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Ethical Issues in Pandemic Influenza Planning. CDC Avian Influenza Training . Learning Objective. Understand ethical considerations pertaining to pandemic influenza preparedness and response. Session Overview. General and specific ethical considerations in public health Public engagement

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Ethical Issues in Pandemic Influenza Planning

CDC Avian Influenza Training


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Learning Objective

  • Understand ethical considerations pertaining to pandemic influenza preparedness and response


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Session Overview

  • General and specific ethical considerations in public health

  • Public engagement

  • Planning and resources


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General and Specific Ethical Considerations in Public Health

http://www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf


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What are Public Health Ethics?

  • A set of principles based on values and beliefs which underlie the principles of public health ethics

  • A guide to actions to promote health and prevent injury and disease in the population

  • Processes to clarify, prioritize, and justify possible courses of public health action based on ethical principles


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Values and Beliefs

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.”

Universal Declaration for Human Rights, Article 25


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12 Principles of the Ethical Practice of Public Health

  • Address the fundamental causes of disease and requirements for health

  • Respect individual rights in the community

  • Ensure an opportunity for community input

  • Empowerment of disenfranchised

  • Seek information for effective policies and programs

  • Provide community with information


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12 Principles of the Ethical Practice of Public Health

  • Act in a timely manner

  • Incorporate a variety of approaches and respect diversity

  • Enhance physical and social environment

  • Protect confidentiality

  • Ensure professional competence

  • Collaborate to build trust and effectiveness


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Benefits of Public Health Ethics

  • Build and maintain credibility and public trust in your agency

  • Foster consensus and resolve value conflicts in an atmosphere of respect

  • Guide decisions when there is scientific uncertainty and varying opinions on how to proceed

  • Increase awareness of the rights of participants and communities in public health activities


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General Ethical Considerations

  • Identification of overall goals

  • Planning

  • Decision-making

  • Preparedness

  • Use of scientific information

  • Global preparedness

  • Balance of individual liberty and community interests

  • Proceduraljudicial mechanism


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Question 1

Fill in the missing words in the following definition of public health ethics:

“Processes to _____, _____, and _____ possible courses of public health action based on ethical principles, stakeholder values, and scientific information”

  • Initiate, carry through, complete

  • Clarify, prioritize, justify

  • Examine, accept, publicize

  • Identify, change, promote

    Answer: B. Clarify, prioritize, justify


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Question 2

Which of the following is NOT one of the 12 principles of public health ethics?

  • Act in a timely manner

  • Provide community with information

  • Protect individual rights over the community

  • Enhance physical and social environment

    Answer: c. Protecting individual rights over the community is NOT one of the 12 principles.


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Identification of Overall Goals

  • Minimize serious influenza-associated complications

  • Preservation of the functioning of society

    Priorities favor those who are responsible for provision of health care, public safety and functioning of key aspects of society

  • Centralization of decision making authority

    To ensure equity in decision making and address need to preserve functioning of society across communities


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Planning and Decision-Making

  • Planning

    • A commitment to transparencythroughout the pandemic influenza planning and response processes

  • Decision-making

    • Public engagement and involvement

      • Public as partner throughout planning and decision-making

      • Particular attention to vulnerable or marginalized members of society


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Preparedness

Responsibility to maximize preparedness to minimize the need for allocation decisions later

  • Proactive planning

  • Develop response strategies

    • Training of staff

    • Development of decision making rules in advance of pandemic


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Use of Scientific Information and Global Preparedness

  • Sound guidelines should be based on the best available scientific information

  • Importance of working with and learning from global preparedness efforts

    • Not merely to benefit U.S. citizens

    • Recognition of common good and global interdependence


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Balance of Individual Liberty and Community Interests

  • Follow three guiding principles:

    • Adopt least restrictive practices

    • Ensure that restrictions are necessary and proportional to need

    • Ensure that those affected receive support from the community

  • Involve diverse public representation in defining restrictions and articulating justification for these restrictions


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ProceduralJudicial Mechanism

Elements of an ideal procedural justice approach:

  • Consistency of standardsacross people and time

  • Impartialand neutral decision makers

  • Adequately reasoned decisions based on accurate information

  • Assurance that those affected by decisions have a voice in decision-making and agree to the proposed process

  • Clear communications with no hidden agendas

  • Revision process whennew information is available

  • Process for appeals

  • Procedures that are sustainable and enforceable


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Question 3

What important ethical balance needs to be maintained during a pandemic?

