Triage for the Next Pandemic: Selecting on the Basis of "Social Worth"
Here is the issue in a “nutshell” as written by Margaret R. McLean in a report prepared by Center Director of Biotechnology and Health Care Ethics for the Santa Clara County (California) Public Health Department on Ethical Preparedness for Pandemic Influenza and as excerpted by the Markkula Center for Applied Ethics at Santa Clara University, July 2007.
“...one of the most vexing questions about the just rationing of health care resources is which ethical principle ought to guide decision making—save the most lives (e.g., in fires and floods); save the sickest (e.g., in organ transplant protocols); save the most-likely to recover (e.g., in triage during war); save people who can preserve society (e.g., the Centers for Disease Control (CDC) recommendation during a pandemic).
Deciding who can best preserve society means making “social worth” distinctions, which, because they run counter to the instinct for fairness, would ordinarily be considered inappropriate criteria. In the emergency situation of pandemic flu, however, making distinctions on the basis of social worth may be necessary. The hard truth of the matter is that failure to make these sorts of distinctions (giving priority, for example, to doctors, EMS workers, law enforcement personnel, vaccine scientists, firefighters, bus drivers, and sanitation workers) could translate into a high level of injustice accompanied by social chaos, exacerbating an already complicated situation. Hence, prioritizing certain essential personnel, while unfair during non-pandemic conditions, may be the best way to minimize, and ideally avoid, further social breakdown during a flu pandemic.”
Triage (deciding because of limitation of resources, who should be energetically treated with the hope for recovery or who should be left untreated) involves medical utility (who is the most sick but also the more likely to recover with treatment) and social utility (what the treatment of a particular individual will contribute to the welfare of the community.) Medical utility is based on science and clinical evidence and the guidelines are not too controversial. Social utility is a different matter and could give rise to much discussion. Read the excellent article reviewing the matter of triage in an influenza viral pandemic prepared by the University of Pittsburgh Medical Center Pandemic Influenza Task Force.
As you will see in this article, social utility is also considered the main ethical consideration but modified by the specific medical utility of each candidate. And finally, if there are a number of eligible patient candidates for energetic treatment but not all can be accommodated because of lack of resources, then those treated and those left untreated should be selected not on the basis of unfair “first come, first served” but on the basis of a lottery.
I don’t see where the ethics of triage in an influenza pandemic and specifically the triage utilizing the criterion of “social worth” in the decisions have been presented to the public educating them that this may be what the public will experience in the next pandemic but also giving them an opportunity to express their opinions about such methods. I hope my blog thread will stimulate some discussion here. ..Maurice.
Graphic: "Balance of Social Worth in an Emergency" created, in part, by me using ArtRage and Picasa 3 tools.
posted by Maurice Bernstein, M.D. @ 4:50:00 PM
33 comments
33 Comments:
The allocation of medical resources is a topic of constant conversation pertaining to health insurance, universal healthcare, and acquisition of pricey medical equipment by hospitals. This discussion becomes even more interesting when applied to emergency situations, in particular, with a pandemic flu outbreak. McLean addresses the idea of rationing which requires us to consider the ethical principles of beneficence, nonmaleficence, and justice. As she points out, in emergency situations we must often go against the grain and reject the notion of fairness as our top priority and instead triage based on social worth and ability to preserve society. Thus we must weigh the principles of beneficence, nonmaleficence, and justice against one another. The ethical frameworks of Utilitarianism and equity give different answers to this solution and pose the question of whether we should treat everyone as equal or do what is best for the majority of people?
The article by Tabery and Mackett discusses how with this type of event we must switch from standard medical ethics with the focus on the individual to public health ethics with a focus on the population. We must utilize moral reasoning and consider a principle-based approach or a case-based approach. In this situation I do not think the principles of beneficence, nonmaleficence, justice, and respect for autonomy will provide an adequate framework for decision-making. Instead we should use a case-based approach because this is an emergency situation that should not be treated as an every-day medical event. The utilitarian perspective that Mclean supports seems appropriate for a situation where survival is in the hands of healthcare professionals and without these professionals no one will be able to survive. Beyond healthcare professionals the line becomes fuzzy as to who has more social worth than someone else. This is where the true debate lies…
However, no matter what is decided it is essential that the public be involved in the decision and that it is a transparent process. Even in an emergency public participation will lessen the blow of the media and other scrutinizers and allow ethics experts to guide the decisions of life saving healthcare professionals.
-KG
No chatter from the United States government or that we the people hear from the WHO regarding triage for the upcoming pandemic. It seems like the migration of current illness primarily to the southern hemisphere has silenced important public education and public input. I am not sure it is wise to wait until the emergency faces us for public discussion and public input to those who will be setting triage criteria. ..Maurice.
I do believe that triage during a pandemic should be based on “social worth.” The article by Tabery and Mackett did a nice job in describing that in a pandemic we cannot judge on medical utility by rather on social utility focusing on the welfare of the society and not the individual. During a pandemic we need to minimize the risk and provide the most benefit to the population. We are a modern society that believes in upholding one’s individual rights; however, a society trumps an individual during a public health crisis. With that said, an individual should have an active role in determining the triage protocol for the population as Maurice suggests. Not to include the public in this discussion and have representation in the decision making process would be unethical.
I agree with K.C.’s discussion that a case-based approach should be utilized in this particular circumstance since this is an emergent situation. Tabery and Mackett did an excellent job of describing the different available frameworks that could be used in response to a pandemic. Although we may not agree on the model to use (utilitarian vs egalitarian vs a hybrid-model), the key is that a systematic process be used to prioritize and justify the course of action based on ethical population health principles and the values/beliefs of ALL the stakeholders. This systematic process and protocols need to be in place prior to the pandemic and all stakeholders should have been involved including civilian representation, medical personnel, and government liaisons.
Gostin (2004) states that public health can be achieved only through collective action and not through individual endeavor; therefore values should be based on community and not on one’s own interest. The recommendation of a Triage Review Board serving as a collective action is an excellent idea by Tabery and Mackett. Each hospital could recommend a committee to organize and convene to discuss such matters. The review board should include community members. The American Public Health Association’s Code of Ethics states that all public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members (APHA, 2002). This is the same principle as IRBs having nonmedical personnel sitting on the board. A Triage Review Board at all levels of the hierarchy would assist in a collective action during the pandemic and allow all stakeholders to be heard and valued during the planning stages.
