Addressing ethical issues in pandemic influenza planning: equitable access to scare medical resources

It is generally expected that sooner or later a novel influenza A virus subtype, easily transmissible from person to person, will emerge and cause pandemic disease. Humans will have little or no immunity to this virus, which could spread at least as easily as common seasonal influenza and infect many people worldwide potentially resulting in very high mortality and morbidity rates. Some scenarios assume attack rates of up to 35% and lethal disease in 1–2% of persons who develop symptoms, yet such assumptions may be a gross overestimation or underestimation of the crisis (1). Mass production of a specific pandemic vaccine will not start for several months, and in the mean time the possibilities for prevention and treatment are limited. Depending on supplies, antiviral drugs could play an important specific therapeutic and prophylactic role. The global demand for antiviral drugs and medical care would be likely to exceed global (and affordable) supplies. Many patients may develop respiratory failure and require mechanical ventilation and the need for such intensive care will go far beyond available resources. Moreover, the disease will hit health-care professionals and related personnel: working in the front-line they run greater risks of infection than other citizens. This will increase pressure on the health-care system, where much more must be done with fewer staff. Triage decisions for allocating scarce treatment possibilities will be inevitable. Such decisions need to be made for supportive medical care (e.g. ventilators), antibiotics, antiviral drugs, and vaccines, as well as for access to health-care facilities in general. One essential way to avoid chaos and to promote an adequate response to a pandemic is to develop action plans for pandemic preparedness. Allocation of scarce medical resources such as antiviral drugs, and development of vaccination strategies are important issues in such plans. Triage and priority-setting clearly raise ethical questions: is it morally justified to give certain persons access to life-saving treatment and to refuse others – and if so, which choices should be made and by whom? In 2006 many countries published action plans for an influenza pandemic but few provide discussion of such ethical issues and even fewer offer systematic ethical justification for priority setting (2, 3). This paper formulates ethical principles and arguments for setting priorities in the distribution of scarce medical resources during a pandemic, especially antiviral drugs, vaccines, access to medical care, and bed and equipment allocation. Priority setting in a pandemic will be a deeply controversial issue. This is not only because there will be extreme shortages in supply of potentially life-saving treatment, but also because routine health-care procedures for illnesses other than influenza may not be applicable or appropriate where drastic interventions are required to mitigate the effects of the pandemic. However, ethical theories do provide clarification and reasonable justification for the principles that should guide decision-making. This paper argues for specific priorities on the basis of maximizing health benefits (notably saving most lives) and equity, but also acknowledges that basic moral principles allow consideration of certain other priorities. The conclusions can only be provisional and incomplete given the lack of important data and inevitable conflicts between and within the basic moral principles. Moreover, some situations involve emergencies and tragedies of such magnitude that ethical theory has little practical guidance to offer