  • Prevention vs intervention

  • Individual liberty vs community interests

  • State vs. Federal powers

  • Vaccination vs quarantine

    Answer: B. Individual liberty (personal freedoms) vs. community interests (public health)


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Specific Ethical Issues

  • Allocation of scarce resources

  • Community mitigation measures


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Allocation of Scarce Resources

Distribution plans should specify:

  • What scarce goods are involved?

  • Who (or what agency) will decide about prioritization and distribution ?

  • What mechanism will be used for disputes or appeals?

  • Who is eligible to be a recipient ?

  • What criteria will be used to assign higher or lower priorities to groups of individuals ?


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Community Mitigation Measures

Social Distancing

  • Isolation of ill individuals

  • Quarantine of personsexposed to ill individuals

  • Closure of schools, day care centers, businesses, public venues, and cancellation of large public events

  • Alternative work practices/schedules

  • Limiting travel


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Community Mitigation Measures (cont.)

Liberty limiting measures should be voluntary and balanced with protection of individual rights:

  • No unwarranted invasions of privacy

  • Maintain confidentiality of private information

  • Restriction on personal freedom should be equitably applied

  • Avoid an unequal burden being placed on specific individuals or groups

  • Protect against stigmatization


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Community Mitigation Measures(cont.)

  • Ensure that necessary support services (e.g., food, water and other essential services) are provided to the impacted population

  • Take into account needs of vulnerable populations (e.g., the elderly, handicapped)

  • Establish appeals process for those affected by the liberty limiting measures


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Question 4

What are two individual rights which must be protected when liberty limiting measures are put into place? (choose two)

  • No unwarranted invasions of privacy

  • Restriction on personal freedom

  • Maintain confidentiality of private information

  • Stigmatization

    Answer:

    a and c



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Pandemic Vaccination Program Goals July-Dec 2005

Purpose:

  • Rank goals for pandemic influenza vaccination program

  • Weigh tradeoffs between competing goals

  • Select goals considered most important to achieve


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Pandemic Vaccination Program Public Engagement Results

Highest goals:

  • Assuring the functioning of society

  • Reducing deaths and hospitalizations due to influenza


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Other Pandemic Vaccination Program Goals

  • Build and maintain the public’s trust

    • Transparent decision making

    • Seek public’s input

    • Early and clear communication and education

  • Flexible implementation of policy

  • Increase vaccine production capacity

  • Develop other public health measures to protect the public from illness

  • Provide resources to other regions of the world


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Community Mitigation MeasuresOct-Nov 2006

Purpose:

  • Discuss economic and social tradeoffs associated with community mitigation measures

  • Identify challenges with implementing these measures

  • Offer solutions to the challenges


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Community Mitigation Measures Public Engagement Results

  • Support for early implementation of community mitigation measures

    • Encouraging sick persons to stay home

    • Canceling large public gatherings

  • Challenges identified

    • Ensuring soundness of planning

    • Minimizing potential economic impacts

    • Addressing information needs of the population

    • Recognizing that social stresses that will be created


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Solutions to Community Mitigation Challenges

  • Full engagement of all key sectors in development of detailed, fully-coordinated plan

  • Transparency of planning process

  • Training for leadership roles

  • Public education campaigns prior to pandemic

  • Connecting community organizations into social networks

  • Linking providers with people in need prior to pandemic


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Question 5

Fill in the blank from the selections given below the question.