We need an ethical SOP, Standard Operating Procedure, with all stakeholders involved prior to the pandemic.
L.C.
Gostin, L.O. (2004). Law and ethics in population health. Australian and New Zealand Journal of Public Health, 28(1), 7-12.
American Public Health Association (2002). APHA Code of Ethics. Retrieved on July 22, 2009 from http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-BD405FC60856/0/ethicsbrochure.pdf.
L.C., thanks for your comment and references. My interest in integrating the public comment into the triage development process was a major reason for creating this thread but also the broadcast the need. Clearly your reinforcement regarding the need for the triage planning board to contain community members is important. But I was also thinking about a more wider access to community input.
Polling of populations would be helpful to understand public views but what is missing in a poll is that the questions are generated by the pollsters and represent their view of the issues involved. In addition, the polls give only gross statistics regarding answers to the questions and cannot bring to the open the nuances of the answer that each respondent brings to the final statistics.
Therefore I was thinking that perhaps the use of internet social networking mechanisms such as Twitter or Facebook, open for response by hundreds of thousands or millions, might provide a more encompassing view of what the public thinks and wants in terms of triage. I am not sure how this could be effectively organized and run and how conclusions could be summarized. But somehow I think we could learn more than just simple polling by Gallup or others.
The other issue to discuss with regard to public education and input is how much should public input contribute to the final decisions regarding the triage protocol itself. Would one think that the issue is so complex, so technical that allowing the public to steer the direction of the triage process would be like allowing the public to direct a surgeon in performing coronary artery bypass surgery.
These are issues that I think would be worthy of further discussion on this thread. I hope you and KG will return here with others and cover this aspect.
Thanks to you both. ..Maurice.
I thought Tabery and Mackett’s article drew wonderful arguments of why we do need to be prepared for the possible influenza pandemic. Disaster training is a requirement in most United States hospitals to prepare for disasters of weather, warfare and crime. It is intuitive that when a threat, such as a new influenza pandemic is present, that a Triage Protocol or Standard Operating Procedure should be implemented specifically for the present threat. I agree with the authors that it would need to be standardized across all hospitals in a given area and possibly, throughout the United States to decrease variability. This would ensure that people were not “protocol shopping” to find where they are most likely to be treated.
Although I believe that everyone should have a say of his or her personal healthcare and policies that affect such healthcare, I also believe that in order to make an educated decision, one must first have the knowledge of the greater picture. Personal healthcare and rights are viewed differently in light of a disease pandemic. When one makes a decision regarding their own health, it becomes a personal decision and not one that takes into account the rest of the population. That is why there are elected officials that are placed into office to sit on boards that would make such procedural decisions. These are the people we trust to make educated decisions regarding the society as a whole. Personal interest technology, such as Twitter or Facebook will assuredly only give accounts of individual case studies and personal feelings. I am not saying that the world is entirely full of ignorant people who are unable to look at the entire picture objectively, but I do think that when someone is faced with a pandemic, chaos takes over and reason is difficult to find. When one is trained to handle such catastrophes, one is able to make objective decisions. If we let the public make the decision and not an elected official, we are in fact directing a surgeon in how to perform coronary artery bypass surgery.
Is the previous Anonymous writer one of the two who had previously written or someone new? It is important for continuity of the discussion for those writing at least provide some consistent pseudonym or initials at the end of the comment. Thanks. ..Maurice.
I apologize for not posting my initials to the previous post. I am J.P. and wrote the last blog comment.
~JP
Unfortunately, health threats posed to the American public by influenza pandemics, civil unrest, and military warfare are on the rise. Having conceptual frameworks in place to assist with answering ethically challenging questions such as level of importance played by medical and social utility is essential. Threats to public health are daunting and without frameworks in place, to shift our perspective from individual patient autonomy & rights, to the overall health of the population, how will we as health care workers truly be able to minimize morbidity and mortality.According to the CDC (2007) public health ethics are not in place to assign blame or find fault, instead they are about making accountable and respectable decisions to ensure the longevity of the population being served.
For years, in wartime battle, military troops have employed triage models to provide care for soldiers who are "salvageable and in greatest need." This system has been fine tuned to the point that questions regarding social versus medical utility are no longer at the forefront. Why as health care practioners have we allowed ourselves to be faced with the consistent uncertainty of medical triage ethics?
We are not discussing ideal situations which warrant an "equal claim to health care," but situations that result in mass illness, limited resources and potential for escalation into disaster????
Although the concept of social utility is highly scrutinized and debated the primary goal in an epidemic should be to reduce the populations overall morbidity/mortality. Having triage frameworks in place may ultimately alleviate the social vs medical utility debate allowing the fundamental goal of overall population survival to prevail.
Sincerely,
SL
Center for Disease Control (2007). Public health ethics at the centers for disease control and prevention: Ensuring health, improving trust.
Tabery, J., Mackett, CW., The ethics of triage in the event of an influenza pandemic.
My reason for putting up this thread was motivated by the inadequate and particularly conflicting information being broadcast to the public by governmental agencies and even the WHO during the recent onset of H1N1 virus infections in the United States and northern hemisphere. With regard to the matter of medical triage actions to be taken when resources are limited in the influenza pandemic, I found no presentation of this to the public. I found nothing regarding the methods and criteria already proposed for triage and nothing about whether the public had any role in the contribution to the proposals or their acceptance.
Should decisions about triage be make by elected officials and/or scientists and/or those experienced in police, fire and emergency medical services and/or hospital administrators? Or should the general public have a significant role in the preparation of the triage protocol? This triage is all about preserving society with temporary removal of certain public rights and principles of justice. One would think a public role would be needed to balance out conflict of interest issues of the "specialists" or politicians. If so, what should be the quantity of public input? A couple community members around the table? How would they be selected? Or should it be by some sort of public polling or public internet discussion? Or, as I mentioned before, is the decisions so complex that forming triage around public opinion would leave a wanting product?
