British Medical Journal
09 May 2015(vol 350, issue 8007)
Ebola and ethics: autopsy of a failure
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h2105 (Published 23 April 2015) Cite this as: BMJ 2015;350:h2105
Christian A Gericke, chief executive and director of research
Thousands died while we argued over the wrong questions
The current epidemic of Ebola virus disease has attracted medical ethics commentators like bees to a honey pot. No previous infectious disease epidemic has elicited such a flurry of articles on the ethical challenges associated with infection control and treatment in such a short time. Has this been of any use?
The ethical questions raised by various authors broadly fall into three categories. The first relates to questions of individual medical ethics, in particular surrounding the compassionate use of experimental drugs and vaccines. The second concerns allocation of resources to these experimental treatments versus infection control. And the third centres on how resources should be spent in the long term—on building a public health and clinical infrastructure that can cope in an epidemic instead of propping up a weak infrastructure during a humanitarian crisis.
The tension between these moral challenges can be grouped along two axes: individual versus public health, and short term versus long term (Download figure)
The short term use of experimental drugs such as ZMapp, first used in a few repatriated health workers from high income countries, attracted far more public attention than it deserved. It generated a series of ethical questions that are hard to answer and distracted from the real, practical, and urgent business of controlling the wider Ebola epidemic. Commentators argued about whether randomised trials were required in the heat of the epidemic, the level of personal risk that might be acceptable for recipients, who should receive these drugs, how to ensure informed consent, and whether health professionals should get preferential treatment, among other things.
The inappropriate focus on experimental treatments for individuals diverted attention away from infection control and other measures that would benefit everyone. In August 2014, Médecins Sans Frontières (MSF) was the first to point out that the international response to the epidemic was “dangerously inadequate.”1 International collective action came too late, and too little was done.2 MSF called for support in the form of laboratory staff, healthcare workers to provide supportive care, and portable equipment to isolate patients.1
Only a few writers have commented on the ethical aspects of a misguided international effort. Bioethicist Udo Schüklenk characterised the humanitarian intervention as a theatrical farce. He described the aid organisations as “a mixed bunch of Christian missionaries busily trying to get their hands on the last available experimental agents while on private medical jets out of west Africa.”3 He also criticised WHO’s recommendations to provide access to experimental drugs as “pointless grandstanding in the face of a pandemic that requires a public health response.”3 David Heymann, an infectious disease epidemiologist, prioritised stopping the outbreak using intensified patient isolation, contact tracing, and community empowerment flanked by properly conducted clinical trials of treatments such as survivor serum.4
In November 2014, Annette Rid and Ezekiel Emanuel published a viewpoint that rightly stressed the need to prioritise strengthening of health systems over experimental treatments because the treatments are unlikely to have a noticeable effect on the epidemic, even if effective.5 Jacob and colleagues wanted effort directed at patient outcomes instead.6 These arguments show why a clear distinction is needed between short and long term responses, and between the needs of individuals versus the wider public health. Where Rid and Emanuel think big picture and long term, Jacob and colleagues think about the needs of individuals, in the short term. Both are important, and they should not compete.
What went wrong?
In my view, the expert meeting on experimental drugs and vaccines convened by WHO in August 20147 not only sidetracked relief efforts but led medical ethicists from all over the world sheepishly down the wrong path. The moral challenges surrounding the compassionate use of experimental drugs and vaccines are complex. Heated debate arose, and the wider public health perspective was lost in the noise. The misguided WHO expert panel and relief effort was picked up by some medical ethicists.3 5 8 However, their insights came too late to change the course of events or the public debate.
What can we learn from this failure? Governments, international organisations, and donor agencies need to take a wider perspective and a longer term view on health system preparedness when it comes to effective prevention of epidemics, including Ebola.
Once an epidemic occurs, rapid deployment of proved methods of infection control should take precedence over experimental treatments. In the wake of the 2009 H1N1 influenza pandemic a WHO review committee recommended the creation of a $100m (£67m; €93m) contingency fund to allow rapid responses to future pandemic threats. This recommendation was ignored, which partly explains the delayed and fractured response to the Ebola epidemic.9
A renewed focus on developing more effective drugs and vaccines against neglected tropical diseases is another important long term measure that should happen now, between epidemics.10
The World Bank estimates that the two year socioeconomic effect of the current Ebola epidemic could reach $32.6bn.11 If only a fraction of this amount had been spent on health system preparedness before the current epidemic, early case identification and containment, contact tracing, and supportive care for the few people affected in the first wave of the disease would have been possible. Many of the more than 10,000 deaths reported by 17 April 2015 might have been prevented.12 Finally, the benefits of a well prepared health system would extend to many other diseases, including HIV/AIDS, tuberculosis, and malaria.
Medical ethics can provide useful insights for decision making in epidemics, provided that you ask the right questions.
01 Médecins Sans Frontières. International response to west Africa Ebola epidemic dangerously inadequate. MSF, 2014.
02 Ebola: a failure of international collective action. Lancet2014;384:637. CrossRefMedline
03 Schuklenk U. Bioethics and the Ebola outbreak in west Africa. Dev World ioeth2014;14(3):ii-iii.
04 Heymann DL. Ebola: learn from the past. Nature2014;514:299-300. CrossRefMedlineWeb of Science
05 Rid A, Emanuel EJ. Ethical considerations of experimental interventions in the Ebola outbreak. Lancet2014;384:1896-99. CrossRefMedline
06 Jacob ST, Crozier I, Schieffelin JS, Colebunders R. Priorities for Ebola virus disease response in west Africa. Lancet2014;384:1843.
07 WHO. Ethical considerations for use of unregistered interventions for Ebola virus disease. Report of an advisory panel to WHO. WHO, 2014.
08 Dawson AJ. Ebola: what it tells us about medical ethics. J Med Ethics2015;41:107-10.
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09 Gostin LO. Ebola: towards an international health systems fund. Lancet2014;384:e49-51.
10 Oprea L, Braunack-Mayer A, Gericke CA. Ethical issues in funding research and development of drugs for neglected tropical diseases. J Med Ethics2009;35:310-4.
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11 World Bank. The economic impact of the 2014 Ebola epidemic: short and medium term estimates for west Africa. World Bank, 2014.
12 WHO. Ebola situation report—17 April 2015. WHO, 2015. http://apps.who.int/gho/data/view.ebola-sitrep.ebola-summary-20150417?lang=en.