In the Worst Case: Pandemic Ethics

What if the flu comes – not the ordinary, every-winter, best-guess-for-the-vaccine flu, but the pandemic? Most of us are aware in one way or another that folks have been thinking about that. A few years ago the fear was a biological terror attack; and then there was SARS; and then bird flu. Folks remember the Spanish influenza of 1918, and then think about how connected we are – remember that Patient Zero for AIDS was a flight attendant? – and are all too aware that it could happen again.

So, what if pandemic flu comes? Suppose you have 100 mechanical ventilators available. Now, suppose you have 105 eligible patients. How do you decide who gets on a ventilator, recognizing that those who go one the vent might never get off; while those that don’t will almost certainly die?

That is the archetypical scenario of discussions of pandemic ethics. They are discussions of limited resources, limited time, and establishing difficult priorities. They are discussions of rationing, and rationing when people are at their most anxious and least rational.

Monday the Department of Health and Human Services released a draft document describing priorities for vaccinations in the event of pandemic flu, that is, once a vaccine has been isolated and manufactured. You can read a news report here, and the HHS document here. I encourage you to read both.

There are some points in the HHS draft that aren’t a surprise. The first to receive the hypothetical vaccine would be critical health care workers, public safety workers, and others critical to keep the essential services going – health, fire, police, power, communications, and, of course, military and Homeland Security. Note that this doesn’t include all workers in those sectors, but only those identified as critical. Among the general population pregnant women and infants and toddlers are in the first rank.

There are two ranks after that for most employment categories. Among the general population there are, in fact, four: children are in the second rank, high risk elderly and adults are in the third, and all healthy non-senior adults are in the fourth.

There’s not much in this surprises me in the document; but, then, I’ve been aware of the conversations in my metropolitan area for some time. There may, however, be surprises to you. That’s why it’s important that HHS has opened this document for public comment beginning this Saturday, October 26. You can link from the HHS page above to offer your own comments.

When we as professionals talk about these decisions, we come back to one critical question: how do we inform the public and get some commitment from them to support these decisions, decisions that might well restrict access in the emergency for some, perhaps for many? We all project enough fear and anger and chaos if the pandemic comes – or, for that matter, any other major disaster: we remember all too well what happened to health care systems in New Orleans. We hope that an informed, reflective public will reduce that somewhat. It won’t eliminate it, but perhaps it will help.

Release of this draft is a prime opportunity to do just that: to inform the public and to discuss among ourselves how we want these decisions made, and how we think we should behave in such dire circumstances. Read the news story. Read the document. Then, take the time to offer some comment. Those of us in health care think about when, not if, the pandemic will come. Please think with us about how our society should respond, and how we should go about making the hardest decisions.