TORONTO | The anticipated second wave onset of an H1N1 pandemic could present some thorny medical ethics issues, according to experts at the University of Toronto’s joint centre for bioethics.

Staff at the centre’s Canadian Program of Research on Ethics in a Pandemic attempted to address some of those issues in nine papers released for public discussion late last month.

The views of 500 Canadians were gathered through a national phone survey and nearly 100 more via a series of town hall meetings conducted between August 2008 and February 2009.

“Now is the time to think through the serious ethical challenges societies may confront, not in the midst of crisis with lineups at hospital doors,” said centre director Dr. Ross Upshur upon release of the papers.

Duty to provide care in dangerous situations is one such issue, he said. In one paper, the centre researchers calculated that as many as 85% of health-care workers, depending on their obligations, could be unwilling to work in a pandemic.

Do health-care workers actually have an obligation to treat patients, despite the risk of infection? Some codes of ethics and professional directives don’t clearly define what is an acceptable risk.

But 90% of those surveyed by the centre researchers said health-care workers must show up for work and face all risks if “safety precautions are provided.” Some 85% believe governments should provide workers free disability insurance and death benefits during a flu crisis.

The research showed “strong agreement” that health-care professionals have an implicit social contract based on their profession and training to provide care under adverse conditions.

“There’s been limited case law, literature and legislation on what a health-care professional’s legal duty to care is during a pandemic,” the centre said in another document. “Health-care professionals can gain insight into their obligations by informing themselves about general legal doctrines developed in non-pandemic cases and legislation.”

Priority setting is another ethical concern, as decisions will be made on the basis of need, “survivability” and social value.

The question could become: Should resources be allocated to save the most lives or give everyone a fair chance at survival?

“Public participants expressed skepticism about the capacity of Canada’s health-care system to respond effectively to an influenza pandemic,” the centre researchers said in a news release. It went on to add that priority setting “is already a challenge in Canadian health care,” with an H1N1 outbreak both highlighting and exacerbating this issue.

When it comes to vaccinations, public health officials will need to justify any coercive measures they take and demonstrate the scientific evidence supporting their population health benefits.

“Arguably, the greater the evidence for population health benefit, the more coercion is permitted,” the researchers said in another paper.

Rarely will individuals be harmed by mass vaccination, but they said, “the more coercive the strategy, the greater are the reciprocal responsibilities of the state to the vaccine recipients.”

Governments and public health officials may also choose to take other restrictive measures to protect the public good, such as limiting basic personal freedoms such as mobility, freedom of assembly and privacy.

A particular challenge the researchers found in their survey is that pandemic planning largely occurs in urban centres for denizens of urban centres—meaning that inhabitants of rural areas and poor communities may wind up being left to their own devices.

 The centre’s research showed that, in the aftermath of SARS, citizens understand and accept the need for extreme measures to control the spread of infection.

A large majority of respondents, 85%, agreed governments should have the power to suspend some individual rights during a pandemic. Half reported that a violation of “an appropriate quarantine order” would be tantamount to manslaughter.

Most respondents (92%) said aid should amount to at least 7% of total resources committed to pandemic preparedness, while 43% felt a more appropriate amount is 10%, a recommendation made in another paper.

While poor communication was a criticism of the response to the SARS outbreak, transparency means “being open about what is known and what is not known.”

“If countries have a moral duty to be transparent, then the global community has reciprocal moral obligations to compensate and support those countries that may suffer economic or health consequences as a result of transparent communication,” the report authors said in another paper.