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Ethical Preparedness for Pandemic Influenza: A ToolkitBy Margaret R. McLean
During the influenza pandemic of 1918, between 20 million and 40 million people died, making that outbreak one of the worst natural disasters in human history. While no subsequent flu outbreak has approached that event in casualties, deadly strains of the influenza virus have broken out in recent years, and the chance of another pandemic is still very real.
In the face of such a disaster, the primary ethical obligation of public health officials is to plan. In response to this need, the Ethics Center worked with the Santa Clara County Public Health Department to develop an ethical toolkit for pandemic preparedness.This tool:
These recommendations are intended for severe pandemics; that is, situations where the virus both results in heavy casualties and is spread across the world or a wide geographical region.
The purpose of this tool is to aid disaster planners to prepare not only medically but also ethically for a pandemic. By providing background on efforts by public bodies, the report offers lessons from what other entities have learned about the importance of ethics in disaster response. The analysis highlights the ethical issues that officials must confront in developing a workable plan for protecting the public's health in the event of pandemic influenza. Recognizing that the tragedy of a pandemic will be exacerbated if ethical questions are ignored, specific guiding principles are suggested: preparedness, justice as fairness, autonomy, and the common good.
III. Ethical Preparedness: A Brief Background
Public health emergencies raise serious ethical issues central to societal and individual well-being and the public perception of fairness. The outbreak and aftermath of Severe Acute Respiratory Syndrome (SARS) in early 2003 brought attention to the importance of establishing an ethical framework for decision making well in advance of any foreseeable medical disaster. The SARS crisis uncovered the risks inherent in not explicitly identifying ethical presuppositions in preparedness planning and implementation—the loss of public trust, poor hospital staff morale, confusion about roles and responsibilities, stigmatization of vulnerable communities, and misinformation.1 To avoid such problems, adequate pandemic preparedness requires a thorough analysis of the ethical considerations.
In 2006, the World Health Organization (WHO) initiated discussions regarding the ethical issues raised in pandemic influenza planning. Their discourse is rooted in a commitment to fundamental human rights but at the same time asserts that freedoms can be restricted when the public's health is in danger. There is a complex struggle between honoring individual rights and freedoms and the necessary restraint on those freedoms justified by community needs during a global health crisis. International human rights law articulates that restrictions on human rights are valid when necessary for the public good. However, finding the balance between the individual and the collective can be extraordinarily difficult, especially during a stressful and uncertain time such as a pandemic flu.
A global public health crisis requires international awareness and planning. And, although many countries have developed pandemic-preparedness plans, the majority of these do not consider ethical issues. Notable exceptions are the plans developed by New Zealand and Canada.2
In July 2006, the New Zealand National Ethics Advisory Committee issued a report outlining a statement of ethical values reflective of national values and describing how that statement is to be used in their planning process. Their interactive plan solicits input from citizens and highlights specific ethical values involved in decision making—inclusivity, openness, reasonableness, responsiveness, and responsibility.3 It describes good decisions as those based on: minimizing harm, respect for persons, fairness, neighborliness, reciprocity, and unity.4 The plan is unique in that it provides scenarios and hypothetical cases to show how the statement of ethical values could be used to prepare for and respond to a pandemic.5
Another example is the often-cited Canadian report Stand on Guard for Thee by the University of Toronto Joint Centre for Bioethics. This report was written after the SARS crisis and illustrates an important set of ethical considerations to be used in preparing and planning for pandemic influenza. Based on extensive research, the Center found that as the SARS crisis worsened and more restrictions were imposed, people became increasingly concerned about whose values should guide the decision-making processes in a public health emergency. The Center ascertained that people are more likely to accept decisions made by their leaders if the decision-making processes are reasonable, open and transparent, inclusive, responsive, and accountable, and if reciprocal obligations are respected.6 The report suggests that a previously established ethical framework can assist public health officials and government leaders in making better-informed decisions in a quickly overwhelming health crisis like pandemic flu. It may also serve to increase public trust and morale, alleviate fear, and reduce the amount of disseminated misinformation. Stand on Guard for Thee highlights four key ethical issues:
It is especially important during times of crisis to have articulated codes or standards of conduct, so that everyone—health care workers and the public—knows what to expect.8
IV. Centers for Disease Control: Ethical Guidelines
