February 2006 - Pandemic Preparedness

The recent spread of the H5N1 strain of avian influenza from Asia to Europe has raised concerns that a major influenza pandemic may be imminent. Other such pandemics in 1918, 1957, and 1968 resulted in millions of deaths worldwide. The World Health Organization is seriously engaged in pandemic planning, both for influenza in general and for avian influenza in particular. Many individual nations have developed or are developing their own plans. Whereas most international and national plans raise the major ethical issues that a pandemic would present, none of them adequately addresses these issues.

To fill this void, a working group from the University of Toronto, Canada, Joint Centre for Bioethics has produced a report on ethical issues in pandemic planning.
The report identifies, discusses and makes recommendations on four major issues:

• health workers' duty to provide care during a communicable disease outbreak;
  
• restricting liberty in the interest of public health by measures such as quarantine;
  
• priority setting, including the allocation of scarce resources such as vaccines and antiviral medicines;
  
• global governance implications, such as travel advisories.

The report proposes an ethical guide for planning and decision-making that can be used both in advance of and during an influenza pandemic. This guide is composed of 15 ethical values, of which 10 are substantive values and five are procedural values. The substantive values are individual liberty, protection of the public from harm, proportionality, privacy, duty to provide care, reciprocity, equity, trust, solidarity and stewardship. The procedural values, which should characterize the process for dealing with conflicting values, are reasonableness, openness and transparency, inclusiveness, responsiveness and accountability.

Several National Medical Associations have been involved in preparations for a potential influenza pandemic, although they have not dealt explicitly with the relevant ethical issues:

• The Australian Medical Association submitted a proposal to Government for a comprehensive communication system that would enable physicians, hospitals and other health facilities to access information in a timely manner from a single reliable source. Such a communication system would also provide the capacity to address localised events and to reach specific physicians or facilities in a particular area. It would also provide a number of communications methods including at least one real time method.
  
• In November 2005 the British Medical Association made a Presentation to the House of Lords Science and Technology Committee calling for further development of measures to deal with an influenza pandemic. The BMA has also prepared a list of resources on avian influenza.
  
• At its June 2005 annual meeting, the American Medical Association adopted a policy on "Avian or Other Influenza Pandemic" that includes a call for more funding for vaccines and antiviral medications and expanded efforts to educate the public about the benefits of influenza vaccination. In November 2005, the Association issued guidelines for protecting patient rights if they have to be quarantined during an epidemic.

In October 2005 the WMA General Assembly adopted the following Resolution on Avian Influenza: "The World Medical Association recognizes the potential global morbidity and mortality as a result of the H5N1 strain of avian flu. This possibility increases with every passing day as more countries find infected birds in their territories. The WMA will work with member NMAs, the WHO and other stakeholders to track the progress of the disease and propose the necessary measures to minimize its impact on the global human population. The WMA also urges governments to engage with NMAs to prepare for the possibility of a pandemic."

January 2006 - Withholding and Withdrawing Artificial Nutrition and Hydration

Withholding and withdrawing life-sustaining measures such as artificial nutrition and hydration (ANH) is one of the most common, and most difficult, medical ethical issues.

During the past 20 years the majority, though not unanimous, view on this subject among both medical associations and medical ethicists has included the following elements:

• Competent patients have the right to refuse any life-sustaining treatment.
• The previously expressed wishes of permanently incompetent patients regarding the withholding or withdrawing of life-sustaining treatment should be honoured.
• The appropriate substitute decision-maker for a permanently incompetent patient who has not expressed such wishes may authorize withholding or withdrawing life-sustaining treatment for the patient under certain conditions.
• ANH has the same medical and ethical status as other life-sustaining treatments.

Recently there have been highly publicized challenges to the last-mentioned of these elements, especially with regard to patients in persistent or permanent vegetative state (PVS). The case of Terri Schiavo in the U.S.A. involved disagreements about the moral and legal appropriateness of allowing her to die by stopping ANH. And speaking to an international conference on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas" on 20 March 2004, the late Pope John-Paul II stated that the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act" and that for many PVS patients, "Death by starvation or dehydration is in fact the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission." The World Federation of Catholic Medical Associations incorporated the papal position in its statement on the issue following the conference.

Despite this controversy, most medical associations have not changed their position on ANH for PVS patients. For example:

• The American Medical Association policy, Decisions Near the End of Life, states, "The principle of patient autonomy requires that physicians must respect the decision to forgo life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration."
• The British Medical Association policy, End of life issues - withdrawing and withholding treatment, states, "The decision to withhold or withdraw artificial nutrition and hydration is a profound one. Where patients make that choice for themselves, it should be respected. It may also be considered in very severe cases where an incompetent patient has no prospect of recovery to a level he or she would find acceptable. The majority of people, with even very severe physical and mental disability are able to experience and gain some pleasure from their lives - and would not fall into that category. Some people, however, have no or very minimal awareness of their own existence or surroundings, no ability to interact at any level and no chance of regaining any awareness. For some of these people, a decision to withhold or withdraw artificial nutrition and hydration may, in the BMA's view, be appropriate."
• The WMA Declaration of Venice on Terminal Illness (currently under revision) includes the following provisions: "The physician may relieve suffering of a terminally ill patient by withholding treatment with the consent of the patient or his immediate family if unable to express his will…. The physician shall refrain from employing any extraordinary means which would prove of no benefit for the patient." The Declaration does not address the issue whether ANH is an ordinary or extraordinary means.

In the absence of consensus on these matters, physicians and other health professionals need to ensure that those considering whether to withhold or withdraw ANH, either for themselves or for others, are fully informed about what the procedure involves and about its benefits and burdens. Such decisions should be voluntary; there should be no coercion either in favour or in opposition to withholding or withdrawing ANH. Finally, individuals should be encouraged to consider in advance whether and in what circumstances they would want to receive ANH and to communicate their wishes to those who will serve as their substitute decision makers if and when they become incompetent.