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Morality in a time of Ebola

2015; Elsevier BV; Volume: 385; Issue: 9971 Linguagem: Inglês

10.1016/s0140-6736(14)61653-6

1474-547X

Arthur L. Caplan,

Ethics in medical practice

The first true epidemic of Ebola led to widespread panic. The virus appeared in so many countries in 2014—including Guinea, Liberia, Mali, Nigeria, Senegal, Sierra Leone, Spain, and the USA—that WHO, officials at the US National Institutes of Health and Centers for Disease Control and Prevention, and many other government officials around the world declared the epidemic to be out of control.1Szabo L Ebola outbreak racing out of control, officials say.http://www.usatoday.com/story/news/nation/2014/09/03/ebola-out-of-control/15015143/Google Scholar, 2Zezima K Ebola outbreak 'out of control', says CDC director.http://www.washingtonpost.com/blogs/post-politics/wp/2014/08/03/cdc-director-ebola-is-out-of-control-in-west-africa-but-can-be-stopped/Google Scholar Talk of desperation and apocalypse with reference to Ebola is not uncommon.3Rotella C This is not the zombie apocalypse.http://www.bostonglobe.com/opinion/2014/10/24/the-ebola-panic-and-zombies/r8wo8gqEjeh5VFcRpKOvLL/story.htmlGoogle Scholar Previous Ebola outbreaks were rapidly contained through a combination of local attentiveness, the availability of resources, focused public education, and a bit of luck. In the 2014 outbreak, resources were slow to arrive, poverty and ignorance held sway, and luck failed to appear. The epidemic jumped from village to village, nation to nation, and from afflicted patients to caregivers and family members at an alarming rate. Ebola reached one nation, Senegal, with major global air connections, another, Nigeria, with a huge population, and a third, the USA, where errors were made in the care of an infected visitor leading to the infection of two nurses, which raised the level of anxiety even higher than it had been.4Weintraub K Mistakes and reversals shake trust in Ebola response, in Dallas and beyond.http://news.nationalgeographic.com/news/2014/10/141019-ebola-outbreak-dallas-airborne-health-medicine/Google Scholar Panic shaped much of the international response to Ebola. Initially, public health officials stressed the importance of isolation, careful handling of the dead, liberal use of disinfectant, gloving, hand washing, protective masking, goggles, travel restrictions, and other public health measures.5WHOFrequently asked questions on Ebola virus disease.http://www.who.int/csr/disease/eboia/faq-ebola/en/Google Scholar The deadly nature of the disease combined with fear of what was a very fast-moving plague during the summer—fear that was stoked by a flood of irresponsible public commentary6Holan AD Sharockman A 2014 lie of the year: exaggerations about Ebola.http://www.politifact.com/truth-o-meter/article/2014/dec/15/2014-lie-year-exaggerations-about-ebola/Google Scholar—quickly shifted attention from public health measures to what could be done prophylactically and to treat infected individuals. The high profile use of an unapproved investigational agent, ZMapp (a combination of three different monoclonal antibodies), in infected health-care workers in the USA and Europe7Caplan AL Why do two white Americans get the Ebola serum while hundreds of Africans die?.http://www.washingtonpost.com/posteverything/wp/2014/08/06/why-do-two-white-americans-get-the-ebola-serum-while-hundreds-of-africans-die/Google Scholar created pressure to find anything that might offer hope of a cure. Many solutions have been proposed, including repurposing existing immunomodulatory drugs such as statins and angiotensin-converting enzyme inhibitors;8WHOStatement on the WHO Consultation on potential Ebola therapies and vaccines.http://www.who.int/mediacentre/news/statements/2014/ebola-therapies-consultation/en/Google Scholar rapid manufacture of ZMapp; testing of broad-spectrum antivirals such as brincidofovir and BCX4430 (a viral RNA polymerase inhibitor); use of vaccines made from modified chimpanzee adenovirus,9Kanapathipillai R Restrepo AMH Fast P et al.Ebola vaccine: an urgent international priority.N Engl J Med. 2014; 371: 2249-2251Crossref PubMed Scopus (94) Google Scholar genetically engineered vaccines from recombinant vesicular stomatitis virus, modified rabies vaccine; and use of antibodies obtained from the serum of Ebola survivors.10CBC NewsEbola crisis: WHO allows some survivors' blood as treatment.http://www.cbc.ca/news/health/ebola-crisis-who-allows-some-survivors-blood-as-treatment-1.2756813Google Scholar The proliferation of possible solutions to the Ebola crisis raises the question of what, if any, ethical standards ought to govern their testing. A few commentators have urged caution in the face of panic, arguing against deviation from standing ethical maxims in testing new drugs or vaccines.11Rid A Emanuel EJ Ethical considerations of experimental interventions in the Ebola outbreak.Lancet. 