Ethics and Epidemics: Volume 9

This volume of essays is based upon the proceedings of a conference on “Ethics and Epidemics” hosted in March 2004 by Albany Medical College and the Graduate College of Union University in the wake of the SARS epidemic. The SARS epidemic was a stark reminder of how quickly infectious disease can spread in our era of fast and frequent worldwide travel. Furthermore, it reawakened interest in and debate about major ethical, policy, political and social issues that arise as societies respond to such acute threats to health, life and liberty. Current concerns about the threat of avian influenza, due to the H5N1 virus, and its potential to evolve into a worldwide pandemic highlight the urgent need to address these issues.

The modern human rights movement, like American bioethics, was born from the devastation of World War II. The multinational trial of the major Nazi war criminals at Nuremberg following World War II was held on the premise that there is a higher law of humanity (derived from natural law rules based on an understanding of the essential nature of humans), and that individuals may be properly tried for violating that law. Universal criminal law includes crimes against humanity, such as murder, genocide, torture, and slavery. Obeying the orders of superiors is no defense: the state cannot shield its agents from prosecution for crimes against humanity.

With the recent outbreak of Severe Acute Respiratory Syndrome (SARS) and on-going concerns about influenza and the use of pathogenic organisms as weapons, the management of outbreaks of contagious diseases has recently taken on a new urgency (Barbera et al., 2001). However, the public health law concerning disease outbreaks is still based on the perspectives, and often the words, of the early twentieth century, when most public officials saw little option but to take a very authoritarian approach to the protection of the public's health. Over the past 40 years, the jurisprudence of involuntary non-criminal incarceration, for example for the treatment of tuberculosis or as a result of mental disease, has changed dramatically, as basic concepts of due process have been incorporated into the process of civil commitment (Gostin, Burris, & Lazzarini, 1999). There is, therefore, a pressing need to rethink the approaches traditionally taken to the control of infectious disease outbreaks to address this gap between the old assumptions of plenary power to act in the public's interests and the rights of individuals threatened with state actions (Davis & Kumar, 2003). It is a canard sometimes used to justify authoritarian actions that the public responds to emergencies by losing control and panicking; indeed it is the consensus of social scientists that people in emergency situations tend to be more cooperative and more generous toward others than they may normally be (Smith, 2001; Clarke, 2002). If anything, it is my reading of such experiences as the bomb attacks on London during World War II (Harrisson, 1989) that it is the poorly prepared and under-supported public officials who are most likely to act in unproductive and socially divisive ways during public emergencies.

The 2003 global outbreak of Severe Acute Respiratory Syndrome (SARS) was an abrupt reminder that infectious diseases pose a continuing threat to human health. In 1967, U.S. Surgeon General William H. Stewart declared “it was time to close the book on infectious diseases” (Garrett, 1994, citing W.H. Stewart, “A Mandate for State Action,” presented at the Association of State and Territorial Health Officers, Washington, DC, December 4, 1967). In the latter half of the twentieth century, many shared this bold view that medical science had vanquished infectious disease. As a result, public health struggled to remain relevant in the face of advances in pharmaceuticals, surgery, genetics and other areas that were becoming increasingly dominant in the quest to extend and enhance human life. SARS forced many to rethink the significance of public health and the crisis, though relatively short-lived, (for commentary on the disparities between the responses to HIV and SARS, see e.g. Altman (2003)) underscored the need to rebuild public health capacity that had been allowed to slip down the health system priority list.

Objectives: To discuss whether, during an influenza pandemic, public health authorities could be ethically justified in implementing a mandatory vaccination program directed at health care professionals.

Methods: Ethical analysis is carried out by examining arguments that can be made in favor or against such a mandatory measure and by seeking a reasonably balanced position between them. Arguments under consideration are based on the duties of health professionals and public health authorities, the consequences of their actions and on other ethical principles. The importance of relevant empirical data is stressed without any attempt to review or analyze them systematically.

Results: Mandatory vaccination of some health care professionals during a serious pandemic of influenza can be justified, but only under certain limited conditions.

Conclusions: In the throes of an influenza pandemic, health care professionals (and to a variable degree, other health care workers) have an ethical obligation to accept influenza vaccination if it is reasonably safe and effective. The ethical responsibility of public health authorities is to limit the impact of a pandemic on the population by all reasonable means, which clearly includes the appropriate use of vaccine. Consequently, the vaccination of health care staff can be made mandatory under certain conditions. However, a critical objection to this conclusion, which upholds that a voluntary vaccination program (an ethically much less problematic intervention) is just as effective, needs to be addressed.

