Ethics in the worst of times: A critical review of ethical guidance for rationing resources in a severe influenza pandemic

Planning for a severe influenza pandemic involves tough decisions about the rationing of health-related resources. Is there general agreement about who should receive pandemic vaccine first when there's not enough to go around? Should social criteria such as age and quality-of-life play a role in prioritizing the use of scarce health-related resources? Should we give scarce resources first to those who expose themselves to risk in the service of others?

As part of the Minnesota Pandemic Ethics Project, we reviewed national and state pandemic influenza plans, guidance documents and scholarly publications in order to answer the following questions: 1) What ethical guidance is there available globally about how to ration scarce health-related resources in a severe pandemic? and; 2) Which ethical issues remain unresolved?

Ethical guidance is limited or absent in the majority of pandemic influenza plans reviewed, but is increasing. Rationing on the basis of risk of mortality, effectiveness, and social function is commonly recommended and the agreement about these priorities crosses geopolitical and cultural borders. There is less consensus on rationing on the basis of age, quality of life and duration of benefit. Ethical arguments regarding these unresolved issues in rationing during a pandemic will be presented.