2014; 384: 1896-1899Summary Full Text Full Text PDF PubMed Scopus (96) Google Scholar However, such calls for caution have not always found a very receptive audience in the face of the deadly epidemic.12WHO Ethics working groupEthical issues related to study design for trials on therapeutics for Ebola virus disease.http://apps.who.int/iris/bitstream/10665/137509/1/WHO_HIS_KER_GHE_14.2_eng.pdfGoogle Scholar Nor should they. Ethical business as usual in the face of an epidemic that kills 70% of its west African victims strikes many as nothing short of ethical fiddling while Africa dies. In a humanitarian emergency—as in situations in which people face imminent death or disability and seek access to unapproved agents13Caplan AL Moch K Rescue me: the challenge of compassionate use in the social media era.http://healthaffairs.org/blog/2014/08/27/rescue-me-the-challenge-of-compassionate-use-in-the-social-media-era/Google Scholar—flexibility in ethical standards is required. What the dying need is a chance at rescue. However, the moral response to panic or desperation is not simply to throw all available resources at any imaginable idea or experiment. Attention to justice, effectiveness, and science are required, even in the face of a fast-moving, incurable infectious disease. Justice during a crisis requires that the bulk of available aid and resources go to the provision of proven interventions rather than new possibilities. Resources ought to go to the measures that promise the best chance for effectively ending the spread of the epidemic and treating the sick rather than to long-shot attempts at rescue. This means continuation of aggressive public health measures. The emergence of successful supportive care in the USA and Europe through hydration, monitoring of electrolytes, and management of bleeding and infections points towards the importance of quickly improving the current standard of care everywhere. Individuals who are infected do have a moral claim to resources. The duty of beneficence compels health-care workers to try to find some way to rescue the dying or individuals who become infected before the Ebola epidemic is stamped out. Panic should not be permitted to distort the force compassion exerts upon the allocation of resources, but it cannot be completely ignored. What compassion requires is the setting aside of a small, fixed amount of resources to be devoted to the hunt for novel curative agents. The goal is to help those patients in desperate need rather than to simply do research on them. To engage in this effort, the dying cannot be asked to bear the entire moral weight of deciding on whether or not to try new remedies and interventions—their desperation leaves them no choice. Morally responsible compassion requires the formulation of a standing body of experts who are capable of quickly weighing proposed ideas for rescue as to their merit. Also needed is a standing institutional review board or research ethics committee that can vet ideas as scientifically sound for use as possible rescue agents without relying heavily on the usual standards of strict informed consent and randomised trials. Neither is always required in a crisis. In a humanitarian crisis, compassion demands that an accountable international ethics board bears most of the responsibility for risk–benefit assessment regarding rescue, and a decision algorithm for deciding who will get to try. Desperate times do not require desperate morality, just different morality. The desire to be rescued ought not to overwhelm the provision of what is efficacious. Experimental blood serum treatment programmes, vaccines that will take a long time to manufacture, and relatively untested antiviral agents ought not to take a lot of money away from education about effective actions such as frequent hand washing, teaching the safe disposal of the dead, and shipping more saline and equipment to under-resourced hospitals. Ethics in the context of Ebola require prioritisation of the use of what is known from previous experience to end epidemics, what is permitting some of the infected to survive, while acknowledging the need to use a small amount of resources to try to rescue the dying with properly vetted agents using creative trial designs. Desperation is a reason to think more, not less, about ethics. I declare no competing interests.