Effective Leadership in a Global Constituency
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Scope and Background
Public health and wellbeing may be the primary concern of health care officials during a pandemic but with the subsistence of various issues that require careful and efficient decision-making, especially on the part of dominant international figures who offer health care assistance to people worldwide, ethics take precedence. Therefore, during a pandemic, the plans and decisions of health care officials must be guided by ethical practices and approaches. Ethical decision-making in pandemic planning is essential because it would help set health care objectives and standards (i.e. fair and adequate distribution of vaccines, antivirals, and drugs) and limitations or boundaries in terms of how control, prevention, and treatment programs will be administered. According to the Joint Centre for Bioethics – Pandemic Influenza Working Group (2005) based in Toronto, health care officials should incorporate ten substantive values when making ethical decisions: (1) individual liberty, (2) public safety and wellbeing, (3) proportionality, (4) privacy, (5) the duty of health care professionals to provide quality care, (6) reciprocity, (7) equity, (8) trust, (9) solidarity, and (10) stewardship. Thompson, Faith, Gibson, and Upshur (2006) also debated that the application of ethical frameworks in decision-making is necessary because it would help mitigate risks, build mutual trust and national and international camaraderie, and improve the delivery of health services during a difficult time.
However, setting ethical guidelines and creating standard ethical frameworks do not guarantee consistent health care practices during a pandemic. The ethical approaches being implemented, for instance, differ based on the financial and medical capabilities and more importantly, the value systems in each country. In the succeeding discussion, prevalent ethical approaches in the United States, Canada, United Kingdom, and Australia will be evaluated to determine how these countries plan and prioritize the distribution of vaccines and drugs. Moreover, forthcoming ethical challenges each country will likely face and recommendations on how they could address these challenges will also be discussed.
Ethical Approaches in Vaccine and Drug Distribution in the Event of a Pandemic – By Country
United States (US)
In the US, the Center for Disease Control and Prevention’s (CDC) Ethics Subcommittee formulated standards to guide the prioritization and distribution of vaccines and drugs in the event of a pandemic. CDC’s Ethics Subcommittee took into consideration the recommendations of The Advisory Committee on Immunization Practices (ACIP) and National Vaccine Advisory Committee (NVAC) to prioritize the vaccination of high-risk groups. Aside from high risk groups, CDC also recommends the prioritization of health care workers especially “those individuals who are essential to the provision of health care, public safety and the functioning of key aspects of society” (Kinlaw & Levine, 2007, p. 3). Consequently, the United States evaluates existing stakeholders to determine which parties play significant roles in the development of national and international health care and public safety. The individuals are considered of high value to society and as a result, the federal government accommodates their need for treatment and immunization.
The CDC’s policy on prioritization has met criticisms from the public because it seemingly designates the social value of individuals and groups, and consequently creates gap within the population. However, CDC insists that the organization provides equal opportunities for all individuals belonging to high-risk groups and that the traditional individual patient-centered approach will not work in a pandemic. Due to limited sources of vaccines and drugs, the CDC is compelled to prioritize those who need utmost care because the federal government’s objective is to mitigate risks by minimizing hospitalization and mortality rates. The CDC’s stance on the issue is linked to the concept of utilitarianism in health care aligned with the ethical principle of respect for life. In pandemic planning, the US government’s “primary objective is to preserve the function of society” therefore, “it may be necessary to identify certain individuals and groups as key to the preservation of society and to accord them a higher priority” (Lemon, 2007, p.3). The approach shifts from patient-centered approach to a population-oriented approach (Butts & Rich, 2012).
In Canada, the objectives of health officials are similar to the aim of the US government - to minimize hospitalization and deaths during a pandemic. However, Canada is implementing a different strategy and approach in distribution vaccines, antivirals, and drugs. Moreover, Canada’s pandemic plan is more comprehensive because it also covers other issues that affect the public. For instance, aside from reducing health risks and deaths, Canada’s national antiviral strategy involves “mitigating societal disruption by reducing the impact of absenteeism due to illness” and “reducing the level and duration of viral shedding, thereby possibly reducing transmission” (PHAC, 2011a). In addition, Canada created the National Antiviral Stockpile (NAS) in 2004 to ensure that there will be enough supply to facilitate “a national early treatment strategy, namely, to provide antivirals to all Canadians expected to need treatment during a pandemic” (PHAC, 2011a). The Public Health Agency of Canada (PHAC) also considers other factors that would affect distribution of vaccines, antivirals and drugs during a pandemic such as the severity of the disease and the availability of health care resources.