When imposing Community Mitigation Measures (e.g. quarantine), your agency must provide support services such as (1) ____________, take into account the needs of (2)______________, establish (3)_______________ for those affected by liberty limiting measures, and provide (4)________________ about the rationale for these measures.

  • Food, water, essential services

  • Advance communication

  • Vulnerable populations

  • Appeals process

  • Sanctuary

    Answer: (1) a (2) c (3)d (4)b


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Pandemic Influenza Vaccine Prioritization Dec 2006 – present

Purpose:

  • Discuss prioritization and allocation of pandemic influenza vaccine

  • Feedback on vaccine guidance*

    Categories of persons who should receive vaccine

    • National security

    • Health care and community support services

    • Critical infrastructure

    • General population

* Available at: http://www.pandemicflu.gov/vaccine/prioritization.html


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Pandemic Influenza Vaccine Prioritization Public Engagement Results

U.S. Example Highest Vaccination Priority (Tier 1):

  • Deployed and mission critical personnel

  • Critical public health and healthcare personnel

  • Critical infrastructure personnel (i.e., EMS, police, fire, vaccine and antiviral manufactures, key government leaders)

  • Pregnant women

  • Infants and toddlers (6-35 months old)

    Prioritization will need to be reconsidered once specifics of new pandemic virus are known.


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Question 6 Results

Which category of persons who may be considered during prioritization decisions for vaccination during a pandemic?

  • National security

  • Healthcare and community support services

  • Critical infrastructure

  • General population

  • All of the above

    Answer:

  • E. All of the above



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Questions to Consider in Planning Results

  • Have public health decisions been made in a clear, open, and transparent manner?

  • Have those who will be affected by the public health measures been given the opportunity to provide input into decision making?

  • Are decisions being made on the best available scientific information?

  • Have the least restrictive public health measures necessary to protect the common good been used?

  • Are decisions about protecting the common good being balanced with protection of individual rights?


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Questions to Consider in Planning Results(cont.)

  • Have efforts been made to minimize the negative impact of the public health measures?

  • Have the public health measures anticipated and respected the diverse values, beliefs, and cultures in the community?

  • Has a process been established to revise or correct decisions to address new information?

  • Have efforts been made to acknowledge and respond to public suspicion and distrust of local, state or federal government decisions?


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Public Health Ethics Resources Results

for Pandemic Influenza

Checklist

Fact Sheet


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Summary Results

  • Public health ethics foster awareness of the rights of participants and communities in public health activities

  • Public health ethics build credibility and public trust in your agency, aid in resolving value conflicts, and guide decisions when there is uncertainty

  • General considerations in public health ethics involve transparency, good practice, and public engagement

  • Specific challenges in pandemic influenza ethics include prioritizing some groups over others in prevention planning, and allocation of scares resources locally, nationally, and internationally.


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Resources Results

  • Ethics Guidance for Pandemic Influenza

    • http://www.cdc.gov/od/science/phec/ guidelinesPanFlu.htm

  • Public Engagement Process

    • http://www.keystone.org/spp/health-pandemic.html#community

  • CDC’s Public Health Ethics Activities

    • http://www.cdc.gov/od/science/phec/

  • James Thomas, Principles of the Ethical Practice of Public Health

    • http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-BD405FC60856/0/ethicsbrochure.pdf

  • James Thomas, Skills for the Practice of Public Health

    • http://209.9.235.208/CMSuploads/EthicalPracticePublicHealth-40199.pdf


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Glossary Results

Public engagement: The process of listening to, interacting with, and gaining greater understanding of a group in order to inform the decision making process

Public health ethics: Principles and values that guide actions to promote health and prevent injury and disease in the population

Procedural judicial mechanism: An established fair process by which individuals or groups who feel their rights have been violated can be heard in court


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Glossary Results

Social distancing: Targeted efforts to reduce interaction between persons at specific or general venues, in order to reduce the probability of disease transmission

Transparency: Providing for openness, communication, and accountability during a process or decision


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