Ethical Issues in Pandemic Influenza Planning

North Carolina – Healthcare Workers Obligations to Work

Confronting the Ethics of Pandemic Planning

Indianapolis, IndianaJuly 14, 2008

Janelle A. Rhyne, MD, FACPPhysician EpidemiologistPublic Health Regional Surveillance Team 2President, North Carolina Medical Board

ProcessPanel convened by North Carolina Division of Public

Health and The North Carolina Institute of Medicine.Diverse membership representatives from:

EthicistsPhysiciansPersons with disabilities

(physical & mental)Policy makersPrivate industryLegalFaith-based groupsHospitalsNursing Board

Medical BoardHealth DirectorsAmerican Association of

Retired PersonsLaw EnforcementMinority populationsSchoolsDepartment of AgricultureRespiratory Therapy

Series of Testimonies, Scientific Presentations

Development of Recommendations

Followed with community focus groups discussingPandemic Influenza overviewCritical WorkersBalance RightsLimited Resources

Ethical PrinciplesIndividual libertyProtections of the public from harmProportionalityPrivacyReciprocityDuty to provide: health care workers and other

critical infrastructureEquityTrustCollaborationStewardship

Procedural ValuesReasonablenessTransparencyTruth tellingInclusivenessResponsivenessTimelinessAccountability

http://www.epi.state.nc.us/epi/gcdc/pandemic/AppendixO1_2008.pdf

www.ncmedicaljournal.com

Hurricane Katrina Hit the Gulf Coast in 2005

6000 PHYSICIANS

LEFT THE AREA

43% OF THOSE FALLING PREY TO SARS WERE HEALTH CARE WORKERS WITH A CASE FATALITY RATE OF ABOUT 15%

2003 Severe Acute Respiratory Syndrome (SARS) Outbreak in Canada

49% OF SARS HEALTH CARE WORKERS REPORTED SOCIAL STIGMATIZATION

31% REPORTED OSTRACISM BY FAMILY MEMBERS

• Many health care professionals left the profession for new careers rather than expose themselves and their families to risks associated with caring for patientswith potentially lethal infectious disease.

DURING THE SARS EPIDEMIC FAILURE TO REPORT TO WORK RESULTED IN PERMAMENT DISMISSAL OF HOSPITAL STAFF

•National, regional and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters.

American Medical Association Policy Statement

Professional’s Duty to Care in a Public Health Emergency

•...The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future.

…continued

•Physicians should evaluate their risk for becoming infected with pathogens, both in their personal lives and in the workplace, and implement appropriate precautions. ...Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous application of infection control methods. The denial of appropriate care to a class of patients for any reason, including disease state is unethical.

The American College of Physicians (ACP) Ethics Statement

Appeal to Professionalism

Professionalism is the basis of medicine’s contract withSociety.It- places the interests of patients above those of the physician- sets and maintains standards of competence and integrity- provides expert advise to society on matters of health

Professional ObligationLicensed and nonlicensed healthcare professionals have an ethical obligation to provide care because:1. The ability of physicians and other licensed healthcare

professionals to provide care is greater than that of the public, thus increasing their obligation to provide care.

2. The licensed professions have a social contract, resulting from the privilege of self-regulation and self-licensure, that calls on members to be available in times of emergency.

3. By freely choosing a profession or job devoted to caring for the ill, healthcare personnel have assumed an ethical obligation to act in the best interests of the ill and to assume a proportional share of the risks to which their professions and/or employment setting expose them.

Reciprocal ObligationGovernment and healthcare organizations have reciprocal duties to healthcare personnel:

1. Healthcare organizations have reciprocal obligations to ensure that the work asked of healthcare personnel does not exceed their professional capabilities, and that the tasks assigned are targeted to addressing the existing emergency. May involve “Just in Time” training.

2. Government and healthcare organizations have reciprocal duties to ensure that healthcare workers are suitably protected, compensated, and supported.

3. Government should provide healthcare personnel and organizations with qualified immunity from liability from malpractice or other suits if they act in good faith to provide needed health services during the pandemic.

Questions????