minnesota pandemic ethics project: a look at vaccines confronting the ethics of pandemic influenza...
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Minnesota Pandemic Ethics Project: Minnesota Pandemic Ethics Project: A Look at VaccinesA Look at Vaccines
Confronting the Ethics of Pandemic Influenza Planning: Confronting the Ethics of Pandemic Influenza Planning: The 2008 Summit of the States The 2008 Summit of the States
J. Eline (Ellie) Garrett, JDJ. Eline (Ellie) Garrett, JDMinnesota Center for Health Care EthicsMinnesota Center for Health Care Ethics
on behalf of the on behalf of the Minnesota Pandemic Ethics Project TeamMinnesota Pandemic Ethics Project Team
Minnesota Center for Health Care Ethics Minnesota Center for Health Care Ethics 2006 Pandemic Influenza Ethics 2006 Pandemic Influenza Ethics
Project on VaccinesProject on Vaccines
Vaccine 25 (2007) 6522-6536
2006 Vaccine Project2006 Vaccine Project
Diverse workgroup, ~35 participantsDiverse workgroup, ~35 participants Prioritization based onPrioritization based on
• Risk of mortalityRisk of mortality• Vaccine responseVaccine response• Risk of transmissionRisk of transmission• Key worker roleKey worker role
Exposure risk not prioritizedExposure risk not prioritized
MN Pandemic Ethics ProjectMN Pandemic Ethics Project2007 – present2007 – present
A collaboration between theA collaboration between the
Minnesota Center for Health Care Ethics Minnesota Center for Health Care Ethics and theand the
University of Minnesota Center for BioethicsUniversity of Minnesota Center for Bioethics
funded by thefunded by the
Minnesota Department of HealthMinnesota Department of Health
Team MembersTeam Members
MN Center for MN Center for Health Care EthicsHealth Care Ethics• J. Eline GarrettJ. Eline Garrett• Karen G. GervaisKaren G. Gervais• Ruth MickelsenRuth Mickelsen• Angela Witt PrehnAngela Witt Prehn• Dorothy E. VawterDorothy E. Vawter
U of MN Center for U of MN Center for BioethicsBioethics• Debra A. DeBruinDebra A. DeBruin• Jeffrey KahnJeffrey Kahn• JP Leider JP Leider • Joan LiaschenkoJoan Liaschenko• Mary Faith MarshallMary Faith Marshall• Steven MilesSteven Miles• Elizabeth ParillaElizabeth Parilla• Carol TauerCarol Tauer• Susan WolfSusan Wolf
Scope of ProjectScope of Project
Ethical frameworks for rationing Ethical frameworks for rationing health-related resources during health-related resources during severe pandemicsevere pandemic• VaccinesVaccines• N95sN95s• MasksMasks• Antivirals (treatment and prophylaxis)Antivirals (treatment and prophylaxis)• VentilatorsVentilators
Recommendations, not mandatesRecommendations, not mandates
Pandemic: Assumptions for Pandemic: Assumptions for Severe Pandemic Severe Pandemic
Groups at riskGroups at risk• Very youngVery young• Very oldVery old• Co-morbiditiesCo-morbidities• Healthy 15-40 yr oldsHealthy 15-40 yr olds
2 sources of mortality2 sources of mortality• FluFlu• Disrupted critical infrastructuresDisrupted critical infrastructures
Guidance is context-specificGuidance is context-specific
ProcessProcess Comprehensive review of plans and Comprehensive review of plans and
literatureliterature• AW Prehn, DE Vawter. AW Prehn, DE Vawter. Ethical Guidance for Ethical Guidance for
Rationing Scarce Health-Related Resources in a Rationing Scarce Health-Related Resources in a Severe Influenza Pandemic: Literature and Plan Severe Influenza Pandemic: Literature and Plan Review Review (2008)(2008)
Convened 100+ Minnesotans to develop Convened 100+ Minnesotans to develop preliminary guidance preliminary guidance • Diverse – expert and “lay”Diverse – expert and “lay”
