Ethical Lessons from the 2009 H1N1 Pandemic
At the University of Pennsylvania School of Medicine on May 14, Arthur L. Caplan, PhD, Emmanuel and Robert Hart Director of the Center for Bioethics and the Sydney D. Caplan Professor of Bioethics at the University of Pennsylvania, gave a talk entitled “Ethical Lessons of Swine Vaccine Rationing.” Caplan, a widely quoted voice in bioethics, noted that the 2009 H1N1 pandemic provided testing ground for pandemic and even bioterror response planning. What can we learn from the experience?
Caplan described several areas for improvement. First, he noted the plethora of plans, developed at different levels of authority, for dealing with the pandemic. Hospitals, corporations, cities, and states developed plans with different priorities and rationales, some of them potentially at odds. Caplan highlighted the conflict between, for example, a state that might decide to quarantine itself to attempt to reduce importation of disease and a vaccine manufacturer in that state with a need to distribute its product. Would the state plan necessarily take the manufacturer’s needs into account?
Messages from the Centers for Disease Control and Prevention highlight the varying levels of jurisdiction and authority involved in the distribution of vaccine. For example, here CDC describes the allocation and dispersal of vaccine: “The federal government allocates vaccine based on population to public health departments in the 62 project areas. These public health departments then make decisions about how to distribute vaccine to providers equitably and efficiently within their jurisdictions with the goal of reaching the priority groups first…. Providers may include, but are not limited to, individual clinicians, provider offices, clinics at places of work, hospitals, local health departments, retail pharmacies, and community vaccinators” (CDC, Vaccine against 2009 H1N1 Influenza Virus). Many players, many potential plans for distributing vaccine.
Caplan pointed to another problem relating to the varying definitions applied to the term health-care worker in relation to vaccination recommendations in different plans. Most pandemic plans took into account the need to vaccinate health-care workers, both so they would be available to care for the ill and so they might prevent disease transmission to vulnerable patients. But who, exactly, is a health-care worker? Just those involved in direct patient care? But what about laboratory technicians, janitors, and food service workers in health care settings? Certainly a well-functioning hospital or clinic relies on people in these auxiliary positions. If they become ill, vital hospital functions might fail. Moreover, Caplan referred to studies that have shown that a high rate of influenza vaccination in a hospital correlates to lower levels of influenza in patients. Presumably these high rates of coverage might include workers who are not at the forefront of patient care. A shared definition of exactly who should receive influenza vaccine in a pandemic might simplify decisions and benefit patient care.
Finally, Caplan noted that none of the pandemic plans he saw addressed the issue of potential scarcity of vital hospital equipment, such as ventilators. If the pandemic had played out according to early predictions of widespread, severe illness, hospitals could have been overwhelmed with patients needing artificial ventilation. In that case, medical personnel might be forced to make decisions about allocating scarce machinery among needy patients, even potentially taking some patients off ventilation so that others might benefit. Without guidelines to make those decisions, medical personnel might find themselves faced with difficult ethical issues at a time of crisis.
Caplan closed with a discussion of a new mandatory influenza vaccination policy for all personnel employed at the Children’s Hospital of Philadelphia. Excepting those people with medical contraindication to vaccination, the mandate was universal, and CHOP achieved very close to 100% coverage for seasonal influenza. (This contrasts with a national average of about 40% influenza vaccination coverage in hospital settings in the absence of a mandate.) Given what he said were the overall safety and efficacy of influenza vaccination, the moral arguments for the policy rested upon the following principles:
- Protect the weak, the vulnerable, and the defenseless.
- Put patient interests first.
- Do no harm.
In the end, however, the mandate faced unforeseen difficulties in relation to 2009 H1N1: vaccine was scarce, and CHOP had difficulty securing it for its employees.