Disaster Medicine and Public Health Preparedness

Research Article

Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making

Donna Levin, Rebecca Orfaly Cadigan c1, Paul D. Biddinger, Suzanne Condon, Howard K. Koh and Joint Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group


Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S132–S140)

(Received October 13 2008)

(Accepted April 29 2009)

Key Words

  • altered standards of care;
  • ethics;
  • public health preparedness;
  • allocation of scarce resources


c1 Address correspondence and reprint requests to Rebecca Orfaly Cadigan, c/o Kirkpatrick Tans, Division of Public Health Practice, Harvard School of Public Health, 677 Huntington Ave, Landmark Center, 3rd Floor E, Boston, MA 02115(e-mail: rcadigan@fas.harvard.edu).

Dr Levin is General Counsel, Massachusetts Department of Public Health; Ms Orfaly Cadigan is Program Manager, Center for Public Health Preparedness, Division of Public Health Practice, Harvard School of Public Health; Dr Biddinger is Director of Operations and Director of Disaster Medicine, Department of Emergency Medicine, Massachusetts General Hospital; Ms Condon is Associate Commissioner, Massachusetts Department of Public Health; Dr Koh, former Director of the Division of Public Health Practice, Harvard School of Public Health, is currently the Assistant Secretary of Health in the US Department of Health and Human Services (DHHS). The article was written before Dr Koh’s appointment as the Assistant Secretary of Health and does not necessarily represent the views of DHHS or the United States.

The contents of this manuscript do not necessarily reflect the views of the Centers for Disease Control and Prevention.