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INSIDE THE ETHICS COMMITTEE

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Programme 2. - Pandemic Flu

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THURSDAYÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌý 31/05/06ÌýÌýÌýÌýÌýÌýÌýÌýÌý 2100-2130

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PRESENTER:ÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌý VIVIENNE PARRY

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CONTRIBUTORS:ÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌý ANDREW HARTLE

ÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýROBERT DINGWALL

ÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýKERRY BOWMAN

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PRODUCER:ÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýMICHELLE MARTIN

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NOT CHECKED AS BROADCAST

PARRY

Welcome to the second programme of our series.Ìý Normally our panel members, all of whom sit on clinical ethics committees, take us through real life medical cases.Ìý But today they'll be doing something rather different - discussing the ethical issues around a clinical event that is yet to take place - pandemic flu.ÌýÌý

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In place of our usual witness statements then, we'll be presenting you with a number of scenarios, as if Britain were in the grip of a pandemic.Ìý To prepare these, we've consulted experts in modelling and planning. All our statistics are based on information contained in the UK Health Department's latest pandemic contingency plan.Ìý We'll also be hearing individual testimonies, read by actors,Ìý which will highlight the ethical problems which will face frontline medical staff when a flu pandemic occurs.Ìý Let me stress that all the reports are of course hypothetical but they will be of critical importance in the future.Ìý

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From the response to last week's programme, we know that you take a keen interest in ethical issues, so if you'd like to add your thoughts by telephone or through the programme's website, I'll be giving you the details later.

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And at that point, let me introduce the panel for today:

Professor Robert Dingwall is a social scientist and director of the Institute of the Study of Genetics, Biorisks and Society at Nottingham University.Ìý He's also a lay member of the Nottingham City and University Hospitals' Clinical Ethics Committee.Ìý Dr Andrew Hartle, consultant anaesthetist on the Intensive Treatment Unit at St Mary's Hospital in London, who also sits on their clinical ethics committee.Ìý And finally on the line from Toronto we have Dr Kerry Bowman, clinical ethicist at Mount Sinai Hospital.Ìý Dr Bowman was involved in the SARS outbreak in the city in 2003 and has experienced at first hand the acute ethical problems posed by such an emergency.

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So Kerry you've experienced this first hand, what are the main ethical issues that pandemic flu might throw up?

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BOWMAN

There are a lot and they surface very quickly indeed.Ìý One of the first is what are our priorities during a pandemic, who do we protect, how do we make decisions related to healthcare and resources?Ìý Another one that came up very quickly is what is the duty to care?Ìý What I mean by that is what is the actual responsibility of a healthcare worker during a crisis of that nature, at what point, if any, can healthcare workers say I do not feel safe, I am not safe, therefore I will not perform my job?Ìý And of course quarantine and personal liberty in a democratic society - at what point can you say you are not allowed free movement you must be quarantined?

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PARRY

Well the most likely way for a human pandemic to occur, would be if a strain of avian flu, for example, H5N1, mutated to a form that could be transmitted easily between people.Ìý This is most likely to occur in China, South East Asia or sub-Saharan Africa where people live in close contact with their animals.ÌýÌý If a person with normal seasonal flu becomes infected with an avian type, the two viruses could swap genetic information to create a new form.Ìý Now let's imagine that this has already happened, creating headlines worldwide.

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NEWS CLIP

The first suspected British case of pandemic flu has been reported in Manchester.Ìý A 50-year-old man has been quarantined in a local hospital.Ìý He's thought to have arrived in Britain on a flight from the Indonesian capital Jakarta two days ago.Ìý Although he showed no signs of illness on arrival he collapsed in the street last night and was taken to hospital.Ìý Tests are now being carried out to confirm whether he has contracted the potentially fatal strain of the virus.Ìý A hospital spokesman said they're waiting for the results of laboratory tests and in the meantime the hospital has been placed on full alert.Ìý Medical authorities in the North West are now trying to establish the man's movements since his arrival.Ìý

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It's now been a month since sustained human to human transmission was reported in South East Asia and border controls in the UK have been put on high vigilance.Ìý The Department of Health has issued a statement advising people to stay at home if they develop flu like symptoms and to call their doctor immediately.

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PARRY

Andrew, tell me first of all, why would pandemic flu be so much worse than the sort of seasonal flu we get every year?

