Transcript March_4_Cho_Yiu

“Ethical” Response to Emergency
Tom Sorell
University of Warwick
Outline
• Emergencies and some of their moral
peculiarities
• Health emergency
• Pandemic influenza as health emergency
• UK Response to Pandemic Influenza
• Some worries
• Some points about morality and emergency
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Outline 2
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DH’s Ethical principles for Pandemic Influenza
Criticism of principles
SARS
The badness of quarantine
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Emergency and Public Emergency
• Emergency: a situation in which there is a high
probability of severe harm or loss of life and a
need to act quickly if the harm or loss of life is
to be prevented or limited
• Public emergency: an emergency affecting a
population in which there is a need for a
public body (e.g. a government, or a
supranational authority) to act quickly
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Meta-ethics of emergency
• Morality and exceptionlessness
• The centrality of truth-telling, promisekeeping, co-operation, sharing to morality in
normal circumstances
• Morality as relatively cost-free, and safe in
normal circumstances
• The unthinkability of killing and the rarity of
life-saving in well-ordered societies in normal
circumstances
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Does emergency create exceptions to
moral precepts? 2
• In emergencies life or great harm is in the
balance
• Life-and-death decisions and decisions about
great harm ought to be constrained
• Emergency decisions urgent and often
unavoidably rushed
• Bad decisions understandable
• Wrong actions in emergency sometimes
excusable
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Domestication of Emergency
• Because of the exception-tolerating nature of
emergency there is a moral need to try to
anticipate and subdue by practised routines
the more likely emergencies: domestication
• Not all emergencies can be domesticated
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Declaration of public emergency
• Can trigger domestic emergency legislation, delivery of
aid, in a jurisdiction
• Declaration of health or medical emergency can
introduce coercive measures, trigger aid mechanisms,
including money and medical relief supplies
• Declarations of non-medical emergencies raise more civil
liberties issues than medical ones
• Declarations of medical emergencies mainly raise welfare
issues and issues of fair welfare distribution
• The idea that other issues are prominent sometimes the
result of assimilating health emergency response to
normal health care
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Health emergency
• Any occurrence that presents serious threat to
the health of the community, disruption to the
service or causes (or is likely to cause) such
numbers or types of casualties as to require
special arrangements to be implemented by
hospitals, ambulance trusts or primary care
organizations
PI: DH Guidance on Preparing Acute Hospitals in England, p. 4
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Swine flu vs Avian Flu
• Global swine flu epidemic began in Mexico in
2009
• Relatively mild: death toll in first wave about
18000 worldwide
• UK pandemic planning before 2009 had
assumed an outbreak of avian influenza
• WHO used a relatively conservative estimate –
from 2 million to 7.4 million deaths
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Pandemic flu as a health emergency
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50,000 -750,000 excess deaths in UK; 2533% of population falling ill
Other effects
1.
2.
3.
4.
Highly disrupted schooling, business
Badly affected health service provision
Significant bereavement effects
Health losses among survivors
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Timescale of spread (Ferguson)
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Daily cases
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2-4 months to peak at source, 1-3 months to
spread to West (in absence of seasonality).
1/3 of population would become ill, 0.5-1
million new sick people per day at peak.
15%+ absenteeism at peak.
1st wave over ~3 months after 1st UK case.
