A report published by researchers at the University of Toronto’s Joint Center for Bioethics is shaping global attitudes towards pandemic preparedness planning.
The Stand on Guard for Thee report, published in 2005, outlines an ethical framework for decision makers—hospital administrators, physicians, nurses, epidemiologists, public health workers—planning for a global influenza pandemic.
The report identifies key ethical issues. For instance, what kind of obligations do health care workers provide when they’re at risk of infection? Who should have priority access to precious reserves of vaccines, and when is it justified to limit civil rights to control a virulent infection?
Dr. Ross Upshur, one of the authors of the report, notes that the report is not a how-to guide. Rather, it outlines the ethical values helpful in making difficult decisions in times of a health crisis.
The team who wrote the report included researchers from several Toronto Academic Health Sciences Centres and the University of Toronto, coordinated through the JCB. The framework was incorporated into the Ontario Influenza Pandemic Plan, published in 2005.
The report was penned as avian flu was spreading across Asia, Europe, and Africa. While experts agree likelihood of an influenza pandemic on the scale of the 1918-1919 Spanish Flu outbreak—which killed more than 40 million people—is slim, they believe it will be difficult to predict the severity of the next outbreak. The time to plan is now.
Many of the issues highlighted in Stand on Guard for Thee stem from research done by members of the JCB on the Toronto SARS crisis of 2005, illustrating the need for ethical guidelines in a successful pandemic plan.
Dealing with potential ethical pitfalls before a pandemic hits will help to avoid situations like SARS and Katrina, says Dr. Upshur. In these instances, conflicting ethical agendas were dealt with in haste, and ad-hoc decisions were made, breeding resentment among both the public and those working on the frontline.
“One indicator of failure is if you look at the pandemic response after the fact and you find that only people with high socio-economic status or connections got into intensive care,” Upshur says. “Then you’ve got a problem, and you have to be accountable for that problem.”
Instead, he suggests it’s important to deal with these issues so that stakeholders—those making the decisions, and those affected by them—have a chance to give their input. “So, like in an election, you may not like the result, but you had your chance to constitute what that response might be.”
The next critical step is gauging public opinion. Dr Upshur is currently heading a nationwide survey asking Canadians what their priorities are in a health care emergency. He and his research team have spent the last two years doing telephone surveys, town hall meetings, and engaging professional organizations.
Interestingly, says Dr. Upshur, many people “think the most important point of pandemic preparedness is actually protecting health globally—saving lives not just within borders.”
The results of the survey were presented at a recent conference in Winnipeg where experts from disciplines including virology, epidemiology, and public health ethics met to discuss the results of a network of two-year studies on pandemic preparedness funded by the Canadian Institute of Health Research. Dr. Upshur hopes the conference will help to strengthen national and international research networks, lending clarity to nationwide pandemic planning policy. It will give researchers from around the world the opportunity to exchange information on how ethical frameworks adapt to different cultures and circumstances.
Governments and organizations world wide have given the report an enthusiastic welcome. The National Bioethics Commission of New Zealand has adapted the principles, integrating Maori values such as neighbourliness to reflect local cultural norms. The World Health Organization is incorporating an ethical dimension into its plan for drug-resistant tuberculosis.
The report calls for a degree of stewardship by developed nations in guiding and mentoring developing nations. These countires could potentially be the hardest hit in the event of an international health crisis and might not have the resources to deal with a large-scale pandemic.