Since we seem to agree here that triage planning before catastrophe is worthy, can we switch the discussion to that of public education of and public input to the process. ..Maurice.
Historically, during times of patient crises (not including pandemic/epidemic events) triage decision making and plans for medical care have primarily been based on the capacities & delegation of a healthcare provider. During a mass casuality trauma, emergency departments have trained MDs as well as RNs who are ultimately responsible for triaging based on the goal of preserving life.
In a pandemic event, such as the H1N1 virus, I having been a health care provider for 12 years, would most certainly want those experienced in medical services such as MDs, RNs, Paramedics & EMTS making the decisions regarding my status and placement within a triage framework. As health care providers it is our duty to protect the population from decisions made by elected officials unaware of healthcare priorities such as level of acuity, illness course & prognosis etc.
The idea of public polling is not without merit. Utilization of social entities like facebook/twitter would allow the population as a whole to present concerns, ideas & questions to those responsible for the ultimate decision making. Fundamentally, however, I believe in order to provide care based on the principles of medical ethics the individuals ultimately responsible for preparation for a pandemic , decision making during a crisis, & the preservation of society should be medically trained.
Sincerely,
SL
Maurice,
My name is E.B. and I, along with my classmates, are responding to your blog as part of a graduate course on population health. (So expect quite a few responses to this post in the next week!)
Your last post asked we switch the focus to public education and input in pandemic triage decision-making. I see many barriers to triage decisions being made by the public. If town meeting meetings were held on this subject they would last forever. If a blog was started, the opinions would span the entire spectrum. Also, a large majority of the country are not familiar with blogging or Twitter. Those who are may be too busy with work and life to engage in discussions on pandemic triage policy. The posts to this kind of discussion would reflect the opinions of a very small percentage of the population, and thus be biased. A national vote on the subject would also be biased considering the number of people who do not vote or who are unaware of political and national health issues. Even if there was a realistic way to get an accurate appraisal of the country’s viewpoint, I doubt there would be any consensus.
You said in your initial post, “this triage is all about preserving society with temporary removal of certain public rights and principles of justice”—and I think you are right. I think this is an issue for policy-makers, and while it should reflect the people’s view, I disagree that it should be made by the people. I do agree, like you suggested earlier, in a round table discussion where the people’s perspective could be gained by the inclusion of figures of various geographic regions, ethnicity, religious beliefs, e.g. in a meeting with policy makers.
The CDC in their discussion of public health ethics (Public Health Ethics at CDC: The What, Why & How of Public Health Ethics at CDC, PHEC, June 2007 Discussion Paper) suggest a model of ethical decision making that includes: identifying the stakeholders and their values, formulate the facts, generate and compare options and decide and justify the actions. If a model such as this is used, and efforts are made to seek opinions from community representatives (to assist in “formulating the facts”) I believe it is ethical to refrain from attempts to have decisions on pandemic triage made by the people.
~E.B.
Understanding social worth and its influence on a triage setting can be a very complex thought for the average person. While the idea of opening up triage protocol to public opinion seems ethically sound, its effectiveness and efficiency is lacking. Allowing the public to have an input seems as though it would cause much anxiety and unrest before a disaster even happens. Furthermore, if the public was aware of the pandemic triage protocol, I believe it would result in complete chaos at the time of the event, maybe even more so than not having a protocol in place. Not to mention the media would have quite a holiday with this story.
Determining who should make the decisions about triage protocol is a very difficult and complex decision. While my first instinct was to respond that a board of elected officials should have the power to make these decisions, I had to reexamine the idea. Perhaps opening the discussion to primary care providers would make the most sense. These are people that are medically trained, would have few ties to hospital politics, and might be willing to place their patients’ health care needs first. There are obviously pros and cons to this argument, but in my opinion they may be a group of the most non partial professionals involved. Furthermore, they would be responsible for a good number of the patients affected by a pandemic.
The thought of public education on triage protocol is extremely complex as well. While using Facebook, Twitter, and other internet systems seems to make sense, one must consider the very limited population that this information would be reaching. For example, all the teens and twenty-somethings on Facebook would read the information, think of how it affects them personally, and use that as means to base their opinion. However, those without computers or access to the internet would still be left in the dark. Isn’t this the same “social worth” profiling that would be used to write the protocols? Can we expect that those who are “further down the list” would be the same ones that would not have access to these educational pieces on internet systems? This might lead to a very biased public opinion.
MT
In the situation of a pandemic, it seems to me, that the most effective stance for treatment would be one of a utilitarian approach – or to strive to maximize the collective benefit. While on an individual level you can ask, “what if it was your child? Mother? Brother?” The idea that a pandemic can kill millions worldwide in short period of time, requires an aggressive counter plan.
The question of whether the public agrees, or even has knowledge of this plan, is interesting. As a healthcare worker, I see the need for a “social utility” triage. Who will treat the patients, who will develop vaccines, who will provide the hospital maintenance? These are all things that we value and would require in a pandemic situation. On the other hand, is it really such a stretch to validate each person’s role in society? Public input on this subject may influence policy more than we think.
And in a situation of international panic, who will enforce such policies?
-MM
Though the idea of obtaining a consensus from the public on what they will accept as criteria to be use in triage may be futile, the idea that the more the public is educated and feels engaged in the process of creating triage protocols may reduce the possibility of citizen outrage and rebellion if the situation arises where the triage must be emergently implemented and long standing public assumptions and rights are denied and decisions and actions are carried out by officials and government with no immediate recourse.
I throw this suggestion out for discussion here: Perhaps the first thing to be done is to follow a public education program which could be analogous to the "public education" as the lead up to the 2008 Presidential elections. Perhaps, not as long.. maybe 6 months or so of daily broadcasts and discussions of what could happen in a influenza pandemic public health catastrophe, what issues were involved and what might need to be done. (Look.. even the conversion of television sets to digital reception was prefaced by an extensive education process--surely pandemic triage is equally important.) During the 6 months, public opinion could be obtained just like what happened during the runup to the election. These opinion statistics would be frequently reported to the public by the media and further discussion developed through televised "town hall meetings" and other presentations. It works for the election, why not for triage education? (Who pays for the education? To me this would be the perfect example of "public service")
Would this education process prevent arguments and unpleasant behaviors during the pandemic triage implementation? I doubt it. But I am sure that people's frame of mind as to the ethics and the practicalities of what was happening would be enhanced and there would be more acceptance of the burdens and consequences.
