Ethics Committee
Members
Jerome Drain, PhD
John Scott Gray, PhD
*Ruth Groenhout, PhD
Amy Kosta
Greg Marco, MD
Cheri Mathis
Rev. Ed Perkins
Robert Petroelje, MD
Beth Thomas, PEM
Steve Triesenberg, MD
Ashley VandeKopple
Carol Wilson, RN
*Committee chair
Davenport University
Project Consultant, Ferris State University
Project Consultant, Calvin College
City of Grand Rapids
MMPC
MMPC
Grand Rapids Area Center for Ecumenism
MSU-College of Human Medicine, Grand Rapids
Ottawa County
Spectrum Health
Michigan Dept. of Community Health, Office of Public Health Preparedness
Mecosta County Medical Center
Objectives

Provide basic ethical guidelines for care provision during an influenza pandemic.

List ethical questions arising after a non-essential services list is publicized.

Define, in ethical terms, how service limitations affect a community.

Develop proposed solutions that communities can agree on.
Assumptions
1) During the course of a pandemic, the ethical rules that govern the delivery of health care shift.
Under normal conditions the heaviest weight is given to considerations of individual autonomy and
rights, while considerations of the public good take second place. During a pandemic the weight
shifts toward public good considerations and the more severe the crisis, the weightier the public
good becomes. This does not mean the individual autonomy disappears as a moral consideration,
only that it carries less weight and can more easily be overridden by considerations of the greater
good.
2) Assumptions concerning the public:
(a) The public is capable of understanding that standards of care must be adaptive to
changing conditions, both during and after the event.
Two competing assumptions:
(b) There will be a rise in anti-social behavior and many citizens will refuse to help others
while hoarding/getting what they can for themselves.
(c) Some citizens will rise to the occasion, support emergency care providers, volunteer as
assistants, obey public health rules, and generally act in ways that serve the greater good.
Evidence supports claim (c) when citizens see that the authorities are communicating
honestly and proposing rules that seem fair to all and connected clearly to the common
good.1
1
PEPPPI (2005) “Citizen Voices on Pandemic Flu Choices: A Report on the Public Engagement Pilot Project on
Pandemic Influenza” http://www.pandemicflu.gov/plan/federal/pepppimaintext.pdf
Caring for the Community | preparing for an influenza pandemic
1
3) Medical care will not be provided as it usually is:
(a) Caregivers, including volunteers, will find themselves called to work outside their
normal range of professional activities.
(b) Caregivers do have a moral duty to continue to provide care during a pandemic. At the
same time, a significant number of caregivers will not be able to serve or will be unwilling
to serve.
4) Ethical considerations will continue to guide actions during the course of a pandemic, and
emergency workers should receive some form of ethics training/basic guidelines in their
preparation for service.
5) Businesses (and other non-health related organizations) will continue to function at some level
and will cooperate with emergency planners.
Background
The work of this committee serves to provide an ethical foundation for the entire project, ensuring that
proposed solutions fall within widely agreed-upon moral principles.
Membership
The Ethics Committee’s membership represents a broad spectrum of perspectives and concerns.
Members include a scientist and administrator (Jerome Drain PhD); physicians with specialization in
infectious diseases and otolaryngology (Steven Triesenberg MD, Robert Petroelje MD, MA Bioethics, Greg
Marco, MD); individuals employed by Homeland Security (Beth Thomas, Amy Kosta) and the MI Dept. of
Community Health (Ashley VandeKopple); Health care professional/administrator (Carol Wilson, RN,
MSN); members of the community with lay perspective or religious training (Cheri Mathis, Ed Perkins,
retired United Methodist minister, member of Grand Rapids Area Center for Ecumenism), and ethicists
(John Scott Gray, PhD; Ruth Groenhout PhD).
The Ethics Committee operated within the background assumptions listed above, and began by articulating
a basic context for decisions.
Context
Under pandemic conditions, the need to maintain basic ethical standards remains, and in fact, may
become more urgent. At the same time, ethics must respond to the particularities of any situation. An
influenza pandemic presents unique and complex challenges that require careful consideration of what
ethical structures best protect both the vital social structures on which all people depend and each
individual’s right to respect and protection.
The committee’s deliberations about what ethical guidelines take precedence under pandemic conditions
were guided by the following considerations.
An influenza pandemic may change the way medicine can be practiced. Under ordinary conditions,
health care facilities have an abundance of supplies, and adequate caregivers are available. Those
needing care do not pose a significant risk of infecting others. During an influenza pandemic, supplies
(vaccines, if available; ventilators; hospital beds) are all likely to be limited, caregivers may themselves be
sick, or may be caring for sick relatives, and those who are sick will need to be isolated to prevent further
spread of infection.2
2
Centers for Disease Control and Prevention. (2007). Interim pre-pandemic planning guidance: Community
strategy for pandemic influenza mitigation in the United States: Early, targeted, layered use of
nonpharmaceutical interventions. (Department of Health and Human Services). Retrieved from:
http://www.pandemicflu.gov/plan/community/community_mitigation.pdf.
