North Carolina doctors and nurses need a strong set of ethical guidelines to help them make the wrenching choices that a future influenza pandemic would force them to make, members of a state task force said Monday.

Before a global outbreak of a new and more virulent strain of flu virus strikes North Carolina, heath-care workers will need a checklist of clear priorities. That list would help them decide who gets treated and who doesn't as they face an overwhelming wave of flu-stricken patients that would rapidly outstrip the supply of hospital beds, medicine and critical medical equipment.

"It's going to exceed our capacity," said Philip Rosoff, director of clinical ethics at Duke Hospital and a member of the pandemic flu ethics task force, a joint project of the N.C. Institute of Medicine and the state Division of Public Health.

"The more stringent and robust our guidelines are, the less chance there is for decisions being made for arbitrary and morally unjustifiable reasons."

But coming up with those guidelines is proving to be almost as agonizing as the life-and-death decisions they are designed to aid. During a four-hour meeting Monday, task force members wrestled with the wisdom of giving children priority for scarce anti-viral drugs and vaccines. Task force members also worried whether their guidelines would cut off the poor and disadvantaged -- or the large number of Hispanic immigrants.

Although no one knows when the next pandemic will occur, medical researchers and public health officials say it is inevitable and long overdue. They point to three deadly outbreaks in the 20th century: the Spanish flu pandemic of 1918-19, which killed 50 million to 100 million people worldwide; the Asian flu pandemic of 1957; and the Hong Kong flu pandemic of 1968.

Scientists are nervously watching the H5N1 avian flu virus, which has killed more than half the people who have become infected but which has yet to mutate into a form readily passed between humans.

Choose one of three

During Monday's meeting, the task force also considered a grim scenario. Three gravely ill flu patients -- a 10-year-old with a 30 percent chance of survival, a 40-year-old doctor with a 25 percent chance and a 65-year-old retiree with a 10 percent chance -- all need the only ventilator available to help them breathe. Who would be hooked up to the ventilator and who wouldn't?

With hospitals across the state already at 85 percent to 90 percent capacity, even a mild pandemic would force doctors and nurses to ration medicine and equipment based on patients' chances of survival, said Rosoff, who is also a pediatric cancer specialist. These are combat-style triage decisions many doctors and nurses aren't used to making.

"Let's say I've got a hospital full of 85-year-olds on ventilators and I've got a 20-year-old who needs a ventilator: Do I take an 85-year-old off and give it to the 20-year-old?" Rosoff asked.

Guiding principles

The task force settled on two broad guidelines for rationing vaccines, anti-viral drugs and medical equipment during a flu pandemic:

* Making sure crucial functions of society aren't disrupted, which would mean giving health-care workers, police, firefighters and employees of critical industries such as utilities priority for vaccines and anti-viral medicine if they're at risk of infection.

* Reducing the number of deaths and infections and preventing the spread of the pandemic.

Since the task force started meeting in May, its leaders have resisted iron-clad directives that might hamper people on the front lines of a crisis. But during Monday's meeting, member John Morrow, health director for Pitt County, called for a more direct approach.

Time to get specific

"We're up here at 30,000 feet making these broad, philosophical statements, but nobody's going to read a paper like that," he said. "We've got folks with 100 doses of vaccine and everybody wants it, and we've got to give them specific guidelines on who gets it and why."

In earlier meetings, the 40-member task force has tackled other tough issues.

Those include the responsibility of doctors and nurses to provide care during a pandemic and a hospital's responsibility to make sure those workers are safe, properly trained to handle unfamiliar tasks and paid for service during a crisis. The task force, which will issue a final report by spring, has also drafted recommendations about limiting individual liberties during a pandemic, including the use of quarantine and the closing of schools, churches and other mass gatherings.

Task force members recognize their recommendations may be unpopular. But a flu pandemic calls for emergency measures.

"What we're talking about, in effect, is the survival of our society as a functioning entity," said John Moskop, professor of medical humanities at the East Carolina University medical school. "That's the way we can justify some of these priorities. What we've got is a threat to our society of such magnitude that we have to override personal rights and liberties."