As I said, I throw this open for further discussion here. ..Maurice.
As a nurse, the idea of treatment not being available for all people is a tough pill to swallow. In addition having to decide on which roles in society are important to preserve is difficult. This definitely involves taking a case-based approach in examining the beneficence of the community over individual autonomy. This utilitarianism way of ensuring society is preserved is a smart way after a pandemic. A panel should be involved to make the primary decision and have a code of ethics agreed upon by the panel.
In order to save the people who can preserve society, we must decide who those people are that will preserve it. Also, will people with chronic or acute disease such as HIV, COPD, cancer, CAD be ruled out of fitting in this criteria, because they will not preserve society as long as others who are healthy and free of disease? What about people with an overweight or obese BMI, they are at higher risk of type 2 diabetes, HTN, ESRD, CAD, and other diseases than those who are healthy. Will they be eliminated? People who smoke cigarettes are at high risk for developing emphysema, COPD, and lung cancer, will they be eliminated from eligibility due to their high risk behavior? Is it just about which positions in life will preserve society, or is it about which positions in life will be able to serve in society they most healthy and the longest? I believe a Darwinist method of survival of the fittest should be considered in the triage of the next pandemic along with social worth. This would promote the good of the community for a longer period of time.
As far as public education is concerned with this triage method, different aims and different types of education will be needed. We must realize that all people will be affected, and which types of people will cause the most outrage. We will have to target certain populations with difficult transportation and working hours with local education. You would also have to educate people on the idea of preserving society. In order to get everyone on board, a speech could be made on national TV, this could help bring everyone together on the idea.
After education on preserving society, meetings should be held to ensure the public has input about which positions preserve society. New technology can allow facebook and myspace uses, but in addition perhaps the old snail mail method for those who lack internet access. This is an important topic and I believe most people will want have their feedback included.
Thanks,
LA
LA, you write " Is it just about which positions in life will preserve society, or is it about which positions in life will be able to serve in society they most healthy and the longest? I believe a Darwinist method of survival of the fittest should be considered in the triage of the next pandemic along with social worth. This would promote the good of the community for a longer period of time."
Triage will be complicated enough than trying in a crisis to determine which person of social value will have the final longest survival. I have a suspicion that what is needed to be decided is which physician or policeman or sanitation worker will be the quickest to recover after using the scarce resources and get back to work and not who will survive the longest. Their immediate value to society is their greatest value in a time of crisis.
This decision by triage will require a high degree of clinical prognostication based on the immediate clinical appearance, any medical history that can be obtained but not necessarily the patient's age for estimating lifetime longevity.
My view is that triage should not look first to longest survival but the quickest recovery and return to work. Any thoughts about this concept in working out triage planning? ..Maurice.
Since our discussion has taken a bit of a turn to that of public education and public input to the process of triage planning for a pandemic, Dr. Bernstein I think you make an excellent point in that engaging and educating the public may be the first step that needs to be taken regarding this issue. However, my concern with this idea lies with how these education programs will acutally be implemented. Obviously indiviudals that are up to date on current events, will be quickly educated regarding the triage options. My concern is with those that do not spend time watching television, reading the newspaper, or engaging in conversation at the local coffee shop. I also have concern for those individuals and families that do not own a television or those that are illiterate and cannot read their newspaper or internet. How can we ensure they are adequately educated and fairly represented in decisions that are made regarding this public health issue using the methods of education you mention?
Since you referred to the election of 2008, only about 60% of registered voters participated in the election (http://www.nytimes.com/2008/11/05/world/americas/05iht-turnout.3.17552445.html), which was one of the highest voting percentages in many years. Yes, this number was high compared to other recent election years, however it obviously does not include all the Americans that are not registered to vote, therefore it represents an even smaller percentage of the actual population. My reason for stating this number is since we are considereing using methods used to reach voters for the Presedential election or similar approaches, we may need to revisit how to reach the other Americans that did not become involved as we missed a large percentage of them. Obviously, just because they did not vote does not mean they were not informed, however there must be a reason they were not involved. As EB said, town hall meetings would potentially be very long, and only reach small numbers of individuals. TV, internet, and newspapers ads also reach limited numbers of the population. Lawrence O. Gostin, from Georgetown University, writes in his article, Law and Ethics in Population Health, that “ society is willing to spend inordinately to save the life of a person with a name, face, and history, but less so to save ‘statistical lives’”. I think this could be our biggest problem with educating the population about the potential pandemic and what toil that may take on our country, world, healthcare, EDs, etc. Because there is no name or face associated with this crisis, getting them involved early may be our greatest challenge. Do you think the public will actually “get it” through this education or will they maintain the same apathy as they do with so many other issues? If they do get it, have we reached enough of the population to actually make a difference? How do we get the population to care and react to this issue prior to the actual emergency?
Thanks.
MS
MS, I am certain there is no method to ensure that even 90% of the population of a country, even in the United States, could be made aware, let alone agree to the process of triage planning or the triage protocol itself. What is needed with regard to education of the public with regard to influenza crisis triage is that enough people are made aware in advance so that, even if that person doesn't agree to some elements of the protocol, they will not be the ones who would add to the catastrophe by rebelling, disobedience, supporting riots or other harmful behavior during that time when attention should be with regard to the illnesses, preventing deaths and maintaining societal structure and function.
Fortunately, whatever the methods of broadcasting information and discussion, except for the rare isolation of individuals from social interaction, people communicate with other people more or less frequently and this communication with those who have been made aware can provide some channels of education to those who have no access to the internet, television, radio and print.
Nevertheless, the point you raise is quite pertinent and would seem to be an initial issue in considering triage planning. What I wrote above was my own response to your concern but I look to yourself and others to make suggestions about this important barrier to "spreading the word". ..Maurice.