Caring for the Community | preparing for an influenza pandemic
2
Whenever resources are limited, distributive justice requires that the rules that determine how those
limited resources can be made available to people must be fair, maintaining the fabric of a functioning
society.3 Further, under pandemic conditions, the balance between individual freedoms and communal
responsibilities shifts to emphasize the common good, though individual freedoms still deserve protection.
The committee’s goal is to provide clear ethical guidelines upon which decision-making is based during a
pandemic. These guidelines should be constructed so that the community can understand why they are
necessary. Populations respond best to emergencies when the public understands and agrees with the
policies that need to be implemented. Voluntary participation is far more effective than coerced
participation, especially in the context of a country as marked by individualism and freedom as the U.S.
The guidelines offered here are intended to function in the context of a society that values individual
liberties, but also recognizes the need to implement policies that protect the interests of the population as a
whole.
The Process
The committee began by generating a list of the ethical problems likely to be faced in an influenza
pandemic, both the difficult ethical issues generated by the crisis itself, and the ethical issues generated by
responses to the crisis. That list was then sorted into general categories, each of which the committee
addressed in turn. Addressing the various issues required developing a general set of ethical guidelines for
addressing issues raised by an influenza pandemic. These guidelines constitute the conclusions the
committee reached.
Tough decisions and issues that generated major discussions:
1. One of the biggest issues to which the committee returned repeatedly is the issue of communication.
While communication difficulties are not, strictly speaking, ethical problems, many ethical issues originate
in failures to communicate clearly. The committee examined the numerous ways in which communication
failures could occur during the response to a crisis. Obviously this committee cannot resolve such issues,
but it did reach consensus that clear communication with the public and a transparent planning process are
both of the greatest importance. (See Supporting Documents for a list of recommendations for
communication developed by the Kent County Public Health Department.)
2. Use of non-medical criteria for allocation decisions raised some very difficult questions. Age as a criteria
for either providing care (as in the case of vaccines) or for limiting care (as some triage proposals would
suggest) was the most controversial of these criteria. The committee did not reach consensus on this
issue.
3. Issues of reciprocity also raised difficult questions. Volunteers and health care professionals are asked
to sacrifice their time, and sometimes their safety, in providing care during a crisis. Society has a duty to
both protect caregivers during their service and recognize their service after the crisis has passed. There
were some on the committee concerned that society would or could not fully discharge this duty.
4. Vulnerable communities raised concern. Groups who either self-segregate (the Amish, for example) or
who are marginalized due to their status in society (the homeless, migrant workers, etc.) are particularly
vulnerable to the risks posed by a pandemic, but given limited resources, it may not be possible to meet
their needs adequately.
5. Conflicts between individual autonomy and the community’s best interests also generated extensive
discussion. While a crisis justifies some limitations on individual rights for the sake of the common good,4
3
Pattison, S. 2006. “The Ethics of Treatment in a Time of Sudden Pandemic: The Need for a Proactive Response—
Justice, Rationing, and the Prophylactic Treatment of Fear and Demoralisation”
http://www.ccels.cardiff.ac.uk/archives/issues/2006/pattison.pdf
4
Toronto Public Health, 2007. Toronto Pandemic Influenza Plan,
http://www.toronto.ca/health/pandemicflu/pdf/school.pdf; The Pandemic Influenza Ethics Initiative Workgroup of the
Veterans Health Administrations National Center for Ethics in Health Care. 2009. Meeting the Challenge of
Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health
Caring for the Community | preparing for an influenza pandemic
3
protection of individual rights is itself a crucial component of the common good. Finding an appropriate
balance between individual and general goods remains difficult, and cannot be absolutely defined in
abstraction from the particulars of a crisis situation.
6. The difficulties of planning for a crisis in the context of a health care system that is already working at or
near capacity most of the time was also a matter for discussion.
7. The committee struggled with the extent of the crisis for which we were asked to plan. Given uncertainty
about how deadly a particular influenza might be, about how quickly people would get sick and recover,
about numbers of health care workers unable (or unwilling) to work in a crisis, emergency planning must be
somewhat flexible and open-ended. Some committee members suggested the creation of a review board
for making ongoing planning a priority.
8. The notion of a ‘duty to treat’5 was also a matter of discussion. Traditionally professionals have been
expected to set personal interests aside and act in ways that serve society’s interests during a crisis.
Legally, Michigan does not have a duty to treat requirement. Members of the committee discussed whether
there is an ethical expectation that professionals will volunteer, or at least serve if asked.
The Conclusion
To respond to the project’s objectives, the committee developed a summary of ethical guidelines and an
expanded version of the guidelines. Following the guidelines is a list of frequently asked questions (FAQs)
followed by brief answers derived from the guidelines.