Karl Marx could only pen the memorable line, “the history of all hitherto existing society is the history of class struggles” because he was heir to the sanitary and public health reforms of the nineteenth century (Marx [1848] 1972, p. 335). The Black Death, which had wiped out much of fourteenth-century Florence and which had regularly decimated sixteenth- and seventeenth-century London, was now but a faint memory. Yet had a historian of some earlier period of European history thought to pen a line as presumptuous as Marx's, it might have read: “the history of all hitherto existing society is the history of struggle with plague or pestilence.” Epidemics and pandemics have haunted human societies from their beginnings. The congregation of large masses of humans in urban settings, in fact, made the evolution of human infectious disease microorganisms biologically possible (McNeill, 1976; Porter, 1997, pp. 22–25). Epidemics have been as determinative of the course of economic, social, military and political history as any other single factor – emptying cities, decimating armies, wiping out generations and destroying civilizations.

Physicians are instrumental to our national defense against epidemics, whether natural or bioterror-related. Broadly speaking, they are obligated to help rapidly identify threats, prevent the spread of disease, and care for infected patients. Each task presents ethical challenges, including the need to address access to care, balance the medical needs of individuals and communities, and ensure that health professionals continue to treat infectious patients in spite of the risk they present. If physicians can acknowledge these duties and meet these challenges, they have an opportunity to strengthen medicine's public trust and professional identity.

In an essay titled, “In Harm's Way. AMA Physicians and the Duty to Treat” (Clark, 2005), I argued that a physician's duty to treat, at personal risk, followed not only from the language, history, and precedents of the American Medical Association's Code of Ethics, but that such a duty was sound in morally relevant ways. A key element in the soundness of the argument was that such a duty had contractual features that were inherent in an implicit social covenant.

Matthew Wynia and his co-authors and Charmers Clark, in their two chapters, take on thorny issues concerning the moral responsibilities of physicians – and, by implication, all health care professionals – regarding preparation for and response to epidemics (Clark, 2006; Wynia, Kurlander, & Green, 2006). Their chapters are especially timely, inasmuch as they address ethical challenges associated with bioterrorism, which, should it occur, could create an epidemic of catastrophic proportions, at least for the locality or localities in which the bioterrorism occurs. In this commentary, I provide a critical assessment of their chapters. I begin with a review of the foundational concept of the Wynia et al. chapter, social-trustee professionalism, and of the Clark chapter, a covenant of public trust. I then take up four issues: the moral demands of social-trustee professionalism and how the social-contract theory of medical ethics advocated by the framers of the 1847 American Medical Association Code of Ethics (American Medical Association, 1847) should be understood; social-role related obligations as ethically-justified limits on fiduciary responsibility in bioterrorism events and how such obligations should be addressed in a preventive ethics fashion by health care organizations; legitimate self-interests as ethically-justified limits on fiduciary responsibility and how such interests should be distinguished from mere self-interests and be addressed in a preventive ethics fashion by health care organizations; and the nature and limits of the standard of care in the large-scale emergencies that bioterrorism events could create.

No other region of the world has suffered from such devastating epidemics in the recent past than sub-Saharan Africa. HIV/AIDS poses the worst single health threat on the continent and approximately 28.5 million of people infected with HIV/AIDS are in sub-Saharan Africa, yet, less than 8% have access to treatment. As African countries start or continue to expand their HIV/AIDS treatment programs with the assistance of international donors, they are facing several ethical and health policy challenges, including difficult decisions on how to ration available treatment, the high cost of drugs, the complexity of treatment regimens, the inadequacy of health and delivery systems, the lack of knowledge about treatment, and the threat of drug resistance.

Research sponsored by entities in developed countries, but conducted in developing countries, has recently been the focus of academic debate, international declarations and media controversy. Much of this attention has focused on whether the trials are exploitative and if so what should be done to avoid exploitation. This chapter takes Alan Wertheimer's principles of mutually advantageous transactions and applies them to the question of exploitation in international research. In this chapter, I develop an analysis of exploitation and apply this to the hypothesis that some pharmaceutical companies who run drug trials in developing countries wrongfully exploit the trial participants.

If you go running in Chicago in the early morning, as the first light glances and reflects on Lake Michigan, you can hear the great flocks of wild geese stirring and calling before you can see them. They have come down from the Arctic, where the winter comes to the Midwest just as the flu season begins. They crowd in the cove with the gulls and the dogs run toward them, and they scatter and fill the air. They will land at the high school in town, in the farms along the interstate, and in the City Zoo, with the ducks and the pigeons.