The other issue beyond the logistic difficulties in educating the public about the details of triage planning or the final triage protocol as already begun to be discussed here is the matter of public acceptance of planning and the final protocol when completed.
I bring this concern up now after listening and reading the current news about how divided the U.S. nation is in the matter of how to broaden healthcare, improve healthcare administration and clinical outcomes, regulate insurances and broaden choices to include government run insurance and finally how to finance all of this. It is complicated but necessary yet there doesn't appear to be substantial public agreement on most of this. One wonders (me) how the public will respond to triage planning and protocol when the word finally gets out if one looks at the public reaction to the current healthcare debate.
Personal medical care and treatment as part of everyday life and personal survival at a time of an overwhelming infection pandemic sets individual self or family-centered priorities against the priorities of society as a whole. The question: "Can we all get along?", come the need, during that catastrophe.
Do you think that the public's response to the current healthcare issue in the U.S. could be a sign of what's to come regarding triage? ..Maurice.
In our Population-Based Approaches to Health Care class, we have reviewed a great deal of evidence of the inequalities in health and in health care in the United States. Not every American or person on American soil has the same opportunities for good health and good health care on a regular basis aside from a pandemic health crisis. Mc Lean (2007) paints a plausible picture of the next pandemic with limited access to medical resources during the crisis. This takes the known situation with health care inequalities and escalates it to a level of increased injustice. If there is any hope for providing any means for autonomy, respecting human rights, and social justice, this must be considered and planned well in advance of the chaos of the pandemic. Once the pandemic crisis is upon us, the medical community must react as Tayberry and Mackett explain by switching from the medical model (familiar to health care providers) where the welfare and desires of the individuals are respected to a public health model that is more utilitarian, more focused on the greater good of the community or society. But what is the greater good? As Dr. Bernstein suggests the public needs some awareness of the challenges of a pandemic and some avenue for input into proposals and definition of the greater good.
Tayberry and Mackett write about the Triage Review Board (TRB) composed of medical, ethical, legal, and most importantly community representatives. All hospitals should evolve their emergency preparedness teams to include the TRB component. As Mc Clean and Tayberry and Mackett write, health care providers need consistent and complete guidance for even attempting to wade through the chaos of a pandemic crisis to care for patients. The health care providers should have clear direction on who to treat at the hospitals and not have the burden of making subjective judgments. The TRB including the community representatives should provide the decision-making criteria. Another value of the community representatives is to promote developing alternate plans for individuals in the community who cannot be immediately served at the hospitals. If the TRB plans to prioritize care for health workers, peace officers, and so forth, satellite community centers should be designated from which community centers can exchange reliable information and receive care or directions for care as needed. People who cannot be served immediately at the hospitals should know that they are not forgotten and there will be intermediary resources available to them. As Dr. Bernstein suggests, these plans need to be communicated out to the public as effectively as possible during development and upon finalization. As Tayberry and Mackett suggest, the TRB’s should not operate in isolation; this would only add to the confusion and injustices. TRB’s from different healthcare systems and hospitals should work collaboratively under state-wide jurisdictions.
DR
References
McClean, M.R. (2007). The Coming Pandemic: Ethical Preparedness.
Tayberry, J. , Mackett, C.W. The Ethics and Triage in the Event of an Influenza Pandemic.
I wonder if anyone here can discuss a point that would be considered important in the creation of a triage protocol and was suggested by me and restated by J.P. earlier on this thread. The point was: the decision making of a triage protocol is so complex, taking into considerations so many social, political, ethical and logistic issues that it might seem beyond the skills and capacity for community members of a Triage Review Board to make a major contribution or change in direction of the final result. (The analogy: the public directing a surgeon how to perform coronary artery bypass surgery). Another way of expressing the issue is let's say that a goodly portion of the public has some means of providing their input to the triage discussion, how much weight should be given to this input particularly if it doesn't fit with the practicalities and goals of the triage as determined by the profession panel? And if the public learns that their input was in some way disregarded in the final protocol, the uprising and rejection at the time of its use would be greater than if there was no prior input from the public and the public would be faced with the details of the protocol only at the time of the crisis?
In summary, the sacrifice of democratic input to preserve a system designed for the people's survival. Any thoughts about that? ..Maurice.
Maurice, I think your analogy in terms of the current public response to the healtcare overhaul debate is very interesting and appropriate. I do believe that we can use that response as a predictor of how the public would react to a triage of influenza vaccine, and it would be similar for the following reasons. As has been pointed out in previous posts, there are still too many out in the public who are not educated (or simply don't care yet) about the current situation and who will have a tendency to react emotionally--and some would even say, selfishly--to the idea of triage and rationing. A select group will use and abuse the internet and media to distort the facts, much like the current ads that suggest the health care reform bills in Congress will turn us into Canada (http://www.cbc.ca/health/story/2009/07/07/health-debate.html).
The irony is that we are already practicing a system of triage of care in the current system of health care, one that is very costly and inefficient, but you don't get as strong an emotional response from your everyday Joe or Jane regarding the current situation. Mention the words "change" or "influenza epidemic," however, and you will elicit the fear that motivates media coverage and TV ads that distort and manipulate the situation. I think that it is important to educate the public so that there is better acceptance of whatever policy decisions are made, but just as it is difficult to get people to care about statistics and agree with the idea of supporting the greater social good, when emotions and self-interest are stimulated it is impossible for the public to make and support an informed and objective decision. It's similar to the concept of the "tyrrany of the majority" as described in the lecture by Dr. Thomas (Module 1: Public Health Ethics versus Medical Ethics http://oce.sph.unc.edu/phethics/modules.htm), except in this case, the happiness of the majority comes at the expense of the gross misery of the majority as well.
On that note, our readings and lectures from this past week provide us with some tools that we can use to objectively look at the situation and apply moral reasoning to determine the best course of action. As mentioned in one of the previous postings, I agree that the principle-based approach that we physicians often use (beneficence, nonmaleficence, justice, and respect for autonomy) do not adquately address the topic we are discussing.