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HARTLE

Well we're all exposed to seasonal flu it just changes gradually so many of us have some form of immunity.Ìý This will be a completely new genetic variant that humans haven't been exposed to before.Ìý It'll spread very quickly between people and no one will be immune to it.

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PARRY

Robert, if we know that flu - or we will see that flu probably starts elsewhere in the world can we not just close the UK's borders?

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DINGWALL

That's not a realistic strategy because of the speed with which people move, relative to the period that the infection takes to develop.Ìý Somebody can pick it up in Jakarta one night and be in London the next day, before they've got any symptoms they're already infectious - they're going to infect people before they present for medical attention.

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PARRY

Kerry, let me come to you now because you've had the other side of that where you had quite draconian travel restrictions, what sort of knock on effect did that have?

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BOWMAN

Well yeah I mean a lot of restrictions were set into motion pretty quickly, they weren't as extreme as some of the plans - we didn't go a later phase if the outbreak had been worse.Ìý But one has to do everything they can to curtail these infections when they start.Ìý And when I heard your Manchester scenario it's very similar to the situation that occurred in Toronto with SARS in which someone in a lift in Hong Kong brought on a flight to Toronto the SARS virus.Ìý And one has to do some serious limitations related to that.Ìý And this is hard, you know in a liberal democratic society people are not accustomed to having any of their freedom curtailed.

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PARRY

How about airport screening Andrew?

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HARTLE

It's unlikely to be effective, the rapid onset of this disease means that you could actually have caught it and be asymptomatic at the beginning of the flight and by the end of the flight you've got flu.Ìý

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PARRY

And what does airport screening actually involve?

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HARTLE

It usually involves questionnaires and so you're first reliant on people answering truthfully, if you're beginning to feel unwell and there's a worldwide epidemic of flu you're probably under a lot of pressure to get home, so people may not be truthful when they answer the questions.

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BOWMAN

And I must say airport screening in Toronto during the SARS epidemic was not effective for the reasons that have been stated, as well as just very hard to implement as well.

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PARRY

The prediction is that pandemic flu will have an incubation period of between one and three days.Ìý People will be highly infectious shortly before they get the first symptoms, and for four-five days afterwards.

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Now can we hear from our first witness?Ìý She's the next door neighbour of the first British case.

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SCENARIO 1

I can't believe this has happened.Ìý I'm going out of my mind with worry.Ìý Well we've all seen the news on the telly from Indonesia, it's just terrible what's been happening and now it's here in our street.Ìý I saw David getting out of the cab from the airport, I said hello and we had a chat, he said he was tired, a bit jet lagged, but he seemed fine to me.Ìý I can't believe this has happened.Ìý Anyway I'm going straight down to the doctors to get some of those antivirals.Ìý I've been looking on the internet and it says that they can reduce your risk of getting ill by 70%.Ìý Surely they'll give them to me, I mean I'm a teacher at St John's Primary and we've got 200 kids at school.Ìý If I catch this I could infect all of them.

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PARRY

Andrew, what will antivirals do and should they be used as prevention as this lady is suggesting or for treatment?

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HARTLE

Well they slow down the replication of the virus.Ìý They can be used in two ways:Ìý they can be used to prevent people catching flu, as a prophylactic measure or they can be used in the first day or two of flu symptoms to treat it.Ìý Now it's unlikely that prophylaxes will be effective for everybody and even effective treatment, once you've contracted flu, is likely only to shorten the duration of the illness rather than stop it and it may possibly reduce the complication rate.Ìý The other problem is that we just don't have enough of them.Ìý The best model at the moment from the Department of Health is that about 25% of the UK population will get pandemic flu and stockpiles have been built up to just over 14 million doses.Ìý If more than 25% of the population are infected we won't have enough.

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PARRY

So Robert, this lady clearly thinks that she needs them for prevention.Ìý She's a teacher, she's had contact with the first flu case, should she have them?

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DINGWALL

I think it's very hard to argue the case that she should get them, the exposure is quite minimal and I'm not sure that I would necessarily regard her as falling into a category of key worker for whom the access to these drugs in a prophylactic fashion might be considered a priority.

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PARRY

But what about all the children she's teaching?Ìý What about if she did have it and then she gives it to all those children?

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DINGWALL

Well the more appropriate response is to consider closing the school and reducing the opportunities for infection that way.Ìý If this really does develop into the pandemic that we're expecting the schools are going to close anyway.

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PARRY

So you would give it to key workers then and on the back of that who would you class as a key worker?

