Public Health
7. Act in a timely manner
8. Incorporate a variety of approaches and
respect diversity
9. Enhance physical and social environment
10. Protect confidentiality
11. Ensure professional competence
12. Collaborate to build trust and effectiveness
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Benefits of Public Health Ethics
• Build and maintain credibility and public trust in your
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agency
Foster consensus and resolve value conflicts in an
atmosphere of respect
Guide decisions when there is scientific uncertainty
and varying opinions on how to proceed
Increase awareness of the rights of participants and
communities in public health activities
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General Ethical Considerations
• Identification of overall goals
• Planning
• Decision-making
• Preparedness
• Use of scientific information
• Global preparedness
• Balance of individual liberty and community interests
• Procedural judicial mechanism
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Question 1
Fill in the missing words in the following
definition of public health ethics:
“Processes to _____, _____, and _____ possible courses
of public health action based on ethical principles,
stakeholder values, and scientific information”
A.
B.
C.
D.
Initiate, carry through, complete
Clarify, prioritize, justify
Examine, accept, publicize
Identify, change, promote
Answer: B. Clarify, prioritize, justify
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Question 2
Which of the following is NOT one of the 12
principles of public health ethics?
a.
b.
c.
d.
Act in a timely manner
Provide community with information
Protect individual rights over the community
Enhance physical and social environment
Answer: c. Protecting individual rights over the
community is NOT one of the 12 principles.
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Identification of Overall Goals
• Minimize serious influenza-associated complications
• Preservation of the functioning of society
Priorities favor those who are responsible for
provision of health care, public safety and
functioning of key aspects of society
• Centralization of decision making authority
To ensure equity in decision making and address
need to preserve functioning of society across
communities
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Planning and Decision-Making
• Planning
A commitment to transparency throughout the
pandemic influenza planning and response processes
• Decision-making
Public engagement and involvement
Public as partner throughout planning and decisionmaking
Particular attention to vulnerable or marginalized
members of society
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Preparedness
Responsibility to maximize preparedness to
minimize the need for allocation decisions later
•Proactive planning
•Develop response strategies
Training of staff
Development of decision making rules in advance
of pandemic
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Use of Scientific Information and Global
Preparedness
• Sound guidelines should be based on the best
available scientific information
• Importance of working with and learning from
global preparedness efforts
Not merely to benefit U.S. citizens
Recognition of common good and global
interdependence
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Balance of Individual Liberty and
Community Interests
• Follow three guiding principles:
Adopt least restrictive practices
Ensure that restrictions are necessary and proportional
to need
Ensure that those affected receive support from the
community
• Involve diverse public representation in defining
restrictions and articulating justification for these
restrictions
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Procedural Judicial Mechanism
Elements of an ideal procedural justice approach:
 Consistency of standards across people and time
 Impartial and neutral decision makers
 Adequately reasoned decisions based on accurate
information
 Assurance that those affected by decisions have a voice in
decision-making and agree to the proposed process
 Clear communications with no hidden agendas
 Revision process when new information is available
 Process for appeals
 Procedures that are sustainable and enforceable
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Question 3
What important ethical balance needs to be
maintained during a pandemic?
a. Prevention vs intervention
b. Individual liberty vs community interests
c. State vs. Federal powers
d. Vaccination vs quarantine
Answer: B. Individual liberty (personal
freedoms) vs. community interests (public health)
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Specific Ethical Issues
• Allocation of scarce resources
• Community mitigation measures
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Allocation of Scarce Resources
Distribution plans should specify:
What scarce goods are involved?
Who (or what agency) will decide about
prioritization and distribution ?
What mechanism will be used for disputes or
appeals?
Who is eligible to be a recipient ?
What criteria will be used to assign higher or lower
priorities to groups of individuals ?
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Community Mitigation Measures
Social Distancing
• Isolation of ill individuals
• Quarantine of personsexposed to ill individuals
• Closure of schools, day care centers, businesses,
public venues, and cancellation of large public events
Alternative work practices/schedules
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• Limiting travel
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Community Mitigation Measures (cont.)
Liberty limiting measures should be voluntary
and balanced with protection of individual rights:
• No unwarranted invasions of privacy
• Maintain confidentiality of private information
• Restriction on personal freedom should be
equitably applied
• Avoid an unequal burden being placed on
specific individuals or groups
• Protect against stigmatization
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Community Mitigation Measures (cont.)
• Ensure that necessary support services (e.g.,
food, water and other essential services) are
provided to the impacted population
• Take into account needs of vulnerable
populations (e.g., the elderly, handicapped)
• Establish appeals process for those affected by
the liberty limiting measures
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Question 4
What are two individual rights which must be protected
when liberty limiting measures are put into place?
(choose two)
a.
b.
c.
d.
No unwarranted invasions of privacy
Restriction on personal freedom
Maintain confidentiality of private information
Stigmatization
Answer:
a and c
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Public Engagement
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Pandemic Vaccination Program Goals
July-Dec 2005
Purpose:
• Rank goals for pandemic
influenza vaccination program
• Weigh tradeoffs between
competing goals
• Select goals considered most
important to achieve
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Pandemic Vaccination Program Public
Engagement Results
Highest goals:
• Assuring the functioning of society
• Reducing deaths and hospitalizations due to
influenza
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Other Pandemic Vaccination
Program Goals
• Build and maintain the public’s trust
 Transparent decision making
 Seek public’s input
 Early and clear communication and education
• Flexible implementation of policy
• Increase vaccine production capacity
• Develop other public health measures to protect the
public from illness
• Provide resources to other regions of the world
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Community Mitigation Measures
Oct-Nov 2006
Purpose:
• Discuss economic and social
tradeoffs associated with
community mitigation measures
• Identify challenges with
implementing these measures
• Offer solutions to the challenges
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Community Mitigation Measures Public
Engagement Results
• Support for early implementation of community
mitigation measures
 Encouraging sick persons to stay home
 Canceling large public gatherings
• Challenges identified
 Ensuring soundness of planning
 Minimizing potential economic impacts
 Addressing information needs of the population
 Recognizing that social stresses that will be created
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Solutions to Community Mitigation
Challenges
• Full engagement of all key sectors in development of
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detailed, fully-coordinated plan
Transparency of planning process
Training for leadership roles
Public education campaigns prior to pandemic
Connecting community organizations into social
networks
Linking providers with people in need prior to
pandemic
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Question 5
Fill in the blank from the selections given below the question.
When imposing Community Mitigation Measures (e.g.
quarantine), your agency must provide support services such as
(1) ____________, take into account the needs of
(2)______________, establish (3)_______________ for those
affected by liberty limiting measures, and provide
(4)________________ about the rationale for these measures.
a.Food, water, essential services
b.Advance communication
c.Vulnerable populations
d.Appeals process
e.Sanctuary
Answer: (1) a
(2) c
(3)d
(4)b
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Pandemic Influenza Vaccine Prioritization
Dec 2006 – present
Purpose:
• Discuss prioritization and allocation of
pandemic influenza vaccine
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Feedback on vaccine guidance*
Categories of persons who should
receive vaccine
National security
Health care and community support
services
Critical infrastructure
General population
* Available at: http://www.pandemicflu.gov/vaccine/prioritization.html
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Pandemic Influenza Vaccine Prioritization
Public Engagement Results
U.S. Example Highest Vaccination Priority (Tier 1):
• Deployed and mission critical personnel
• Critical public health and healthcare personnel
• Critical infrastructure personnel (i.e., EMS, police, fire,
vaccine and antiviral manufactures, key government
leaders)
• Pregnant women
• Infants and toddlers (6-35 months old)
Prioritization will need to be reconsidered once specifics of new
pandemic virus are known.
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Question 6
Which category of persons who may be considered
during prioritization decisions for vaccination during a
pandemic?
a.
b.
c.
d.
e.
National security
Healthcare and community support services
Critical infrastructure
General population
All of the above
Answer:
 E. All of the above
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Planning and Resources
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Questions to Consider in Planning
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Have public health decisions been made in a clear, open, and
transparent manner?
Have those who will be affected by the public health measures
been given the opportunity to provide input into decision
making?
Are decisions being made on the best available scientific
information?
Have the least restrictive public health measures necessary to
protect the common good been used?
Are decisions about protecting the common good being
balanced with protection of individual rights?
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Questions to Consider in Planning (cont.)
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Have efforts been made to minimize the negative impact of the
public health measures?
Have the public health measures anticipated and respected the
diverse values, beliefs, and cultures in the community?
Has a process been established to revise or correct decisions to
address new information?
Have efforts been made to acknowledge and respond to public
suspicion and distrust of local, state or federal government
decisions?
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Public Health Ethics Resources
for Pandemic Influenza
Checklist
Pandemic Influenza Ethics Checklist
This checklist should be used by public health officials when developing or approving
plans that will have a substantive impact on policy, practice or the public. Not every
question may be applicable in every situation, but every question should be considered.
