Eric M. Meslin, Ph.D.Director, Indiana University Center for Bioethics

Associate Dean for Bioethics, IU School of MedicineProfessor of Medicine, Medical and Molecular Genetics, Philosophy

Co –Director, IUPUI Consortium for Health Policy, Law and Bioethics

 

Incorporating Ethics into Planning:Indiana’s Approach

July 16, 2008

Ethics Advice to ISDH

• 2006: IUCB is named ethics technical advisor to ISDH on pandemic influenza planning • Community Advisory Groups

included ethics representatives• Tabletop exercises/educational sessions for local health officials

Ethics Advice to ISDH

2007 Products• Technical Advisory Documents

Points to Consider (Ethics Framework)

Altered Standards of Care Workforce Issues Triage of Patients Vaccine Availability

• Annotated Bibliographies

Ethical Framework: Using Principles

Ethical Principles• Do no harm (non-maleficence)• Maximize patient well

being/welfare (beneficence)• Protect privacy/confidentiality• Allocate resources fairly• Ensure social solidarity• Respect for persons/personal

autonomy• Principle of precaution• Tell the truth

Ethical Principles vs. “Points to Consider”

Points to Consider• Consistency with the Professional

Values of Health Care• Transparency• Public Accountability• The Value of Collaboration vs.

Going it Alone• Fairness in the Allocation of

Resources• Permissible Noncompliance and

Exceptions

• The Problem with Principles Appeal to single principles (or even

several) cannot comprehensively provide explicit guidance

Principles are difficult to rank and adjudicate between

• “Points to Consider” used in other policy setting

environments (e.g., NIH, rDNA) participants must publicly

acknowledge ethics Useful as a template against which

to assess policy

Fairness in the Allocation of Resources

• Procedural Fairness ensure those affected by

policy have some way of being engaged in its design and/or implementation

• Substantive Fairness avoid use of ethically

inappropriate criteria to discriminate against persons or groups

Types of Procedural Fairness

• passive engagement: inform public

• authorization: grant public the power to authorize policy (voting)

• expressions of interest: public has opportunity to express views, but no right to expect policy will accommodate (comment period)

Criteria for Substantive Fairness

• obviously relevant on their own:

existing medical conditions, quality of life before/after treatment

• obviously irrelevant on their own:

race, ethnicity, gender, country of origin, political/religious affiliation, sexual/lifestyle preference, socio-economic status, educational attainment

Permissible Noncompliance and Exceptions

Difference between noncompliance as an instance of civil disobedience to oppose a perceived unjust policy, and a permissible bypassing of policy under justifiable circumstances.

Points That Policy Should Consider

• Does the policy permit deviations or exceptions and if so how are these to be adjudicated?

• Will individuals be permitted to opt out, seek assistance elsewhere?

• What procedures will be in place for monitoring policy implementation and for proposing revisions to it?

IUCB Advice to ISDH (cont’d)

2008 Products • Updated/Revised TADs (+ case

studies)• Expert Panel: Implementation of

TADs• National survey of public opinion• Legal analysis• Online website access • 2008 Summit of the States

Summit Highlights/Goals

Goals• Bring state and territorial

health officials together to discuss in detail the ethical issues that all face in planning for pandemic influenza

• Share best practices• Identify ethical concerns

and actions that might be taken

Confirmed Attendees (N=35)Alabama, Alaska, California, Delaware, District of Columbia Federated States of Micronesia, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New Jersey, New York, North Carolina, Oklahoma, Ohio, Pennsylvania, Puerto Rico, South Carolina, South Dakota, Texas, US Virgin Islands, Utah, Virginia, Washington, West Virginia,

What are the key ethical challenges that states and territories face in planning for pandemic influenza?

• Meeting the obligation to engage communities in planning and response to ensure fairness, transparency and participation.

• Identifying and defining criteria for allocation of scarce health care resources and critical infrastructure.

• Defining criteria and mechanisms for implementing altered standards and places of care.

• Preventing exacerbation of disparities in access to care.

• Balancing the rights and duties of health care workers.• Providing palliative care.• Meeting the needs of at-risk populations.• Selecting effective community containment strategies.• Respecting cultural and religious practices in the face

of mass fatalities.

Indiana Pandemic Influenza Ethics Team

IU Center for Bioethics• Eric M. Meslin, Ph.D.• Margaret Gaffney, M.D.• Paul Helft, M.D.• Eleanor Kinney, J.D., M.P.H.• Amy Lewis Gilbert, M.P.H.• Jere Odell, M.A., M.L.S• James Wolf, M.A.• Jennifer Alyea, M.P.H.• Katie Carr, B.A.

Indiana State Department of Health

• Janet Archer, R.N.• Jennifer Bruner, J.D. • Mitch Klopfenstein, M.A.

410 West 10th Street, Suite 3100Indianapolis, IndianaUSA 46202-3002Tel: (317) 278-4034Fax: (317) 278-4050www.bioethics.iu.edu