Ethical Guidelines, Summary Statement
Ethical Guideline
1.Transparency, Accountability
Examples of Application
·
·
·
2. Fairness, Equity, Consistency,
Responsiveness
·
·
·
·
Principles for deciding who gets
care are clear, reasonable, and
public
Decision-makers are clearly
identified, accountable for their
decisions, and qualified to make
decisions
Processes for developing criteria
are open to public comment and
discussion
Principles and guidelines for
practice are fair to all who need
treatment
Medical criteria determine levels of
care
Everyone is treated with equal
respect
Principles are adjusted to ensure
fairness as a crisis develops
Administration www.ethics.va.gov/ethics/nec/index.asp
5
Ruderman, C., et al. 2006. “On Pandemics and the Duty to Care: Whose Duty? Who Cares? BMC Med Ethics 20:5;
Huber S.J., Wynia M.K. 2004. “When Pestilence Prevails…Physician Responsibilities in Epidemics” American
Journal of Bioethics 4:1.
Caring for the Community | preparing for an influenza pandemic
4
3. Proportionality
·
Measures taken to respond to a
crisis are appropriate to the level
of emergency
4. Collective Responsibility:
Collaboration
Reciprocity
·
Being willing to share resources
fairly
When caregivers are asked to go
beyond their usual duties, they
also need the resources and
protection that allow them to do
their jobs
Working together to protect the
whole community, taking
responsibility for the common
good
·
Solidarity
·
Guidelines & FAQs
1. Transparency, Accountability
Transparency refers to the openness and public accessibility of any policies, or criteria for allocation, or
adapted standards of care that would be used during a crisis. Transparency is necessary to make sure that
policies and practices are fair, that everyone using the policies knows what they are, and that those
affected by the policies, both caregivers and patients, have a chance to play a role in deciding what the
policies should be. Both those making policy and medical decisions and the public at large need to know
what the policies and criteria for care giving are, how they were decided, and how to challenge them if they
seem unfair. This places a responsibility on policy makers and health care providers to use a process for
making and communicating decisions that is open and public, and that is explained in a clear and concise
6
way.
Transparency creates a culture of accountability and ethical legitimacy. When decision-making
processes are not secret but open to comment and revision both within the health care community and the
community of public opinion, it creates a culture of trust and reliability. Accountability is particularly
important during a pandemic, when standards of care require adaptation, and when difficult decisions
about the use and distribution of scarce resources must be made. The indicators for moving to an adapted
standard of care need to be clearly articulated to the public before the emergency takes place. Further,
decisions about care need to be based on objective medical criteria, and they need to be arrived at by way
of a process that is open and communicated to the public, especially those likely to be affected by adapted
standards of care. Both before and during the pandemic, there will be a need for the creation of processes
for public consideration and feedback.
2. Fairness and Equity, Consistency, Responsiveness
Fairness is an essential ethical concern. Public responses to emergencies must be fair to everyone, and
they must be seen to be fair to the greatest extent possible.
6
Kinlaw, K. and Levine, R.2007. Ethical Guidelines in Pandemic Influenza—Recommendations of the Ethics
Subcommittee of the Advisory Committee to the Director, centers for Disease Control and Prevention
http://www.cdc.gov/od/science/phethics/panFlu_Ethic_Guidelines.pdf
Caring for the Community | preparing for an influenza pandemic
5
Fairness requires equity, not equality. Fair treatment under normal conditions generally means equal
treatment. But under emergency conditions, fair treatment will more likely be equitable, governed by fair
7
rule of distribution. For example, during an influenza pandemic, it is likely that there will not be enough
ventilators to supply one to every patient who needs one, for example. Equal treatment under those
conditions is clearly impossible. But if the process for deciding who has access to the ventilators is fair and
reasonable, then the distribution is equitable. An influenza pandemic is likely to overwhelm hospitals,
limiting access to beds, equipment and professional care. It could result in a shortage of first responders as
caregivers themselves get sick or have to care for family members. It is likely to produce shortages in
supplies as citizens at all levels of society get sick, or have sick family members, and workplaces shut
down or operate at drastically diminished levels.
Everyone is entitled to equitable access to care—that is, whatever is available should be made
accessible to all on the same basis. There may have to be limits on who receives certain treatments, but
those limits should be directly related to the reality of the pandemic and to the best use of the available
resources. Access to treatment should never be denied on the basis of a person’s social category. For
example: race, gender, level of income, religion, political party or similar considerations cannot determine
who is treated. (See allocation guidelines in the following section).
Does this mean everyone will receive the same level of treatment? Unfortunately, no. Some people will
become ill at an early point in the development of the pandemic. People who get sick later, when resources
are depleted, face more shortages. This is not unfair or inequitable. When shortages are particularly
severe, caregivers will need to reserve treatments for those most likely to benefit from them, a practice
known as triage. For example, some people who are so sick that they are likely to use large amounts of
care but unlikely to survive will be provided with comfort care, but no aggressive treatment. Others who
have a better chance of surviving with treatment will get more extensive care. As long as these decisions
are made on the basis of relatively clear medical criteria, and not on the basis of criteria that are not
relevant to medical outcomes, the decisions can still be seen to be fair and equitable.
Fairness requires consistency. Fair rules for distributing limited amounts of treatment are rules that are
consistent. Everyone who falls below a particular standard will be offered comfort care only, for example,
and the standard will be as clear and widely shared as possible. Inconsistent application of rules leads to
unfairness. If the first responders in one neighborhood are making decisions about who to transport to the
hospital for treatment based on criteria that are wildly different from the criteria being used in another
neighborhood, people will see this inconsistency as unjust, and will be much less likely to accept the
authority of the first responders or accept the rules governing access to care.
