Global & Disaster Medicine

Pandemic planning: Ethical epidemic response


Flu season and pandemic planning: Ethical epidemic response

Triage and ethical considerations in prioritizing care for healthcare professionals and the public in an influenza pandemic

Feb 28, 2018

By Jeffery A. King, faculty, American Military University

The Centers for Disease Control and Prevention recently signaled that the 2017-2018 flu season is expected to meet the criteria for a “high severity” epidemic. At the end of January, there were more than 83,000 reported cases of flu with heightened mortality. This year’s viruses are beginning to overwhelm healthcare providers around the country. The challenge of caring for so many is only compounded by shortages of rapid influenza diagnostic tests, Tamiflu, IV bags, and even bed space in many hospitals.

Trials like this can force public health officials and healthcare providers into the unenviable position of making impulsive and impactful decisions during unprecedented situations. As with so many other public safety initiatives, these decisions can test American ethics by pitting individual liberties and other shared values against approaches that are hard to swallow but often necessary to achieve a greater good. Here are a few ethical challenges to consider for current and future pandemic planning.

Ethical challenges: how to prioritize care?

One of the more difficult challenges that can arise for public health and healthcare decision-makers is the task of prioritizing care among otherwise equally affected patients. It is worth pointing out that during an epidemic, patients cannot always be directed to other facilities, and medicine and equipment cannot always be borrowed or redistributed because multiple regions are suffering from similar shortages.

Determining how patients are prioritized and how treatment is managed when there simply are not enough personnel, beds, equipment or medicine is a morally unpleasant choice. Providers can either treat patients on a first-come, first-served basis, which could leave scores without appropriate healthcare, or they can triage patients based on factors like the relative acuteness of their illness, overall health, age and other characteristics.

Triage during a resource-constrained epidemic might exclude many of those who are too sick or who would require overly intensive care, thus allowing concentrated effort on those most likely to recover. Beyond the deathly ill, what other factors might the public consider justifiable toward accomplishing the greater good? Is it only acceptable under epidemic conditions to deny treatment to complex cases, such as those with other acute or chronic health conditions, the disabled or the elderly? If the elderly are to be denied treatment, at what age would the limit be set? What about an elderly physician or nurse who may be able to assist in the response if she can recover?

All of these decisions require consequentialist thinking – an attempt to justify decisions by their expected outcomes. The difficulty with a consequentialist approach is that decisions can easily slide into the arbitrary depending on context, variables, and the decision-maker’s subjective appraisal of the outcomes. Decision-makers are rarely able to foresee the full consequences and the law of unintended consequences will almost certainly introduce suspicion into any well-intended triage and treatment plan. In order to achieve agreement on the just and equitable provision of healthcare during an epidemic, the process and procedures for decision-making should be publicly and openly debated well before an epidemic ever occurs.

Prioritizing healthcare workers

In a 2014 case study on ethical decision-making during catastrophic pandemics, Dr. Linda Kiltz advocates strongly for the prioritization and protection of healthcare providers. Influenza and other viruses are not discriminatory in their transmission; like water, viruses follow a path of least resistance. As the most seriously affected patients make their way to healthcare facilities, the employees at those facilities are in the direct path of the virus.

Medical professionals who are obligated or willing to expose themselves directly to a viral epidemic should receive prioritized care if they contract the virus. They are accepting risk to their own health, and communities owe them a certain respect and reciprocity for that sacrifice. In short, where healthcare workers have a duty to care for the community, the community has a reciprocal duty to support them.

Communities must, for example, ensure that healthcare workers have access to the appropriate training and personal protective equipment to perform their jobs competently and safely. Communities must also ensure that healthcare workers’ personal and family needs, like child and elder care, meals, and even mental and spiritual care, are supported.

Beyond reciprocity, protecting and supporting healthcare providers during an epidemic serves a distinctly utilitarian purpose. It is easily agreed that healthcare providers are one of the most valuable resources during an epidemic. These professionals represent a valuable, limited human resource, so protecting their health and supporting their personal needs can help to ensure their continued availability for response.

Protecting the public

Protecting the public by controlling the spread of viruses is another priority during epidemics. Quarantine and isolation are common public health tools used to prevent or mitigate the effects of an epidemic. While these practices have long been authorized by law, officials still must appreciate the sensitivities and impacts, and plan for supporting those affected. Nowhere else is the struggle to balance public health priorities against individual liberties more palpable than it is with implementing preventative actions.

Restrictions on freedom of movement are, practically speaking, the most disruptive burdens for citizens placed in isolation or quarantine. Restricting a person’s movement means impairing their ability to support themselves and their families. It precludes and jeopardizes employment, prohibits attendance at school and church, and cuts families off from all manner of goods and services.

Beyond due process and mere fairness, citizens placed in isolation and quarantine also require support from the government and their communities. If citizens know that their needs will continue to be supported, and their employment and other opportunities protected, then restrictions on their liberty will be far less distressing and disagreeable.

Engagement and collaboration

An influenza epidemic like the one the U.S. is currently experiencing can present a significant threat to public health and overall domestic safety and security. Seeing the ethical challenges in decisions being made during a frenzied response should encourage communities to address the issues early. The more time a community has to fully discuss, negotiate, and agree on policies and plans that will guide action during response, the less distrust those actions will incur.

If the decision-making during an epidemic response appears arbitrary and unequitable, it can break down a community’s trust and motivation for compliance. In the end, collaboration between the government, the healthcare sector, and the broader community is necessary to create consensus on these ethically challenging matters.

About the Author

Jeff King is a retired Coast Guard judge advocate and a faculty member in the School of Security & Global Studies at American Military University, where he primarily teaches undergraduate and graduate courses in law and ethics. To contact him, email

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