Pandemic Influenza Preparedness Ethics Case studies for group discussion


 There has been an outbreak of pandemic influenza in a small area of a country. For the moment, the disease has not spread beyond a few rural communities. The government is faced with making very difficult decisions to preserve the public health, while respecting ethical norms. There is a facilitator's guide to these cases available on the WHO influenza training Web site.  You can find the link to this site in the Training Materials library on this Web site.

1) Non-pharmaceutical interventions

After serious deliberations, and according to their Pandemic Influenza national plan, the government has decreed the isolation of all patients and the quarantine of all exposed persons living in the outbreak area. Exit from and entry into the area is only possible through a few checkpoints heavily controlled by the army. Schools and work places have been closed, and all social gatherings have been suspended for one month.

The population so far had not been aware of any Pandemic Influenza planning, and compliance with the quarantine and the social distancing measures is only moderate. A few persons who tried to flee the area or refused to take the prophylaxis have been taken into custody, which has infuriated their families and sparked the concern of international human rights organizations.

 2) Obligations of health care workers

Dr. Saleh is a surgeon at the main public hospital in the affected area. Despite prophylaxis with Tamiflu, a number of Dr. Saleh’s colleagues have contracted influenza. Dr. Saleh fears for his own safety, and is also concerned about exposing his wife and two young children to influenza. His wife insists that he stay home from work rather than risking exposure, but Dr. Saleh has a deep commitment to his profession, and feels a strong duty to care for his patients.

Furthermore, as a surgeon, Dr. Saleh deeply opposes the hospital's decision to provide key critical care interventions only to those patients with an expected survival of greater than six months. This new rule requires that Dr. Saleh cancel a bowel obstruction surgery for a patient with incurable cancer scheduled for later this week. Without surgery, his patient - a 60 year-old woman - will be in great pain. With surgery, the patient may live for another couple months. Dr. Saleh is considering performing the operation in violation of hospital rules, potentially risking his career.

In light of his concerns and disagreement with recent hospital policies, Dr. Saleh is torn between his personal desire to protect himself and his family, his professional mission to use his skills and expertise to help the patients who need him, and his obligation to observe the rules of his institution.

 3) Equitable access to treatment and prophylaxis

The rapid containment strategy in the affected area has successfully delayed the spread of the epidemic to the rest of the country for some time. But by now it has reached all of the country and some of the other countries in the region.

The doses of Tamiflu that had initially been allocated by WHO for the containment effort have all been used and no replenishment is possible at this time. For the 18 million inhabitants, the country has only 1 million doses of Tamiflu left. There are also first indications that Tamiflu might be twice as effective with people aged 60-80 than with patients aged 20-40.

The Medical Association demands that, even if at this time there is little evidence that they are at greater risk, most of the remaining Tamiflu should be used for prophylaxis and treatment of infections in health care workers and their family members. The government argues that ministerial officials are an essential resource and should receive priority access, including their families. The First Lady claims that "children and women always come first". 

Author (s): 

World Health Organization

Department of Ethics, Equity, Trade and Human Rights

Andreas Reis et al. v2008

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