Consistency requires responsiveness. When caregivers are in the middle of a crisis, they generally
don’t have the perspective to know what is going on in other locations or with other caregivers. An
influenza pandemic is an event that unfolds over time—some estimates are that it will occur over the space
of 6 – 8 weeks—long enough so that differences in responses can become apparent to those looking for
care, and can be addressed by caregivers and responders. For example, if there are discrepancies in care
and outcomes between rural and urban facilities, efforts need to be made to provide more resources for the
areas with worse outcomes.
Part of the purpose of pandemic preparedness is to avoid the worst inequities—to plan for the use of
resources and the delivery of care to ensure that people have equitable access to what is available.
Responsiveness, then, is the capacity of the system to respond to information provided by those outside
the system. Some people will complain that they don’t have access to needed care. An ethical system
needs to have principles for providing care that are fair. It also needs systems for responding to complaints
by checking on how the whole system is functioning. Responding to criticism and concern does not always
mean that the critic gets what s/he wants, but it does keep channels of communication open so that
inequities can be addressed and communicated to the public.
7
Indiana State Department of Health. 2008. Confronting the Ethics of Pandemic Influenza Planning: Communique
from the 2008 Summit of the States. http://www.bioethics.iu.edu/communique_2008_summit_of_the_states.pdf
Caring for the Community | preparing for an influenza pandemic
6
3. Proportionality
8
Proportionality requires that any proposed response is appropriate to the severity of the circumstance.
It also requires the specification of clear indicators for moving from one level of response to another. As the
severity of a pandemic increases, causing greater need with limited resources, the standard of medical
treatment needs to be adjusted. For example, the need to respond proportionately justifies practitioners
working outside of their normal scope of practice with appropriate supervision.
Any societal restrictions should be proportional to the severity of the event. In worst-case scenarios, for
example, when an influenza with high levels of mortality and easy transmissibility occurs, it may be
necessary to prohibit unnecessary travel or large social gatherings, and it might be necessary to enforce
that prohibition. In contrast, the existence of a few, quarantined cases of an avian flu variation with very low
transmissibility could not justify a blanket prohibition on travel—the response is out of proportion to the
problem.
4. Collective Responsibility
Collective responsibility is the responsibility to each other that all share as members of the community. It
includes the responsibility on the part of health care institutions to the public; individual responsibility to the
community as a whole; government institutions’ and society’s responsibility to support first responders; and
the responsibility of the public health profession to the public. Measures such as quarantining individuals or
requiring social distancing ask the public to recognize that each person has a responsibility to the
community. In order to fulfill these responsibilities, it is crucial to act collaboratively with others, to be willing
to reciprocate when others contribute time and resources, and to exhibit solidarity with all those working to
respond to the crisis. Individual rights may need to be limited to maintain the common good and sustain a
functional society.
Those responding to a crisis need to support each other. During the crisis everyone needs to work together
so that resources are used efficiently and the best response can be mobilized to meet the needs of the
public. Collaboration also ensures that after the crisis everyone can return to life together as a community
without resentment or feelings of unfairness. It is particularly vital to maintain cooperation and respect
between and toward professionals.
Reciprocity demands that society recognize and support those who carry the burden of protecting public
health. This burden in the case of an influenza pandemic includes expanded workplace duties, physical
and emotional stress, isolation from peers and family, and increased personal risk, including especially the
9
risk of contracting influenza.
During a crisis society must secure the safety of health care staff as much as possible. Those doing the
work of caring for the ill during an influenza pandemic should be among the first to receive basic benefits
(vaccines, for example). The principle of reciprocity also justifies the protection from liability that emergency
caregivers are provided during the crisis. Ideally it would also include fair compensation for the extra work
10
and risks caregivers undergo.
Solidarity involves honest and open communication, collaboration and coordination between society and
health care providers. First responders and health care providers must act in such a way that they
8
Iowa Department of Public Health. 2007. An Ethical Framework for Use in a Pandemic.
http://www.idph.state.ia.us/common/pdf/publications/panflu_ehtical_guidelines_manual.pdf
9
Emergency Preparedness@Maryland, Web site:
http://www.umd.edu/emergencypreparedness/pandemic_flu/intro.cfm
10
Eckenwiler, L. 2004. “Ethical Issues in Emergency Preparedness and Response for Health Professionals” Virtual
Mentor 6:5
Caring for the Community | preparing for an influenza pandemic
7
endeavor to maintain solidarity both during and after the event has run its course. They must recognize
mutual relationships within the community and work within the community to ensure social prosperity.
This involves the continuous flow of pertinent information to the public. Standing in solidarity with others
who are responding to the crisis ensures that the social fabric is maintained and even strengthened in spite
11
of the crisis.
We will not all die during a pandemic, but we will all have to live together when the crisis is over. Paul
12
Reitemeier
FAQs
1. Will there still be rules for how people are treated in the case of an influenza pandemic, or will health
care workers and emergency responders do whatever they think is best?