Instead, I believe that a combination of rights-based and duty-based theory is more appropriate. This is also discussed in Dr. Thomas' lecture, and he describes duty as both the flip side of rights (where there is a right, there is also a duty) as well as the opposite of entitlement. There is a current push to portray health care as a right, and that stimulates self-interest and a reluctance to make sacrifices. Perhaps this is why Obama's plan is in so much trouble, with multiple constituencies reluctant to support the plan because of what they stand to lose with reform. If the influenza epidemic is instead approached as a situation in which people have to make sacrifices out of a sense of duty to each other and to society as a whole, and if the education of the public and the discourse is approached from this angle, then maybe really can all get along.
--LH
As pointed out in both articles, the switch from thinking of the individual's best interests to those of society is an upsetting change for healthcare professionals. I would have a very difficult time using one's judged social worth as a factor in their plan of care, coming from the perspective that everyone has an equal right to fair treatment. I think that the fundamental triage duty of care, the attempt to treat as many patients and save as many lives as possible is ethically the ideal triage plan to have and the strategy that would have the minimum amount of public and healthcare ethical objections.
As healthcare providers, we are trained to provide care to the individual, not to provide care to meet society's overarching goals. We are patient advocates first, and as many of us have experienced, we often find ourselves in settings in which society's standard rules need to be slightly nudged to meet our patient's needs. We allow for the blurring of typical societal lines because it is clear that individuals, especially individuals with severe illness, tend not to fit within the societal mold planned.
Using a scale of social worth to determine who deserves to be saved in a disaster is to change the rules of the healthcare game. It is to damage the very core of ethics that guides us all within healthcare. The motions may remain the same, but the profession as a whole will be shattered. Our patients need to trust that we will help provide the best treatments for them. They need to have the trust that we will not abandon them physically, through treatment options, or emotionally, through judgments based on perceived social value.
I agree this topic is critical and that any social guidelines made must be made within the setting of a transparent public forum. It should involve as many people as possible, through polling, public referendums, television and internet broadcasts, involving a multitude of ethical leaders, because the decision of triage based on social merit will affect the entire population at every level. Medical triage will continue to be left up to the medical professionals, as common sense would dictate. However, societal triaging is not a concept that is owned, embraced, or monopolized by healthcare professionals. It is a decision making process that is foreign to healthcare practitioners, and the entire population is on equal footing to sort through this ethically questionable area.
Ideally, with increased awareness of this topic, the urgency of increased preparedness will become a priority. This increased preparedness would have the goal of allowing healthcare providers to maintain the main triage strategy of treating as many patients and saving as many lives as possible. Increased preparedness would include extra revenue allocated for additional emergency medical equipment, increased funding for nursing, medical and allied health education, as well as perhaps a global collaborative agreement of support during times of health crises. Any extra effort taken now to prevent the use of a social hierarchy to determine care will be worthwhile.
-A.D.
Reference:
http://www.scdhec.gov/administration/ophp/docs/MUH-Ethics-Committee-Disaster-Triage-Policy.pdf
Taybery and Mackett’s article on preparing for the real possibility of a pandemic was quite an eye opener for me. I had never thought about how many issues would arise if a true pandemic were to occur. After reading the article I realize that there are many concerns that need to be addressed prior to the emergency actually occurring. There’s been a lot of talk about a need for public education on the reality of a pandemic. I agree education is essential especially since I as a nurse hadn’t even thought about how many issues, especially ethical ones will arise. As a nurse I’m very familiar with the medical utility approach of triaging. It’s the idea of social utility that’s new to me. It sounds like this is where most of the ethical concern would reside. Deciding what makes one person more valuable to society than another will be a huge issue if it’s left to be decided at the time of crisis. If this is the case, chaos will occur in our society. As mentioned in the article, it will take a clear set of guidelines to decide which individuals will be saved or receive treatment. Ideas of how to set these guidelines needs to be dealt with immediately. An idea mentioned previously on the blog stated that some sort of public education could be done similar to what’s done for the presidential elections. I think this would be a great way to get the public aware of the situation and their ideas on the topic. I think the public should have the right to elect individuals who they feel are adequately equipped to make these big decisions and these individuals could form a committee. Then this committee could sit come together to set out guidelines and rules of ethics for how triaging will occur in the event of a pandemic crisis. The committee should have people like doctors and individuals who are aware of what issues we as a society will face. The committee will have the last say on the guidelines but they can get feedback from the public on how they feel about the situation. The main issues I have noticed from the readings this week from our Population Health course and from the article mentioned on this blog is the public needs to become more aware of the issue at hand and actions need to be already in motion to prepare for a pandemic instead of waiting for when the crisis finally arrives.
~KK
May I say here that I am greatly and favorably impressed by Dr. James C. Thomas's internet course on public health ethics from the University of North Carolina's School of Public Health. I think taking and reviewing this short course would be most appropriate for all those who will sit on a triage review board preparing the triage protocol, particularly the community members. It would be essential that all members are aware of all aspects of public health ethics. (I am particularly concened about those who wear some political or administrative agency hats on the review board but then also physicians and others may need ethics refreshers.) Certainly, elements of Dr. Thomas's teaching should be part of the public education program. (Although,some might argue like the cartoon strip noted in Module 1 of the course, some members of the public may find the issues too complicated for them and would rather remain ignorant of public health ethics and rather than trying to understand the issues would decide to simply let their emotions speak out about the issues.)
Again, I am impressed by the course and now the valuable responses of the students. Thanks to Dr. Thomas and to those course visitors to this blog thread. ..Maurice.
My experience as an Emergency Department nurse offers perhaps a different perspective of this issue. First of all, I believe one of the most important points in the Tabery, Mackett & UPMC Pandemic Influenza Task Force article lies in this distinction: prioritization of early treatment (prevention of illness) vs. prioritizing the critical care treatment of individuals. The prioritization of early treatment is already promoted in the United States, with additional recommendations by the CDC for vaccination of healthcare providers (CDC, 1997). The justification of such preferential distribution of resources is that the community health is improved by what is considered an “upstream” intervention: maintaining the health of the professional care providers. The professional duty of health care providers as perceived by the public is foundational to this justification.
