Ethical Issues in Influenza Pandemics

Introduction Throughout history, there have been significant pandemics that have left a great impact on humankind. The first influenza pandemic to occur took place in 1918-1919. This pandemic was later classified as the Spanish influenza A H1N1. Successive outbreaks of influenza had occurred almost simultaneously throughout North America, Europe and Africa with not much being know about the virulence of the virus. It has been estimated that this pandemic caused around fifty million deaths in only twelve months. Half of the deaths that occurred were among those twenty to forty years of age. To this date there is still much controversy over where the virus originated, with suggestions being either from China or US military camps in the mid-west. Several years later, another pandemic spread across the world. This next pandemic was known as the Asian Influenza A N2H2 of 1958. This time is was certain that the virus originated in China. Since this new virus had completely different antigens than the first virus that spread in 1918, mortality rates were still considerably high. Again, the virus spread worldwide and many people became infected and fell ill. The death rate for this pandemic was estimated at 69 800 deaths, with more than fifty percent of the deceased were aged five to nineteen. Another pandemic that occurred throughout history was the Hong Kong influenza H3N2. This virus shared some of the properties of the virus that was isolated in the Asian influenza pandemic, but also carried some different properties with it. Mortality rate of this pandemic was estimated at 33 800, which is almost half of the mortality rate of the previous pandemic. Experts believed that the severity of this new virus was reduced because many people around the world had already been exposed to the Asian influenza in which their bodies produced antibodies towards. In the past, following the trends of these pandemic outbreaks led experts to believe that they had to occur every ten to fourteen years. With recent research on pandemics and their occurrences, it is now clear the influenza pandemics occur at unpredictable intervals throughout time. Not being able to judge when the next influenza pandemic will hit, many countries across this globe have developed pandemic plans of action to help them prepare for whatever new strain of influenza has in store for humankind.
Ethical Issues Gaining an understanding about influenza pandemics that occurred in the past and the ethical issues that co-inside, will help international and government officials devise pandemic plans that are ethically appropriate and effective. Although some of the ethical issues that surround influenza pandemic outbreaks have been addressed by government officials and implemented into their plans of action, there are still many issues that need to be addressed. Many of the ethical issues discussed around the topic of influenza pandemic outbreaks violate human rights. One issue discussed by the World Health Organization, stated that in the event of an influenza pandemic, quarantine, isolation and international travel and boarder control would be implemented. But, the document also discusses “Social separation can infringe individual rights and disrupt social and economic life... Freedom of movement is a basic right protected by national laws and international treaties.” This shows one of the many ethical dilemmas with influenza pandemic outbreaks. In the article by Pahlman, Tohmo and Gylling, it states “It can be argued all human beings have a moral duty to help other people in great need.” If this is the case, and every human shared this same moral duty, should only health care professionals put their lives at risk to save others? Should there be advanced training implemented into the national plans for members of society to take part in order to prepare more citizens to aid health care professionals at the time of a pandemic? These ethical issues are only a few issues pointed out by these various authors. There is a great magnitude of ethical concerns that arise when an influenza pandemic outbreak occurs.