The rules that govern health care delivery in declared emergencies change, but there are still legal
guidelines and rules for how health care will be delivered. Professionals will work outside their area of
licensing, for example, but non-licensed, non-trained individuals will still not be allowed to practice health
care. See the Legal Issues Committee Report for further specification of the legal situation.
2. Will health care still be available to whoever needs it during an influenza pandemic?
Health care workers and supplies will be in short supply during an influenza pandemic, and the standards
of care will have to adapt to emergency conditions. Health care professionals will still work to provide the
best care possible, under the circumstances, to everyone who needs it, but the care available will not be as
extensive as it is under normal conditions. The principles of collective responsibility explain the ways in
which everyone, health care workers and ordinary people alike, need to work together and take
responsibility for getting through the emergency together.
3. What will happen to people who get sick from something other than the flu during a pandemic?
An influenza pandemic will not prevent people from getting other types of needed health care. Part of the
emergency preparedness planning process involves planning to provide needed health care of all kinds
during an influenza pandemic. Arrangements will be made to provide the necessary care for women who
go into labor, for accident victims, and all other serious health problems. Depending on the severity of the
pandemic, however, non-emergency treatment may be delayed due to the need to use facilities to treat
influenza patients. Fairness and proportionality determine that all health care emergencies need to be
responded to as effectively as possible.
4. Will everyone have equal access to vaccinations or Tamiflu?
In the case of an influenza pandemic, access to vaccinations or other treatment will not be equal because
some people will have greater need for the vaccines, while other people may be given the vaccines to
allow them to provide needed services. The highest priority will be given to the people who are needed to
keep health care available and society functioning smoothly: active health care workers, emergency
responders, and the police will all have priority for receiving vaccines. The principle of reciprocity justifies
providing the vaccine first to those who risk their own health to provide care for others. Groups of people at
highest risk from the flu will also have higher priority for receiving the vaccine. The principles of fairness
and proportionality both support providing the vaccine first to those who need it most. Transparency and
accountability require those who decide what the priority rankings will be to make that information publically
11
Brody H, Avery E. (2009). Medicine’s duty to treat pandemic illness: Solidarity and vulnerability. Hastings
Center Report, 39 (1), 40-48.Center for Disease Control and Prevention. (2007). Ethical guidelines in Pandemic
Influenza – Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director. Retrieved from:
http://www.cdc.gov/od/ science/phec/guidelinesPanFlu.html
12
The Ethics Committee is grateful to Paul Rietemeier, Associate Professor in the Research and Development
Division of the Office of Graduate Studies and Grants Administration at Grand Valley State University, for the
valuable assistance he provided. In addition to providing extensive references and material for deliberation, his
guidance and recommendations to the committee were of enormous value.
Caring for the Community | preparing for an influenza pandemic
8
available and clear.
5. Will individuals lose their basic rights during an influenza pandemic?
No. Even when a state of emergency is declared, people still have the right to be treated with respect, in
ways consistent with the law, and to be treated fairly. However emergency conditions do allow the
authorities to limit certain types of freedom that people normally enjoy. For example, individuals with the flu
may be quarantined so that they cannot move about freely. This is justified by the need to prevent harm to
others who might get the flu from the infected individual. Under extreme conditions, schools, churches, and
other meeting places might be closed to limit the spread of the disease. The principle of solidarity requires
people to work together to protect their community during an emergency. Any limitations of this sort must
be proportional to the level of emergency.
Allocation Guidelines:
Green Light: Criteria that are acceptable for making care decisions
Medical criteria directly relevant to prognosis
CDC guidelines for treatment
Narrow Social Worth: (The worth of an individual due to the vital role they play in maintaining social
services during an emergency)
1.
Status as care provider during crisis (medical workers providing care, public health
workers, EMTs, etc.)
2.
Status as support personnel during crisis (police, transporters, other essential service
providers)
Yellow light: Criteria that should be recognized as problematic
(There is reasonable disagreement about the use of these categories; if they are used, it is important to
recognize them as controversial)
13
Age
Chronic conditions
Disabilities that affect the prognosis
Aggressive or anti-social behavior
Red Light: Criteria that are not acceptable for making care decisions
Citizenship
Disabilities unrelated to prognosis
Broad social worth (General considerations of social worth due to economic value, social prominence, or
intellectual ability)
Religious affiliation
Race or ethnicity
Gender or sexual orientation
Supporting Documents:
Glossary of Ethical Terminology
Accountability: Decision makers should be answerable for their action or inaction.
Broad Social Utility: (See Social Utility)
Collaboration: 1) Working together with one or more people to achieve something.
13
The use of age as a criterion for distribution of benefits or exclusion from treatment is problematic. As noted in the
report of the Legal Issues Committee, it is “illegal for rationing protocol to exclude a patient from treatment based
explicitly on the patient’s age (Age Discrimination Act of 1975, 42 USC 6102 (1975)). CDC recommendations for
priority vaccinations, however, routinely use age guidelines for determining which patients should be vaccinated first.