The United States Centers for Disease Control and Prevention (CDC) has also addressed the ethical issues involved in pandemic planning. In February of 2007, Ethical Guidelines in Pandemic Influenza was issued and provides an excellent and succinct set of guiding principles to inform public decision making in the face of pandemic influenza. The document's central goal and organizing principle is preserving societal functioning in the case of pandemic influenza.9 While minimizing serious influenza-related complications is an important goal as well, it is seen as a lesser priority. Beyond this central organizing principle, the document maintains overarching commitments to the transparency of decision-making processes; to the involvement of a diverse cross-section of the public in such decisions, with particular attention to historically marginalized communities; to maximizing preparedness; to the use of the best available scientific evidence (where realistic); to networking with global preparedness efforts in pursuit of the common good;10 to balancing individual liberty and community interests, including restricting individual liberty only with great care and concern for those most affected; to fair process (procedural justice).11
The document counsels certain particular ethical steps. First, scarce resources (e.g. vaccines, antivirals, and the time of health care professionals) should be allocated with an emphasis on fair decision-making processes and an attendance to the consequences of the implemented measures, while honoring certain limits grounded in the values of respect for persons, nonmaleficence, and justice. These limits might include a commitment to refrain from harming individuals or to employ the least restrictive measures that will nevertheless preserve social functioning and protect the public good.12
Based on the CDC's goal of preserving societal function, a central criterion for the distribution of scarce resources is "to each according to his or her social worth." The document recognizes this criterion as ordinarily an inappropriate standard for scarce resource distribution; but, in the case of pandemic influenza, it is necessitated by the need to prioritize those persons and groups who are "'key' to the preservation of society."13 These individuals and groups of persons should receive priority for the distribution of certain goods such as antiviral pharmaceuticals and vaccines. Although the CDC leaves it to each planning entity to determine who is "key" in their particular context, such a "social worth" category might include health care workers, bus and truck drivers, police, firefighters, and vaccine scientists.14
The CDC acknowledges that certain restrictive measures will need to be taken to facilitate public health—for example, isolation of those infected, quarantine of those exposed, school and other public venue closures (e.g., sports arenas), restricted access to essential public venues (e.g., grocery stores), guidance on flexible work possibilities, and travel limitations. These liberty-limiting restrictions should be considered in advance, voluntarily undertaken wherever possible, and, especially where mandated, carefully justified by representative bodies in a transparent public process. They should be equitably applied, with procedures in place for public appeal and care taken to avoid stigmatization and unwarranted invasions of privacy. Such decisions should rely on the best available scientific evidence, with the acknowledgment that perfect scientific evidence may be unavailable. Restrictive measures are ethically justifiable only when a failure to implement such measures will likely result in grave harm to the functioning of society or to public well-being.15
Further, the CDC recommends that measures be taken to ensure that persons (and their families) and groups directly impacted by restrictions on movement will have adequate access to food, water, other essential services, job security, and aid with economic obligations. It does not specify how such social obligations will be met but rather holds that the agencies with decision-making authority should attempt to ensure that "some agency stands prepared to provide such goods and services."16 Even if this level of social support proves impossible, the need for it should be weighed as a genuine cost of mandating liberty-restricting measures. Finally, the document advocates centralized decision making in order to facilitate disease tracking and to best preserve social functioning across communities.
The CDC's approach to pandemic ethics is further refined in Ethical Guidance for Public Health Emergency Preparedness and Response: Highlighting Ethics and Values in a Vital Public Health Service, published in 2008. Prepared by Bruce Jennings of the Center for Humans and Nature and Yale University, and John Arras, of the University of Virginia, the document specifically addresses the role of the CDC and other public health officials. Like the other guides above, the document stresses the importance of advance planning that involves representatives of all elements in the community so that guidelines for who receives treatment and processes for making decisions are perceived by the public as fair.
A special focus of the guidance is the treatment of persons with special needs or vulnerabilities. Advance planning is especially necessary to address the needs of this population, the report advises:
When many needs are calling for attention, the voice of the vulnerable and those who have been socially or culturally marginalized is most likely to be drowned out unless it has been heard in advance and special provisions have been made.17
V. The Veterans Administration: The Duty to Provide Care
In 2010, the Veterans Administration also looked at ethical issues in pandemic influenza preparedness. In addition to addressing issues of fairness, dignity, and transparency, like the previous reports, the VA also provided guidance for its employees on the duty to provide care. At a time when health care workers will be exposed to extra dangers, and also may have extra concerns about the welfare of their own families, how much risk should they be expected to take on?
