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Ethics in a Time of Ebola

By Michael Cook

The Ebola outbreak has revealed a number of ethical issues that need to be sorted urgently.

Of all the calamities that a society can experience, war included, plague is probably the most frightening and socially disruptive. In the late 14th century the Black Death killed 30–50% of Europe’s population, leading to decades of depopulation and social upheaval. The 1918 influenza epidemic killed 50–100 million people, many of them young and healthy. In more recent times, AIDS, SARS and the H5N1 bird flu have created panic verging on national emergencies.

So it is no surprise that the Western world is taking an acute interest in the west African countries of Guinea, Sierra Leone and Liberia, where Ebola has killed hundreds of people. The mortality rate is 50–90%, and the agony of the afflicted is terrifying.

In this situation, you might think that bioethicists would throw ethical scruples to the winds. In fact, the Ebola epidemic has led to a lively debate about a whole range of issues.

Ethics of access to experimental drugs.
There is no proven cure for Ebola, and at the moment all that can be done is to provide comfort and keep victims hydrated. One drug that looks promising, ZMapp, is made by a small American company and has never been tested on humans. Besides, it takes weeks to produce and only enough for two patients was available when the epidemic broke out.

Under normal circumstances it would be absolutely unethical to give a patient an untested drug like ZMapp. The side-effects could be lethal. But in a fast-spreading epidemic it may do more good than harm for people who are already infected and face at least a 50% chance of death.

“We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,” said the World Health Organization.

In mid-August a WHO ethics panel concluded that “it is ethical to offer unproven interventions, with as-yet unknown efficacy and adverse effects, as potential treatment or prevention”. But it surrounded this with admonitions to respect “transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community”.

WHO was not being over-scrupulous. People stricken with Ebola are desperate and vulnerable. It is quite possible that they could be treated as experimental subjects with an interesting disease rather than as human beings.

Ethics of resource allocation.
If there is a shortage of vaccines, who gets priority? This was an immediate issue, as the first people to be treated with ZMapp were two white American missionary healthcare workers, not Africans. The reasoning behind this decision was that the safety of health workers has to take priority – otherwise no one would volunteer for such a dangerous job. But Africans, naturally, accused Americans of being selfish.

When more vaccines become available, who should get them? There are different theories on this. Egalitarians argue that everyone should be treated equally and the drugs should be allocated by a lottery. Utilitarians would give them to those who could benefit most. Or they could simply be given to those who are worst off.

The ethics of caring.
Should health workers risk their lives to treat victims of Ebola? It is very risky business, and a number of dedicated doctors and nurses have already died. In Nigeria, four Indian doctors claimed that they were being forced to treat Ebola cases and that their passports had been confiscated to keep them from leaving. Not everyone wants to be a martyr.

The ethics of drug development.
Why haven’t drug companies developed a treatment for one of the world’s deadliest diseases? The answer is simple: there is no money in a cure for a disease that attacks rural Africans. “This is the moral bankruptcy of capitalism acting in the absence of an ethical and social framework,” says Prof John Ashton, the president of the UK Faculty of Public Health.

The ethics of ethics.
In times of desperation only rich people are likely to heed bioethicists. In the three worst-affected countries, governments have taken the most drastic step possible – drawing a “cordon sanitaire” around the areas where the outbreak is most virulent. The perimeter is guarded by soldiers and no one is allowed in or out until the plague runs its course. It’s brutal, but it works.

In an age when a disease can spread from Lagos to Chicago in a single day, we are bound to experience more of these scares. We need to develop ethical solutions after the experience of this year’s Ebola outbreak.

Michael Cook is editor of the online bioethics newsletter BioEdge.