Caring for the Community | preparing for an influenza pandemic
9
2) Willingness to share resources so that all have fair access.
Community Members: Every human residing in the geographic area covered by this document is a
community member. Some would argue that animals are members of the community as well, but
there is no consensus on this issue. Animals should, clearly, be treated with as much respect and
consideration as possible during the course of any emergency.
Distributive Justice: Specification of what principles of distribution fall within the limits of justice.
Determines how limited resources can be made available to people in ways that are fair, and in
ways that maintain the fabric of a functioning society.
Duty to Treat: The ethical responsibility of health care professionals to provide treatment due to their
specialized knowledge and place in society. Ethicists disagree about whether or not there is a duty
to treat. Those who argue that there is such a duty also argue that it increases with increased
authority. A public health officer has a stronger responsibility to fulfill his or her duties, for example,
than a hospital janitor; a physician who is in charge of delivering care during a pandemic has more
14
responsibility than a plastic surgeon.
Equal Treatment/Egalitarian Treatment: Equal treatment requires that each individual be treated the
same way. Egalitarian treatment requires that treatment be fairly distributed, though it may be
unequal in content or result. Equal treatment is only possible when there are sufficient resources to
provide everyone with the same treatment. Under normal conditions, for example, every patient in
a hospital who needs a ventilator will receive one. Under emergency conditions, when ventilators
are in extremely short supply, triage decisions about who will benefit most from ventilator usage
may be made, and only some patients will receive ventilators. So long as the decisions are made
on the basis of medical indicators and are fairly structured, this distribution is equitable (though not
equal.)
Ethics: Principles or standards of human conduct.
Inclusiveness: Decisions made with stakeholder views in mind. Engaging stakeholders in the decisionmaking process.
Individual Liberty: 1) The right of individuals to act as they choose.
2) In a Public Health crisis, restrictions to individual liberty may be necessary to protect the public
15
from serious harm.
Isolation: Restriction of individuals who have a disease.
Medical Utility: To maximize the welfare of the person(s) suffering.
Narrow Social Utility: (See Social Utility)
Proportionality: A reasonable relationship between problem and solution. The measures taken to respond
to a crisis should be appropriate to the level of emergency.
Quarantine: Restriction of individuals who have been exposed to a disease.
14
American Medical Association Journal of Ethics. 2004. “Duty to Treat versus Personal Safety” with commentary
by M. Hughes and D. Marcozzi. Virtual Mentor 6(5). http://virtualmentor.ama-assn.org/2004/05/ccas1-0405.html
15
Emergency Preparedness@Maryland, Web site:
http://www.umd.edu/emergencypreparedness/pandemic_flu/intro.cfm
Caring for the Community | preparing for an influenza pandemic
10
Reciprocity: Appropriate recognition for those who provide help or benefits to others. In particular this
requires provision of resources and appropriate protection for service providers and volunteers.
Responsiveness: Opportunities to revisit and revise decisions as new information emerges throughout a
16
crisis. There should be mechanisms to address disputes and complaints.
Social Distancing: Measure designed to reduce personal interactions and thereby the risk of disease
transmission. These interventions can apply to individuals or groups.
Social Utility: Measuring worth in terms of benefits to society.
Broad Social Utility: Consideration of a person’s overall value to society, whether because of
economic contributions, or other considerations.
Narrow Social Utility: Considerations of a person’s particular value to society because of social
roles or functions. Health care workers, for example, take on enormous narrow social utility during
an influenza pandemic, and so should receive preferential consideration for vaccines so that they
can continue to help others.
Solidarity: Working together to protect the whole community. Standing together as a unified community
rather than acting solely in one’s own interests.
Transparency: Principles for deciding who gets care are clear, reasonable, and public. People who make
decisions are clearly identified, qualified, and accountable for their decisions. Procedures by which
17
decisions are made are open to public scrutiny.
Triage: The process of prioritizing patients for treatment to make sure that available resources are used to
achieve the greatest good possible.
Utilitarian principle: To do the greatest good for the greatest number (of people).
18
II. Issues of communication, especially with vulnerable populations, are central to the concerns of this
committee. The Kent County Health Department has developed a list of communications considerations
for special populations that is relevant to these concerns and provides helpful information. Because of its
relevance the committee has included it below as an Appendix.
Appendix A: Communication Considerations for Special Populations
Kent County Health Department, October 2008
Deaf and Hard of Hearing
 Do not assume the person you are addressing can hear you. Check with the person to make sure
you are understood.
 American Sign Language (ASL) is not a visual equivalent of English. ASL is a distinct language
with its own grammatical structure and syntax.
 Write messages for the Deaf at fourth grade reading level if possible, to accommodate the broad
education spectrum within the Deaf community. Make sure messages are free of slang and idioms.
