Pandemic flu planning in the community: what can clinical ethicists bring to the public health table?

It is still remarkably difficult for public health officials charged with developing and implementing pandemic influenza preparedness plans at the community level—where care is delivered— to obtain clear, concrete, and consistent guidance on how to construct plans that are both ethical and actionable. As of mid-2007, most of the federal and state pandemic plans filed with the Centers for Disease Control and Prevention, describing how public health officials will coordinate public agencies and private entities in the event of an outbreak, failed to include ethical guidance for first responders responsible for providing essential services and making fair decisions during a public health emergency. A survey of these plans, published in the American Journal of Public Health in June 2007, noted that planners were following a federal template that did not require them to be specific about how their plans met the test of public health ethics during a disaster: preparing first responders to act fairly when forced to think differently about their duties and priorities within their communities. Some planners, in state departments of public health, in the nation’s 3066 counties, and in private entities such as state hospital associations, are becoming aware that there is a moral and practical gap in the plans they are charged with carrying out. If these plans are not candid about the ethical challenges first responders will face, and if these plans do not provide clear rules and tools for first responders to use once a state of emergency is declared, the burden on these frontline workers will be increased, and poor, crisis-driven decisionmaking may result. But where can planners—specifically, public health officers responsible for coordinating health and safety services and public health educators responsible for providing community members with information about how to use these services—turn to ensure that their plans are both ethically sound and will work in practice? How can they avoid the tendency to lean on abstractions (‘‘rationing,’’ ‘‘justice’’), or to shift hard yet foreseeable decisions onto the shoulders of frontline workers? How can they learn how to anticipate and discuss foreseeable ethical challenges and to prepare first responders to make ethical decisions when, inevitably, unanticipated dilemmas arise? And how, when discussing pandemic planning scenarios in public forums, can they acknowledge and overcome the mistrust created by what has been described as a ‘‘post-Katrina consciousness’’ of health and healthcare disparities among Americans? The short answer would seem to be ‘‘bioethicists.’’ Recruiting the chair of