Incorporating explicit ethical reasoning into pandemic influenza policies

Since the emergence of the H5N1 highly-pathogenic (avian) influenza threat in 2004,1 scholars and policy-makers have been actively preparing for a potential pandemic. These five years represented an unprecedented opportunity. Although historically, three to four global pandemics have occurred each century,2 never before had the world been given prospective warning about such a potentially serious influenza outbreak. This early warning meant that steps could be taken to prevent, or at least mitigate, the health effects of this looming global public health emergency.3 Social distancing strategies were devised and implemented, medical countermeasures were developed and stockpiled, and careful thought was given to buttressing critical infrastructure from the impending social disruption.4 Beyond these medical, social, and public health preparedness efforts, scholars and government officials also had an opportunity to grapple prospectively with the ethical impact of preparedness and response activities, with the goal of ensuring that the burdens of disease and benefits of intervention would be distributed equitably.5 Unfortunately, these ethical preparedness efforts have been of limited utility to-date. While numerous scholars have identified and explored a range of important ethical issues, data indicate that ethical considerations are not regularly incorporated into actual pandemic preparedness plans.6 The consequences of this failure have yet to be felt for H5N1, since the virus remains only a potential threat. But with H1N1 influenza (swine origin) rapidly emerging as a real global public health danger, the current situation presents an interesting opportunity to assess how our public health system reacts under pressure, allowing us to ask important questions about how, and to what extent, policy-makers are incorporating ethical considerations into their deliberative processes.7 As an example of a situation in which ethical considerations influence policy-making processes, this essay will briefly explore issues surrounding domestic and global H1N1 vaccine allocation decisions. Important policy decisions that influence allocation, such as prioritization of a scarce H1N1 vaccine, require careful balancing of multiple considerations. Decision makers have to weigh epidemiologic and scientific evidence alongside practical and ethical considerations. Policies developed without sufficient ethical discourse run the risk of undermining public trust and cooperation by contributing to a perceived lack of fairness and transparency. This is particularly true when making potentially controversial decisions about how to allocate a demonstrably scarce resource. Given that the emerging pandemic is still in its early phases, with rapidly shifting surveillance data and assumptions, the goal of this essay is to ask a preliminary set of questions about incorporation of bioethical reasoning into H1N1 policy decisions. After first summarizing current information about the epidemiologic characteristics of the disease and projected vaccine availability, I will focus on two recent U.S. vaccine allocation policies: the domestic allocation recommendations promulgated by the Advisory Committee on Immunization Practices (ACIP), and President Obama’s decision to share ten percent of the country’s vaccine supply with developing countries. I will demonstrate that while both of these policies are reasonable and appropriate, they could have been better supported by the inclusion of more explicit ethical reasoning. The failure to do so raises serious questions about the fundamental ethical underpinnings of our political actions.