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 allow the public to express their opinion regarding certain ethical scenarios and policies. These views would then be considered by health authorities, without an obligation for them to implement it. (Silva et al., 2012)
Ever since the 2009 pandemic of the swine flu, many articles have been written about the prospect of another global pandemic. These articles have listed several other reference sources for more information and have been open to queries and concerns from the general public. Governments and International organizations have also supervised the creation of many websites that share full information and policies. However, most of these websites contain content that is too compact for most readers. Also, most of these websites send readers to the same few sources. A full search on the topic provide too many sources, most of which may hold little relevance to most readers. (International Affairs, 2005)
Only a few researches have evaluated population awareness regarding a pandemic flu. Evaluating awareness and community preparedness may be a good method of evaluating the role of awareness campaigns. In a study conducted in two cities in Saudi Arabia on 1,548 subjects, awareness, attitudes and practices related to Influenza A was studied. A great proportion (54.8%) of subjects showed high concern towards the possibility of an outbreak. The level of education was a significant factor that was related to the level of concern displayed. Despite the great level of concern expressed by a majority of participants, 60.8% took minimal or no precautionary measures. The study concluded that a higher level of concern did not increase compliance with precautionary measure. (Balkhy, Abolfotouh, Hathlool & Jumah, 2010)
In another study conducted in France, the outcome of public health policies in the country was assessed. After the April 2009 outbreak, the French government issued a policy of mass vaccination against the H1N1 pandemic. Out of the 2,113 respondents, only 35% perceived the H1N1 Influenza strain as a severe disease. Acceptability of the A/H1N1 vaccine was only 17%. Respondents who were formally advised to receive the vaccine had a higher acceptability rate. Amongst respondents who refused the vaccine, a great majority (71.2%) expressed concerns about vaccination safety. (Schwarzinger M, Flicoteaux R, Cortarenoda S, Obadia Y, Moatti J-P, 2010)
The above two researches provide compelling evidence regarding public unawareness in two countries. These studies were conducted 7 months and 12 weeks following the start of the 2009 pandemic, respectively. Results of both studies show that even during a pandemic, public awareness efforts were inadequate to dispel community concerns. This raises another ethical issue regarding effective communication between healthcare workers and the community at large. Even though one might argue that too much information may cause unnecessary anxiety, it still remains to be a crucial factor determining campaign effectiveness.
Another nasty concern bought out into the open after previous pandemics has been the issue of fairness. Trends in some hospitals and pharmaceutical companies may be inconsistent with any account of justice. During a pandemic, health authorities are also faced with an equal risk. These authorities who have the power to set priorities and allocate resources may not be held accountable for favoring their friends, families or ethnic groups. This discrimination violates the rules of the prioritization grid. By using stockpiles of drugs and vaccines to protect their own groups leaves others at a susceptible situation and contributes to public mistrust. This is a clear violation of human right principles and the basic foundation of legal laws that have been laid down for pandemic situations. (Addressing ethical issues, 2008)
In the panel set out by the WHO for pandemic flu preparedness and response, several duties of a healthcare worker have also been discussed. These duties have also been a controversial issue and the debate continues over the ethical articulation of a healthcare workers’ duty to treat. An obvious issue regarding this subject is the healthcare worker’s susceptibility to infection. Estimates from past endemics report that at least 25% of the workforce will become infected in the face of a pandemic flu. These first line responders may also fall prey to a great proportion of initial unpreventable deaths. It is only after the first few case reports that the alarm for the need of vaccines occur. Pre and post exposure vaccines may not entirely be preventative. These facts put health care workers in a vulnerable position. (Addressing ethical issues, 2008)
To incentivize healthcare workers to consent to put their lives at risk to treat patients include certain measures. These include allowing healthcare workers to be the first to receive the vaccine, when it becomes available, and the first to receive antiviral drugs. Additional support for family members, supplemental life/disability insurance coverage for workers and their families, hazardous duty pay, personal protective equipments and training; and specialized training for dealing with virulent infectious diseases are other measures that may help incentivize health care workers. (Shabanowitz & Reardon 2009). However, this would institutions to make financial as well as moral investments for the lives of healthcare workers.
In a study conducted by Shabanowitz & Reardon (2009), opinions from healthcare workers, regarding their duty to treat under such circumstances, were obtained. Results concluded that healthcare workers expressed a willingness to work in the event of an endemic flu. More than sixty percent of employees did not agree that it was ethical to abandon the workplace during a pandemic. However, even though the majority of employees did want the autonomy to decide whether or not they wanted to work, about seventy nine percent of workers agreed to work if provided with incentives and protective options.
The results of another study, conducted by Damery et al. (2009), did not match the above mentioned conclusion. The outcome of this research revealed that about eighty five percent of health care workers are likely to abandon work place in the face of a pandemic, with potential absentees concentrated amongst nurses and ancillary workers. Despite inconsistent results, both studies still come to a common conclusion of providing proper incentives to overcome barriers linked to ‘willingness to work’.