Community engagement (in process)Community engagement (in process)• Web-based public commentWeb-based public comment• Small groups – metro and ruralSmall groups – metro and rural
Ethical Guidance for Rationing Ethical Guidance for Rationing in Severe Pandemicin Severe Pandemic
State State GeneralGeneral AntiviralsAntivirals PPEPPE VaccinesVaccines VentilatorsVentilators
FloridaFlorida ++
New YorkNew York ++
TennesseeTennessee ++ ++ ++ ++
UtahUtah ++
WisconsinWisconsin ++ ++
As of March 2008
MN Ethical Frameworks: OverviewMN Ethical Frameworks: Overview
Statewide, public-private perspective Statewide, public-private perspective Guidance for decision-making Guidance for decision-making
• CommitmentsCommitments• PrinciplesPrinciples• GoalsGoals• StrategiesStrategies
Ethical CommitmentsEthical Commitments
Pursue common goodPursue common good• Be accountable, transparent, Be accountable, transparent,
trustworthytrustworthy• Promote solidarity, mutual responsibilityPromote solidarity, mutual responsibility• Respond fairly, effectively, efficientlyRespond fairly, effectively, efficiently
Principles and GoalsPrinciples and Goals
Protect the population’s healthProtect the population’s health• Reduce mortality and serious morbidityReduce mortality and serious morbidity
Protect public safety and civil orderProtect public safety and civil order• Reduce disruption to critical Reduce disruption to critical
infrastructuresinfrastructures• Promote public understanding and Promote public understanding and
confidence confidence
Principles and Goals Principles and Goals (cont.)(cont.) Treat people fairly, recognizing moral Treat people fairly, recognizing moral
equality of allequality of all• Reduce significant differences in Reduce significant differences in
mortality/morbiditymortality/morbidity• Remove barriers to fair accessRemove barriers to fair access• Honor reciprocity obligations to workersHonor reciprocity obligations to workers• Reduce significant differences in opportunities for Reduce significant differences in opportunities for
normal lifespannormal lifespan• Use fair processUse fair process
Principles (not goals)are co-equal; must Principles (not goals)are co-equal; must be balancedbe balanced
Strategies: GeneralStrategies: General
Do not ration based on: Do not ration based on: • Social value (gender, socio-economic Social value (gender, socio-economic
class, race, citizenship, etc.)class, race, citizenship, etc.)• Quality of lifeQuality of life• Duration of extended lifeDuration of extended life• First-come, first-servedFirst-come, first-served
Ration based on combinations of Ration based on combinations of clinical and non-clinical clinical and non-clinical considerations considerations
Key Worker StatusKey Worker Status
To reduce mortality and disruption of To reduce mortality and disruption of infrastructures infrastructures
Highest priority goes to workers with Highest priority goes to workers with additional characteristics, e.g., high additional characteristics, e.g., high exposure, risk of mortality exposure, risk of mortality
Usually prioritized simultaneously with Usually prioritized simultaneously with groups in general population, based on groups in general population, based on different considerations different considerations
Age-based Rationing?Age-based Rationing?
An alternative to random processesAn alternative to random processes Depends on broad public agreementDepends on broad public agreement
• Children before adults?Children before adults?• Younger adults before older?Younger adults before older?• Elders before others?Elders before others?