Citing the health care ethics providers' "professional obligation of non-abandonment," the VA asserted that employees "have a duty to provide care for patients, even at some personal risk." However, the agency also spelled out what VA facilities should do to minimize that risk and allow employees to meet other obligations. This included
VI. Pandemic Influenza: The Obligation to Plan
It is clear that an effective response to an influenza pandemic cannot be worked out once the crisis hits. Communities that plan for disasters are better able to face the complexities that follow and maximize preparedness in order to minimize harm. Such planning requires not only operational preparedness but ethical preparedness as well. Once disaster strikes, difficult decisions will need to be made without the luxury of time. Just as fire drills increase the chance of survival through repetition, thinking through pandemic scenarios and responses ahead of time increases the chance of making ethically defensible decisions in a time of crisis. In addition, identifying the values and ethical perspectives inherent in preparedness planning engenders public commitment to and trust in the resulting plan.
Three primary ethical obligations must be met:
In the event of a pandemic flu, communities will not be able to meet the hospitalization demand as sky-rocketing illness and fatality rates will quickly overwhelm the existing health care system. The CDC advises that the most prudent approach to the challenge a pandemic poses to the local health care system is the maximum expansion of medical surge capacity while reducing anticipated demand by limiting disease transmission.19 In order to meet the medical needs of ill people under conditions of limited access to hospital beds and to minimize illness and death, many communities may choose to set up Alternative Care Centers (ACCs). That was the plan of the Santa Clara County Public Health Department (The Influenza Care Center Plan or ICCP). The following sections provide guidance on ethical decision making for ACCs based on the Santa Clara County model.
VII. Alternative Care Centers: The Obligation of Ethical Preparedness
A flu pandemic will not hit and run but will occur in waves over a period of a year or more. In order to maximize preparedness, planners should assume the worst case scenario in the worst case pandemic, one in which demand for hospital beds, respiratory support, and basic medical care will far outstrip the supply. As health care needs consume available human and material resources, many dilemmas will have no best outcome, only one or more least-worst outcomes. Certainly, medical science and public health can provide information valuable to the decision-making process, but while necessary, they are insufficient as the sole basis for decision making in a time of crisis. Pandemic planning requires a serious consideration of ethics, not allowing urgent medical needs, resource scarcity, and panic to drive decision making. Since health care and public health decision making have both medical and moral dimensions, such planning involves assumptions about core values, guiding principles, and individual and local needs.
VIII. Triage Guidelines: Determining What Is Fair
In pandemic planning, as in medicine in general, the allocation of scarce medical resources is the most difficult ethical issue confronting the current health care system. No one wants to speak of rationing, but it occurs daily and necessarily escalates during a disaster. In a time of pandemic, rationing is inevitable and must be done in a manner that is fair, transparent, respectful of persons, inclusive, accountable, proportional,20 and minimizes harm. Current public expectations about access and the level of health care provided must change in light of the realities of a public health crisis.
Arguably the most important lesson from the SARS outbreak is that in a time of crisis when ". . . guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important, rather than less."21 Fairness is important on two levels: (1) the process by which decisions are made must be fair (procedural justice); and, (2) the distribution of scarce human and material resources must be fair (distributive justice).
A. Procedural Justice
When resources are scarce, procedural fairness requires that a triage protocol be developed to provide guidance and consistency in resource allocation. From the point of view of procedural justice, the principle of distribution is not so much the concern as is the just application of that principle. A common guiding precept is based on the utilitarian commitment to provide the greatest good for the greatest number—maximizing survivability for people receiving hospital level care while providing medical support to flu victims less likely to benefit from hospitalization because it is either unnecessary or unavailable. That medical support could be provided by Alternative Care Centers (ACCs). Patients who are medically ineligible for hospital admission or who cannot be admitted because there are no available beds and who cannot be adequately cared for at home and who met ACC admission criteria would receive medical support in the form of oxygen and intravenous hydration, increasing the survivability of these unhospitalized patients as well. For those unlikely to survive, ACCs would provide palliative care, facilitating patient comfort, family presence, and dignified death.