Philosophers and Bioethicists Opinions In the article Preparing for an Influenza Pandemic: Ethical Issues, Kotalik discusses a majority of ethical issues that can be grouped into categories. These categories include: scarcity, vaccines and anti-virals, healthcare workers and communication. If an influenza pandemic were affect many countries around the world, there would be a great number of sick people requiring care all at the same time. Since many people around the world live with other greater health conditions on a daily basis, would they have to give up their ventilators that have been breathing for them for the past year to someone who has been hit with the influenza virus? The ethical question then is “Who will take priority when supplies become scarce during the pandemic?” Since many countries have learned from past influenza pandemics, plans have been devised to ensure preventative as well as what should be done immediately if an outbreak were to occur. Kotalik wrote: “An effective vaccine is the best way to decrease the impact of the new virus, but production cannot be started until the new virus strain is isolated.” Since production of a vaccine cannot take place until the new virus strain is evident, vaccines will be produced and shipped out a gradual rate and again the question of who takes priority for these new vaccines is posed. On the topic of vaccine administration, health care workers in most job settings are mandated to receive the influenza vaccination on a seasonal basis. If they do not do so, it could result in a loss of their job or weeks without pay. During a pandemic, since health care workers are working on the front lines, they are expected to receive this new vaccine that has only been briefly tested. Is this ethical to make a person take something that has not been tested thoroughly with unknown adverse effects? Another issue Kotalik analyzes in his article address communication among nations. He explains how he believes that the content of pandemic plans devised by various countries should be communicated throughout in order to level the playing field of all nations if a pandemic outbreak were to occur. If there are nations who are unable to develop such plans due to lack of resources, then this communication technique will aid these countries and pandemic plans will be made available to all nations to implement at the time of another influenza outbreak. Kotalik also touches on the use of media during an influenza outbreak and expresses that “A concern that public discussion of a probable flu pandemic will cause alarm among the public is not sufficient justification for non-communication.” What Kotalik was trying to get across with this statement is that yes, at times the media can over exaggerate things like an influenza pandemic outbreak, but is that fair to society to be kept out of the loop about the important issues going on around them? Is it ethical to keep information from people when there is a chance they may be exposed to something that could be detrimental to their health? Bioethicists Kotalik brings to light some important ethical issues to consider if a influenza pandemic were to occur sometime during this century. Most articles presented by philosophers and bioethicists look at the moral obligation of health care professionals when a pandemic outbreak occurs. But what about everyone else in society, do they not hold the same moral principles to care for those in need? What if the first line of vaccinations was ineffective and most of the health care professionals fell ill to the influenza virus? Would there be anyone in society to care for the healthcare professionals? In the article Non-Professional Healthcare Workers and Ethical Obligations to Work during Pandemic Influenza, the authors look at other staff members that work within hospital settings and provide services that assist healthcare professionals to complete their jobs and care for clients effectively. The authors consider “ whether non-professional healthcare workers-porters, domestic service workers, catering staff, clerks, IT support workers, ect.-have an obligation to work during and influenza pandemic.” These bioethicists used interviewing techniques to analyze the factors that made healthcare professionals decide not to attend work if an influenza pandemic were to occur. Many of these reasons included: obligations to care for their own sick children or family at home, lack of child care availability, lack of transportation methods and fears about vaccination. If pandemic plans were able to implement strategies to overcome these obstacles to working, then more healthcare professionals would be able to take part in caring for others during a pandemic outbreak. It was also pointed out in this article: Healthcare professionals have abilities others lack, abilities that are particularly likely to do good, and so healthcare professionals have strong obligations to exercise these skills when they are needed. But the ability of these professionals to exercise their skills effectively depends partly on the support of those working in nonclinical and/or non-professional roles.
Here it is indicated by the bioethicists of this study, that in a state of emergency, if an influenza pandemic were to occur, it is the obligation of everyone in society to continue to work and help one another out in order to maintain the obligations each individual withholds. In looking at another point of view from international bioethicist, Tzeng and Chang, they analyzed the feelings of nursing staff and the fears they express about future pandemic outbreaks: People’s level of fear is high and lasting when faced with the possibility of an H5N1 influenza pandemic. Because nurses usually work in the front line of care and have the most contact with patients, more attention should be paid to their concerns about the possibility of an avian influenza pandemic before such an outbreak occurs.
These bioethicist continue to elaborate on the importance of listening to the fears healthcare professionals are expressing and to implement strategies to decrease these fears before an influenza pandemic occurs. The discussed how fears that healthcare professionals express can turn into phobias if not enough attention is given to the situation. If the front line workers develop phobias about an upcoming pandemic, they will not be able to carry out their obligations and care for those who have fallen ill from this new virus. From interviewing nursing staff, “42% of the nurses did not think that, if there were an outbreak of avian flu, their working hospitals would have sufficient infection control measures and equipment to prevent nosocomial infection in their working environment.” Sp by recognizing these fears, organizations can implement strategies to ensure the proper measures are being met to reduce these fears before the occurrence of a pandemic.
