ebola and public health ethics (ebolaethics?)

via reuters, KFF recently posted a short article about the ethics of giving experimental treatment to the ‘hero doctor’ Sheik Umar Khan — and, really, to any of the trained health professionals who continue to show up to work even though they were at very real risk in Sierra Leone, in Liberia, in Nigeria and, now, contemporaneously but apparently unrelatedly, DRC.

there’s a complex of issues at stake, here, around rationing a scarce (and experimental) resource when need is greater than supply. i only going to wade in on the one issue i feel comfortable putting a point on; questions of ethics related to the nationality of who has been treated and where they were treated, or the ethics of using an experimental drug once other options were exhausted are important issues — but beyond the scope of this post.

this post is specifically about priority-setting for who gets treated: those who work in health care and those who do not. whether human resources for health (HRH) — Dr. Khan, medical volunteers from abroad, Sierra Leonean nurses, etc —  should be given priority in the face of a health crisis raises the Kantian issue of whether people should be used as means for ends (with Kant saying “no.”). if HRH are prioritized because of their ability to save more lives by having their own life saved, it is because they are being viewed as a means to an end — namely, the end of potentially saving more lives. this does not, inherently, treat all individuals of being of equal moral worth.

the case above at least keeps things within the “sphere” of health, rather than raising questions about favoring saving the young versus the old, or the powerful (say, the president or prime minister) over other citizens in the face of disaster. these too are difficult questions.

the debate will continue about whether and how Dr. Khan and others should have been treated with the experimental ZMapp, of which there is expected to be a long-term (rather than a quickly resolved) scarcity relative to need. demand significantly and dauntingly and heartbreakingly outweighs supply. but the question of whether Dr. Khan — or other HRH still fighting the fight — should be given priority to receive the treatment needs to be answered along several lines: should HRH be given preference? if so, should that preference be given based on whether, once cured, they will continue to treat patients? what happens once there are no more treatments to continue treating with — does the prioritization scheme shift?

this is a separate — but important — set of questions from the more politically charged question of the nationalities of recipients of the limited supply of ZMapp. i suspect these questions of power and race and exploitation, of where drugs were developed and where they were tested and who paid for them in what ways, will dominate the discourse. but other questions of ethics, desert, scarcity, and priority-setting require consideration for dealing with the present crisis and planning for future outbreaks, as well as strengthening health systems and equipping them to make decisions more generally.

further reading on these topics include: Norm Daniels, Frances Kamm, and Dan Brock. i hope these scholars will discuss and debate these issues in the near future.

 

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2 thoughts on “ebola and public health ethics (ebolaethics?)

  1. Thanks Heather — I believe you’ve succinctly described the ethical dilemma around prioritizing HRH for scarce health resources.
    I feel it would be remiss in any discussion of ethics, Ebola, and West Africa to not consider the trade-offs that rich countries routinely make between improving access to life-saving drugs (e.g. for malaria, TB and HIV) in poor countries and all of the other endeavors they undertake (e.g. war spending, as-if-it-were-war spending on law enforcement, agricultural subsidies, lawsuits against the president, etc). Ebola has captured our attention in similar ways to 9/11 and the Japanese tsunami, but more devastating tragedies slide by unnoticed under the guise of quotidian normality.

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    • agree, of course. we do a bad job looking at how some of “our” (rich country) policies in/directly are contrary to our humanitarian efforts, which catch our attention when they are sudden and scary (as opposed to slow or silent tsumanis or whatever we call the ‘regular’ set of disease).

      much of the conversation now, it seems, is about how ebola revealed the weaknesses in the health systems in affected countries. the question of *why* those health systems were never built or have been torn down or run down has not yet started (beyond noting that a civil war did occur).

      karen grepin makes some of these points (that it’s not just about having a treatment): http://karengrepin.com/2014/08/do-we-really-need-a-new-drug-or-vaccine-for-ebola.html

      i believe focusing on trade (and raid/war) rather than aid is deaton (inter alia)’s main message?

      building R&D, manufacturing capacity (and not doing things to undermine it) in SSA also important.

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