Altered standards of care during an influenza pandemic: Identifying the ethical, legal, and practical principles to guide decision-making

In January 2006, the Massachusetts Department of Public Health (MDPH) and the Harvard School of Public Health (HSPH) jointly convened an advisory group to make recommendations to the Commonwealth of Massachusetts on the key ethical, legal, and practical issues regarding altered standards of care during an influenza pandemic. After first reviewing all relevant literature, the group collectively agreed that when possible, recommendations should be made proactively, and in full consultation with stakeholders and the public. The group decided to begin by establishing underlying principles to guide decisions. To facilitate progress towards such principles, the advisory group created a series of five scenarios to illustrate the potential considerations arising regarding allocation of scarce resources, prioritization of critical care, and government seizure of private assets. In July 2006, MDPH and HSPH jointly convened two stakeholder group meetings to raise the key issues surrounding altered standards of care and obtain structured feedback from a more diverse audience. Each group was comprised of 12-15 participants; the first was primarily consumers, the second was primarily healthcare providers. Each group engaged in facilitated discussions of the five scenarios. A subcommittee within the advisory group subsequently developed a framework to define the triggers, processes, and authorities informing decision-making regarding altered standards of care. This framework incorporated the feedback obtained from the stakeholders, and was vetted through the advisory group prior to presentation before the Massachusetts Statewide Surge Committee in November 2006. We offer the Massachusetts process and framework as a model for other states considering this topic.