Monday, July 27, 2009

The Ethics of Flu and the Trauma of Ethics

Shortly after 9-11, as the anthrax attacks were starting to unfold, I remember a friend of mine telling me that she had called her doctor to make sure that her smallpox vaccination was up to date and arrange to get a booster.  She was quite surprised to learn that not only was such a booster not recommended for her, it wasn't available.  There literally was no vaccine out there in the world.  When the WHO declared that smallpox had been eradicated back in the 1980's, they stopped manufacturing the vaccine for general use. 

This was surprising to most affluent Americans, because we are generally used to being able to get whatever health care we are willing to pay for.  The notion that a technology exists and we can't have it -- not just that our doctors don't want us to have it but that we can't have it -- goes against the way we believe the health care system works.  Unlike some aspects of our world view, such as the ones I discussed yesterday involving trauma with children, a lot of people actually believed this one, from our heads to our hearts to our guts, to be true.  We really thought we could have any health care that existed.  We were wrong.

I suspect we are up against that issue once again, because the medical research community is coming out with a vaccine for H1N1, probably in early October, and there is a good likelihood that there will be more people who want it right away than the initial supply.  Over time, the supply will probably increase and everyone can have it, but in the meantime, someone is going to have to decide who gets it.  Or, more to the point, somebody is going to have to decide who doesn't.  Of course, this isn't news to the powers that be, who issued guidelines and recommendations on this before H1N1 had come on the scene (although it is notable that the United States government flu website still refers to a pandemic declaration as a hypothetical event, despite the fact that it was issued in June).

We've dealt with a shortage of flu vaccine before.  In 2004 there was a production quality problem that limited the supply of seasonal flu vaccine, and for several months you could only get a vaccine in the U.S. if you were "high risk."  I remember this distinctly because I was pregnant, and hence I could get the vaccine and my daughter could not.  But this time will be different, because not everyone wants the seasonal vaccine, and an awful lot more people are going to want this one.  An awful lot of people who don't know that "no" is even a possibility are going to be told no.

But it gets worse, because another thing that has kept us relatively calm about H1N1 is that we know that science has advanced in its treatment of respiratory illness.  We comfort ourselves that if the 1918 flu pandemic repeats itself, we have ventilators to keep people alive.  We also know that health care is more advanced in the U.S. than in most parts of Mexico, so we believe we'll be more "OK" than they were this spring.

There's only one problem.  If a pandemic like 1918 comes around again, there very well may not be enough ventilators to help everyone who needs one.  The recommendation is that, in a severe and deadly epidemic, ventilators be used only for people who are most likely to survive.  Let me put it another way.  In the event of a "Spanish Flu"-like epidemic, you could be critically ill and they would not attempt to save you, because giving you treatment would take it away from someone else with a better chance.

I first heard about this charming nugget of information during a training with the public health community in November, before "swine flu" was even in our lexicon.  This was the same one, you may recall, at which it was stated that people would not overwhelm ER's because they would be told not to go to the ER.  And we all know how well that worked this spring.  At any rate, the plan I heard was for only those who were likely to survive to even get to the hospital.  Those too sick to have a good chance would be left at the triage center, where they would die.  Oh, and I wasn't supposed to tell anyone.

Well, the cat's out of the bag, because the Canadian national newspaper, the Globe and Mail, reported this morning that New York's pandemic working group is recommending removing or withdrawing ventilators by those likely to die during a serious pandemic.  So now I can rant publicly.

Don't get me wrong.  I get it.  I get that we can all only get all the medical care in the world if we have available all the medical care in the world, and that given limited resources we should give them to the people most likely to benefit from them.  I also get that that is a complex and difficult line to draw, and that's why we have medical ethicists out there working on this stuff.  I am also glad I am not them.

But let's get down to brass tacks.  If this pandemic gets bad, particularly in terms of the virulence of the virus, implementing "the plan" is going to be hard.  People are going to go to the hospital when we ask them not to.  People who are low on the priority list are not going to like that they can't get vaccine.  And people are going to get really, really upset when their loved ones are not allowed a ventilator or some other piece of intervention.  That is a given.  What are we going to do about it? 

If there's a plan out there, I haven't seen it.  I know in my county that they are including mental health in the planning.  They are also aware that the likelihood is that about 80% of us won't be able to respond because of our own illness or illness in our family.  If you read the federal guidelines, it looks like perhaps we are in the second tier of vaccination priority, but no mention is made of volunteers, which accounts for an awful lot of us.  I fear that once again we are in danger of underestimating the panic and even the rage that is going to occur.  All I can say is, I'm ready to be part of the solution and I promise not to be part of the problem.  I hope there are a lot of like-minded folks out there.

(For related Quarterbacking, see Getting It Right the Second Time, Flu Preparedness:  Body AND Mind, and The 2009 Flu Pandemic)


Colleen said...

M*A*S*H...remember when they taught the nurses to do triage?

Meet the Quarterback

My Photo
Naomi Zikmund-Fisher
is a clinical social worker, former school Principal and a Crisis Consultant for schools and community organizations. You can learn more about her at
View my complete profile

Subscribe via email

Enter your email address:

Delivered by FeedBurner

Quarterback for Kindle

Blog Archive