Health officials have been tackling the difficult question of how to apportion mechanical ventilators in a severe influenza pandemic when the demand far exceeds the availability of the treatment. Yesterday, a prestigious group of advisors to the U.S. Centers for Disease Control and Prevention moved closer to delivering their guidance.
A subcommittee of independent ethicists approved, with minor changes, what it terms a draft ethical framework to help federal, state, and local policymakers develop guidelines about which patients should receive ventilators. The document, prepared by a group of CDC and non-CDC employees that met for more than two years, will now go to the full advisory committee to the CDC for approval. At yesterday's meeting, the subcommittee agreed to a request from CDC leadership that the document state it would not apply to the current H1N1 or "swine flu" pandemic unless a significantly more severe or widespread strain appeared.
As we reported yesterday, the guidance suggests that health care workers dealing with a pandemic assign patients a score based on several factors, such as their need for ventilators, their likelihood of survival, and their years of expected life. The document also suggested that maximizing the health of the public in a disaster by directing ventilators to those with the best chance of recovery be weighed against giving all patients with a reasonable prognosis "a fair chance at survival." The group advised against factoring an individual's perceived contributions to society into decisions about allocating scarce ventilators.
The subcommittee embraced the controversial idea that hospitals could remove from ventilators patients whose prognosis had significantly worsened, regardless of their wishes, and provide those ventilators to those with a better prognosis. However, the document advises policymakers to include the public in "frank dialogue and genuine deliberation" about the various tradeoffs among the ethical principles.
The public was able to listen to the subcommittee's teleconference yesterday by calling a toll free number. The vote to approve the document, which was unanimous among subcommittee members who attended the meeting, took place before the scheduled public comment period.
A CDC official who helped run the meeting said, "there are a lot of members of the public on the call today." The exact number and their identities were unclear. They were invited to make comments, but only two chose to do so.
A caller who identified herself as Marcia Baker argued that the government should "build for the peak of a severe pandemic" rather than focusing on categorizing patients into what she referred to as "polite terms for lives not worthy to live."
Harvard University ethics professor Norman Daniels responded that he was "very puzzled" by Baker's comments. "It seems you're suggesting we could purchase ventilators to meet any crisis," he said. "I'd like to know whether you want to pay the taxes."
Baker said, "Yes, and not pay the bailout."
Daniels countered. "You don't want a functioning economy but you want all these ventilators?"
Drue Barrett, chair of the CDC's public health ethics committee, said that the ethics guidance discusses "the importance of building our infrastructure to meet public health needs." She said the full advisory committee to the CDC director will meet within the next two months to consider the ventilator guidance.
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