Mortality and Morality: The Ethics of Ebola

by Jackson Allen

If not controlled within sixty days, the United Nations warned recently, the current Ebola outbreak will lead to an unprecedented and unplanned situation (1). Over the past year, the epidemic has been building in three countries in West Africa: Liberia, Guinea, and Sierra Leone. Outside of public health circles, the outbreak remained largely under the radar until recently, seen as just another bout of disease in a far-off land. Beginning in March 2014, twenty-three deaths were attributed to a mysterious hemorrhagic fever (2). It was not until August that the World Health Organization (WHO) declared the outbreak in West Africa an international public health emergency, a full five months and over three thousand deaths later (3). Recently, the first cases of Ebola were confirmed in the United States and Europe, as the death toll surpassed 4,000 in West Africa (2). When coupled with a 70-90% mortality rate, the ominous CDC prediction of 1.4 million cases by January 2015 is a clear indication that the world must act (2).

This outbreak has brought to light many bioethical issues that are often not considered until an epidemic occurs. For example, much of the confusion in the initial stages of Ebola resulted from problems with the coordination of efforts to combat the disease (3). In a case like Ebola, we must ask which agency should be responsible for leading the international effort. Individually, the CDC, WHO, or groups like Doctors without Borders are unable to completely manage an epidemic of this scale (3). Clearly, there is a need for coordinated efforts by national governments, humanitarian aid organizations, pharmaceutical groups, and public health agencies like the CDC and WHO. However, this raises more questions related to power structure, ability to adjust to changing circumstances, and unified efforts for containment.

Secondly, the worldwide community must examine why quarantine—typically the most effective method of stopping disease spread—was ineffective at containing this epidemic. Ebola is not an airborne illness; it is only spread by contact with the blood or bodily fluids of those suffering from the disease. Thus, the outbreak should have been relatively easy to contain by isolating sick individuals (2). Still-increasing death tolls clearly demonstrate that something went wrong with this response. Fear of Western medicine, cultural differences, and inadequate resources all contributed to the unraveling of the situation in West Africa. Though the problem here is clear in hindsight, a better process for controlling this type of outbreak has eluded us thus far.

Finally, the world has recently seen the rise of several experimental drugs for the treatment of Ebola (4). The rush to produce an effective treatment raises many ethical questions. And if the world’s scientists were to find an effective treatment that is considered safe after very limited human trials, it remains unclear to whom the vaccine would be distributed, and how. Suggestions include vaccinating healthcare workers and military personnel first (5). Other arguments can be made that citizens of the affected countries should be among the first vaccinated. However, there are serious ethical pitfalls with either route.

Quarantine

The primary public health procedures for treating a disease like Ebola focus on quarantine, which requires health care workers to isolate those affected for up to a few weeks (2). This is typically most effective in countries where governments and public health experts are able to take control swiftly and without opposition. In the chaos of this epidemic, however, quarantine has been largely ineffective (2). Frequently, medical clinics are overrun by those fearing foreign intervention and medical practices that are not well explained or understood (6). The violence and fear accompanying the outbreak create a very difficult environment in which to manage an epidemic (7). The geography of West Africa also makes widespread quarantine efforts more difficult, as rural villages often have no resources for medical treatment, and people are unable or too afraid to seek treatment (3, 7). Doctors Without Borders, an international humanitarian organization, found that their resources to contain the outbreak were wholly insufficient, even after expanding their operations (7). As the only available medical treatments for Ebola focus on quarantine and giving fluids, lack of supplies is clearly a major problem. In August, a Doctors Without Borders report noted, “It is not currently possible to administer intravenous treatments” (7). The report also cited lack of safety equipment and problems with disposing of bodies as grave concerns for the future (7). As a result, many medical triages have been forced to shut down or drastically reduce their ability to care for patients.

A swift response in the early stages of the outbreak would likely have contained the virus while building trust among those living in affected countries. But by now, the outbreak is too large for quarantine alone to constitute a sufficient response. Even so, the world must continue its efforts to slow the spread of disease and save lives. The best method for doing so, however, remains unclear. Quarantine enforced by military personnel is one option, albeit one that would be costly, slow, and likely to further alienate the very people needing treatment. The world is unlikely to support such action in a sovereign country. Other methods of enforcing quarantine come with similar problems. For example, humanitarian organizations lack the power and jurisdiction to enforce quarantines. Additionally, containment efforts must not ignore the human side of this epidemic. In light of reports that those brought to medical centers often disappear into quarantine and are never seen again, we must place a high importance on communication with the families of those affected (7). The Agence France-Presse put a face on this aspect of the tragedy in a report from outside a Red Cross clinic in Monrovia, the capital of Liberia (7). A mother in the crowd described her worst fears over her son in the clinic: “We get no record from the authorities. They always say we should wait. I come here every day. I want to see my son! Maybe he is already dead” (7).

