EMPHNET

Ethical issues in Public Health emergencies and disasters s

Ghaiath M. A. HusseinMBBS, MHSc. (Bioethics), PhD Researcher

Email: ghaiathme@gmail.com

Regency Hotel, Amman, Jordan15-19 June 2014

Module’s objectives

2

• Distinguish between the different levels of effects of disasters (mainly pandemics) and their ethical implications

• Apply the ethical frameworks to analyse and manage the ethical issues associated with provision of public health care during disasters

• Compare the appropriateness of implementation of the PH ethical core values to the settings of disasters

Module’s Outline

• Different types of disasters (natural & man-made)• The ethical implications of disasters and the associated

PH interventions • Triage, evacuation and Resource allocation• Duty of care & Standard of care during disasters• Privacy and confidentiality (safety of collected data)• Duty to report• Consent• Media and its role in balancing information coverage

during disaster and protection of privacy and rights.

Different types of disasters (natural & man-made)

Let’s give it a thought …• What do we mean by a disaster?• Natural vs. manmade• Any examples from EMR?

Mapping of ethical issues in (natural) disasters

International

Disproportional burden

COI (®Tamiflu, vaccine)

Community & NationalResource allocation

Consent Public

engagementSub-optimal

productsSurveillance (research?)InequalitiesTrials (review)

Individual Loss of

property &work hours

Access to care

Restricted movement

Confidentiality

Professional duty

Ethical values• Individual liberty• Protection of the public from harm• Proportionality• Reciprocity• Transparency• Privacy• Protection of communities from undue stigmatisation• Duty to provide care• Equity• Solidarity

(Singer et al., 2003)

Triage, evacuation and Resource allocation

How should we decide on who gets what?• Concept of need• Concept of utility• Non-comparative concept• Privileging concept or ‘social worth’

Duty of care/share?• Do (public) health professionals have the duty to provide

healthcare services even if that would endanger their lives?• What are the factors that help us draw that extent?

Duty of care/share?Indonesia refuses to share H5N1 virus samples (1)

• Since July 2005 to December 2007, Indonesia has reported the highest number of influenza A (H5N1) human cases in the world, i.e., 116 cases with an extremely high fatality proportion of 81%.

• Indonesia designated hospitals in which clinical specimens from suspect human H5N1 are obtained (swabs, aspirates, and lung biopsies from deceased patients)

• For 1&1/2 years, Indonesia had sent all clinical specimens to a couple of international laboratories participating in the WHO global influenza surveillance.

Duty of share?Indonesia refuses to share H5N1 virus samples (2)

• Since January 2007, however, the Government of Indonesia has decided to withhold the specimen (virus) sharing and pulled out of the Global Influenza Surveillance Network (GISN).

• It was concerned that its strains of H5N1 would be used to make vaccines in the rich countries then “resold” to Indonesia at unaffordable prices. They were also concerned that scientists in high-income countries would be able to take out patents based on these strains, which they asserted was their sovereign property.

Discussion:• What are your initial responses to this situation? What are the most

important ethical considerations in this scenario?• Discuss if there is a moral duty on Indonesia to keep/share the

samples? AND whether rich countries are morally obliged to help Indonesia facing the pandemic and to what extent?

Privacy and confidentiality• What is the key difference?• When it is ethically (& legally required) to breach them?• Examples from disasters?

Consent• What constitutes an informed consent?• How does disasters affects the consent giving process?• In a disaster, what needs consent?

– Surveillance?– ‘assessment surveys’?– Vaccine clinical trial?– Photography?

Media and its role• Too soon or too late?• Inadequate and incorrect

information about the disaster

• Photography and Breaching privacy

• Promoting injustices & blaming the victims

• Conflicts of interest (advocacy vs. news reporting)

DUTY TO CARE SCENARIO (1) (Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)

• The media is reporting that the World Health Organization has officially determined that a pandemic influenza is now underway.

• The Public Health authorities has confirmed person-to-person spread in several cities.

• The local media is 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.

DUTY TO CARE SCENARIO (1) (Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)

• Maria is a 35-year-old family physician and mother of three children aged 4-8. She works in a primary care clinic in a main hospital 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.

• First Set of Questions– What are your initial thoughts and feelings about this?– What do you think are the most important considerations for Maria in making

her decision?– Would your opinion change if the day care centre was closed? Why?

DUTY TO CARE SCENARIO (1) (Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)

• 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.

• 2nd group of questions:– What do you think of the clinical group's decision?– Do you think society has an obligation to health care workers in the

event of a pandemic outbreak?– 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.

– In your view, is the health status of a health care worker an acceptable reason not to respond to a pandemic virus?

DUTY TO CARE SCENARIO (1) (Source: Case Studies of Ethics During a Pandemic, McDougall, 2010)

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.• Should health care providers face consequences for refusing to show up for work?• If no, why? If yes, what sorts of penalties do you think would be fair?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.• What do you think about this possibility?• Do you think such laws would violate the rights of health care workers?Final Questions

– In your view, is it justifiable for health care providers to refuse to provide care?– Who should make these kinds of decisions?– How should these kinds of decisions be made? In the absence of a consensus, how should these

decisions be made?

References & readings• SINGER, P. A., BENATAR, S. R., BERNSTEIN, M., DAAR, A. S., DICKENS,

B. M., MACRAE, S. K., UPSHUR, R. E. G., WRIGHT, L. & SHAUL, R. Z. 2003. Ethics and SARS: lessons from Toronto. BMJ, 327, 1342-1344.

• Chong, S. A., Capps, B. J., Subramaniam, M., Voo, T. C., & Campbell, A. V. 2010, "Clinical Research in Times of Pandemics", Public Health Ethics.

• Hawryluck, L., Lapinsky, S., & Stewart, T. 2005, "Clinical review: SARS and lessons in disaster management", Critical Care, vol. 9, no. 4, pp. 384-389.

• 2004, Humanitarian Charter and Minimum Standards in Disaster Response, Sphere Project., Geneva.

• Sztajnkrycer, M. D., Madsen, B. E., & ejandro Bez, A. 2006, "Unstable Ethical Plateaus and Disaster Triage", Emergency Medicine Clinics of North America, vol. 24, no. 3, pp. 749-768.