Minnesota Pandemic Ethics Project:
A Look at Vaccines
Confronting the Ethics of Pandemic Influenza Planning:
The 2008 Summit of the States
J. Eline (Ellie) Garrett, JD
Minnesota Center for Health Care Ethics
on behalf of the
Minnesota Pandemic Ethics Project Team
Minnesota Center for Health Care Ethics
2006 Pandemic Influenza Ethics
Project on Vaccines
Vaccine 25 (2007) 6522-6536
2006 Vaccine Project


Diverse workgroup, ~35 participants
Prioritization based on
• Risk of mortality
• Vaccine response
• Risk of transmission
• Key worker role

Exposure risk not prioritized
MN Pandemic Ethics Project
2007 – present
A collaboration between the
Minnesota Center for Health Care Ethics
and the
University of Minnesota Center for Bioethics
funded by the
Minnesota Department of Health
Team Members

MN Center for
Health Care Ethics
•
•
•
•
•
J. Eline Garrett
Karen G. Gervais
Ruth Mickelsen
Angela Witt Prehn
Dorothy E. Vawter

U of MN Center for
Bioethics
•
•
•
•
•
•
•
•
•
Debra A. DeBruin
Jeffrey Kahn
JP Leider
Joan Liaschenko
Mary Faith Marshall
Steven Miles
Elizabeth Parilla
Carol Tauer
Susan Wolf
Scope of Project

Ethical frameworks for rationing
health-related resources during
severe pandemic
• Vaccines
• N95s
• Masks
• Antivirals (treatment and prophylaxis)
• Ventilators

Recommendations, not mandates
Pandemic: Assumptions for
Severe Pandemic

Groups at risk
•
•
•
•

2 sources of mortality
•
•

Very young
Very old
Co-morbidities
Healthy 15-40 yr olds
Flu
Disrupted critical infrastructures
Guidance is context-specific
Process

Comprehensive review of plans and
literature
• AW Prehn, DE Vawter. Ethical Guidance for
Rationing Scarce Health-Related Resources in
a Severe Influenza Pandemic: Literature and
Plan Review (2008)

Convened 100+ Minnesotans to develop
preliminary guidance
• Diverse – expert and “lay”

Community engagement (in process)
• Web-based public comment
• Small groups – metro and rural
Ethical Guidance for Rationing
in Severe Pandemic
State
Florida
General
Antivirals
PPE
Vaccines
Ventilators
+
+
New York
Tennessee
+
Utah
+
Wisconsin
+
+
+
+
+
As of March 2008
MN Ethical Frameworks: Overview


Statewide, public-private perspective
Guidance for decision-making
• Commitments
• Principles
• Goals
• Strategies
Ethical Commitments

Pursue common good
• Be accountable, transparent,
trustworthy
• Promote solidarity, mutual responsibility
• Respond fairly, effectively, efficiently
Principles and Goals

Protect the population’s health
• Reduce mortality and serious morbidity

Protect public safety and civil order
• Reduce disruption to critical
infrastructures
• Promote public understanding and
confidence
Principles and Goals (cont.)

Treat people fairly, recognizing moral
equality of all
• Reduce significant differences in
mortality/morbidity
• Remove barriers to fair access
• Honor reciprocity obligations to workers
• Reduce significant differences in opportunities for
normal lifespan
• Use fair process

Principles (not goals)are co-equal;
must be balanced
Strategies: General

Do not ration based on:
• Social value (gender, socio-economic
class, race, citizenship, etc.)
• Quality of life
• Duration of extended life
• First-come, first-served

Ration based on combinations of
clinical and non-clinical
considerations
Key Worker Status



To reduce mortality and disruption of
infrastructures
Highest priority goes to workers with
additional characteristics, e.g., high
exposure, risk of mortality
Usually prioritized simultaneously with
groups in general population, based on
different considerations
Age-based Rationing?


An alternative to random processes
Depends on broad public agreement
• Children before adults?
• Younger adults before older?
• Elders before others?

MN not alone in considering age
• WHO
• US Interagency Working Group
• Indiana 2006 recommendations
A Look at One Framework:
Vaccines
De-Prioritized or Excluded
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Natural immunity
Medical contraindications
Unacceptable vaccine response
Imminently and irreversibly dying
Satisfactory alternative protections
Strategies:
2 Parallel Tracks with 6 Tiers
Track B:
General Public
Tier 1
Track A:
Key Workers
+
Tier 2
+
+
Tier 3
+
+
Tier 4
+
Tier 5
+
Tier 6
+
Track A – Key Workers

Tiers based on combinations of:
• Risk of occupational exposure
• Risk of morbidity/mortality
• “Irreplaceability”
• Vaccine response
Track B – General Population

Tiers based on combinations of
• Risk of morbidity/mortality
• Vaccine response
• Possibly age (children at moderate risk
prioritized over adults at moderate risk)
Moving from 2006 to
Current Project

Adjust resource-specific frameworks
to work as a package (and to
coordinate with comprehensive plan)
• Don’t systematically disadvantage (or
advantage) any group


More attention to occupational
exposure risk
Possibility of age-based rationing
(esp. prioritizing kids)
Fit with Feds?


2005 HHS guidance for moderate
pandemic
Proposed federal guidance for severe
pandemic:
• Multiple goals, tracks and tiers
• Protects infrastructures
• Prioritizes children before adults in some
circumstances
• Attends less to differences in response and
availability of alternative protections
• Attends to homeland security and national
defense goals
Draft Reports



DE Vawter, JE Garrett, AW Prehn, et al. For
the Good of Us All: Ethically Rationing Health
Resources in Minnesota in a Severe Influenza
Pandemic: Preliminary Report (2008)
DA DeBruin, E Parilla, J Liaschenko, et al.
Implementing Ethical Frameworks for
Rationing Scarce Health Resources in
Minnesota During Severe Influenza Pandemic
(2008)
Available (soon) at www.stolaf.edu/mnethx
and www.bioethics.umn.edu
Next Steps

Public comment (web-based)
• Watch www.stolaf.edu/mnethx or
www.bioethics.umn.edu

Public engagement pilot
• Small groups
• Metro, rural
For more information

Ellie Garrett
MN Center for Health Care Ethics
garrette@stolaf.edu
(612) 964-9425

Contact info for other team members:
www.stolaf.edu/mnethx or
www.bioethics.umn.edu