For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic Dorothy E. Vawter,* J. Eline Garrett,* Karen G. Gervais,* Angela Witt Prehn,* Debra A. DeBruin, Carol A. Tauer, Elizabeth Parilla, Joan Liaschenko and Mary Faith Marshall * Guarantors responsible for the integrity of the work as a whole, from inception to this report. Minnesota Pandemic Ethics Project Report www.health.state.mn.us/divs/idepc/ethics 2010 A project of the Minnesota Center for Health Care Ethics and the University of Minnesota Center for Bioethics Sponsored by the Minnesota Department of Health With funding from the US Centers for Disease Control and Prevention Minnesota Pandemic Ethics Project: Resource Allocation Panel Report Minnesota Pandemic Ethics Project Team Minnesota Center for Health Care Ethics (MCHCE): J. Eline Garrett, JD; Karen G. Gervais, PhD; Ruth Mickelsen, JD, MPH; Angela Witt Prehn, PhD;* Dorothy E. Vawter, PhD University of Minnesota Center for Bioethics (UMCB): Debra A. DeBruin, PhD; Jeffrey Kahn, PhD, MPH; J. P. Leider; Joan Liaschenko, RN, PhD, FAAN; Mary Faith Marshall, PhD; Steven Miles, MD; Elizabeth Parilla, MPH;** Carol A. Tauer, PhD; Susan M. Wolf, JD Corresponding author: J. Eline Garrett, JD Minnesota Center for Health Care Ethics, Carondelet Center, 1890 Randolph Ave., St. Paul, MN 55105 612-964-9425, [email protected], www.mnhealthethics.org _________________________ * Midway through the project Dr. Prehn also became affiliated with Walden University. ** Ms. Parilla worked for the University of Minnesota Center for Bioethics during much of the project. When Ms. Parilla accepted a position with the Minnesota Department of Health, she moved to a solely advisory role on the project. Inclusion here reflects her early contributions to the project team. © Minnesota Department of Health 2010 Minnesota Pandemic Ethics Project: Resource Allocation Panel Report Acknowledgments The authors gratefully acknowledge the many individuals and organizations that contributed to the Minnesota Pandemic Ethics Project. We especially thank the Minnesota Department of Health for supporting the project while providing the freedom necessary for the work to remain truly independent. We owe thanks as well to the US Centers for Disease Control and Prevention for its generous financial support. Above all, we thank the members of the Resource Allocation Panel and each of the work groups (Appendix A), all of whom generously contributed time, energy, intellect and even humor to this work. The panel with its diverse membership embodied and embraced the values of genuine public engagement; they listened respectfully, thought creatively and spoke candidly. It is with immense respect that we bring the panel‘s final recommendations forward in this report. Hundreds of people enriched the panel‘s work by engaging with others in their communities and sharing their perspectives and values or by sending us written comments. To each we extend our deepest appreciation. We worked with a remarkable and committed group of people. In particular we acknowledge the contributions of: Julia Anderson, RN; Roger H. Bernier, PhD, MPH; Patricia Bloomgren, MS; Rynn Burke, RN, MD; Susan L. Craddock, PhD; Richard Danila, PhD, MPH; Kathryn J. Draeger, PhD; Denise Dunn, RN, MPH; Charles G. Durbin Jr., MD; Jody Erikson; Buddy Ferguson; Kerry G. Hjelmgren; Jane Harper, RN, MS, CIC; John Hick, MD; Pamela Hoopes, JD; Lawrence R. Jacobs, PhD; Allan Kind, MD; Barbara A. Koenig, PhD, RN; Niki Koszalka; Nick Kuhnley, RCP, RRT; Peggy Kvam; J. P. Leider; Aggie Leitheiser, RN, MPH; Emily A. Litt, RN, MSN, DNP, PHN; Franci Livingston, JD, MPH; Ruth Lynfield, MD; Sanne Magnan, MD, PhD; LuAnne McNichols, RN, MN; Ruth Mickelsen, JD, MPH, MA; Sheila Mirembe-Larsen; Angela Morley, JD; Daniel T. O‘Laughlin, MD; Bruce Pederson; Jean Rainbow, RN, MPH; Johanna Raquet; Christopher Tate, MPH; Pat Tommet, RN, PhD, CNP and Caitlin Wills-Toker, PhD, MA. We also are indebted to the dozens of people who volunteered to be trained and to serve as small group facilitators or note takers for the community forums in Duluth and Owatonna (Appendices C – D). Finally, we extend our thanks to the numerous other state and local agencies and organizations whose employees lent their expertise and time to this project: The Minnesota Departments of Employee Relations, Human Services, Labor and Industry, and Public Safety; the Minnesota Boards of Aging, Nursing and Pharmacy; Clay County Public Health; Community Education Division of Independent School District 518; Community Health Information Collaborative; Courage Center; Dodge County Department of Health; Fond du Lac Reservation‘s Min No Aya Win Human Services Center; The Keystone Center; Leech Lake Band Health Division; Minneapolis Urban League; Phillips Neighborhood Clinic; Saint Louis County; Steele County Community Awareness & Response; Steele County Public Health; Virginia Rotary Club and the West Side Citizens Organization. Minnesota Pandemic Ethics Project: Resource Allocation Panel Report Table of Contents Executive Summary ..................................................................................................................... i 1. Introduction ....................................................................................................................... 1 2. The Minnesota Pandemic Ethics Project ........................................................................... 2 3. Scope of Recommendations ............................................................................................. 2 3.1. Palliative care .......................................................................................................... 3 3.2. Statewide population health perspective ................................................................. 3 3.3. Containment ............................................................................................................ 3 3.4. Adapt and integrate into comprehensive plan .......................................................... 3 4. Process ............................................................................................................................. 4 4.1. Development of preliminary recommendations ........................................................ 4 4.2. Further public engagement ...................................................................................... 6 4.3 Development of final recommendations................................................................... 8 5. Assumptions ...................................................................................................................... 8 5.1. Pandemic assumptions ........................................................................................... 9 5.2. Demographic assumptions .....................................................................................11 5.3. Resource assumptions ...........................................................................................13 6. Definitions ........................................................................................................................15 7. Ethical Frameworks for Rationing .....................................................................................16 7.1. Ethical commitments ..............................................................................................18 7.2. Ethical objectives ...................................................................................................18 7.3. Strategies: Overview ..............................................................................................19 8. General Recommendations ..............................................................................................21 8.1. Extend and manage supply ....................................................................................21 8.2. Remove access barriers .........................................................................................21 8.3. Adjust and refine ethical frameworks ......................................................................21 8.4. Other recommendations .........................................................................................22 9. How to Read and Apply the Frameworks .........................................................................22 10. Ethical Frameworks for Rationing Antivirals ......................................................................24 10.1. Antiviral assumptions .............................................................................................24 10.2. General recommendations for rationing antivirals ...................................................26 10.3. Antiviral treatment strategies ..................................................................................27 10.4. Antiviral prophylaxis strategies ...............................................................................29 10.5. Discussion: Rationing antivirals ..............................................................................31 11. Ethical Frameworks for Rationing N95s and Masks .........................................................35 11.1. Assumptions about N95s and masks .....................................................................35 11.2. General recommendations for rationing N95s and masks ......................................37 11.3. Discussion: Rationing N95s ...................................................................................39 11.4. Discussion: