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Public Debate Needed on Ethics Behind Tough Choices a Pandemic Would Force

Posted on: Sunday, 27 November 2005, 21:00 CST

By HELEN BRANSWELL

TORONTO (CP) - It's time to engage the public in open and frank debate over the excruciating choices a flu pandemic could force governments and health-care delivery systems the world over to have to make, a new report suggests.

Governments need to throw open discussions already well underway to determine who gets first crack at eventual vaccine and who won't get limited antiviral drugs, so the public can be assured those decisions are being based on an ethical foundation that reflects shared values, the authors suggest.

Such deliberations should address what societies can reasonably ask of health-care workers, who could be risking their own lives during a pandemic, and what protections societies are willing to offer them in return, notes the report, written by ethicists from the University of Toronto's Joint Centre for Bioethics.

"The time to figure out what roles, responsibilities and expectations are going to be is now. Not when the emergency rooms are starting to fill up. Not when we're trying to deal with intense numbers of very sick individuals," one of the authors, Dr. Ross Upshur, said in an interview.

But one of Canada's leading infectious diseases experts warned it is easier to call for such deliberations than to actually have them.

Planners in the health-care arena shudder at the thought of having to decide what to do when they've run out of life-saving mechanical ventilators and a gravely ill 15-year-old comes through the emergency department door, Dr. Allison McGeer admitted.

Do they take the oldest person on a ventilator in the hospital off it? Do they call around to other hospitals to see if someone older still can be removed from a ventilator across town?

"I think, at least among health-care workers, to even have the discussion somehow creates a sense of playing God," she said.

"People know if they get in the situation where the decisions will have to be made, they'll have to be made. But to overtly have a discussion ahead of time about making them? . . . The general response up till now among health-care workers is that people really don't think they can do that."

She's not certain the public wants to contemplate the scenario underlying the tough choices either, noting a rising chorus of criticism that those warning of the dangers of a pandemic are being unduly frightening.

"It's hard to have these discussions without being scary," said McGeer, head of infection control at Toronto's Mount Sinai Hospital.

She pointed to the dilemma of deciding priority lists for pandemic flu vaccine - should adults go before children? - to illustrate her point.

"That's only an important question, really, if there is a risk of probably, realistically, death associated with making the wrong decisions. And in a fairly mild pandemic, that's not really on the table," explained McGeer.

"As soon as you start the process of 'If it's severe enough that we really need to have this discussion,' that's looking at a situation that none of us want to look at."

None of the 100-plus national pandemic plans that have been written to date have a dedicated section aimed at helping people make ethical decisions should an influenza pandemic trigger a public health crisis, noted Dr. Peter Singer, another of the authors.

"That's really sort of ironic because the ethical issues are . . . going to be the glue that holds a society together when it's struggling through a very, very tough time if the pandemic in fact is severe," said Singer, director of the bioethics centre.

The report lays out four key issues the authors think require an ethics-based debate: the duty of health-care workers; the use of liberty-restricting measures like quarantine; the implementation of international travel bans and the setting of priorities for rationing scarce medical resources such as antiviral drugs.

A senior official said the Public Health Agency of Canada wants to put out parts of the Canadian pandemic plan for public deliberation, including its policy on who should get drugs like Tamiflu and under what circumstances.

"We have to further refine that, but then state it in such a way that we can go out to Canadians and say: 'This is our position. What do you think of it?' " said Dr. Paul Gully, deputy chief public health officer.

"It is not good enough to have these (ethical) issues in the back of the mind. One actually has to demonstrate absolutely clearly that one had actually taken them into account."

The duty of health-care workers to provide care is a key area that needs clarification, according to the report, which raises a spectre few planners like to acknowledge but many fear - the prospect of some health-care workers refusing to work during a pandemic.

It happened during SARS, Upshur admitted. While many hospital workers performed heroically, some overtly refused to treat SARS patients or "distanced themselves from engagement."

"The distribution of risk was by no means equitable within health-care institutions," Upshur said. "And that's probably not the best way to think about how to staff an infectious disease emergency."

The report notes that after the devastating Spanish Flu pandemic of 1918-19, the Canadian Medical Association wrote into its code of ethics that "when pestilence prevails" doctors have a duty to "face the danger . . . even at the jeopardy of their own lives."

That code has since been rewritten. And there is a general lack of guidance from the organizations governing the medical professions as to how far the "duty of care" extends, the report warns.

It calls on these groups to spell out clearly what members's responsibilities would be in a major infectious disease outbreak. And it calls on governments to do as much as they can to protect health-care workers and to offer disability insurance and death benefits for those harmed or killed while performing their duty.

The authors acknowledge the discussions won't be easy and they won't make the news any less devastating at the individual level if, during a pandemic, a doctor informs a person his mother can't be put on a ventilator because someone else needs it more.

"It may not take the sting out of it. But where it might lead us to is a situation that people recognize that some of those really tough choices that we will be faced with are perhaps unfortunate, but not unfair," said Singer.

Source: Canadian Press

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