Study: Few states advance ethics guidelines for pandemics

Sep 26, 2011 (CIDRAP News) – Few US states have addressed ethical issues surrounding pandemic flu preparedness in recent years, according to a new study in the American Journal of Public Health.

Also, the study authors found, states that have tackled the issues have focused rather narrowly, typically on allocating scarce hospital resources, while virtually ignoring such issues as community engagement surrounding isolation and quarantine plans.

And having high-level support for ethical issues was key in including them in preparedness plans.

Researchers James C. Thomas, PhD, MPH, and Siobhan Young, MPH, from the Gillings School of Global Public Health at the University of North Carolina in 2010 scoured plans from all 50 states and the District of Columbia on flu.gov and the Council of State and Territorial Epidemiologists Web site. They searched headings and subheadings for "ethics" and other relevant keywords. They also searched state health department Web sites for ethics-related material.

If a state did have recommendations on ethics preparedness, the researchers followed up with phone calls to gather more specifics.

They were assessing progress made after a 2007 survey by Thomas and colleagues, reported in the same journal, found states wanting in the area of ethics and pandemic preparedness. Their current study was funded by the Centers for Disease Control and Prevention (CDC).

The new study found that six states—Iowa, Indiana, New Mexico, North Carolina, South Carolina, and Tennessee—had their own guidelines for ethical decision making, and three others referred visitors to CDC guidelines: Utah, West Virginia, and Wisconsin.

In addition, four states' Web sites linked to presentations on ethics and pandemic flu: Iowa, Idaho, Minnesota, and North Carolina. Idaho's site linked to North Carolina's presentation, and the Minnesota health department's site linked to materials on the pandemic flu Web site of the University of Minnesota School of Public Health.

The researchers also noted that only 1 of 21 recent state-sponsored pandemic flu summits had an ethics discussion on the agenda—that of North Carolina.

Thomas and Young also assessed progress after the Indiana State Department of Health and the Association of State and Territorial Health Officials (ASTHO) convened a national meeting in July 2008 on pandemic flu ethics, which resulted in a list of key issues and steps states should take.

They found that seven states made recommendations to further develop ethics-related policies or capacities following this summit. Of these, six states—Iowa, Indiana, Minnesota, North Carolina, New York, and South Carolina—created a task force to make recommendations. The most common recommendations made were related to allocating scarce resources in hospitals.

The seventh state, California, listed eight legal and ethical recommendations but had not acted on implementing them and had not designated anyone to follow through on them.

In the other six states, task force recommendations were being acted upon.

In Minnesota and New York, state health department were reviewing the recommendations, while officials in North and South Carolina were working with medical and hospital boards to implement them.

In Indiana, meanwhile, the state health department was nearly finished implementing 1 of 15 recommendations.

And after Iowa's task force developed an ethical framework, the state's epidemiologists were trained in the new policies and then conducted half-day regional workshops for hospital administrators and public health professionals. They also provided follow-up support, such as help in creating ethics panels.

The authors found that the key factor in promoting progress on ethics steps was "unambiguous": support from the top. The main barrier to progress in California, they said, was "a lack of appreciation for, or priority given to, public health ethics among those receiving the recommendations."

In contrast, the authors said that strong cultures of community involvement in Iowa and corporate citizenship in Minnesota fostered advancement on these issues.

The authors conclude, "The sense of urgency for pandemic influenza preparation, including ethical considerations, seems to have passed," but warn, "In a pandemic of highly pathogenic influenza, there will be little time to sort out complicated issues such as the particular values or needs of minority populations."

They recommend as long-term solutions more teaching of ethics in schools of public health and incorporating ethics into health departments' criteria of accreditation.

They also encourage national organizations like the CDC and ASTHO to disseminate best ethics-related practices, coach state health departments on implementing best practices, and help in identifying gaps and addressing, with funds and expertise, how to fill those gaps with comprehensive guidelines.

Thomas JC, Young S. Wake me up when there's a crisis: progress on state pandemic influenza ethics preparedness. Am J Public Health 2011 (published online Sep 22) [Abstract]

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