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While experts on animal and human health were meeting this week at the International Partnership on Avian and Pandemic Influenza in Vienna, we at the Center got a reminder that the front-line institutions must prepare for such a disaster not only medically but also ethically.
Our Web site's feedback feature received a message from a member of a hospital ethics committee trying to prepare for the ethical challenges that would confront them should a pandemic strike. As the author noted, "The model of caring for patients in a disaster will be greatly different from the way we typically serve our sick and healthy community. This will have a huge impact physically and emotionally on our staff. Do you have any advice for us?"
Margaret R. McLean, director of the biotechnology and health care ethics for the Center, responded:
First, I would like to congratulate your hospital and your ethics committee for having the foresight and the courage to consider disaster response not only in terms of actions to take but also in terms of impact on personnel and community relationships. I think that Washington state is far ahead of the other 49 of us in planning for a possible flu pandemic.
One of the intriguing questions that your ethics committee might consider is how to respond to staff members who are ill and want to continue working until they can no longer stand. Will you send nurses home at the first cough or low-grade fever? Or will you isolate staff who become ill on the job? Will you turn patients away when staffing becomes inadequate? In all of our considerations about a possible pandemic, we tend to forget that physicians, nurses, respiratory technicians, housekeepers, and janitors will become ill, as well.
This raises a second set of issues--criteria for triage. When staffing becomes inadequate and/or the patient load too great (and both will likely happen), how does one decide who receives treatment and who does not? Possible criteria include: first come, first served; treat the sickest first; treat the most likely to recover first; treat health care professionals and hospital employees first (so they can recover and help); treat community leaders first (police, firefighters); treat those with adequate insurance first. Since it is likely that respirators may be needed for many victims to recover, these are deadly serious considerations. It is likely that a number of criteria may be used, e.g., treat the sickest first if and only if they have a good chance of recovery.
And, of course, you realize the emotional toll that such decision making will take on the staff. Some good work could be done on pastoral responses to the flu pandemic. It seems prudent to have chaplains, social workers, and mental health professionals trained and available to help those who are literally making life and death decisions minute to minute and who, no doubt, will be dealing with the illness and death of loved ones themselves.
Of course, we all hope that avian flu will be contained. But
thinking through the moral issues that would confront us in
the event of a pandemic is an important part of any disaster