Prioritizing the critical care treatment, or more generally hospital-based care, of individuals in a pandemic crisis, is a different issue. Tabery, Mackett & UPMC Pandemic Influenza Task Force state “We recommend that hospitals first consider medical utility and secondly narrow social utility in making triage decisions during a severe influenza pandemic” (pg. 6). Triage is a process that consists of clearly defined criteria, but ultimately relies upon the judgment and experience of the nurse or physician. There is a duty placed upon these individuals, with both utilitarian (providing the most good to the most people) and egalitarian expectations (assistance of those in greatest need), that is inherent in the triage model. The “hybrid-model” suggested by Tabery et al. is not conceptually new to triage in the prioritization of medical utility. I would suggest it would be difficult for hospitals to manage in any pre-determined, organized way the prioritization of narrow social utility of patients. Unless the individual at issue is one of the hospital’s own emergency essential staff, how should the triage nurse and physician determine the validity of the patient’s claimed social utility? On any given day, triage nurses are barraged with patients clamoring to be seen by providers, and are busy monitoring and providing care to patients still waiting. In a crisis it is improbable that a triage team would have the resources available to appropriately evaluate diverse societal utility.
As Dr. Bernstein suggests in this blog, education of the public prior to a pandemic disaster may prevent rebellion, riots or harmful behavior (to others or society) in the event of a crisis. Here I must say, that I agree with J.P. Triage is a very complex process, that I do not believe the public should believe they are participating in or have control over. However, my experience tells me that a background of understanding does help individuals to cope in situations in which they have little control. In the emergency department where I worked on the west coast, brochures were distributed in the waiting room describing the process of triage, explaining that patients were not selected on a first come, first served basis, as well as that patients were being selected for urgent care services and emergency services at different rates. Anecdotally, this information provided patients with an understanding of the management of the waiting patient flow and an appreciation for the complexity of the triage nurses’ duties. Customer satisfaction reports supported this observation. Again, based on personal experience, I would also suggest that much of the public in the United States does in fact have an appreciation for the greater good in disaster management. The times at which I have witnessed the most patience, caring and concern for others by patients in the emergency department have been times of disaster. Reinforcement of this behavior via public educational programs should be considered; if fire drills and airplane evacuation are effective preparedness, national disaster management preparedness should be considered as well.
S.G.
I agree that education is extremely important regarding this subject. I too have heard very little regarding action plans/protocols if there is a severe influenza pandemic. I know that where I work they do have a triage plan, but they have not explained it to us. They rationalize it by saying that they do not want to scare us too much. (I tend to disagree with their reasoning.) But it does make me wonder how the general public would respond to the issues posed in this discussion. That is where the education factor becomes very important so that we do not contribute to anxiety or possibly adversely affect the general publics’ well-being before the pandemic even begins.
I agree that the public should be involved. The use of television, radio, internet, and mail can all be used to help disseminate the information, and gather the general publics’ response to polls. Although the public should be involved, I too agree that once they have weighed in their votes it should be left up to elected officials/scientists/emergency personnel (members of the TRB) that make the final draft of the protocol. Once the final draft is completed there needs to be more education. This second aspect of the education is to inform the public what the final draft is, and why some things that the public wanted may or may not be used. This will hopefully open a dialogue in which disagreements can be resolved before the crisis happens.
BG
As I read the blog posting, articles, and comments made, a large number of thoughts and questions arose.
As we discuss triage following a pandemic, I have a difficult time believing that one does not exist or is not already being planned. While we may not all be aware of it, I believe the recent scare of H1N1 would have the government working with medical professionals to establish a triage system that can be applied. So if the triage criteria is already being developed, what role does the public have in its development?
I agree with some of the other comments that suggest that the public's role in minimal. The public overall is not able to see the big picture, and are not familiar with the in's and out's of disease, ethics, and the resources available. I believe trusted individuals should be developing the triage plan to best serve and maximize the lives saved.
Rather than focus on triage and who will be treated and who won't, public education could focus on the importance of getting healthy, and continuing to make healthy decisions as this affects how well you respond to things that you may be exposed to, such as influenza, radiation, or food borne illnesses. Using different mediums to present education and focusing on wellness, health, and prevention overall may have a greater impact than discussing the shortfalls of the future triage system.
As health care professionals, we have a duty to do everything we can to save lives no matter the circumstances we face. I think of airlines, and their teaching in putting oxygen on yourself first, so that you are then able to help others. The information presented throughout this blog has helped me to further raise questions regarding ethics and triaging patients no matter the situation.
~AA
Here are some questions all the previous great comments have led to in my thinking. First, while it seems that most agree that the public, if maybe not the major generators of a triage protocol, should at least be kept informed regarding the issues being discussed by the protocol writers and the general education regarding an infectious disease pandemic and its consequences. The question I pose is how much should the public be told about the probabilities and consequences of a pandemic crisis? Should they be told more than they want or need to know or should the entire spectrum of possibilities and consequences be transparently related to the public and not hide some particularly disturbing issues hiding behind a curtain? For example, with informed consent by the patient for a procedure or treatment, what is told the patient is not every single possibility either regarding benefit or risks but only a medical and legal standard of what the "average person in the same situation might want to know" and additionally what the patient specifically asks about.
So what and how much information should be presented? One could argue that some facts or theories if presented to all the public would not contribute to better education but rather contribute to more intense and widespread panic. But this is what I would like to read what others feel about this point.
The next question is whether the education should be presented to the public in an off hand, didactic fashion with no emphasis of this or that? Or on the other hand should it be given in a "no holds barred" direct and almost dictatorial fashion to assure(?) attention and respect?
How the quantity of content and its presentation is made I would think could represent important factors in how the education is accepted by the public. What is needed at the time of crisis is understanding and cooperation by the public. At a minimum to help with the answers to these questions would be the presence of skilled social scientists, psychologists and public relation specialists as part of the education team beyond those scientists, lawyers, administrators and others on the Triage Review Boards. What do you think?