Another effective measure that must take place at all times, and especially during periods of pandemics, is a proper infection control system. The Healthcare Infection Control Practices Advisory Committee set by the Center for Disease Control & Prevention has come up with specific guidelines for the control of Infectious Diseases. These include the mention of specific healthcare etiquettes and the use of disposable gloves, gowns and masks. This may be a novel practice for most healthcare facilities in low income countries, or even in high income country during a pandemic. Nevertheless, the maximum possible control and isolation need to be practiced as part of an ethical duty of nurses and other healthcare workers. (CDC, 1998)
All employees are at risk of exposure, therefore, all staff members should remain up-to-date with hospital paid vaccines and annual flu shots at all times, if available and not medically contraindicated. Pre-pandemic drills should be conducted in order to keep all employees well informed of any necessary precautions. Employees also need to be aware of where to notify in the face of a pandemic flu. Annual training sessions and monthly evaluation need to be conducted for employees. Employees who have been exposed at work or at home, or employees who are ill, need to be isolated and quarantined until they are safe or fit to work. During this time, they need to be given preference for treatment. (CDC, 1998)
Having discussed both sides’ core ethical and legal issues regarding a pandemic situation, it is also important to outline the duty of nurses and other healthcare professionals during such a circumstance. Since nurses form the base of most healthcare facilities, their active part will help prevent collapse of the healthcare system. A nurse’s duty starts from the arrival of the very first patient suffering from a mutated Influenza strain. During every pandemic, the first few patients are more liable to suffering from a severe disease and eventually its consequences, which may even be death. It is important to recognize who these patients may be and provide them with prophylactics. Moreover, recognizing the illness early and reporting it to health authorities is also an important factor that may determine spread. With the flooding of hospitals and occupation of every hospital bed, most of which may be occupied by critical care patients nurses need to work in collaboration to provide the best possible care. Furthermore, sound ethical judgment on part of the nurses may help save the most number of patients.
Flu pandemics have occurred after every 30-40-year periods. (Tam & AW, 2003)The last pandemic in 2009 left the world in a state of fear. Key issues regarding ethical and legal debates were put out in the open. Based on the three principles of equality, equity and procedural fairness, a group of experts discussed these issues amongst themselves and the public. Inferences were put on a panel and published online. (Addressing ethical issues, 2008)
Prioritization of patients in the face of an outbreak has been a matter of debate for decades. Nurses and other healthcare workers play an important role in deciding who gets the critical care bed and who doesn’t. These decisions need to be made in the face of sound knowledge regarding ethics and the different outcomes of health in different patients. Public opinion through surveys has also been collected on the matter, most of which express the same opinion, “do the best good for the most people.” (Silva et al., 2012)
Workplace ethics during a pandemic is another issue that concerns healthcare workers. Providing incentives, such as allowing them to be the first to receive vaccines and antiviral drugs, have incentivized most employees to hold on to their duty. Pre-pandemic drills regarding infection control and prevention also minimize panic during an actual threat and increase effectiveness of health systems. Being properly informed of how to handle such a situation and of any notification centers also form part of an ethical obligation of the healthcare authorities. (Shabanowitz & Reardon 2009)
Legal issues concerning such a situation include promoting transparency and public accountability. This will help promote public trust and will prevent injustice on part of authoritative figures. (Kotalik, 2005)
Finally, concerning the role of nurses and other members of the healthcare team, providing the best possible care, by using sound ethical and work knowledge, is the main duty. Promptly informing health authorities incase of illness or exposure, whichever one occurs first, is also part of an ethical responsibility. In such a case, health workers should be liable to the same measures of isolation and quarantine as the general public. (CDC, 1998)
Addressing ethical issues in pandemic influenza planning. (2008). World Health Orginazation.
Retrieved from www.who.int/csr/resources/publications/cds_flu_ethics_5…
Balkhy, H., Abolfotouh, M., Hathlool, R., & Jumah, M. (2010). Awareness, attitudes, and practices related to the swine influenza pandemic among the saudi public. Infectious Diseases, 10(42).
Damery, S., Wilson, S., Draper, H., Gratus, C., Greenfield, S., Ives, J., & Parry, J. (2009). Will the nhs continue to function in an influenza pandemic? A survey of healthcare workers in the west midlands, uk. BMC Public Health, 9(142), doi: 10.1186/1471-2458-9-142
Elizabeth A. Bolyard, RN, MPH, a Ofelia C. Tablan, MD, aWalter W. Williams, MD, b Michele L. Pearson, MD, a Craig N. Shapiro, MD, a Scott D. Deitchman, MD, c and The Hospital Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel. CDC. June, 1998; 26(3): 289-351.
International Affairs. (2005). Pandemic flu awareness. Retrieved from http://net-savvy.com/international/pandemic-flu.html
Kotalik, J. (2005). Preparing for an influenza pandemic: Ethical issues. Bioethics, 19(4),
Lewis, J. (2009). Preparing for a flu pandemic. Retrieved from studenthealth.unomaha.edu/documents/pandemic_prep.ppt.
Schwarzinger M, Flicoteaux R, Cortarenoda S, Obadia Y, Moatti J-P (2010) Low Acceptability of A/H1N1 Pandemic Vaccination in French Adult Population: Did Public Health Policy Fuel Public Dissonance? PLoS ONE 5(4): e10199.doi:10.1371/journal.pone.0010199
Silva, D., Gibson, J., Robertson, A., Bensimon, C., Sahni, S., Maunula, L., & Smith, M. (2012). Priority setting of icu resources in an influenza pandemic: a qualitative study of the canadian public’s perspectives. BMC Public Health, 241(12), 1-11.
Shabanowitz, R.B., & Reardon, J.E. (2009). Avian flu pandemic – flight of the healthcare worker? HEC Forum, 21(4), 365-85.
Stroschein, J. (2010). Look who’s back: Pandemic flu risks rise again. ISHN, 44(9), 72-72, 74.
Tam, N., & AW, H. (2003). The epidemiology and clinical impact of pandemic influenza. Vaccine, 21(16), 1762-1768. doi: .doi.org/10.1016/S0264-410X (03)00069-0
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