Religious Views It was difficult to locate information about influenza pandemics or vaccinations from various religious denominations in Canada. In the article Pandemic Influenza Preparedness and Response Among Immigrants and Refugees, it discussed the feeling of non-catholic members of an African tribe to catholic members. Those who were non-catholic members saw the influenza virus as a plague sent from their ancestors for breaching traditional ways or the work of witchcraft. Whereas catholic members held the belief that with faith and medical intervention this disease would rid their tribe. No ethical considerations from religious denominations were found using an academic search base.
Case Study #1:
During an evening shift, a patient with a potential diagnosis of avian flu is admitted to an acute medical unit in a large urban hospital. The emergency department nurse who facilitates this transfer indicates that they have been alerted to expect other suspected cases. The man is admitted and placed in isolation. Little information is available concerning his diagnosis, and the staff is concerned for their own safety and the safety of other patients. The unit manager has been involved in planning for such an event, but none of the staff on duty have received any education or information related to a suspected flu outbreak. The evening supervisor is called in to assist. Ellie, a registered nurse (RN), is assigned to care for the patient. Ellie works part-time on the unit. She is a single parent of two school-aged children. Ellie also works as a casual employee in home care, which provides her with more flexible working hours and extra income. Currently, she does not work weekends, as child care is not available. Ellie is concerned about her health, the health of her children, and the implications that an outbreak will have on her work schedule. This evening, the unit is short-staffed and morale is low: one full-time RN called in sick, and again no replacement casual RNs were available. The unit manager has indicated that the unit is over budget for staff hours, and that staff must minimize their use of supplies to balance the budget, which includes using caution with how many gloves and masks are used daily. Moreover, overall reductions in the healthcare budget have resulted in bed closures throughout the hospital, and a consistent backlog of patients awaits placement in the Emergency Department. In this case study, Ellie the RN who is assigned to care for the patient with suspected avian flu, faces a couple ethical issues. Working as a healthcare professional, Ellie understands that it is her duty to care for those who are ill. But, as a mother of two young children, Ellie also has a duty to protect them from illness and harm. There is another issue of the budget cuts taking place throughout the hospital, in which the manger on Ellie’s unit has advised them to use their supplies wisely. Thus, the unit may not have the proper equipment for Ellie to protect herself from contracting the virus and bringing it home to her family and client’s she visits in their homes as well. Since there have been many sick calls on the unit and a limited number of nurses available to work, is Ellie obligated to care for this client even if it puts her family and other clients health at risk? Also, the unit manager failed to inform staff on the unit about what to expect and what should be done in the event of an influenza outbreak, which increases the unsafe working conditions when the patient was brought up on the unit. If I were in Ellie’s position, I would demand a briefing session from my unit manager in order to become educated on the proper protocol and protective measures that should be taken in order to care for a client with a suspected case of influenza. I would also ensure that the proper protective equipment was available on my unit to protect myself from potentially contracting the virus and bringing to home to my family. For example, if there were no protective masks my size on the unit due to budget cuts, I would ask one of my colleagues on the unit who did have a proper mask available to take over the care of my client until I was able to obtain the proper protective equipment. There are many ethical issues proposed in this case study, but the biggest dilemma Ellie has to face is her moral duty. Does she uphold her moral duty has a healthcare provider to care for those who are ill no matter what circumstances, or does she uphold her duties as a mother and wife, to protect her family from illness and harm? For this case, Ellie could take a utilitarian view which indicates she would choose an action that would produce the greatest amount of good for the greatest amount of people. Therefore, by Ellie either refusing or transferring her care of the client with suspected avian flu, she would be doing the greatest amount of good for everyone living in her household as well as all the clients she visits while working at her other job and only disappointing one or two people at work.