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DINGWALL

Well at one extreme clearly you have people like safety critical staff at nuclear reactors but at another you might have some quite odd people.Ìý I mean if you're trying to make it easy for people to stay in their own homes, for example, you might think of doing the delivery drivers from major supermarkets, would we want to encourage people to stay home and order their groceries online and have them delivered to the front door, rather than going to supermarkets and potentially getting together in a crowd and picking up infections that way?

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PARRY

I was just going to point out that in Britain actually there are no plans for mass prophylaxis because our antiviral stocks are primarily intended for treatment.Ìý Andrew?

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HARTLE

The bottom line is that there just isn't enough of this drug.Ìý It's got a single manufacturer who's making an awful lot of tablets but the demand is worldwide.Ìý The United Kingdom is probably way ahead in terms of stockpiling compared with many other countries.Ìý But even so we've only got enough doses to treat about 25% of the population.Ìý I mean the current estimates are that that's the number of people who will catch flu and that may be very conservative.Ìý Prophylaxis takes three times as many tablets as treatment.

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PARRY

If we use it for prophylaxis presumably we won't have enough for treatment.

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DINGWALL

Well if we use it for prophylaxis we may be able to treat somewhere between 5-10% of the population.Ìý But we ought to be debating very seriously whether that's actually a more effective use of the available supplies, given their limited efficacy as treatment - as you've heard from Andrew they will shorten a course of infection by maybe one day but that's not necessarily going to be the best use of this resource to keep the country going.

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PARRY

Andrew, the current emphasis is really very much on treatment and the line is that actually these drugs may mean the difference between life and death for somebody who's affected - would you go along with that?

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HARTLE

The evidence isn't really that strong.Ìý Firstly, we're still not certain that these drugs will work in this particular strain of flu, so we're making a lot of assumptions if we think this is a panacea.Ìý There is some evidence that if taken by high risk groups after exposure it reduces the instance of complications.Ìý The government is certainly hopeful that the use of these drugs will reduce hospital admissions and deaths but we just don't know until we try it.

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PARRY

Kerry, let me come to you now.Ìý Do you think that our antivirals should be used for prevention and if so who should get them?

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BOWMAN

I mean our position on this is first of all antivirals would certainly be used by healthcare workers and not from a position of privilege but from a position of duty - that they have a duty to protect and work with very sick people.Ìý Beyond that the categories we're looking at is in fact the most vulnerable people - elderly etc., young children - those kinds of things.Ìý But absolutely we would be looking at healthcare workers.

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PARRY

But wouldn't you have chaos if you gave antivirals to some people but not to others?

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BOWMAN

You may but what we learned in SARS is that you absolutely must have a solid efficient healthcare system and the hospitals must be fully staffed and functioning at peak efficiency in a crisis and you cannot risk having hospitals that don't function.Ìý If we have high absenteeism rate because of illness we cannot deal with the crisis at hand.

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DINGWALL

I mean I'm a little concerned by the emphasis that Kerry is placing on maintaining the integrity of hospitals because I think it's very important that we remember that most sick people and most treatment will be in the community.Ìý And the crucial thing is actually sustaining the infrastructure that will make it possible for people to stay in their own homes and to be looked after in their own homes.Ìý So that is going to point to things like keeping the supermarkets supplied, keeping the food systems going and I think that's something we need to think through very carefully.

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PARRY

Kerry.

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BOWMAN

Absolutely, you do want, in a crisis situation or a pandemic outbreak of this nature, to keep people at home in the community but what we learned in SARS, if people have what they believe is potentially a life threatening illness they will show up at a casualty or emergency department very quickly and it is extremely hard to turn anyone out of that door.Ìý So that's the reality, no matter what public message, when people panic they will be there.

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HARTLE

I think it's a really important point, this is really a public health emergency, by the time people are sick enough to come to hospital they're going to be really sick.Ìý The key to success here is going to be primary care, prevention and public health measures.Ìý Things that we've traditionally always done very well in the United Kingdom.

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PARRY

How are you going to ensure that the system is fair because when something like this happens the tendency is for everyone to be out for themselves because in the end it's about what's important to you and your mum's health, partner's health?

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HARTLE

It's very, very difficult for doctors because they are going to have so many patients and maybe we are the ones who should decide who gets this prophylaxis and this really is a public policy issue and I think there needs to be informed discussion about this now rather than waiting until we actually face an epidemic.

