- Ethics Home Page
- About the Center
- Focus Areas
- Contact Us
- Site Index
The Coming Pandemic: Ethical Preparedness
by Margaret R. McLean
With sporadic deaths reported from avian flu in Asia and the
Middle East, public health departments all over the world are
preparing for a possible influenza pandemic, an outbreak of
a new virus to which humans have little or no immunity. Part
of that planning must include ethical preparedness.
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 limitedperhaps steadily decreasingresources, from transportation to medication, hospital beds, physicians, etc.
In pandemic planning, as in medicine in general, the allocation
of these 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 transparent, respectful
of persons, inclusive, accountable, proportional, fair, and
Drawing on the Canadian experience with the 2003 SARS outbreak,
the authors of SARS and Hospital Priority Setting
(Jennifer AH Bell, et al) argue that a public health crisis
demands heightened attention to fairness: In the midst
of a crisis such as SARS where 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.
It 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
On the first level, when resources are scarce, fairness requires
that a triage protocol be developed to provide guidance and
consistency in resource allocation. In formulating explicit
inclusion and exclusion criteria for care, triage guidelines
provide clarity and transparency to the medical decision-making
process. Like cases are treated the same and unlike cases are
treated differently, fulfilling the formal principle of justice.
On the second level, one of the most vexing questions about
the just rationing of health care resources is which ethical
principle ought to guide decision makingsave the most
lives (e.g., in fires and floods); save the sickest (e.g., in
organ transplant protocols); save the most-likely to recover
(e.g., in triage during war); save people who can preserve society
(e.g., the Centers for Disease Control (CDC) recommendation
during a pandemic).
Deciding who can best preserve society means making social
worth distinctions, which, because they run counter to
the instinct for fairness, would ordinarily be considered inappropriate
criteria. 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.
This article is an excerpt from a report prepared by Center Director of Biotechnology and Health Care Ethics Margaret R. McLean for the Santa Clara County Public Health Department on Ethical Preparedness for Pandemic Influenza.