Case Study #2
The media is reporting that the World Health Organization (WHO) has officially determined that a pandemic influenza is now underway. The Public Health Agency of Canada has confirmed person-to-person spread in several Canadian cities. The local media are reporting increased demands for emergency room and family physician office visits. Some deaths have been reported, but no one is really certain how serious the problem may be. Little is known about the actual virus at this point. Maria is a 35-year-old family physician and mother of three children aged 4-8. She works in a primary care clinic in Saint John and is one of 12 doctors practising in the clinic. Her husband, hearing the media reports, is concerned that she may become ill or bring home illness to her family because of the increased exposure at work. He encourages her not to go to work. Maria is concerned for the care of her children. They attend a day care centre. Her husband works in an accounting firm. She is also worried about abandoning her patients and increasing the workload of her colleagues, many of whom, like her, have young families. Maria decides she will go to work. She is concerned that her clinic lacks the appropriate amount of protective equipment. The clinical group meets and decides that they are committed to providing care to people with influenza, but will only do so if the ministry of health provides appropriate protective equipment. One of Maria's colleagues is close to retirement. He has diabetes and heart disease. He tells the clinic that he will not come to work as he feels the risk to his own health is too great. The influenza outbreak is now well advanced. Many people are sick, including a large number of health care workers. Many health care providers in hospitals and clinics are not showing up for work. Many refuse to work because they fear infection. The government has now officially declared a health emergency. It is enacting legislation mandating health care workers to participate in the efforts to control the outbreak.

My initial thoughts about this case study are about human right violations which are mainly brought about in the very last sentence. Since many of the healthcare workers have fallen ill due to the viral outbreak or refuse to work due to fear, the government issued that healthcare workers must take part in the efforts to control the outbreak occurring. It is against the human rights legislation to force someone to do something they have no desire to be involved with or do not want to take part in due to fear. As a physician, Maria took the Hippocratic Oath which implies that she must perform her moral duty to do good for others and to cause no harm to the patients under her care. Taking this into consideration, Maria made the right choice by choosing to work during this influenza pandemic and come to the aid of her patients. Maria’s colleague on the other hand, took a consequentialism approach to the situation at hand. He weighed out the benefits of coming to work and providing care to patients with influenza against the health consequences and possibly death he may face if he contracts the virus from one of his patients. I feel it would be in Maria’s family’s best interest to remove her children from day care. Day care can be a place where the influenza virus can spread very easily and rapidly. If the children were to remain in day care, this would notable increase the family’s risk of contracting the virus due to the fact that everyone in the household except the husband would be exposed to high risk areas of contamination. In my opinion, I feel that it was in the healthcare provider’s best interest to only agree to work if they are supplied with the proper protective equipment. During this meeting, they should have also discussed other interventions such as frequent hand washing, disrobing uniforms at the workplace and vaccinating staff in order to help reduce the spread of influenza. In this case study, there is another ethical issue that needs to be considered. If many of the healthcare workers are falling ill themselves and are unable to work, how can the government mandate that these people must attend work to help control the outbreak? If all healthcare professionals fell ill from the virus, who would be mandated to care for them? Should there be a change made to the legislation that would include all members of society to care for those ill during a state of emergency and mandate all healthy members in society to take part in controlling the outbreak? From my point of view, I feel that healthcare providers do indeed have a duty to care for the ill, but in a time of emergency, such as an influenza pandemic, other members of society should take an active part in controlling the outbreak as well. Another ethical issue that can be looked at in the case study, questions whether healthcare workers should face consequences for refusing to show up for work? For example, Maria’s husband works at an accounting firm. If he were to call in sick because he feared contracting the virus from someone at work, would he have to serve consequences? If the government is not going to penalize other members of society for not showing up to work during a flu outbreak then health care professionals should not have to serve consequences either. In addition to this, should healthcare providers be able to justify their choice to refuse to come to work instead of being mandated to? Take Maria’s colleague for example, is his own health enough justification to refuse to work. Do his patients needs take priority over his own health needs? As discussed earlier in the paper, many members of society rely on the moral obligations of healthcare professionals to care for those who are ill in the event of a pandemic, but what moral duties do other members of society hold?
Hutchinson Method of Value Clarification
Definition of the Issue The ethical issue to evaluate using this method is: in the event of an influenza pandemic, should all members of society be mandated to receive a vaccinations? Within our society today, it is strongly encouraged by healthcare professionals to receive the vaccination in order to protect themselves and the vulnerable population they work around. If healthcare professionals do not receive an influenza shot, the consequences could include weeks off work with no pay or even job loss. Other members of society may refuse to obtain the influenza injection due to egg allergies (egg products are used in the production of influenza injections) or because they feel the shot makes them sick. If an influenza pandemic were to occur in the near future, would the government mandate that everyone must receive the shot? Why should only healthcare professionals serve consequences for not obtaining an injection?