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PARRY

Andrew, what about vaccines - what's the position on those?

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HARTLE

Well this is going to be a new virus so we won't have a vaccine ready to go, we'll need to analyse the virus, create a vaccine, make sure it's safe and then make enough of it.Ìý There are going to be lots of problems.Ìý We know quite a lot about influenza virus as it is and there will be shortcuts but for example it's often grown in eggs and we may be limited by the quantity of eggs available to grow it.Ìý There's clearly going to be issues with safety, we won't be able to go through the whole licensing process and it's likely that the first people you're going to test this on are your healthcare workers and you don't want to run the risk of making them sicker, rather than making them safer.

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PARRY

But how long will those take to produce?

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HARTLE

I would have thought four months, approximately, if we're lucky.Ìý There are shortcuts that can be taken but then they make the vaccine itself riskier.

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DINGWALL

The importance of that is to understand that in the first wave of the epidemic the primary tools that we will have to disrupt its transmission are social and behavioural, they're not clinical.Ìý The clinical contribution in that first wave will be relatively small.

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PARRY

So it's really the quarantine measures - people staying at home …

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DINGWALL

Yes, what we can do to disrupt the transmission of infection, that's the critical thing, much more than either treatment or frankly prophylaxis.

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BOWMAN

I think one of the questions with vaccines as well is do we protect the labour force, the young healthy labour force, to keep society as functional as possible, if in fact we have a major outbreak, or in fact do we look to the most vulnerable people within our society and protect them first?Ìý Different people are in different places as to how they believe this should be done.

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PARRY

And of course as yet we wouldn't know who the virus would preferentially attack because it might be young people, it might be old people, it might be another group altogether.

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HARTLE

Oh we don't know yet because we don't know which strain of virus we're going to be facing.Ìý Certainly if we look at the three major pandemics of the 20th Century they all had very different age specific effects and we'll be learning quickly.Ìý And I think one of the big things to come out of this is that whatever plan we have now we're going to have to learn a lot quickly and change out plans.

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PARRY

You're listening to Inside the Ethics Committee. Today we're discussing the ethics surrounding pandemic flu.Ìý It's now two weeks since the disease was first confirmed in Britain. There's been over 31,000 cases reported with 250 deaths.ÌýÌý Each person with the disease is likely to infect at least two more people although it might be as many as six.Ìý The first case was in Manchester but there are now reports from every part of the British Isles, with most in major cities and some in isolated outbreaks elsewhere.

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NEWS CLIP

The government has announced today that the forthcoming major football fixtures will be postponed due to the pandemic flu crisis.Ìý Theatres, cinemas and other large public venues will remain shut until further notice, whilst school and nursery closures are being controlled by local authorities.Ìý So far a number of major companies have restricted employee movements and are telling staff to work from home if possible.Ìý The Department of Health is advising people to cancel non-essential travel and to follow the basic hygiene measures outlined by the Chief Medical Officer.Ìý Anyone developing flu like symptoms should call the NHS flu action number immediately.

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PARRY

Most people are being treated at home but over one and a half thousand people have already been taken to A&E, with 350 being admitted for hospital care.Ìý This is a slow start but medical staff are already beginning to feel the strain.Ìý We hear now from a nurse in a major London hospital.

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NURSE

Yesterday one of my colleagues was diagnosed with flu.Ìý Everyone's terrified, I mean it's only a matter of time before another one of us comes down with it.Ìý It's not so much that I'm worried about myself, I mean if you work in healthcare these are the kind of risks you take, but I've got a three-year-old son with leukemia.Ìý He's in remission at the moment and he's back home but if I catch flu and infect him, well it doesn't bear thinking about.

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PARRY

Her husband is putting huge pressure on her not to go into work.

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HUSBAND

I can't believe she's going into work, I know this is her job, I know she has to take risks but our son's still recovering, his immune system is very weak.Ìý If he catches this he'll die.

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NURSE

Hospital management are telling us that we all have a duty to report for work and we can't afford for me to lose my job, especially not now.Ìý I mean my husband is frantic with worry.Ìý So do I come into work or do I stay at home?

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PARRY

Kerry, this comes to the core of what you were talking about earlier - duty of care.Ìý How worried were staff about coming into work when you had SARS in Toronto?

