Should a pandemic strike the United States, states and local communities are ready with protective equipment and plans for allocating vaccines. But some important ethical questions aren't addressed in state pandemic flu plans, one public health expert says, and those are the issues that might derail the best-laid disaster plans.
James C. Thomas, MPH, PhD, an epidemiologist at the University of North Carolina School of Public Health, Chapel Hill, has researched the pandemic preparedness plans of all 50 states, the District of Columbia, and the federal government, and found some critical weaknesses shared by all.1
"The things that are being addressed most are those having to do with vaccines, antivirals, protective equipment, and those sorts of things," says Thomas. "What's being less well addressed in the plans are how to prepare a state or a local community for the decisions that will have to be made. Right now, the decision-making plans are centralized and limited to a few issues.
"Many of the issues that will be faced are going to be difficult to foresee, so what needs to be happening now is that we need to be preparing local health departments to make difficult ethical decisions."
Thomas found all the preparedness plans lacking in key ethical terminology, including accountability, autonomy, collaboration, confidentiality, and privacy.
'Opaque reasoning' leaves room for error
Some points in the pandemic plans, Thomas reasons, are set out as thoroughly as can be done ahead of time, but sometimes miss some important ethical points.
"On some questions, such as who should get the vaccines when they become available, the guidelines created by the CDC [Centers for Disease Control and Prevention] and others are available, and there have been a lot of very well-informed people who are part of those decisions," he says.
But the thought given to what to do in the time between when a virus is identified and when the antivirals and vaccines are available for it "is disproportionate to the number of issues we'll be facing."
Also, plans that call for immunizing the most vulnerable and most needed — the chronically ill, elderly, and very young, and those responsible for public health and public order — leave out some ethical questions that could prove very troubling.
"What about prison populations?" Thomas asks. "Prisoners are not high on the list of people who are needed to maintain order, nor are many of them on the list of people who are physically vulnerable. But they are in a crowded situation that they can't leave, so if the virus gets into their population, it can sweep through them."
Immigrants, undocumented people living in the country, and those without health care or in extreme poverty are among those who will likely be hit hardest, earliest, and longest by a pandemic, Thomas adds.
"When a crisis happens, it exacerbates disparities, and people whoare vulnerable are, by definition, vulnerable, and they need to be given extra vigilance," he says. Working against their favor is the "two-list" model of ensuring vaccines and antivirals for the physicallyvulnerable and those needed for public order, both of which stand tooverlook other vulnerable populations.
Thomas says many of the plans he and his colleagues reviewed employ "opaque ethical reasoning;" they carry the implied messages of "trust us and do as we say" and "ethics are self-evident, just do what isneeded to preserve lives."
But many of the ethics are not self evident, Thomas predicts, and state and federal plans should take steps to anticipate them better and train public health providers — and all levels of government— to identify and address the ethical decision making that canbe faced during a public health emergency.
Thomas says many plans recognize the need to address ethical questions, but sidestep the issue by simply stating that ethicists would need to be consulted at some point.