of bird flu manages to mutate and spread between humans (IPRP, 2005). Influenza Pandemic: A Model for Development of Administrative Policies and Procedures to Guide Preparedness for Influenza Pandemic Actions in Catholic Hospitals in Pennsylvania. Author: John Mary Mooka Kamweri Graduate Student - Center for Healthcare Ethics, Duquesne University, PA. It is critical that Catholic hospitals in Pennsylvania develop provisional administrative policies and procedures to guide actions in the event of an influenza pandemic outbreak. Health officials are concerned that a highly pathogenic influenza A pandemic (H5N1) could occur when the H5N1 strain of bird flu manages to mutate and spread between humans (IPRP, 2005). This could lead to ethical and legal questions about restrictive public health interventions that could disrupt personal liberties like individual autonomy, privacy, confidentiality, freedoms of association, and access to limited supplies. The Pennsylvania’s Influenza Pandemic Response Plan (IPRP), has provisions for mandating the exercise of intrusive powers like culling, isolation and quarantine by public health care workers. Triage and suspension of treatment

liberties, and justice in distribution of scarce resources. Continuation…. of non-influenza pandemic related illnesses could pose a challenge to the ethical ‘duty to care’ and diminish physician-patient trust relationship. Patient- load will overwhelm physicians and staff who will also be concerned with personal safety. The provisional administrative policies and procedures will seek to propose values to guide ethical decision-making in Catholic hospitals in the event of a pandemic influenza outbreak. The values to be considered in policy drafting include: the duty to care, social beneficence, individual liberties, and justice in distribution of scarce resources.  Objectives: . Identify ethical actions, in a clinical setting, essential for effective responses to a pandemic emergency. . Demonstrate a balance between individual liberties and protection of the public in developing policies for a pandemic response. . Describe the process of formulating policies and procedures from abstract ethical principles.

INFLUNZA PANDEMIC (H5N1) PERIOD AND INTERVENTION 1. Introduction Pandemic Period Estimated morbidity and mortality during Influenza Pandemic within 12-16 weeks, in Pennsylvania: Outpatient care - 1.6 million; Hospitalization – 37,800; Death – 9,100 (IPRP, 2005). Interception Shortages: Vaccines, medical supplies, medical staff, facilities… Possible invasive measures: Mandatory Vaccination, quarantine, isolation.. (IPRP, 2005). Ethical / Legal Issues Protection of civil liberties (autonomy, freedom, privacy, justice). Preservation of the safety and health of the population –principle of self-defense; Police Powers – substantive and procedural; Standards (necessity, reasonable, proportionate and prevention from harm ) ; common good ( solidarity, cooperation, membership, communication, trust).

Clinical: Individual Interests- autonomy, privacy… 2. MIXED-INTERESTS ETHICS MODEL (MIEM) Balancing Individual Interests and the Population’s interests. Clinical: Individual Interests- autonomy, privacy… Autonomy / (bodily integrity) Beneficence Non-maleficence Justice Public Health: Population Interests- Health /Safety. Common Good Self-defense: Vaccination, Quarantine, Isolation… Legal: Constitution- Police powers, Substantive & procedural due process . Standards: Necessity Reasonable Proportionate Avoid harm . Catholic : Common good, Dignity, Solidarity, stewardship.. Principles: Double effect Lesser evil Proportionality Self-defense

Priority Setting (Justice) Liberty Interests 3. DEVELOPMENT OF POLICY (Duty to care, Protection from Harm, Liberty interests, and Justice) DUTY TO CARE Stewardship (trust, transparence, responsibility) Care (compassion, fiduciary..) Solidarity (collaboration, communication) Protection (of public) from harm social beneficence Common Good (safety and health) Subsidiarity (shared decision-making) Control measures (forced diagnosis, vaccination, ….). Priority Setting (Justice) . Priority Setting (Justice) (justice as fairness, allocation of resources, triage). Liberty Interests Autonomy, Justice-Due process: Reasonable, Necessary, Proportionate, Harm avoidance).

Population Interests Sub-committee RECOMMENDATION (Four Interdependent Policy Development Sub-Committees) Standards: necessity, proportionate, reasonable, and harm avoidance. Influenza Pandemic Policy Development Committee Population Interests Sub-committee Providers’ Interests Sub-Committee Priority Setting / Allocation Sub-Comm. Individual Liberty Interests Sub-Committee

SUMMARY Government intervention actions in an Influenza Pandemic that are non-voluntary and intrusive raise ethical and legal issues. In a clinical setting administrative policy oversight is required in areas concerning: the professional’s duty to care; the protection of the public from harm; the preservation of individual liberties; and, justice in distribution of scarce resources. To be relevant and effective, policy need to be a hybrid of individual interest-based ethics and common good-based ethics. I refer to the approach as “Mixed-Interests Ethics Model (MIEM).” Upon the legal doctrine of bodily integrity and the ethical notion of autonomy, clinical practice protects the individual’s interests in liberty, freedom, privacy and confidentiality. Based upon the principle of self-defense, the government safeguards the population’s interests in health and safety. The constitutional basis for the state’s authority is police powers. The limits to the authority is the constitutional requirement for substantive and procedural due process. The Constitutional standards are necessity, reasonable, proportionate, and harm avoidance. The two traditions are relevant in policy development for Influenza Pandemic intervention. Catholic Hospitals are advantaged since Catholic moral guidance in health care provides for respect for the person and a moral obligation to help others. In the practical application, principles such as double effect, lesser evil, proportionality and altruism are relevant to administrative policy development for Influenza Pandemic intervention actions. An Influenza Pandemic policy development committee is more effective when composed of focus sub-committees in defense of health providers interests, individual liberties, population’s interests and distributive justice.

Sources   Pennsylvania Department of Health. “PA Pandemic Flu Preparedness: Pennsylvania’s Influenza Pandemic Response Plan (IPRP).” Available at http://www.pandemicflu.state.pa.us/pandemicflu/cwp/view.asp?a+496&q=151651&pp=12 Gostin, Lawrence O. ed. “Pandemic Influenza: Public Health Preparedness for the Next Global Health Emergency.” 32 J.L. Med. & Ethics 565 (winter 2004). Gostin, Lawrence O. ed. Public Health Law and Ethics: A Reader. Berkeley and Los Angeles, CA: University of California Press, 2002. Toronto Joint Center for Bioethics. “Stand on Guard for Thee: Ethical considerations in preparedness planning for pandemic influenza”, A report of the Toronto Joint Center for Bioethics Pandemic Influenza Working Group (November 2005). United States, Department of Health and Human Services. PandemicFlu.gov: General Information, 2007. United States Conference of Catholic Bishops. “Ethical and Religious Directives for Catholic Health Care Services, 4thed.” Washington, DC: United States Conference of Catholic Bishops (2005).