The checklist is intended to enhance ethical decision making and is not meant to be used
for official reporting or accountability purposes.
General Ethical Considerations
Yes No
Have public health response decisions been made in a clear, open, and
transparent manner?
Have those who will be affected by the public health measures been provided
with timely information and given the opportunity to provide input into
decision making?
Are decisions being made based on the best available scientific evidence?
Have the least restrictive public health measures necessary to protect the
common good been used?
Are decisions about protecting the common good being balanced with
protecting the rights of individuals?
Have efforts been made to minimize the negative impacts of the public health
measures?
Have the public health response measures anticipated and respected the
diverse values, beliefs, and cultures in the community?
Has a process been established to revise or correct decisions to address new
information?
Have efforts been made to acknowledge and respond to public suspicion and
distrust of local, state or federal government decisions?
Have state and local authorities had adequate opportunity to have input into
decision making?
Have efforts been made to work with and learn from global preparedness and
response efforts?
Fact Sheet
ETHICAL GUIDELINES for RESPONSE to PANDEMIC INFLUENZA
General Ethical Considerations
 Transparency and public engagement – commitment to clarity and openness in
decision making, sharing of information, and obtaining input from the public.
 Sound science – commitment to making decisions based on the best available
evidence.
 Global community – commitment to working with and learning from global
preparedness efforts.
 Balancing individual liberty and community interests – commitment to using
the least restrictive public health measures necessary to protect the common good
and minimizing negative impacts of these measures.
 Diversity in ethical decision making – commitment of public health officials to
foster the trust of all diverse members of society.
 Justice (fair process) – commitment to fair distribution of resources, such as
vaccines and antiviral medications and in imposing restrictions, both on a local
and global level.
 Overall goal of pandemic response – commitment to preserving the functioning
of society and protecting the public’s health.
Recommendations Regarding Allocation of Resources
 The primary goals of the distribution system should be clearly specified.
 Individuals and groups of persons who are identified as key to maintaining critical
infrastructure should be accorded a high priority for the distribution of vaccines
and antiviral drugs.
 The distribution criteria should be evaluated according to their ability to
contribute:
o Realization of the primary goals.
o Maximizing fairness (or equity) in the distribution process.
 Balance protecting the common good and individual rights:
o Refrain from harming or injuring individuals and communities.
o Equal opportunity to access resources should be assured to those within
agreed upon priority groups.
o Respect for individual autonomy by, for example, employment of the least
restrictive interventions that are likely to be effective.
 Distribution plans should specify:
o What scarce goods are involved in the distribution plan.
o Who (or what agency) will decide about prioritization and distribution.
o What mechanism will be used in the case of a dispute or an appeal.
o Who is eligible to be a recipient?
o The criteria used to assign higher or lower priorities to groups of
individuals
Continued on Back
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Summary
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Public health ethics foster awareness of the rights of
participants and communities in public health activities
Public health ethics build credibility and public trust in your
agency, aid in resolving value conflicts, and guide decisions
when there is uncertainty
General considerations in public health ethics involve
transparency, good practice, and public engagement
Specific challenges in pandemic influenza ethics include
prioritizing some groups over others in prevention planning,
and allocation of scares resources locally, nationally, and
internationally.
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Resources
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Ethics Guidance for Pandemic Influenza
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Public Engagement Process
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CDC’s Public Health Ethics Activities
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James Thomas, Principles of the Ethical Practice of Public Health
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James Thomas, Skills for the Practice of Public Health
 http://www.cdc.gov/od/science/phec/ guidelinesPanFlu.htm
 http://www.keystone.org/spp/health-pandemic.html#community
 http://www.cdc.gov/od/science/phec/
 http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBDBD405FC60856/0/ethicsbrochure.pdf
 http://209.9.235.208/CMSuploads/EthicalPracticePublicHealth40199.pdf
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Glossary
Public engagement: The process of listening to, interacting
with, and gaining greater understanding of a group in order
to inform the decision making process
Public health ethics: Principles and values that guide actions
to promote health and prevent injury and disease in the
population
Procedural judicial mechanism: An established fair process
by which individuals or groups who feel their rights have
been violated can be heard in court
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Glossary
Social distancing: Targeted efforts to reduce interaction
between persons at specific or general venues, in order
to reduce the probability of disease transmission
Transparency: Providing for openness, communication,
and accountability during a process or decision
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