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
0
First GB
case
30 60 90 120 150 180
Day of global outbreak
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WHO classification of pandemic phases
• http://www.who.int/csr/disease/avian_influen
za/phase/en/index.html
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Main elements of 2007 UK plan
• Concentration on vaccine production and distribution and use
of anti-virals before vaccine available
• NHS Direct as first port of call for symptom-reporting
• Individual anti-infection measures at home
• Voluntary isolation
• School closures on a local level at discretion of local
authorities
• Voluntary cancellation of mass public events
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Main elements of UK plan 2
•
SHAs and PCTs to make local arrangements for use of acute
hospitals in relation to:
1. Influenza treatment vs other emergency, general acute,
cases
2. Priorities among those infected with influenza e.g. children
vs adults; young adults vs elderly
3. “anti-social behaviour” of disappointed patients presenting
themselves or children for treatment
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Main elements of UK plan 3
• Accurate and up-to-date influenza information by masscommunications
• Normal maintenance of public order, legal system
• Maintenance of public utilities, food distribution through preassessed plans of providers
• “Business as usual” message from official sources
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Some worries
• Relatively unaggressive strategy on
containment
• Rationing of acute treatment in cases where
life-threatening conditions very widespread
• Business as usual: denial or reassurance
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Emergencies and Morality
• In emergencies, some moral precepts may be
overridden
• In emergencies, some democratic political
precepts may be overridden: certain liberties
are rightly taken away for the sake of saving
life
• In emergencies, fair distributions of goods can
involve rationing
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Pandemic flu and morality
• In pandemic flu, provision of health care is far
more likely than normal to be high-risk to
providers and ineffective for patients
• In pandemic flu, questions about whom to
prioritize for treatment are harder than in
other kinds of emergencies
• In pandemic flu, measures for minimizing loss
of life can in principle involve measures that
are unusually coercive
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DH 2007 Ethical Framework
for response to Pandemic Influenza
• Supposed to be used by planners and strategic
policy makers at national, regional and local
level
• Supposed to influence decisions on, criteria
for hospital admissions
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The Framework
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Treat people with concern and respect
Minimize harm of pandemic
Distribute health resources fairly
Work together
Reciprocate
Keep things in proportion
Be flexible
Make decisions openly, inclusively, accountably, reasonably
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Treating people with concern and respect
• “Everyone matters
• People should have the chance to express their views on
matters that affect them
• People’s personal choices about their treatment and care
should be respected as far as possible
• When people are not able to decide [decisions should be
made] in the best interests of the person as a whole rather
than just…their health needs”
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Minimizing harm
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Preventing spread of pandemic to UK
Minimizing spread within UK
Anti-virals
Minimize disruption to society
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Fairness
1. ‘Fair’ vs equal access, equally timely access
to rationed resources
2. ‘Fair’ in relation to the likely benefits of
health resources
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Working Together
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Official planning
Mutual help among individuals
Minimizing risk
Sharing information about effective treatment
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Reciprocity
• ‘If people are being asked to take increased
risks, or face increased burdens, during a
pandemic, they should be supported in doing
so, and the risks and burdens should be
minimized as far as possible.’
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Keeping things in proportion
• Accurate public information
• Decisions to disrupt daily public life should be
in proportion to risk of continuing with daily
public life as usual
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Flexibility
• Plans sensitive to evolving information
• Opportunity for public consultation as far as
possible
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Good decision-making
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1.
2.
3.
4.
5.
Openness and transparency
Inclusiveness and accountability
Accountability
Reasonableness in decisions
Rational
Not arbitrary
Evidence-based
Result from process appropriate to circumstances
Should have a chance of working
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Criticisms
• Uncertain audience for principles –sometimes
decision-makers, sometimes everyone
• Not clear that principles guide the treatment
of serious emergency—most might be applied
all the time; some—flexibility and good
decision-making-- ignore the justified
suspension of normal democratic decisionmaking processes in emergencies
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Criticisms 2
• ‘Harm’ over-inclusively understood, and it’s
not clear that minimising harm and fairness
are equally important in an emergency as
opposed to normal times
• Concessions to ‘choice’ agenda inappropriate;
• ‘reciprocity’ as reasonable non-emergency
principle for a Health Service permanently
under strain.
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More on ‘choice’ agenda
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Consumerism of Thatcher reforms continued by Labour
Downplaying in medical contexts of ‘minimising harm’,
reciprocity principles where they conflict with
consumer/democratic choice
1. Kennedy report
2. MMR
3. Pandemic
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A better framework
• Priority for minimising harm
• Overridingness of minimising harm where it
conflicts with fairness
• Framework reduced to principles of
minimising harm, fairness and co-operation
(combining current “working together” and
“reciprocity” principles)
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Disproportionate burdens
• Public tasks should not be assigned that
require their discharge to be heroic
• Examples: military, police
• Pandemic flu may require, or appear to
require, heroic self-sacrifice on those most
exposed to infection through their work
• So, much more needs to be done to protect
these workers, including health-care workers
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Difficulties
• Hard to put out for consultation a document
that reduces liberties, scope for consultation,
unless the difference between emergency and
non-emergency situations widely grasped
• Ethical guidelines for emergencies, if put out
for consultation, will probably end up looking
like DH’s
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SARS
• Very similar ethically to pandemic influenza
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Annas’ Criticisms of Hong Kong,
Canada in SARS outbreak
• Worst Case Bioethics
• Quarantining in Hong Kong disproportionate
• Even voluntary quarantining in Canada
disproportionate
• Approporiate framework in normal and
abnormal times is human rights framework
• H-R anti-coercive
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Annas, p. 223
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SARS and HR
• Either Annas is right and HR theory and
practice open to the charge of modelling the
normal on the abnormal
• Or else Annas is wrong and HR limits liberties
for the sake of life
• HR instruments certainly limit liberties for the
sake of emergency, and not even a healththreatening emergency
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ICCPR
• http://www1.umn.edu/humanrts/instree/b3c
cpr.htm
Article 4
Article 22
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