April 26, 2024
medical practice

Ebola outbreak prompts ethical questions

Michael Cook

The World Health Organisation has declared it an international public health emergency, although it has not suggested general bans on travel or trade.

The worst-ever Ebola outbreak has prompted bioethical discussion on two fronts. The viral disease has killed about 1,000 people in West Africa, mostly in Guinea, Sierra Leone and Liberia. A few cases have been diagnosed in Nigeria. The chances of dying in this outbreak are about 50%. Newspapers in Western countries like the US, the UK and Australia are highlighting the possibility of their own epidemics. The World Health Organisation has declared it an international public health emergency, although it has not suggested general bans on travel or trade.

The first issue, as bioethicist Arthur Caplan points out, is that developed countries only worry about exotic diseases like Ebola when it threatens them:

“The harsh ethical truth is the Ebola epidemic happened because few people in the wealthy nations of the world cared enough to do anything about it. We do need headlines about Ebola. They should ask how did this incurable plague get out of control in Africa when medicine knows how to contain it? What are we going to do to fund research to find vaccines and treatments for diseases that don’t immediately threaten us, but kill a lot of people in far away lands? A public health policy that ends at our borders is not fair, just or even smart.”

The second is equitable distribution of a vaccine. There is no approved vaccine at the moment. A small American company, Mapp Biopharmaceutical, has been testing a vaccine called ZMapp on animals. But no one knows whether it is safe or effective on humans. Only a handful of doses at the moment and scaling up production to thousands of doses would take months.

However, two white American medical missionaries, Kent Brantly and Nancy Writebol, who contracted the disease in Africa have been given two precious doses of ZMapp and seem to be improving. Why were they chosen instead of Africans? Apparently it is regarded as good practice to treat “first responders” first because of a social responsibility to help those who help others.

“These were people who had volunteered to put themselves in harm’s way to help people who were affected by this,” bioethicist G. Kevin Donovan, of Georgetown University Medical Center in Washington told USA Today. “It’s not unreasonable for them to have the expectation that we would try to help them.”

But bioethicists are chary of manufacturing an untested drug to distribute in West Africa. ZMapp is unproven. The partial recovery of the two missionaries may have had nothing to do with the drug. Instead of curing people, it might make them worse.

The WHO has convoked a gathering to discuss the ethics of providing an untested vaccine. “We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,” says Dr Marie-Paule Kieny, of the WHO. “We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”

Some doctors have argued that African governments should make up their own minds on the ethics. Writing in the Wall Street Journal, three doctors contended that “African governments should be allowed to make informed decisions about whether or not to use these products, for example to protect and treat health-care workers who run especially high risks of infection.”

Arthur Caplan takes another tack. He favours boosting public health response in West Africa which so far has been chaotic and underfunded. “Morally, everyone is keenly interested in who should get the drug,” he told the New York Times. “But the most important moral question is, ‘What is the best thing to do to bring that outbreak to a close? And I don’t think it’s drugs.’”

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