At the ACC, patients would be assigned to either an acute ward—for those patients who were severely ill or who were admitted with co-morbidities—or a subacute ward for less severely ill patients receiving standard treatment with oxygen and/or fluids. If treatment proved ineffective, a patient might be placed in palliative care within the ACC.
Because ACCs are designed to treat as many flu victims as possible, treatment is not patient-specific but governed by standard orders. The majority of ACC patients are likely to be adults without co-morbid conditions. Some more vulnerable patients, such as asthmatics on metered dose inhalers, diabetics on insulin, people with heart failure, and women with uncomplicated pregnancies more than one week prior to due date, could be admitted to an ACC with special orders. Generally speaking, however, staffing ratios, expertise, level of care, and the type of medical equipment available at a typical ACC would preclude admission of any patient requiring a higher level of care, e.g., patients on dialysis for chronic renal failure or those with unstable angina. A patient determined to be ineligible for ACC admission could either be sent home with home care instructions or transferred to a hospital for a higher level of care.22
The activation of ACCs can maximize medical benefit to the overall patient population, minimize harm to moderate-acuity patients, and provide a fair, efficient, and consistent distribution of scarce medical resources through a common triage protocol active at all entry points, i.e., physician's offices, emergency departments, urgent care centers, 911 response, ACCs. In formulating explicit inclusion and exclusion criteria, a triage protocol provides clarity and transparency to the medical decision making process. Under such a protocol, medically like cases are treated the same and medically unlike cases are treated differently, fulfilling the formal principle of procedural justice.
B. Distributive Justice
Under ideal conditions, all patients have an equal claim to the health care that they need. A pandemic necessarily alters opportunities for access due to the burden of mass illness and limited—perhaps steadily decreasing—resources, from transportation to medication.
One of the most vexing questions about the just rationing of health care resources is which ethical principle ought to guide decision making. Although the noncomparative principle of "first come, first served" seems, at first glance, to be the fairest, in practice, it privileges certain groups and disadvantages others, e.g., those who have transportation and those who do not. Other principles applied in real-world health care rationing include "save the most lives" (e.g. in disasters such as fires or floods when triage is impossible); "save the sickest" (e.g. in organ transplant protocols); "save those most likely to recover" (e.g. in triage during war); "save people who can preserve society (e.g., the CDC recommendation during a pandemic).
Let us focus on two of these principles: saving the most lives and saving those who are most likely to recover. The National Vaccine Advisory Committee (NVAC) and the Advisory Committee on Immunization Policy (ACIP)23 recommend saving the most lives, which includes providing surge capacity to deal with flu sufferers who do not require traditional hospitalization. In addition, a standard triage protocol can privilege those most likely to recover, i.e., those without significant co-morbidities. Absent ACCs, it is hard to see how either the principle of saving the most lives or of saving those most likely to survive would be met. Overwhelmed emergency rooms and clinics could likely rely on the principle of "first come, first served," a distributive justice standard currently employed in hospital and ICU admission—e.g., when current less ill patients retain beds while trauma victims are diverted to another facility—but inappropriate in a time of public health crisis.
Concentrating on saving the most lives, essentially classic utilitarianism, can produce consequences that are unjust for some. Classic utility would impose great harm on the few in order to maximize benefit to the majority. Recognizing this, the CDC recommends that the brutal effects of classic utilitarianism be modulated by the "side constraints" of justice, respect for persons, and the avoidance of harm.24
As an example, the fair distribution of available medical resources can be supported by triaging patients to appropriate and available levels of care, including palliative care, thereby preserving scarce resources for those most likely to benefit and survive. In any plan, the triage response must be proportional, denying hospital or ACC access only when resource limitations and the common good demand it.
Although the primary goal of pandemic planning is to maximize the number of lives saved, despite our best efforts, thousands will die in local communities, almost 2 million nationwide during a severe pandemic.25 A secondary goal is to provide comfort to and minimize the suffering of those who are dying and their families. Those who will not survive cannot be ignored nor should they receive scarce resources from which they are unable to benefit, e.g., a hospital bed. The needs of dying persons can be met through the provision of palliative care, minimally providing family presence and relief of pain and anxiety. Families may be reluctant for social, cultural, religious, and practical reasons to have a loved one die at home. The availability of palliative care at an ACC fulfills the ethical obligation to treat the dying as persons deserving of respect.
