Flu pandemic ethics: rationing scarce resources.

In an earlier post, I pointed you toward the preliminary report (PDF here) issued by the Minnesota Pandemic Ethics Project this January. This report sets out a plan for the state of Minnesota to ration vital resources in the event of a severe influenza pandemic.

Now, a rationing plan devised by an ethics project is striving for fairness. Rationed resources are those scarce enough that there isn't enough to go around to everyone who might want or need them. If someone will be left out, what's a fair way to decide who?

Let's have a look at the rationing strategies discussed in the draft report:

The panel considered several different criteria in developing rationing strategies:

• Risk of flu-related mortality and serious morbidity;
• Good or acceptable response to the resource;
• Risk of occupational or non-occupational exposure to flu;
• Recent known unprotected exposure to flu by members of the general population or occupational exposure by key workers;
• Risk of transmitting flu to others at high risk of flu-related mortality and serious morbidity; and possibly
• Age (among the general population, e.g., children before adults or younger groups before older).

Various combinations of these characteristics warrant prioritizing some groups of the general population and/or some key workers to receive particular resources before others. These characteristics vary in their importance and relevance among resources and most often combinations of characteristics drive the recommendations. Most frameworks include one set of rationing criteria for the general population and another for key workers. In general, those prioritized first among key workers are those with the highest occupational exposure to the flu or high risks or mortality and serious morbidity, so long as they are likely to respond well to the particular resource. Similarly and simultaneously, those groups of the general public who are at the greatest risk of flu-related mortality or serious morbidity are also prioritized for resources, so long as they are likely to respond well to the resources. The most significant differences between the general population and key workers are that key workers are also prioritized by virtue of their role in supporting core infrastructure on which all Minnesotans depend and by reciprocity obligations owed those exposed to the flu in the service of others. In addition, non-clinical age considerations may be considered in the general population in some circumstances as an alternative to resorting to a strictly random method of rationing resources to similarly prioritized persons.

The panel also proposed criteria for ineligibility or de-prioritization to receive a particular resource, depending on the scarcity of the resource. These characteristics include: assumed or confirmed immunity (e.g., have contracted and recovered from influenza or are successfully vaccinated); availability of satisfactory alternative protections, and; medical contraindications or imminent death (e.g., have a known co-morbidity incompatible with life beyond a short timeframe).

The panel rejected several criteria for rationing. These criteria are inconsistent with the fairness principle and its commitment to the moral equality of all Minnesotans. Specifically, resources should not be rationed based on:

• social value, e.g., race, gender, education, religion or citizenship;
• quality of life;
• duration of benefit (with the exception of persons who are imminently and irreversibly dying); or
• first-come, first-served.

(pp. 15-16)

Remember here that the Minnesota Pandemic Ethics Project is concerned with bringing about a good outcome for the state of Minnesota and for its citizens in the event of a severe flu pandemic. If it were possible to protect every single Minnesotan from flu, that might be the strategy. However, given that influenza does some rapid genetic reassortment that makes it hard to develop an effective vaccine in advance of a flu outbreak (and that it takes time to produce thousands of doses of vaccine), the odds are against vaccinating all Minnesotans before the flu cases begin.

The attainable goal, then, is halting the spread of the flu and minimizing the harm it does to the people who get it.

It's that second part, I think, where the ethical considerations about rationing resources become important. If keeping the flu from spreading beyond people who already had it was the sole aim, then locking them in their houses or some containment facility until the virus burned itself out would do the job. However, we recognize that we have, as a society, duties to care for the people who get sick -- even if they are sick with a virus which could spread to and sicken others. Being sick, even being contagious, doesn't remove you from the moral community. Indeed, there are practical reasons for us to recognize our duties to people with flu -- if we didn't, they might reciprocate by deciding they had no duties to try not to infect others, or to refrain from using force in securing medical care for themselves.

While we have a general duty to care for the sick, however, we are not required to offer measures that will be futile. Thus, we don't owe people who are already infected the vaccine that would have prevented infection (if they weren't already infected), nor do we owe the patient for whom death is imminent a full-scale medical response with vanishingly small probability of being effective. Those vaccines and medical responses are better directed to the people for whom they might make a difference.

You'll note that one group of people is singled out for access to preventative measures and treatments, namely "key workers" (such as health care providers). The priority they are given in the rationing scheme is pay-back for taking on increased risk of flu in the service of others, as well as a recognition that these key workers are part of the health care and public safety infrastructure on which everyone else relies. If that infrastructure breaks during a sever flu pandemic, everyone will have a harder time getting access to vaccines and medical treatment. Key workers who are sick with flu and/or spreading flu themselves can break the infrastructure.

These two pieces of the rationing strategy -- protecting the people whose job it is to care for the sick and to keep the virus from spreading to the healthy, and not applying scarce resources where they will not work -- strike me as pretty uncontroversial. My guess, however, is that the remaining details, about how to distribute resources among a large group of people who could be helped by them but only some of whom will be able to get the resources, might be more controversial. On paper, when the scheme is laid out and you have as good a chance as anyone else of getting the vaccine, or the antiviral drug, or the ventilator, it's hard to offer an alternative that would be more fair. In practice, when the lottery for the resources is held, will the losers still endorse the results?