Pandemic planning in Canada changes every year and PHAC has made its approaches more flexible to the diverse needs of the public. Priority groups are selected depending on the results of evaluation and the prioritization of vaccine, antiviral, and drug distribution depends on the severity of the disease and the individuals who will more likely suffer due to its effects. Selecting priority groups, however, seems to be the least concern in the country because PHAC prioritizes prevention and early treatment to provide equal health care to all. PHAC organized various programs such as the National Antiviral Stockpile (NAS) and the National Emergency Stockpile System (NESS) to facilitate mass vaccinations as a preventive measure (PHAC, 2011b). PHAC also strives to align its ethical approaches to the standards set by the World Health Organization – an ethical framework for vaccine, antiviral and drug distribution that follows the principles of utility, equity, age, and non-discrimination as well as the importance of setting goals to make health care in the country competitive (PHAC, 2009).
United Kingdom (UK)
Prioritization in the UK is more specific compared to the prioritization plan in the US. While CDC selects priority groups based on at-risk factors and social value, public health organizations in the UK prioritize younger age groups on the basis of fair innings, which “promotes the egalitarian concept of equal opportunities, which implies that a child or young adult has a stronger claim to protection than an elderly person” (WHO Europe, 2008, p. 6). Furthermore, a prominent concept in the UK’s ethical framework in dealing with a pandemic is the government’s acknowledgment of its role in the global community. As a result, UK’s Department of Health (DH) plans its strategies and approaches based on the health situation in the UK and around the globe, thus, its involvement in the World Health Organization’s (WHO) health initiatives.
The underlying principles in the UK DH’s ethical framework include “equal concern and respect” and the acknowledgment that: (1) everyone matters, everyone matters equally, public concern is everyone’s concern, and minimizing the harms of a pandemic should be a priority (DH, 2007). To achieve the Government’s objective, DH maintains a national stockpile of antiviral drugs which covers immunization for 25 percent of the entire population. UK’s stockpile also includes pre-pandemic vaccines specifically administered to health workers (DH, 2007).
The Department of Health and Ageing’s (2008) ethical framework adheres to the principles of: (1) public safety for all, leadership and good decision-making, trust, equitable access, proportionality, reciprocity, provision of care, individual liberty, and privacy. The Department does not explicitly limit the distribution of vaccines and medicine but the organization prioritizes high-risk groups before providing supplies, if possible, for the rest of the population. However, when vaccines and medicine are scarce, the government prioritizes high-risk groups based on the nature and severity of the pandemic. “Dependent upon the scale of the pandemic… priorities for the provision of emergency welfare will be determined on the basis of greatest need of assistance” (Government of Western Australia, 2008). In essence, Australia’s ethical framework and approaches are similar to the policies of CDC in the US.
Future Challenges and Recommendations
The forthcoming challenges that may serve as barriers to the development of efficient pandemic plans in the US, Canada, UK, and Australia include social, economic, and scientific or technological factors. Social factors include differences in value system among the four countries that could interfere with their collaborative process and the increasing population which would make it difficult for health organizations to produce an adequate supply of vaccines and medicine. The US, Canada, UK, and Australia are already experiencing deficiencies in their resources despite efforts to stockpile vaccines, antivirals, and drugs and continued population growth around the globe will further limit health care capacities and resources not only in these countries but especially in the third world. Consequently, the US, Canada, UK, and Australia will not be able to contribute to the resolution of a pandemic on a global scale. Another social issue is the difference in value systems and priorities among the four countries which may cause conflict, misunderstanding, and poor communication.
Nevertheless, belonging to highly developed countries, the US, Canada, UK, and Australia must work together in order to improve national and international delivery of health care services in the event of a pandemic – through increased mass immunization, coverage of health care, advances in research, workforce planning, and the development of adequate and operational infrastructure and facilities. Economically speaking, the US, Canada, UK, and Australia fare better than other countries and therefore, they have the capacity to help other countries mitigate risks and decrease hospitalization and mortality rates during a pandemic. These countries also have the kind of technology to research strains and develop effectual vaccine formulae, and a strong health workforce capable of efficiently addressing the health care needs of the population. The discovery of unidentified diseases and strains may also force the four countries to work together. Effective leadership in a global constituency means that politically, economically, socially, and technologically capable countries like the US, Canada, UK, and Australia command efforts and initiatives to solve a worldwide issue that threatens the life and wellbeing of the human population.