Finally, to AA. I am not sure that the usually valued advice to "stay healthy" necessarily will be of help in a infectious disease crisis pandemic such as influenza which may seriously affect many "healthy" individuals. Except for the health practice of appropriate immunization for the influenza if available, I am not sure that general healthu practices (except not smoking to prevent underlying chronic bronchitis or COPD) will be necessarily protective for the infection or complications. What a healthy lifestyle for the public would do is reduce the cost of medical care and perhaps allow more prophylactic and therapeutic resources. including more hospital beds, to be available in case of crisis rather than used for the chronic diseases. Also more money would be available for reconstructing society after the catastrophe. ..Maurice.
In response to your question of how the public should be told Maurice, I think they need to be educated in the most straight forward way possible. You mentioned informed consent and how the doctors don't tell the patients "everything" that may happen as a result of the procedure/treatment. But, the real issue with informed consent is not that the doctor doesn't say everything that could happen, but rather that the patient has no understanding of the information that they are receiving. Working in the hospital setting and witnessing patients sign informed consents for various surgeries and procedures, I would say 85% of the time the patient has no real idea of what the doctor actually means. This whole concept can be applied to how the public is educated on what could happen during a pandemic. It may not be that the public needs to know "everything" that could happen, but just understanding the risks and the rationale behind the allocation of resources. If the public understands the background and the rationale then the rest of the details won't matter as much. And really, isn't it unethical to have someone sign a piece of paper, like an "informed consent" when really they aren't informed at all? We don't let those who we label as "mentally ill" sign for informed consents, so why would let the "uninformed" sign? I guess that is the same thought behind the education behind the pandemic crisis. How do we expect people to act if they have no idea what is going on and how/why resources are allocated the way they are.
The most important concept that should be portrayed to the public, whether you follow a social utility where resources can be divided by the "social worth" of the patient, or a medical utility which is based on saving the greatest amounts of people, is that the theory is based on the ethical belief to do no harm. There are so many factors that can go into the process of triage. Not only do you have to quickly determine the patient's acuity and priority of resources but you also must consider the financial aspect of the business, or hospital - which is something that is based on the social utility principle. Each facility and each triage center should have their own ethics based guidelines or protocol as to how they will prioritize patients. In a pandemic event there should also be a ethics based prioritization of allocating resources for triage.
ALB
ALB, you bring up another issue that also needs to be more fully discussed. You write: "Not only do you have to quickly determine the patient's acuity and priority of resources but you also must consider the financial aspect of the business, or hospital - which is something that is based on the social utility principle. Each facility and each triage center should have their own ethics based guidelines or protocol as to how they will prioritize patients."
There is going to be enough feeling amongst the public regarding apparent personal injustices rendered by triage in a pandemic crisis that I wonder whether the public would accept at the outset a hospital's concern for its own finances and differing principles of triage amongst the various hospitals. One may say that preservation of the hospital's finances as a primary element like the attempt to preserve physicians, firemen and sanitation workers is for the social good. but I wonder if immediate financial concern of the hospital should trump decisions regarding patient triage. Moreover, wouldn't variations in general patient triage principles between hospitals or cities or states just add to public feelings of injustice? ..Maurice.
Blog post 7/28/09
The TRB concept presented in the Tabery and Mackett provides a workable model to develop a community based response to a pandemic. If we accept the goal of public health with regard to a pandemic in Tabery and Mackett's article, " the preparation for and response to an influenza pandemic sets goals that seek to protect the public health—to minimize morbidity and mortality during the pandemic" then planning a response prioritizing treatment for care givers that can immediately impact the response to the pandemic, (the narrow medical definition) makes sense.
The public should be made aware of the plan, and there will certainly be resistance to it. In most cases, the general public will consider any delivery of care that gives priority to one group, or the other, to be a severe injustice, and being encouraged to provide input to determine how care is delivered will not change the public's perception of the situation, but without a system to deliver resources no one will receive care.
The more difficult issue is can healthcare providers, once the pandemic crisis breaks, switch from the medical model, based on the rights of the individual, to a public health model that is focused on preserving society. I understand this "switch" is a function of the TRB, but in a chaotic situation communication could be limited and valuable time lost in treating the patients.
IP
References
Tayberry, J. , Mackett, C.W. The Ethics and Triage in the Event of an Influenza Pandemic.
I wrote the following to a bioethics listserv to which I subscribe. This then was followed by a reply by a physician-ethicist. I thought you might be interested as the issues discussed on this thread ties into the current healthcare reform debate both in Congress and amongst the public. ..Maurice.
I wrote:
You know, I was thinking: If healthcare reform planning in the U.S. is controversial, politically and otherwise, just wait until the public gets wind of the fact that pandemic triage planning may be going on without the public's full input and that when notified as the crisis falls upon us all, can you imagine the outcry and disruption of attempts to follow protocol, maintain control and try to preserve society and its function? As an example, in the August 17 2009 issue of Time Magazine, there are 6 pages of description of the history of flu pandemics, epidemiology and planning issues but not one word on the specific issue of hospital triage in terms of scarce healthcare providers and other limited critical resources.
I have written about this before here and have a thread on the same subject on my blog. I still say that the government and public media should begin now and tell the story of what is going on now and what might be the triage plans for hospitals come the catastrophe. I can see town hall "meetings" or should I say "riots" at the doors of the hospitals at the time of crisis.
The reply:
Maurice,
Let's compare your suggestions with the current controversy.
Everyone is going to die at some time. Most of them will die in the hospital and most of those after some limitations on care. Still, we can't get most people to discuss their preferences in advance with their own doctors and we can't get doctors to consistently bring up the conversation either. Despite passing the PSDA nearly two decades ago, during the peak of an era of government by unfunded mandate, we have just begun to consider paying doctors for spending the time to do this. Look at the unfounded uproar. Many attempts have been made to create forums to help people learn about health care proxies. The response has been underwhelming.
So lets not apply the same ideas and methods to a much less predictable event. There is a reason for representative government. Authorities should do some publicity and, as with any legislation, there will opportunities for public input. But in this circumstance my nuanced suggestion would be that experts use their time and efforts building good plans rather than wasting their planning time trying to do public education. Plans shouldn't be made in secret and should be made publicly available. But use moderation in efforts, rather than a dedication to an elusive ideal of public autonomy. The riots are just as likely to occur anyhow.
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