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BOWMAN

Extremely worried and very worried very quickly.Ìý Once the outbreak struck there was a great deal of fear. ÌýAnd as the hospital ethicist I was quickly inundated from senior administration to frontline nursing as to where is the duty to care ethically, at what point can a worker if any say I can't do this?Ìý I have many nurses coming by my office saying very, very close to that scenario, that they were afraid for the wellbeing of their children or they were under enormous pressure at home from a spouse.Ìý We had a lot of family tension and quite a rash of divorces after SARS because the families of healthcare workers really were not on board and had not really thought through some of this before the crisis happened.

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PARRY

Were there any that you allowed to stay home?

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BOWMAN

There certainly were some.Ìý I mean the case you mentioned with immunosuppressed people at home, that was a consideration.Ìý But we were really quite broad sided by this because the duty to care had not been clearly defined, certainly in Canada anyway, and I suspect in many Western countries, because we've had a pretty peaceful and easy time for decades and it didn't occur to a lot of people when they went into healthcare that there could be a prolonged crisis situation.Ìý So there were some people, such as with immunosuppressed children or a parent or a sibling at home, that stayed put.Ìý But you know this evolves, so what are we saying - are we saying someone with a baby at home shouldn't come in, what about a two year old, what about a five year old, what about a parent?Ìý If you let that spin out I mean what you've got is only single people are going to go to work, well that's not ethical either, so you have to set some limits somewhere.

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PARRY

Did you know many of the people who got infected - healthcare workers?

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BOWMAN

Yeah several colleagues and friends of mine got infected, one of which died in fact, and that really brought it home in a way that any amount of discussion or reading doesn't.Ìý The reality was very powerful.

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PARRY

Robert, duty to care, it's an expression that perhaps we're not very familiar with.

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DINGWALL

And I think we ought to be careful not to get it wholly out of perspective.Ìý I mean historically it's a fairly recent notion that healthcare workers have any kind of obligation to put their own lives at risk in the care of their patients.Ìý When the Great Plague came to London the members of the College of Physicians were the first people to get on their horses and leave town and nobody thought any the worse of the them for doing so.Ìý And that does mean that I think it's important that hospitals use their imagination to think of ways to make it easy for people to fulfil that expectation.

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PARRY

Andrew, you're a frontline medical worker, have you ever been put in a position where you had to choose between possible infection from a case and your family?

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HARTLE

Thankfully not but one does remember that only 20 years ago when HIV started appearing in the health system many doctors, nurses and other therapists were afraid to treat these people because of putting themselves at risk.Ìý I think there's another important point to make that the choice between going to work and staying at home in this circumstance isn't an absolute choice between risk and no risk, it could be that you're more at risk of catching the flu from your children than you are at work.Ìý And indeed you're going to have to travel to work so some form of public transport will still need to be working and all of these places are potential risk of catching the disease, so it's not an absolute choice.

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PARRY

Kerry, what happened to those members of staff who didn't show up for work, were they disciplined?

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BOWMAN

Well it's hard to know why people don't show up for work and you know particularly with nursing absenteeism is often relatively high with the shift work and the stress of it to begin with, so it was very hard to prove anything and I know of no one that was directly disciplined in that way.

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PARRY

Kerry, another ethical issue of course here is quarantine, will people be quarantined and will it be effective?

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BOWMAN

Well it can be effective if it's done in a timely fashion.Ìý Quarantine's a hard one because we had voluntary quarantines in which people were willing able to stay home for 10 days and I know that that may not sound like the worst thing in the world for some people yet within your home is most often your family and contact with your family had to be kept to an absolute minimum.Ìý We were very close to looking at legal structures for quarantine as well and possibly having people forcibly quarantined.

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PARRY

Were you quarantined?

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BOWMAN

I was quarantined twice, I was very unfortunate, we had what we called SARS 1 and SARS 2 in which there was two waves of the outbreak and I was directly exposed to a patient with SARS in the intensive care unit in the early days and then in the second wave I was exposed to a healthcare worker.Ìý But having said that I did not get sick.

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PARRY

But how was the quarantine for you?

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BOWMAN

Awful, awful.Ìý You know you're completely isolated within your own home, if people know what it is you do for a living, even deliveries, people don't want to come to the door.Ìý A good friend of mine, a nurse manager with three children and a husband, when she came home from work she stayed in an unfinished basement and slept on an air mattress in a sleeping bag and her family brought her dinner to the top of the stairs and that is how she lived.Ìý But remember this went on for weeks and this was not a pleasant existence.

