Who lives? Flu crisis may make us pick (2006)

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Who lives? Flu crisis may make us pick

Experts are divided on who gets the limited vaccine in case of a pandemic. By

LISA GREENE, Times Staff Writer Published May 28, 2006

Imagine the worst: A deadly new strain of flu speeds across the globe, and as it

approaches the United States, the reality is grim.

There isn't enough vaccine to prevent people from getting the virus. Not enough

medicine, hospital beds or even ventilators to treat the sick.

Whom do you save?

What was once an abstract philosophical dilemma has become an urgent health

policy question. The most immediate danger, Asia's killer bird flu, hasn't

turned into a worldwide epidemic because it hasn't yet developed the ability to

spread easily from person to person.

But public health officials must prepare for the threat of a disease that could

spread with explosive speed. A global epidemic could kill nearly 2-million

people and hospitalize nearly 10-million just in the United States. If a

pandemic hits any time soon, scientists estimate that there may be only enough

vaccine for about 10 percent of the population during the first year of the

illness.

" In a situation like that, we will have to choose,'' said Dr. Greg Poland,

director of the Mayo Clinic Vaccine Research Group and a member of the advisory

committee on vaccines for the federal Centers for Disease Control and

Prevention. " We're not used to that. We want everyone to get on the lifeboat.''

But in this instance, most people won't fit. And already, some of the nation's

top ethicists and flu experts disagree about who should go first.

" I'm not a fan of the rules as they've been presented,'' said prominent

bioethicist Arthur Caplan, director of the Center for Bioethics at the

University of Pennsylvania. " I'm not sure they've explained why they're doing

what they're doing.''

The priority vaccinations

The guidelines now listed in the federal pandemic flu plan call for health care

workers and vaccine producers to be vaccinated first. Few argue with that;

without them, there will be nobody to care for the sick.

" If you have doctors and nurses that don't come to work, you have nobody taking

care of flu patients,'' said Dr. Bruce Gellin, director of the National Vaccine

Program Office for the federal Department of Health and Human Services.

After that, the guidelines call for certain vulnerable groups to be vaccinated,

such as pregnant women, and then people older than 65. Healthy children would

come last, along with other healthy people ages 2 to 64.

It's more than an abstract policy for LeeAnne Cochran.

The 27-year-old Tampa resident was watching her three kids make their way to a

park play gym one afternoon last week. She had a quick reaction to who should

get the first vaccine: " The kids, I think.''

But her youngest child, 6-year-old Chelsey, was listening.

" No, you should get it first,'' she told her mother.

" But I don't want my kids to die,'' Cochran said.

" We don't want you to die!'' Chelsey said.

" But you have a whole life ahead of you.''

Is it that easy? Should Chelsey, Marissa and Devin get vaccine before, say, the

elderly? Before their grandmother?

" I don't know,'' Cochran said. " It's a hard decision. Yeah. I'd have to say the

kids. It's kind of selfish. But I have three kids.''

That question has been a key point of contention for scientists as well.

" There was substantial discussion of priority for children, " Gellin said. " It's

not as if they were ignored … healthy children have been at low risk in prior

pandemics.''

Does age matter?

It's the age question that has incited the most debate. In setting the

guidelines, the federal group assumed that this pandemic would be similar to

earlier ones in 1957 and 1968, and that the elderly would be among the most

at-risk for severe illness and death.

But others question whether that's true. In the worst flu pandemic, the 1918

Spanish flu that killed more than 40-million people around the globe, the most

deaths occurred among healthy young adults.

What would really save the most lives?

" Government policies have been, the people most likely to get sick, the people

most likely to be in danger,'' Caplan said. " But you could argue that in real

scarcity, it makes sense to take into account the best chance of surviving.

Instead of the 85-year-old with pneumonia, you could say you're going to treat

the 30-year-old.''

Caplan and colleagues recently put together a group, the Ethics of Vaccines

Project, to discuss such questions.Protecting children makes medical sense,

Poland said. Some studies show that vaccinating children for regular flu

decreases the spread of flu in the whole community. Children gather together in

school, swapping homework, hugs and germs at a rapid rate.

" Children tend to be super-spreaders,'' Poland said. " So in reality, if I give

it to a 2-year-old, I'm protecting the 2-year-old, the parents, the sibling, the

grandparents. If I give it to an 80-year-old, I'm probably not going to protect

the same number.''That depends on the nature of the pandemic, Gellin said. Who

gets vaccinated could change depending on who gets sickest.

" All this is shaped by how a pandemic looks,'' he said. " You need to have a

process that would allow that kind of flexibility — to have some understanding

of how it's playing out.''

Also, studies that show vaccinating children provides a protective effect on the

community reflect situations when enough vaccine was available to cover all the

children, Gellin said. In a pandemic, that might not happen.

Underlying the medical questions are more philosophical choices. Whom do you

want to save? How do you decide which lives have the most value? Dr. Ezekiel J.

Emanuel, chair of the Department of Clinical Bioethics at the National

Institutes of Health, recently upped the debate with a provocative essay in

Science magazine.

Federal guidelines suggest saving the most lives, rather than giving people a

chance to live more years or their natural lifespan, wrote Emanuel and a

co-author, expressing their personal opinions, not federal policy.

The two propose giving younger people higher priority based on that idea, then

combining it with what they call an " investment refinement. " They would give a

higher priority to 13-year-olds than 2-year-olds, balancing the teenagers' " more

developed interests, hopes and plans " that have not yet come to fruition.

The federal guidelines follow the same philosophical principles as vaccination

for a normal flu season, Emanuel said.

" It's a completely different situation,'' he said. " The potential for mortality

is high. The potential for social chaos is completely different … the principles

underlying pandemic flu (vaccination) need to be realigned too.''

Some say protect children

Others also argue for protecting children as a philosophical choice.

" The thing that would make the most sense to me, is not to prevent deaths, but

to preserve as many quality years of life as possible,'' said Dr. Sinnott,

clinical director of the Signature Program in Allergy, Immunology and Infectious

Disease at the University of South Florida College of Medicine.

How choices are made is an essential part of the equation, too, Caplan said.

Although there have been some government-sponsored forums on the topic, Caplan

said there hasn't been nearly enough public debate.

" The person who's more informed is more likely to comply,'' he said. " Part of

the reason to have a discussion of the rules is so people will follow them. It's

all the glue you've got.''

Other hard decisions would have to be made as flu spread. Who would get flu

medicine, such as Tamiflu? Ventilators? Beds in hospitals' intensive care units?

Some of those decisions would be similar to those made with vaccine, doctors

said. Health care workers, once again, would be high priorities for getting

Tamiflu, an antiviral medicine that could reduce the severity of the flu. But

other decisions might mean uncomfortable choices: giving beds to the extremely

sick — but not the frailest of all.

" When you're really overwhelmed, you start to ration by triage,'' Caplan said.

" Let go of the people so injured and sick that you don't know if you can help

them. Like on a military field … we do it a lot in war.''

And that, doctors say, is what a true pandemic would be.

http://www.sptimes.com/2006/05/28/Worldandnation/Who_lives_Flu_crisis_.shtml