16
The Pandemic Influenza Ethics Initiative Workgroup of the Veterans Health Administrations National Center for
Ethics in Health Care. 2009. Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health
Care Professionals in the Veterans Health Administration www.ethics.va.gov/ethics/nec/index.asp
17
The Pandemic Influenza Ethics Initiative Workgroup of the Veterans Health Administrations National Center for
Ethics in Health Care. 2009. Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health
Care Professionals in the Veterans Health Administration www.ethics.va.gov/ethics/nec/index.asp
18
Beauchamp, T.L. and James F. Childress. 1994. Principles of Biomedical Ethics, 4th Ed. New York: Oxford
University Press.
Caring for the Community | preparing for an influenza pandemic
11



Email, text messages, television and video phones are communication resources for the Deaf.
Most Deaf Kent County residents have video phones.
Deaf & Hard of Hearing Services has an email notification network, and may provide emergency
interpretation. Contact Deaf & Hard of Hearing Services at 616-732-7358.
Voices For Health provides interpretation for the Deaf. Contact Voices For Health at
(616) 233-6505 or (800) 834-3347.
Blind and Visually Impaired
 Radio is a good communication resource for the blind.
 Blind and visually impaired people watch television. Emergency messages on television should be
spoken and scrolling text should be large.
 Community and neighbors are important notification resources.
 Door-to-door notification of blind and DeafBlind citizens by law enforcement personnel should be
done with a trusted neighbor, since visual identification of the officer is not possible.
 Not all people who are blind, visually impaired or DeafBlind live with a caregiver.
 Printed materials should be in at least 14 – 16 points in size, and in a sans serif font such as Arial
or Verdana.
 While roadways as boundaries are easily understood by the general population, landmarks are
more easily understood by the blind community.
 Association for the Blind & Visually Impaired does not have an emergency notification network.
Language and Culture
 Churches, cultural centers and sponsor families are trusted information sources for refugees and
Hispanic/Latino cultures.
 Bethany Christian Services is available to assist with local cultural services.
 Refugee elders assist with news dissemination through informal word-of-mouth networks.
 Expect Hispanic/Latino population to show up for health services rather than call on the phone.
 Voices For Health is a resource for emergency interpretation. Voices For Health dispatchers can
help determine a spoken language at no charge. Call Voices For Health at 616-233-6505 or
1-800-834-3347.
Mental Health
 Network 180 can tap into a national network of mental health systems to coordinate response in a
large scale event. Contact the Network 180 Access Services line at 616-336-3909.
 If possible, coordinate with clinicians to accompany law enforcement personnel during door-to-door
notification.
Elderly and Homebound
 Elderly citizens may need the same communication considerations as the Deaf, blind or cognitively
challenged. Make written and verbal messages simple and concise in visual and audible media.
 Homebound citizens receiving home care services may have a personal information packet
containing emergency contact information and a medications list.
 Medical supply vendors and meals-on-wheels programs are communication resources for the
homebound.
 Area Agency on Aging of West Michigan has a call system for homebound clients. Contact Area
Agency on Aging at 616-222-7003.
General Considerations
 In an evacuation, remind the public to take their medications and durable medical equipment,
including hearing aids and batteries.
 Do not separate any person from his or her caregiver, family members, friends or pets.
 Do not shine a flashlight into the face of any person when in the dark.
Caring for the Community | preparing for an influenza pandemic
12
References
Berlinger N, Moses J. (2007). Bioethics backgrounder: The five people you meet in a pandemic- and what
they need from you today. The Hastings Center. www.thehastingscenter.org
Brody H, Avery E. (2009). Medicine’s duty to treat pandemic illness: Solidarity and vulnerability. Hastings
Center Report, 39 (1), 40-48.Center for Disease Control and Prevention. (2007). Ethical
guidelines in Pandemic Influenza – Recommendations of the Ethics Subcommittee of the Advisory
Committee to the Director. Retrieved from: http://www.cdc.gov/od/
science/phec/guidelinesPanFlu.html.
Centers for Disease Control and Prevention. (2007). Interim pre-pandemic planning guidance:
Community strategy for pandemic influenza mitigation in the United States: Early, targeted, layered
use of nonpharmaceutical interventions. (Department of Health and Human Services). Retrieved
from: http://www.pandemicflu.gov/plan/community/community_mitigation.pdf.
Centers for Disease Control and Prevention. (2006). Interim guidance on planning for the use of surgical
masks and respirators in health care settings during an influenza pandemic. Retrieved from:
http://pandemicflu.gov/plan/healthcare/maskguidancehc.html.
Challen K., Bentley A., Bright J., & Walter D. (2007) Clinical review: mass casualty triage – pandemic
influenza and critical care. Critical Care. (11), 212.
Childress, James. (2005). Just care: Rationing in a public health crisis. Update 20, no.3 September 2005.
Christian MD., Devereaux AV., Dichter JR., Geiling JA., & Rubinson L (2007). Definitive Care for the
Critically Ill During a Disaster: Current Capabilities and Limitations. From a Task Force for Mass
Critical Care Summit Meeting, January 26-27, 2007. Chicago, IL. Chest 2008, 133(5_suppl):8S-17
Christian MD. (2006). Critical care during a pandemic: Final report of the Ontario health plan for an
influenza pandemic (OHPIP). Working Group on Adult Critical Care Admission, Discharge and
Triage Criteria. Hamilton, ON: McMaster University Medical Centre, April 2006.