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PARRY

What is the ethical position about forcing people into quarantine because presumably some people would refuse?

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BOWMAN

Some people would refuse and we had a situation in which we had some mass exposures and some people were refusing.Ìý People will feel differently about this from an ethical point of view but the risks are so high of a person refusing quarantine that many people would feel that in fact the law can be enacted in this case to force someone into a quarantine situation rather than have an outbreak spread through a major city.

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PARRY

And Andrew would it work?

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HARTLE

I'm not sure, I'm not sure who's going to force the quarantine issue.Ìý Where are you going to put them?Ìý Are you going to put them at home and how are you going to keep them there?Ìý A voluntary quarantine would certainly work but sticking a policeman - and there aren't going to be as many of those around as we want - outside your door to keep you there is probably not a good idea.Ìý If you actually then wanted to quarantine a group of people together that almost guarantees that it'll spread like wildfire and it's residential homes, barrack blocks, prisons that flu spreads through amazingly quickly.

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PARRY

Robert, what are the legal problems here if you quarantine people, I mean are there ethical issues in detaining people of their liberty?

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DINGWALL

I mean clearly you are looking at a form of preventive detention here and although it could be done under civil emergency powers in this country I think it is fair to say that a lot of public health law is in a state of some decay, it hasn't been comprehensively updated for a very long time, and it's not clear how well it will apply into the situation of this increased fragmentation of the National Health Service.

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PARRY

And presumably some of it would be in direct contradiction to the Human Rights Act?

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DINGWALL

Well I think the, as we've been reminded, I mean the Human Rights Act is always subject to caveats about public safety and I don't think that people should be unduly concerned about legal difficulties if they have acted on a basis of good evidence and good faith.

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PARRY

Andrew, do you think you can tell people to stay at home and effectively quarantine them, and expect to stay there, won't they just pitch up at accident and emergency if they've got symptoms?

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HARTLE

I think that's the natural response and even more so if it's your child.Ìý

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DINGWALL

And I think what we keep coming back to here is the importance of proactive engagement of the population with the decision-making, the policy issues that are going on here, right back to Kerry saying, at the beginning, how do we deal with panic?Ìý Well one of the ways in which we deal with panic is trying to prevent it happening and that does mean taking people with you, it depends on strategists persuading people to adopt - to do sensible things, persuading people to voluntarily quarantine themselves.

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PARRY

So that you're not faced with the ethical issues that extreme situations …

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HARTLE

A kind of reliance on state authority, on command and control, on coercion is always going to be ineffective.

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PARRY

Kerry, I can hear you agreeing with that.

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BOWMAN

Yes, I'm agreeing wholeheartedly.Ìý If there's one thing we learned from SARS is that we weren't ready and one thing that we are certainly doing in Canada, and Toronto specifically, in preparation for a potential pandemic of flu is broad public discourse and to have these conversations ahead of time.Ìý It's not just what decisions we make, it's how we make these decisions.

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PARRY

Let's move on now to the question of resources.Ìý The pandemic has peaked, some six weeks after the initial case, with over three million people contracting flu a week.ÌýÌý Hospitals are full and there are between three and five people needing every hospital bed available.Ìý All non-essential treatment has been cancelled. Staff are under impossible strain.Ìý In one hospital, troops have been brought in to protect doctors from angry relatives as their loved ones are turned away.Ìý We now hear from a respiratory physician on the triage team in an intensive care ward.

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PHYSICIAN

We've got three floors packed with flu patients and now we've reached capacity and we're out of beds.Ìý The flu patients in intensive care all have respiratory failure and are ventilated.Ìý But now we've only got one ventilator bed available and there are two patients who need it urgently.Ìý A mum's just brought in her 17-year-old daughter who's been knocked of her bike, she's got severe concussion from a head injury and she's lost her spleen due to bleeding.Ìý And the other is one of my colleagues, a physician who's caught the disease from one of his patients.Ìý He's 38, got two kids and he also has diabetes and moderate renal failure.Ìý This is an extremely difficult call.

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PARRY

Andrew, you've been in that situation, how would you make that call?

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HARTLE

Well at present we don't have to make the call, at present if we decide you need intensive care you'll get intensive care, you may need to be transferred to another hospital but you'll get it.Ìý In this circumstance you won't necessarily get it, there won't be enough beds.

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PARRY

Okay but let me pin you down on that.Ìý What would be your thinking process if the facilities you only had the one bed, how would you decide between those two cases?

