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A sanitary-veterinary worker puts a domestic goose in a plastic container to be killed and incinerated in the village of Scarlatesti in Romania. A turkey has been found with the H5 strain of bird flu at Scarlatesti, and authorities responded by slaughtering poultry in the area. A total of 15,000 birds will be killed and incinerated, with owners receiving payments to compensate their losses. (DANIEL MIHAILESCU/AFP/Getty Images)

President Bush's cabinet members are coming to Minnesota soon to discuss the state's plan for a bird flu pandemic. President Bush unveiled a federal plan more than a month ago calling for billions of dollars to invest in vaccine research and production. Some public heath officials in Minnesota and around the country have criticized the federal government's plan. They say it doesn't not addresss the ethical challenges a flu pandemic would pose. Minnesota officials say they plan to talk about ethics at some point, they're just not sure when.

St. Paul, Minn. — State officials say they will talk about ethics before a bird flu pandemic hits. But it's not as easy as calling a simple meeting. Harry Hull, the state's epidemiologist, says the discussion will have to consider questions of life and death that most people have never had to ponder. "We've got a very difficult situation here," Hull says. "How can we get through it and to maximaize the number of people that's going to survive, to provide the best care that we can to people, realizing that we don't have the best resrouces that we do?"

But so far there's no discussion planned. No one has written up a list of topics to talk about. And no state agency is clearly in charge of the issue.

That's what happened in Canada before the SARS outbreak of 2003.

Dr. Ross Upshur says when severe acute respiratory syndrome -- SARS -- hit, Canadian officials didn't have guidelines covering the ethical considerations of a pandemic. So he wrote them, and has now adjusted them for bird flu.

Upshur, a researcher at the Joint Center for Bioethics in Toronto, had heard that governments were struggling to prepare for the ethical questions raised during a pandemic.

"Our point is if you have some plan in place for the communities affected so they have some trust in the process, particulalry where their individual interests may be possibly compromised, then you have more trust in the process when the time comes," Upshur says.

Upshur's guide is meant for audiences around the world. It's designed to adapt to fit to their needs. There are some constants, like the duty of governments. For example, if public health departments enact a quarantine, they should clearly explain its justification to the public.

And the government should take care of people under quarantine, Upshur says, "because what you're going to be asking individuals to do is ask them to restrict their interests for the greatest common good. And in those circumstances it's imperative that they be supported. So if people stay home, there has to be some way to arrange for them to be cared for -- for them to have food."

Upshur says different communities will make different decisions about how to distribute scarce resources and that's OK. But they should make those decisions transparent. For instance, take the matter of flu shots. There's disagreement about who should get influenza vaccines during normal flu season. In different countries the decisions are based on different priorities. In the U.S. and Canada vulnerable populations are first in line. That includes older people, those with compromised immune systems, and kids under two years old.

Upshur says in Japan, however, kids get the shots before anyone else.

University of Minnesota bioethicist Jeffrey Kahn says deciding who gets care will be the hardest.

"What counts most? What you will contribute in the future? What you contributed in the past? Should we try to save the most people possible? Which are the values that we think are the most important?" he says.

He says the standard we use now for treatment may need to change, including who gets a flu shot.

"Now maybe in the coming pandemic it won't be that group that's most vulnerable. But we seem to be committed to treating the vulnerable first. And if that's our commitment, then we should honor that and figure out who those people are and they should be the first in line."

Many of the obvious questions come from the doctors' offices or hospitals. But in the workplace there's a whole different set of ethical considerations. Does business shut down in the event of a pandemic? Should employees have to come to work? What role does the government play in any of that?

The state's plan for a flu pandemic includes shutting down schools and public gathering places. So far it offers little guidance for the private sector. So businesses are on their own to decide what to do.

When contacted by Minnesota Public Radio, most private corporations didn't want to discuss their response plans to a pandemic or even talk about their company's preparations. None planned to shut down regional operations and send employees home in the event of a bird flu outbreak.

Toro officials said they would wait for the governor to give them directions in an emergency. A representative from Cargill said the company is more concerned with its international employees and keeping them safe.

Chris Terzich, who is in charge of emergency management for Wells Fargo banks, heads up an emergency planning group of area businesses called the Minnesota Information Sharing and Analysis Center. The group recommends something called "social distancing" in a pandemic.

"The closer people are and the more time they spend in that close proximity, the more significant their chances of transmitting something like the flu would be. So you have to take and consider that in a workplace environment and look for opportunities to spread people out," Terzich says.

Terzich's group recommends moving desks, or staggering work shifts.

That's one of 10 steps the group suggests for working through a pandemic. He estimates that company's will have to do business with absentee rates of up to 30 percent.

"To look at it as 'we'll simply shut our doors and go home until it's over,' I don't think anybody is talking in that way, unless they happen to be a very unique business, a custom business, that can do that," Terzich says.

Terzich says many businesses provide essential services and would do more harm by shutting down. It's part of his groups's job to figure out just what those essential services are.

Bioethicist Jeffrey Kahn at the Univerity of Minnesota's Center for Bioethics balked at the idea of social distancing at work. He says expecting people to come to work during a pandemic could hasten the spread of a disease as contagious as bird flu.

"If we knew there was a way to prevent that from happening, wouldn't it be worth losing two weeks of productivity in the state or even the country to prevent that serious level of illness or even death?" he says.

Kahn says he wouldn't go to work. It wouldn't be worth putting his family at risk. It's probably not an issue for him, since his employer, the U of M, is already planning to shut down if there's a pandemic outbreak of disease. In the meantime, private businesses don't have a clear response plan to an outbreak of bird flu. And it seems that many are waiting to get word from the government about what they should do.