IX. ACC Admission: Applying the Principles of Justice
Among the most pressing ethical concerns related to ACCs will be questions related to admission and denial of admission. The duty to treat and simple compassion and altruism will doubtless be strong motivators for ACC staff to admit anyone who desires admission. However, limited resources and stringent admission criteria will likely mean that not all patients who desire admission will be able to be admitted into ACCs. When patients fail to meet the ACC eligibility criteria and are turned away, respect for persons requires that some process for appeal of the decision not to admit to an ACC should be available. Ethical preparedness includes procedures whereby individuals could fairly and rapidly initiate an appeal process.
Once the basic eligibility requirements for ACC admission have been met, there may not be an available bed. Thus, there will be a need for a further prioritization of patients. The American egalitarian instinct for fairness naturally inclines us toward seeking a fair, or equitable, way of distributing the scarce resource of access to the ACCs. One common way of implementing justice as fairness is to adhere to a "first come, first served" system—in this case, allowing admission for sick individuals who fulfill the admission criteria and present at an ACC when there are beds still available. However, such a system is not in fact a perfectly fair way of determining admission priority for ACCs. As the CDC notes, the criterion "first come, first served" contains its own, hidden system of prioritization (e.g. prioritizing those with access to cars, those who live close to care centers, those who are better informed, etc.).26
In determining categories of prioritization for ACC admission, the proposed CDC guidelines are informative in the designation of primary health policy goals and, correlatively, of distribution criteria that do (or do not) serve these goals and thus can be considered fair or unfair under the limited circumstances of a pandemic. Specifically, these goals include not only minimizing serious influenza-related complications, but also the preservation of a basic level of social functioning. Accordingly, the CDC recommends making difficult but necessary distinctions based on social worth in order to determine who receives care in the event of medical resource shortages.27
Making such social worth distinctions for the distribution of health care runs counter to the instinct for fairness, and it would thus ordinarily be considered an inappropriate criterion. In the emergency situation of pandemic flu, however, making distinctions on the basis of social worth may be necessary. The hard truth of the matter is that failure to make these sorts of distinctions (giving priority, for example, to doctors, EMS workers, law enforcement personnel, vaccine scientists, firefighters, bus drivers, and sanitation workers) could translate into a high level of injustice accompanied by social chaos, exacerbating an already complicated situation. Hence, prioritizing certain essential personnel, while unfair during non-pandemic conditions, may be the best way to minimize, and ideally avoid, further social breakdown during a flu pandemic.
Focusing on the goals of minimizing influenza-related complications and preserving basic social functioning allows for the rejection of some modes of prioritizing patients for ACC admission. Not only would a "first come, first served" approach be unfair, it would do nothing to further overarching societal and public health goals. Also inappropriate would be prioritization schemes that favor individuals according to purchasing power, desert, race, ethnicity, religious belief, gender, sexual orientation, or IQ.28 All of these strategies would link the scarce resources of ACC admission to categories that have little or nothing to do with individual survival or the preservation of social functioning.
Whichever categories are used for patient prioritization, conversations about how to fairly rank individuals who meet the basic eligibility requirements for ACC admission should be initiated in advance of a pandemic. Such conversations should be carefully reasoned, transparent, and open to substantial public input, so that the process may be as fair as possible and so that unnecessary discrimination may be avoided. Moreover, a process that is transparent and open will help to bring the public "on board," contributing to public understanding of and cooperation with any resulting prioritization rules or guidelines.
X. Restrictive Measures: Autonomy and the Common Good
Finally, there is the question of restricting individual freedom in the interest of the common good by measures such as quarantine and/or isolation at home or in an ACC. Initially, such restrictive measures may be the most efficient way to prevent spread of the virus.
In general, restrictions on individual liberty such as isolation or quarantine seem to thwart the American ideal of personal freedom. Respect for the ethical principle of individual autonomy is rooted in respect for human dignity and the general duty of non-interference in the lives of others. Autonomy can, however, be justifiably restricted when exercising freedom puts others at risk of harm, such as attending large public gatherings during a pandemic. Protection of public health will likely require social distancing restrictions, at least sometimes, during a pandemic. Such decisions require weighing individual freedom and the common good. Although individual autonomy can be limited in the interest of the common good, respect for autonomy does require that there be systems of appeal in place for individuals who would challenge liberty-limiting measures.