Devereaux AV., Dichter JR., Christian MD., Dubler NN., Sandrock CE., & Hick JL. (2007) Definitive care
for the critically ill during a disaster : A framework for allocation of scarce resources in mass critical
care. Task Force for Mass Critical Care summit meeting, January 26-27. 2007. Chest. 2008,
(133),51S-66S.
Eckenwiler, L. 2004. “Ethical Issues in Emergency Preparedness and Response for Health Professionals”
Virtual Mentor 6:5
Huber S.J., Wynia M.K. 2004. “When Pestilence Prevails…Physician Responsibilities in Epidemics”
American Journal of Bioethics 4:1.
Indiana State Department of Health. 2008. Confronting the Ethics of Pandemic Influenza Planning:
Communique from the 2008 Summit of the States.
http://www.bioethics.iu.edu/communique_2008_summit_of_the_states.pdf
Iowa Department of Public Health. 2007. An Ethical Framework for Use in a Pandemic.
http://www.idph.state.ia.us/common/pdf/publications/panflu_ehtical_guidelines_manual.pdf
Kinlaw, K. and Levine, R.2007. Ethical Guidelines in Pandemic Influenza—Recommendations of the Ethics
Subcommittee of the Advisory Committee to the Director, centers for Disease Control and
Prevention http://www.cdc.gov/od/science/phethics/panFlu_Ethic_Guidelines.pdf
New York State Workgroup on Ventilator Allocation in an Influenza Pandemic. (2007). Allocation of
ventilators in an influenza pandemic: Planning document draft. Retrieved from:
http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/docs/ventilta
or_guidance.pdf
North Carolina Institute of Medicine. (2007) Stockpiling solutions: North Carolina’s ethical guidelines for an
influenza pandemic. Retrieved from: http://www.nciom.org/projects/flu_pandemic/panflu. html.
The Pandemic Influenza Ethics Initiative Workgroup of the Veterans Health Administrations National
Center for Ethics in Health Care. 2009. Meeting the Challenge of Pandemic Influenza: Ethical
Guidance for Leaders and Health Care Professionals in the Veterans Health Administration
www.ethics.va.gov/ethics/nec/index.asp
Pattison, S. 2006. “The Ethics of Treatment in a Time of Sudden Pandemic: The Need for a Proactive
Response—Justice, Rationing, and the Prophylactic Treatment of Fear and Demoralisation”
http://www.ccels.cardiff.ac.uk/archives/issues/2006/pattison.pdf
PEPPPI (2005) “Citizen Voices on Pandemic Flu Choices: A Report on the Public Engagement Pilot
Project on Pandemic Influenza” http://www.pandemicflu.gov/plan/federal/pepppimaintext.pdf
Caring for the Community | preparing for an influenza pandemic
13
Rubinson L., Hick JL., Hanfling DG., Devereaux AV., Dichter JR., Christian MD., Talmor D., Medina J.,
Curtis JR., & Geiling JA. (2007). Definitive care for the critically ill during a disaster: A framework
for optimizing critical care surge capacity. From a task force for mass critical care summit meeting,
January 26-27, 2007. Chicago, IL. Chest 2008, 133(5_suppl):18S-31.
Ruderman C., Tracy CS., Bensimon CM., Bernstein M., Hawryluck L., Shaul RZ., & Upshur RE. (2006). On
pandemics and the duty to care: whose duty? who cares? BMC Med Ethics, 7(5). doi:
10.1186/1472-6939-1187-1185.
Talmor D., Jones AE., Rubinson L., Howell MD., & Shapiro NI. (2007) Simple triage scoring system
predicting death and the need for critical care resources for use during epidemics. Critical Care
Medicine. (35),1251-1256. Retrieved from:
http://www.aemj.org/cgi/content/full/14/5_Supplement_1/S157-a.
Thompson AK., Faith K., Gibson JL., & Upshur RE. (2006) Pandemic influenza preparedness: An ethical
framework to guide decision-making. BMC Med Ethics, (7), E12.
University of Toronto Joint Centre for Bioethics. (2005). Pandemic influenza and ethics – stand on guard
for THEE: Ethical considerations in preparedness planning for pandemic influenza. Retrieved
from: http://www.utoronto.ca/jcb/home/documents/pandemic.pdf
U.S. Department of Health and Human Services. (2005). Altered standards of care in mass casualty
events.
Vawter D., Garret E., Gervais K., Prehn A., DeBruin D., Tauer C., Parilla E., Liaschenko J., & Marshall M.
(2009). For the good of us all: Ethically rationing health resources in Minnesota in a severe
influenza pandemic. Retrieved from: http://www.ahc.umn.edu/mnpanflu/preliminary/home.html
Vawter DE., Garrett JE., Prehn AW., & Gervais KG. (2008) Health Care workers' willingness to work in a
pandemic. The American Journal of Bioethics, 8(8),21- 23.
World Health Organization. (2007). Ethical considerations in developing public health response to
pandemic Influenza.
Caring for the Community | preparing for an influenza pandemic
14