By Brieanne Lyda-McDonald

As concerns over state and local responses to the COVID-19 (coronavirus) pandemic increase, the North Carolina Institute of Medicine (NCIOM) is looking back to a report published in 2007 on the ethical implications of a pandemic. In the wake of bird flu and Severe Acute Respiratory Syndrome (SARS) epidemics and challenges faced after Hurricane Katrina, the NCIOM convened a Task Force in partnership with the North Carolina Division of Public Health to study ethical principles that should guide the state’s response to a potential flu pandemic. COVID-19 is not the same as flu, yet there are many similarities to the impact on health and health care services that our communities may be facing in the coming weeks.

In its work, the Pandemic Flu Task Force “developed an ethical framework for guiding decision making in the following areas:

• responsibilities of health care workers and other critical workers to work during the pandemic and reciprocal obligations to these workers,
• the balance between the rights of individuals and protection of the public, and
• prioritization and utilization of limited resources.”

This framework was guided by considerations of “the need to ensure accountability, equitable treatment among similarly situated individuals, proportionality of actions, and inclusiveness and timeliness in decision making.”

The Task Force made 16 recommendations in their final report, “Stockpiling Solutions: North Carolina’s Ethical Guidelines for an Influenza Pandemic.” Here are the most relevant recommendations for public and private entities as the COVID-19 pandemic is developing.

Workers’ Responsibility to Provide Care or Services– (Recommendations 2.1 and 3.1) Workers in health care and critical industries have an ethical responsibility to perform their regular duties and to assume new responsibilities they are trained for, as long as these actions won’t lead to greater harm than the failure to act.

• Health care workers include those working in hospitals, nursing facilities, health departments, home health, hospice, physician offices, drug stores, and medical suppliers.
• Critical industry workers can include those working in agriculture and food, energy, public health/health care, banking, water treatment, information technology, telecommunications, postal, transportation, chemical, commercial facilities, dams, government, emergency services, nuclear power, and national monuments.

Government, Health Care Organization, and Critical Industry Employer Responsibilities to Personnel – (Recommendations 2.1 and 3.1) These organizations and employers must ensure that personnel are protected, supported, and trained to fulfill their duties. Frontline and critical workers, and others at increased risk of infection, should have priority in receiving available resources like personal protective equipment and vaccinations.

General Organizational Responsibilities to Employees – (Recommendation 3.3) During a pandemic, organizations should prioritize the health of their employees and reduction of the spread of disease over the financial position of the organization and have the duty to follow the recommendations, guidelines, and restrictions made by public health and other government officials (e.g., recommendations on social distancing).

Responsibilities of Government Leaders– (Recommendation 4.1) Government leaders should implement restrictions on personal liberties deemed likely to be effective to limit illness and mortality, but should limit these measures to the least restrictive alternative reasonably necessary to protect the public.

Responsibilities of the North Carolina Department of Health and Human Services (NC DHHS) – (Recommendation 4.2) During the course of a pandemic, the NC DHHS should:

• Partner with local health departments to develop a public outreach campaign to promote community awareness and understanding of the pandemic. This effort should include community stakeholders and the media and should allow for community feedback during the pandemic.
• Should continue to work with stakeholders to create an understanding of the need to use social distancing measures and other community mitigation efforts to prevent the spread of disease.

Responsibilities of the Governor’s Office – (Recommendation 4.3) The Governor’s Office should work with NC DHHS and the Department Public Safety to develop a coordinated communications plan for timely, accurate, and continuous information about the pandemic for the public. This information should be communicated in an accessible manner for special populations, including people who are low-income, people who do not speak English, and people who have visual or hearing impairments.

Allocation of Limited Health Care Resources – (Recommendations 5.1 and 5.2)

• Allocation of nonpharmaceutical prevention resources (e.g., personal protective equipment) should be made with the goal of assuring the functioning of society and preventing the spread of the disease.
• Allocation of nonpharmaceutical treatment resources (e.g., ventilators and hospital beds) should be made with the goal of reducing illness, hospitalization, and death.
• Disease control and medical decisions should be based on clinical factors, the epidemiology of the spread of disease, and assuring the functioning of society. Decisions about which people to treat and what services to provide should not be made based on socioeconomic or other factors unrelated to these criteria.

In the coming weeks, state and local authorities could be facing challenging decisions and may have limited information to do so. These recommendations form the basis of an ethical template that can guide some of the tough ethical choices that public and private organizations and individuals are facing as we deal with COVID-19.