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October 27, 2005

The Ethics of Tamiflu Ownership


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Much has been written about the making of moral decisions, and moral development. There is the famous academic disagreement between Lawrence Kohlberg and Carol Gilligan in which Gilligan challenged Kohlberg's theoretical heirarchy of moral behavior based on the value of justice (and research done almost exclusively on white males) by arguing that women base their moral judgements on the value of care instead, and therefore differ significantly from men, but are no less "developed". More recently, others have studied cross cultural moral decision making, and the possibility that moral behavior is biolologically based, summarized beautifully in a piece (well worth reading if you have the time) by Rebecca Saxe, called " Do the Right Thing".

Peter Sandman has elucidated the dilemmas that come with ordering one's own tamiflu. In lieu of doing a lick of work myself, I have, once again, blatantly, copied this interchange, directly from his site:

Adrienne, a local public health officer, wrote to Dr. Sandman on October 12, 2005:

"I have a concern about your suggestion to individuals to get a prescription for Tamiflu or Relenza now before supplies run out.

If everyone does so, there will be no medicine for those who may need to be treated this fall/winter for the run-of-the-mill flu, even if there is no pandemic. There may be thousands of doses sitting in people’s medicine cabinets just in case of a pandemic, but none for vulnerable people who may need it for treatment or prophylaxis within the next few months during the normal flu season which will definitely occur.

While the prospect of a pandemic is very frightening, and I can understand why people and physicians would want to stockpile some Tamiflu to protect themselves and their families, I would also want it to be available to sick or exposed vulnerable people this flu season and to critical service providers in case of a pandemic.

If I cannot support everyone taking this approach because of its negative impact on the health of individuals and groups, I cannot in good conscience prescribe Tamiflu for myself and my family.

I agree with you that the focus on antivirals and vaccines, which are unlikely to be available if a pandemic occurs soon, is detracting from other important planning efforts at the local level.

Thank you for your many useful and stimulating comments on pandemic influenza."

Dr. Sandman answered:

"I think you’re right. Any treatment course of Tamiflu (or Relenza) that’s sitting on someone’s shelf waiting to be needed isn’t going to be available to someone else who needs it already. Of course this is also true of a can of soup; there are hungry people right now who would have use for what I’ve stockpiled in my kitchen. But there’s no sign that the supermarkets are running out of soup, whereas the drugstores are very likely to start running out of Tamiflu soon. So many of my friends share your view that we should let the available Tamiflu remain unallocated, so it will be there for the first people who get sick and need it.

On the other hand, there hasn’t traditionally been much Tamiflu use for the annual flu. It needs to be taken within 48 hours of the onset of symptoms, which isn’t much time to get in to see your doctor — and many people with the flu don’t see the doctor for it at all. And most doctors (and patients) haven’t been all that interested in a drug that cuts the duration and severity of a disease most regard as an inconvenience, not a threat.

Moreover, Tamiflu for the annual flu is a little like the morning-after pill. People worried about the annual flu are supposed to get themselves vaccinated. Their ethical claim on Tamiflu if they neglected to get vaccinated seem less compelling to me than the claim of someone worried about a potentially pandemic flu strain for which there is no available vaccine. (Of course there are also people who couldn’t get vaccinated, or whose vaccinations didn’t take.)

The more common argument against personal stockpiles is that they diminish the supply available for a communal stockpile. Wouldn’t it be best for the government to centralize all the Tamiflu and, in the event of a pandemic, distribute it to those who need it most? Or, as is likelier, to those we most need to keep healthy?

There is truth in that one too, even though Roche claims its supply chain for individual prescriptions and its supply chain for government bulk orders are independent. (I don’t know if I believe that.) Of course the federal government has had at least as much forewarning as the rest of us; it ordered as much Tamiflu as it decided to order, presumably leaving the rest for you and me. And if state and local governments decide to commandeer the remaining Tamiflu supply (as they commandeered the flu vaccine supply last summer), they will. They haven’t yet.

Six months ago I argued that individual orders of Tamiflu were a double good: Not only did you get your Tamiflu, you also built the demand and thus the incentive for Roche to increase production capacity. By now I guess Roche has all the incentive it needs. So the question is straightforward. If you get your own Tamiflu now, your chances are better of having it available if you or someone you love gets the flu — whether it’s the annual flu or a pandemic flu. If you don’t get your own Tamiflu now, there will be that much more available for someone else to stockpile, or for the government to nationalize and allocate, or (your hope) for someone who already has the annual flu to start taking.

I respect, even admire, those who choose to forgo the chance to protect themselves now in the hope that someone else will be able to meet an imminent need instead. I nonetheless urge my family and friends to protect themselves now.

There’s also an interesting middle ground to consider. Small groups of friends and neighbors might be able to develop a shared stockpile. This would lessen the chances of a dose sitting unused on a shelf, while still freeing the participants from dependence on a very chancy government supply. Of course the issues of trust and equity could get hairy!

The ethical issue for the prescribing physician is a little different. Assume you believe that public health is best served by denying your patient a Tamiflu prescription, leaving one more treatment course in the communal pool, available for people who are already sick or whose health is especially important to protect. But you also know your patient’s health — the patient sitting in your office right now — is best served by providing the prescription, so your patient can be prepared if he or she gets the flu after there is no Tamiflu to be had. To whom does the doctor owe a higher duty: the doctor’s vision of what’s best for the general public or the doctor’s knowledge of what’s best for the individual patient? I’d have thought it was the latter, but I’m neither a physician nor a medical ethicist.

Despite all of this, the most important bottom line is personal morality. If getting (or prescribing) Tamiflu seems unethical to you, don’t do it."

Because supplies of Tamiflu are extremely limited, you must make your moral decision soon, or it will be made for you. Should you decide to purchase Tamiflu, it is still available on line without a prescription. Of course there is much more to personal preparedness than simply acquiring antiviral drugs. And when you finish that list, think about what you can do in the larger community.

Photo note: Is it on or off the hook? Ironically, the building belongs to Harvard, where Kohlberg and Gilligan did their thing.

Posted by Dakota at October 27, 2005 06:00 AM