Ideally, mandatory quarantine or isolation should only be undertaken if there is scientific evidence that such measures will be effective at controlling the spread of the disease and thus maintaining public health, order, and well-being. However, pandemic response will not include the luxury of time, and some social distancing procedures will necessarily be employed despite little or no scientific support. The CDC recommends an "evidence-informed" decision making model that is less rigorous than the usual "evidence-based" model in the interest of protecting the public health of society in a timely manner.29
As with triage protocols, the process for decision making about social distancing mandates should be determined in advance. The social distancing process ought to rely on the least restrictive means of protecting the public from harm. People need to be fully informed about the concerns, including the risks and benefits of social distancing measures. The public should understand the nature and rationale for restrictive measures, the benefits of compliance, and the consequences of non-compliance.30 The need to severely restrict individual autonomy in the interest of the common good is never to be taken lightly and should be revisited at regular intervals throughout the crisis.
XI. Ethical Preparedness: Next Steps
The need for pandemic preparedness extends beyond operational plans to include the ethical values underlying such plans and important in their implementation. The SARS crisis demonstrated that ethical preparedness is at least as important to good outcomes as emergency preparedness. With the goal of furthering ethical preparedness, these next steps may be considered.
1. Thompson, Alison K, Karen Faith, Jennifer L Gibson, and Ross EG Upshur: "Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-making," BMC Medical Ethics, 7:13 (2006).
2. The reports discussed herein are available on-line. Because of ever-changing locations, web addresses are not provided. The reader can obtain a specific report by googling its title.
3. National Ethics Advisory Committee, Ministry of Health, New Zealand: "Ethical Values for Planning for and Responding to a Pandemic in New Zealand," p 2 (July 2006).
4. Ibid, p 3.
5. Ibid, pp 7-18.
6. University of Toronto Joint Center for Bioethics: "Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza," p 4 (November 2005).
7. Ibid, p 5.
8. Ibid, pp 10, 16.
9. Centers for Disease Control and Prevention: "Ethical Guidelines in Pandemic Influenza," p 3 (February 2007).
10. The "common good" encompasses the interests of a group or community with certain attributes and interests in common. It suggests that the interlocking relationships among persons—not individual autonomy or rights—is the basis of ethical reasoning. The "common good" as used here is meant to draw attention to the common conditions that are important to the welfare of everyone during a disaster such as an influenza pandemic.
11. Ibid, pp 3-5.
12. Ibid, pp 6-8.
13. Ibid, p 7.
14. Elsewhere the CDC indicates that the preservation of a functioning society prioritizes persons responsible for the provision of health care, public safety, and the functioning of key aspects of society. See "Public Health Ethics at the Centers for Disease Control and Prevention" presented by Drue Barrett at the Association for Practical and Professional Ethics Annual Meeting, February 24, 2007.
15. Ibid, pp 8-11.
16. Ibid, p 11, footnote 5.
17. The Centers for Disease Control: "Ethical Guidance for Public Health Emergency Preparedness and Response," p 17 (Oct. 30, 2008)
18. Veterans Administration: "Meeting the Ethical Challenges of a Severe Pandemic Influenza," p 2 (Sept. 2010).
19. Centers for Disease Control and Intervention: "Interim Pre-Pandemic Planning Guidance—Community Strategy for Pandemic Influenza Mitigation in the United States," p 17 (February 2007).
20. Proportionality requires that restrictions to access to health care resources, limitations on individual liberty, and actions taken to protect the public from harm not exceed that which is necessary to maximize lives saved, protect societal functioning, and respond to the actual level of risk.
21. Bell, Jennifer AH, Sylvia Hyland, Tania DePellegrin, Ross EG Upshur, Mark Bernstein, and Douglas K Martin: "SARS and Hospital Priority Setting: A Qualitative Case Study and Evaluation," BMC Health Services Research 4:36 (2004).
22. See ICCP Section 5 and Tool 7 for details regarding triage and admission criteria.
23. U.S. Department of Health and Human Services: "HHS Pandemic Influenza Plan," Appendix D, p D-10 (November 2005).
24. CDC: "Ethical Guidelines," p 6.
25. "HHS Pandemic Influenza Plan," p. 18.
26. CDC: "Ethical Guidelines," p 7.
29. Ibid, p 9.
30. "Stand on Guard," p 15.
31. CDC: "Ethical Guidelines," p 7.
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