judgments. Although they must be informed by science and best available evidence, they are not the responsibility of scientists or other experts alone. Ethically informed plans to allocate antivirals on grounds other than individual medical need or the principle of “first come, first served” require the considered judgment of persons with diverse experience and expertise, including the public. In this chapter, the committee indicates ethical commitments, principles, and goals to be considered in developing an ethical framework to guide decisions concerning the allocation and dispensing of antivirals in a severe pandemic.

Ethical frameworks have been offered from several sources, including the World Health Organization (WHO), the Department of Health and Human Services, several countries, and some states. A review of state pandemic influenza plans found that although most state plans acknowledged the importance of ethical considerations, they included little explanation of steps to take to ensure ethical decision making (Thomas et al., 2007). There is reason for concern that ethics may be viewed as important but secondary to programmatic activities such as planning dispensing sites and conducting exercises, rather than as the foundation for sound decision making.

The proposed federal guidance on antiviral use strategies includes four ethical principles: fairness (all equally eligible have equal access to antivirals), utility (minimize harms of the pandemic), reciprocity (minimize risks to those occupationally at risk to benefit society broadly), and flexibility (adaptability to emerging information). The federal guidance also acknowledges the importance of procedural ethics, transparency, public inclusiveness, and reasonableness (i.e., rational choices consistent with societal values, especially when science is lacking). The committee considers this a good start on an ethical framework for resource allocation in a severe pandemic, and provides some distinctions, principles, and goals to consider, and a recommendation to build on this foundation.

Many of the ethical frameworks that have been promulgated so far include ethical principles and goals, some include strategies and sample allocation plans based on detailed assumptions about the pandemic being planned for, and all of them include what might be described as “integrity factors” or ethical commitments based on respect for persons and the public (Kass, 2005, 2008). The committee finds it helpful to distinguish these three components of the ethical framework needed: (1) integrity factors/ commitments, (2) ethical principles, and (3) ethical goals. It is on the basis of the ethical framework that strategies for allocating scarce resources will be determined in an actual pandemic. The committee here offers a starting point for a broadly based effort to build a national ethical framework for use of scarce health resource, and specifically antiviral, allocation in a severe pandemic. What follows is an example of a set of ethical commit-



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