MN not alone in considering ageMN not alone in considering age• WHOWHO• US Interagency Working GroupUS Interagency Working Group
• Indiana 2006 recommendationsIndiana 2006 recommendations
De-Prioritized or Excluded De-Prioritized or Excluded
Natural immunityNatural immunity Medical contraindicationsMedical contraindications Unacceptable vaccine responseUnacceptable vaccine response Imminently and irreversibly dyingImminently and irreversibly dying Satisfactory alternative protectionsSatisfactory alternative protections
Strategies: Strategies: 2 Parallel Tracks with 6 Tiers2 Parallel Tracks with 6 Tiers
Track A: Track A: Key WorkersKey Workers
Track B: Track B: General PublicGeneral Public
Tier 1Tier 1 ++
Tier 2Tier 2 ++ ++
Tier 3Tier 3 ++ ++
Tier 4Tier 4 ++
Tier 5Tier 5 ++
Tier 6Tier 6 ++
Track A – Key WorkersTrack A – Key Workers
Tiers based on combinations of:Tiers based on combinations of:• Risk of occupational exposureRisk of occupational exposure• Risk of morbidity/mortalityRisk of morbidity/mortality• ““Irreplaceability”Irreplaceability”• Vaccine responseVaccine response
Track B – General PopulationTrack B – General Population
Tiers based on combinations ofTiers based on combinations of• Risk of morbidity/mortalityRisk of morbidity/mortality• Vaccine responseVaccine response• Possibly age (children at moderate risk Possibly age (children at moderate risk
prioritized over adults at moderate risk)prioritized over adults at moderate risk)
Moving from 2006 to Moving from 2006 to Current ProjectCurrent Project
Adjust resource-specific frameworks Adjust resource-specific frameworks to work as a package (and to to work as a package (and to coordinate with comprehensive plan)coordinate with comprehensive plan)• Don’t systematically disadvantage (or Don’t systematically disadvantage (or
advantage) any groupadvantage) any group More attention to occupational More attention to occupational
exposure riskexposure risk Possibility of age-based rationing Possibility of age-based rationing
(esp. prioritizing kids)(esp. prioritizing kids)
Fit with Feds?Fit with Feds?
2005 HHS guidance for 2005 HHS guidance for moderatemoderate pandemicpandemic
Proposed federal guidance for severe Proposed federal guidance for severe pandemic:pandemic:• Multiple goals, tracks and tiersMultiple goals, tracks and tiers• Protects infrastructuresProtects infrastructures• Prioritizes children before adults in some Prioritizes children before adults in some
circumstancescircumstances• Attends less to differences in response and Attends less to differences in response and
availability of alternative protectionsavailability of alternative protections• Attends to homeland security and national Attends to homeland security and national
defense goalsdefense goals
Draft ReportsDraft Reports DE Vawter, JE Garrett, AW Prehn, et al. DE Vawter, JE Garrett, AW Prehn, et al. For For
the Good of Us All: Ethically Rationing Health the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Resources in Minnesota in a Severe Influenza Pandemic: Preliminary Report Pandemic: Preliminary Report (2008)(2008)
DA DeBruin, E Parilla, J Liaschenko, et al. DA DeBruin, E Parilla, J Liaschenko, et al. Implementing Ethical Frameworks for Implementing Ethical Frameworks for Rationing Scarce Health Resources in Rationing Scarce Health Resources in Minnesota During Severe Influenza Pandemic Minnesota During Severe Influenza Pandemic (2008)(2008)
Available (soon) at www.stolaf.edu/mnethx Available (soon) at www.stolaf.edu/mnethx and www.bioethics.umn.edu and www.bioethics.umn.edu
Next StepsNext Steps
Public comment (web-based)Public comment (web-based)• Watch www.stolaf.edu/mnethx or Watch www.stolaf.edu/mnethx or
www.bioethics.umn.edu www.bioethics.umn.edu Public engagement pilotPublic engagement pilot
• Small groupsSmall groups• Metro, ruralMetro, rural
For more informationFor more information
Ellie Garrett Ellie Garrett MN Center for Health Care EthicsMN Center for Health Care Ethics
[email protected] [email protected]
(612) 964-9425(612) 964-9425 Contact info for other team members:Contact info for other team members:
www.stolaf.edu/mnethx or www.stolaf.edu/mnethx or www.bioethics.umn.eduwww.bioethics.umn.edu