Abstract
It is generally expected that sooner or later a novel
influenza A virus subtype, easily transmissible from
person to person, will emerge and cause pandemic
disease. Humans will have little or no immunity to
this virus, which could spread at least as easily as
common seasonal influenza and infect many people
worldwide potentially resulting in very
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high
mortality and morbidity rates. Some scenarios
assume attack rates of up to 35% and lethal disease
in 1–2% of persons who develop symptoms,
yet such assumptions may be a gross overestimation
or underestimation of the crisis (1). Mass production
of a specific pandemic vaccine will not start
for several months, and in the mean time the possibilities
for prevention and treatment are limited.
Depending on supplies, antiviral drugs could play
an important specific therapeutic and prophylactic
role. The global demand for antiviral drugs and
medical care would be likely to exceed global (and
affordable) supplies. Many patients may develop
respiratory failure and require mechanical ventilation
and the need for such intensive care will go
far beyond available resources. Moreover, the disease
will hit health-care professionals and related
personnel: working in the front-line they run greater
risks of infection than other citizens. This will
increase pressure on the health-care system, where
much more must be done with fewer staff. Triage
decisions for allocating scarce treatment possibilities
will be inevitable. Such decisions need to be
made for supportive medical care (e.g. ventilators),
antibiotics, antiviral drugs, and vaccines, as well as
for access to health-care facilities in general.
One essential way to avoid chaos and to promote
an adequate response to a pandemic is to
develop action plans for pandemic preparedness.
Allocation of scarce medical resources such as antiviral
drugs, and development of vaccination strategies
are important issues in such plans. Triage and
priority-setting clearly raise ethical questions: is it
morally justified to give certain persons access to
life-saving treatment and to refuse others – and if
so, which choices should be made and by whom?
In 2006 many countries published action plans for
an influenza pandemic but few provide discussion
of such ethical issues and even fewer offer systematic
ethical justification for priority setting (2, 3).
This paper formulates ethical principles and
arguments for setting priorities in the distribution
of scarce medical resources during a pandemic,
especially antiviral drugs, vaccines, access to medical
care, and bed and equipment allocation. Priority
setting in a pandemic will be a deeply controversial
issue. This is not only because there will be extreme
shortages in supply of potentially life-saving treatment,
but also because routine health-care procedures
for illnesses other than influenza may not be
applicable or appropriate where drastic interventions
are required to mitigate the effects of the
pandemic. However, ethical theories do provide
clarification and reasonable justification for the
principles that should guide decision-making.
This paper argues for specific priorities on the
basis of maximizing health benefits (notably saving
most lives) and equity, but also acknowledges that
basic moral principles allow consideration of certain
other priorities. The conclusions can only be provisional
and incomplete given the lack of important
data and inevitable conflicts between and within
the basic moral principles. Moreover, some situations
involve emergencies and tragedies of such
magnitude that ethical theory has little practical
guidance to offer.
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