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HARTLE

It's the person who will get the most benefit rather than the person who has the most need.Ìý I think you could have two patients who are equally sick but one much more likely to survive and I think in this circumstance the one who's likely to survive is the one you're going to treat.

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DINGWALL

And that's not necessarily related to age, as Andrew was saying, we don't know who the high risk groups will be in the pandemic.Ìý One could imagine young patients with multiple organ failure and old patients, who are in reasonably good health, where the only thing that is affecting them is the respiratory distress from the influenza.Ìý And in those circumstances it would be the older patient who would get the preference.

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PARRY

And what about if it's your top flu expert, whose information and whose brain power is desperately needed in this situation?

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HARTLE

Well that's an issue that we try not to think about normally, we don't try to place a value on somebody to society, that's not our role, that we should treat each patient on the basis of their medical need.Ìý You can foresee a really drastic situation where it might be felt that some people were more important or of more value than others.

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PARRY

I mean for instance an intensive care specialist.

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HARTLE

Well I should declare a personal interest but possibly.Ìý It's very difficult because we know that this pandemic isn't going to be confined to this six week period …

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PARRY

No we've got another wave coming.

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HARTLE

There are several waves coming.Ìý Not to start placing values on individuals, that's something we don't do, and again I think that's why this is a matter of public policy.

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BOWMAN

I agree.Ìý But one thing about decision making in triage to some extent it pulls us out of the usual ethical terrain.Ìý Certainly in this country, and my understanding is Britain as well, is it's very much focused on the choices of patients and patient specific care.Ìý In a crisis of this nature we shift to what would be called more utilitarian, and what I mean by that in looking at outcomes, looking at what is best for the largest numbers of people.Ìý And so we do have a shift in our ethical blueprint and that can be very hard to change gear so quickly and that could create tension within society very quickly, which is why we need these public discussions.

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PARRY

So how different would the situation in a pandemic be from what you face from day to day?Ìý Andrew.

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HARTLE

Well the current predictions are that we will have twice as many patients with flu alone needing intensive care than we currently have.Ìý Eighty per cent of ICU admissions in this country are emergencies and those aren't going to go away, so the demand for intensive care is going to be increased.Ìý There are national and local plans to increase critical care capacity but there are very real concerns amongst very senior people in the intensive care world that we won't cope.Ìý We are going to be as affected by flu as the general population - that's 25% of staff off.Ìý I think we're going to struggle to maintain our existing level of care, rather than providing more intensive care.

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PARRY

Robert, what's your reaction to that?

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DINGWALL

Well I think there's certainly also a case for saying that maybe we won't have intensive care in the form that we currently recognise it if the pandemic gets really severe.Ìý In the terms that Andrew's outlined it would actually make more sense to close the units and redeploy the staff as, if you like, ventilation life support consultants on general wards trying to see what could be done for the greatest number of people.Ìý But certainly recognising that for example patients who go into multi-organ failure will probably simply be given palliative care and allowed to die quietly and as comfortably as possible.Ìý Of recognising that certain sorts of pretty ineffective interventions, a lot cardiopulmonary resuscitation for example, again simply wouldn't be attempted because the resources that it consumes could be used more beneficially elsewhere.

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PARRY

How will you cope with the relatives of the patients - we heard about …?

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DINGWALL

Well this is why it's so important to be clear up front about the parameters within which the health service will be operating and within which the professionals will be making the decisions and these have to be matters of community consent and public policy because if we don't protect and support the professionals we are putting them in an impossible position.

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PARRY

Sorry Andrew you had a point.

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HARTLE

There's a real problem here and that's sick children.Ìý It may be that in this pandemic children are more affected than young adults, yet there's much less provision for paediatric intensive care than there is for adults.Ìý Many local district hospitals won't have intensive care facilities for children, so your local hospital may not be able to look after your sick child.

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PARRY

How could you turn sick children away?

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HARTLE

I can't imagine it, I just don't know how we'll do it.Ìý Do we have a waiting list of sick children to be transferred between hospitals or do we start treating children on adult intensive care units where the intensive care doctors and nurses aren't used to looking after sick children and will be putting even further pressure on very limited intensive care beds and that's going to be a real dilemma.

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PARRY

Kerry, how tricky did it get in Toronto?