Initial Response My initial response when presented with this ethical question is violating human rights. If the government were to mandate everyone in society to receive the influenza injection during a pandemic outbreak, this would be violating our freedom of choice as humans. Everyone lives with their own beliefs and values. By the government stepping in and applying their own beliefs on everyone in society is an ethical matter. I feel that provided with the proper information about the injection and potential adverse reactions, members of society should be able to use their own discretion and make their own decision as to whether they will receive the vaccination during a pandemic outbreak.
Evidence
Evidence from the government perspective is that the most effective way to stop a pandemic from spreading across their entire country would be to vaccinate all members. By vaccinating everyone in society, many people will gain immunity to the virus which helps stop the person to person transportation of the virus. On the other hand, as stated previously in this paper, vaccinations for new strains of influenza cannot be produced until the new strain can be isolated. During the pandemic, government officials would be expecting quick production of this vaccination to stop the outbreak spread. When procedures in medicine are rushed, there is often no attention paid to potential adverse affects or even the effectiveness of the vaccination over a length of time. Is it safe to mandate society to receive an injection that has not been thoroughly tested? Looking at the healthcare professional’s position on the influenza injection, I feel that these people are also active members of society and should be able to use their own discretion as to whether they will receive the influenza injection and not be penalized for their decision. What kind of consequences should the government implement to non-healthcare professionals who do not receive the influenza injection? Even though healthcare professionals have an obligation to serve those who have fallen ill and would be working on the front lines if a pandemic were to occur, they should still be able to make the choice about how they want to protect themselves, whether that be by receiving the injection, using protective equipment and practices at work or not attending work because they feel their risk for contracting influenza is greater to their health than the benefits of helping other people.
World View Taking a look at the perspective of a healthcare professional working during an influenza outbreak, we can analyze how one might come to the decision not to receive the vaccination. Working either as a nurse or doctor, entering the medical field holds certain obligations and responsibilities to its profession. You are obligated to care for those who are unable to care for themselves and hold a responsibility to provide the most efficient care to all patients. You also have the obligation to respect you patient’s choice and cannot to anything against his wishes. For example, if one of you patients came into the clinic complaining of flu like symptoms and you were the nurse working with him, you cannot give him and influenza injection without his consent. You can educate him about his decision and point out the consequences to not receiving the vaccination, but in the end, the patient still has the final say in their own care. What if healthcare professionals hold the say views as their patients? Shouldn’t they be able to use their judgement and assess their own risk for receiving the influenza injection or not? How can we expect a certain profession to hold up their responsibilities and obligations, when in the end the government is doing exactly what their profession frowns upon; forcing people into doing something they don’t want to necessarily do but do not want to serve the immediate consequences of job loss.
Ethical Argument When looking at the issue of the government mandating influenza injections to all members of society during a pandemic, I think each individual should be able to reflect on their own situation and make that judgement themselves as to whether they should receive an injection. Each member of society, including healthcare professionals, should take a consequentialism approach. Each person should look at their own benefits to receiving the injection whether it is to gain immunity against the virus, stop person to person transmission or to have a feeling of security and protection. Others could look at the consequences of the injection as not knowing the long term effects, quick production of the vaccination with little testing done, allergies to some of the products used in the vaccination, unknown adverse effects and fear they will fall ill from the vaccination. Every individual should be able to weigh their benefits and consequences of receiving the vaccination and make the call as to whether the vaccination will produce the most good for themselves based on their decision.
Integrated Conclusion From my point of view, with the proper education, teaching and pandemic plans in place, all members of society should have the choice as to whether they want to receive the vaccination or not. Some individuals may choose social isolation and quarantining themselves within their own homes as a measure of protection if a pandemic were to hit. One cannot impose their own values and beliefs about receiving the vaccination onto others without violating are right to make our own free choices. It becomes a human rights issue if the government were to make vaccinations mandatory for all members of society, which basically goes against everything the Canadian Charter of Rights and Freedom has been established for.