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Ethical Response to Emergency

• Tom Sorell
• University of Warwick

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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

• DHs 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, promise-keeping,
  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

• 50,000 -750,000 excess deaths in UK 25-33 of
  population falling ill
• Other effects
• Highly disrupted schooling, business
• Badly affected health service provision
• Significant bereavement effects
• Health losses among survivors

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Timescale of spread (Ferguson)

• 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.

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WHO classification of pandemic phases

• http//www.who.int/csr/disease/avian_influenza/pha
  se/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
• Influenza treatment vs other emergency, general
  acute, cases
• Priorities among those infected with influenza
  e.g. children vs adults young adults vs elderly
• 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
  mass-communications
• Normal maintenance of public order, legal system
• Maintenance of public utilities, food
  distribution through pre-assessed 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 Frameworkfor 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

• 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
• Peoples 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 justtheir health
  needs

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Minimizing harm

• Preventing spread of pandemic to UK
• Minimizing spread within UK
• Anti-virals
• Minimize disruption to society

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Fairness

• Fair vs equal access, equally timely access to
  rationed resources
• Fair in relation to the likely benefits of
  health resources

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Working Together

• 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

• 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 emergencymost might be applied all the
  time someflexibility and good decision-making--
  ignore the justified suspension of normal
  democratic decision-making processes in
  emergencies

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Criticisms 2

• Harm over-inclusively understood, and its 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

• Consumerism of Thatcher reforms continued by
  Labour
• Downplaying in medical contexts of minimising
  harm, reciprocity principles where they conflict
  with consumer/democratic choice
• Kennedy report
• MMR
• 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 DHs

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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
  health-threatening emergency

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ICCPR

• http//www1.umn.edu/humanrts/instree/b3ccpr.htm
• Article 4
• Article 22