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Ethical Principles During a Public Health Emergency

The goal of public health is to improve the health of a population or community rather than the well-being of an individual patient (Childress et al., 2002; Gostin, 2008; Gostin et al., 2003). Public health is utilitarian, seeking to improve aggregate measures of community health. During the 2009-H1N1 influenza A pandemic, the mission of public health is to prevent mortality and morbidity caused by influenza and to maintain essential societal functions. Because of this focus on population outcomes, public health officials may adopt measures that are not in the best interests of individual citizens and may restrict liberties. This section specifies the goals of public health during this pandemic, then discusses how to balance public health powers with individual liberty and fairness. Next, it analyzes how ethical principles for a declared public health emergency should be specified and balanced. When ethical principles are overridden, they are not ignored or voided but must be observed to the extent that is possible under the circumstances, consistent with the public health goals. Finally, this section illustrates how ethical principles have been invoked—either implicitly or explicitly—in federal guidelines to allocate vaccines, antiviral drugs, and ventilators during the 2009-H1N1 influenza A pandemic.

The Goals of Public Health Emergency Policies

When responding to an H1N1 pandemic, the public health system aims to prevent or reduce harms resulting from the pandemic. This goal is community- oriented and inherently utilitarian (IOM, 2009), seeking to minimize aggregate harms to society. “Utility” can be specified in many ways: for example, maximizing total lives saved, maximizing total number of life-years saved, minimizing new instances of infection, or minimizing societal harm by maintaining public functions. To be operationalized, public health goals need to be specified in more detail. This specification will depend on the particular public health intervention being considered.

One goal would be to prevent deaths from 2009-H1N1 influenza A; in other words, to save the most lives (IOM, 2009). This goal would be appropriate when allocating ventilators and other life-sustaining technologies during a severe pandemic. More broadly, the public health goal might focus on morbidity as well as mortality. The goal might be to prevent cases of severe influenza in order to reduce the aggregate morbidity and burden of disease. This goal would be appropriate if antivirals and vaccine were in short supply and needed to be allocated.

An even broader goal would be to minimize the total number of cases of influenza, including mild as well as severe cases. This would be an appropriate goal if there were no shortfall of vaccine, but a priority system still needs to be established in order to deliver the vaccine to the population.

During a severe pandemic, another goal might be to maintain essential functions of society. The image of basic services such as shelter and public safety



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