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BOWMAN

It got quite tricky.Ìý The ICUs were very difficult places to be because the rate of infection was very high and it was extremely difficult when people had respiratory failure with SARS in terms of intubating them and how much time do you take to get the full precautions on, it was very difficult.Ìý But you know one of the things that we're looking at, as you are in Britain, is coming up with triage policies - benefit versus need is an understandable and wonderful way to proceed.Ìý It's so hard to make any decision that is not at least partially valuating in medicine.Ìý Age comes into it, social factors creep in on the side, all these kinds of things.Ìý So it's very important that we have policy.

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PARRY

And what was the atmosphere like within your wards?

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BOWMAN

It was difficult, it was very difficult.Ìý I was assigned to the doors and we all had emergency assignments, it was extremely difficult.Ìý I personally was working with pregnant women who were in labour, coming in, it was extremely difficult.Ìý People tended to rise to it with time, as the weeks went by people got pretty tough, they'd grit their teeth and they said we have to do this and we have to survive this.Ìý And in fact the camaraderie between and amongst healthcare workers was really quite strong.Ìý Our families was another story.

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PARRY

You say you were on the doors, explain what you mean - what was it like in the wards, how did they look?

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BOWMAN

They were unfortunately like something out of a science fiction movie.Ìý At the SARS wards themselves we had plastic sheets, we were in what looks to the public like essentially a space suit, they were pretty frightening places.Ìý And we were still having breakthrough cases, meaning healthcare workers picking it up somehow, someway.Ìý Working on the doors - the hospital was sealed, except for one entrance, we were masked, gloved, gowned.Ìý As patients came to the hospital we took their temperature on the spot, we sat down and interviewed them, some of them had dying relatives within our hospital - non-SARS related, occasionally SARS related - we had to make decisions about that.Ìý They were frightening looking environments, I really felt for the patients that already were frightened.

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PARRY

Well Andrew, just a final point with you.Ìý Might we see separate institutions, like the infectious disease hospitals of old, where we put people with flu?

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HARTLE

It's an attractive idea but I don't think it's going to be practical.Ìý Firstly, I think the number of flu patients and the number of people requiring hospitalisation will mean that you won't actually be able to separate flu and non-flu hospitals.Ìý In the early stages it could work in central London where you actually have several hospitals very close by.Ìý But for most Britons they only have one choice of hospital and if you're sick you'll go to that hospital.

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PARRY

Well some very chilling thoughts there.

Ìý

It is estimated that about half of Britain's population will be infected by pandemic flu, of which half will have symptoms.Ìý It is thought that there will be 55,000 deaths.Ìý But in the worst case scenarios, this figure rises to over half a million.

Ìý

But let me come back to you, the panel, finally - how real are the situations we've been talking about and what sort of ethical debates do you think need to be had now.

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HARTLE

The Chief Medical Officer has always said when and not if and I think these are very real scenarios and it's what will happen.Ìý I think there needs to be an open informed public discussion about how we make these decisions, rather than leaving the decisions to the healthcare professionals at whatever time the epidemic starts.

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PARRY

Robert.

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DINGWALL

I would endorse that but I would also add that I think it's really important that we don't see this as a matter that's confined to hospitals and healthcare professionals, that it's the resilience of the communities and it's about thinking what we can do to enhance that and that does imply a strategy that has a much greater involvement of the social sciences and of the bioethicists in promoting the debate on public policy than we've seen so far.

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PARRY

Kerry, you've seen this at first hand, are we scaremongering?

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BOWMAN

I don't think we are, it's a reality, you know it hit us and it hit us hard, it hit us overnight and it hit us like the Manchester scenario at the beginning, it's a reality and Toronto will say that.Ìý We will be judged on the decisions we make in a crisis and this is what defines what a society is all about, this is the time for discussions, not frightened discussions but open discussions.Ìý And in a democratic society like both of ours these things do need public engagement.Ìý So much of the SARS problems could have been avoided if the conversations had taken place first.Ìý To counter that some people would say you're creating fear and you're wasting a lot of resources for something that may never happen, what I say to that is if this never happens and we waste our time hallelujah - I'll be very pleased about that.

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PARRY

And if you'd like to have your say about the issues that we've raised today then go to bbc.co.uk/radio4 and follow the links to Inside the Ethics Committee where you can leave your comments.Ìý Or you can call the Radio 4 action line on 0800 044 044.Ìý And thank you for all your comments on last week's programme.

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Join us at the same time next week, goodbye.

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ENDS