Chain of Command

Another serious problem with the initial response to the outbreak stems from confusion over the role of different leading health authorities. The CDC, for example, was very active in the initial stages of the epidemic but has since taken a less active role as WHO and others joined the fight against Ebola (3). For its part, WHO was lackluster in its initial response to the outbreak. “There’s no doubt we’ve not been as quick and as powerful as we might have been,” noted WHO Assistant Director General Dr. Marie-Paule Kieny (3).

Budget cuts in recent years have forced reallocation of emergency preparedness funds to other WHO programs, limiting the response of the primary health agency of the United Nations, which recently estimated $1 billion would be necessary to stamp out the disease in West Africa (7). Recently the epidemic response department of WHO, which included anthropologists working to overcome cultural differences during outbreaks, was closed due to lack of funding (3). Much of the mistrust of Western healthcare workers results from the limited ability of the countries affected—primarily Guinea, Sierra Leone, and Liberia—to contribute mightily to the containment effort. As the world’s health needs vastly outpace WHO funding, Director General Dr. Margaret Chan has called on the countries affected to take primary responsibility for management of the outbreak (3). WHO simply lacks the resources necessary to take control in the manner the world would like to see during an epidemic. This problem becomes much graver when epidemics hit countries that cannot contribute much to the public health response, as is the case with Ebola. The entire annual budget of Guinea, for example, is only $1.8 billion, less than WHO’s (8).

Experimental Drugs

In the months since the first cases of Ebola, the world has seen an incredibly swift response from scientists rushing to produce any potential vaccine. The leading drug candidate, called ZMapp was rushed into use before even beginning human clinical safety trials with the FDA (5). The first doses of ZMapp were given to two American aid workers. The two Americans recovered, as did two Liberian doctors and a British nurse who also received the experimental therapy. Two other patients treated with ZMapp died from Ebola (5). The release of this news provoked outrage in both the West and in the countries currently affected by the outbreak. Three leading experts on Ebola, including Peter Piot, co-discoverer of the virus, called for the treatment to be given to patients in West Africa, invoking notions of Western insensitivity from many Africans on the front lines of the outbreak (4). While the decision to give the experimental drug to Westerners first may seem questionable, the argument can also be made that “experimenting” on African patients before examining the safety of ZMapp is just as slippery a slope. It would be tremendously morally reprehensible to give it to under-informed citizens who lack knowledge of the drug’s adverse side effects.

However, the use of ZMapp in a few cases raises further ethical questions as Mapp Biopharmaceuticals ramps up its production capacity (9). As the world’s supply of ZMapp is built up over the coming months, a system for allocation of the drug must be worked out. Healthcare workers are most likely to receive ZMapp first if they fall ill with Ebola, following the logic that these people are vital if other patients are to continue being treated (4). American military or government personnel would likely be very high on the list as well, especially given that development of ZMapp and other experimental treatments was partially funded by the National Institutes of Health (9). Though supplies of an experimental therapy would be very limited, giving a working treatment to as many people in Africa as possible represents the hope of building trust in Western medicine in Liberia, Sierra Leone, and Guinea. Though supplies of an experimental therapy would be very limited, there could be tremendous benefit from treating as many people in West Africa as possible. Currently, the CDC estimates that Ebola cases total two and a half times the official figure (2). Demonstrating that doctors can provide curative treatment could lead to increased reporting of Ebola cases and cooperation with efforts to quarantine the sick. Then again, one must carefully consider how people would react to the knowledge that a very limited supply of treatments exists.

In the near future, modern science will likely produce therapies to combat the Ebola virus. Soon after will come the arguments for and against every conceivable group receiving treatment first. Doing so invokes parallels to Seattle’s “God committee,” which in the 1960s infamously used social criteria like church membership and earnings to justify the distribution of extremely limited kidney dialysis treatments to terminally ill patients at Seattle’s Swedish Hospital (2).

The Future

The future for this year’s Ebola outbreak is foreboding, but the challenge of containment is not insurmountable. Recently, WHO reported to the United Nations that drastic changes to the worldwide response must be seen within sixty days, or the world may “face an entirely unprecedented situation for which we do not have a plan” (1). The epidemic could grow to 10,000 new cases per week (1). The death rate has also risen simultaneously and may continue to climb as the infrastructure for providing medical care becomes overwhelmed (1).

In the coming months, the world’s scientists, humanitarian organizations, and leaders must find ways to shift the tide of the epidemic. This response must primarily focus on new treatments, safety procedures, and the expansion of access to medical care in West Africa. The world’s efforts will focus entirely on reducing R₀, or the basic reproduction number, associated with the Ebola virus. The current R₀ indicates that a contagious person can infect about two new people with Ebola (10). Bringing R₀ below one new person per infected individual will cause the disease to die out (10). This can be accomplished through treatments, vaccines, quarantine, sanitation, as well as other factors.

Yet, in these efforts to combat the outbreak, the world must not lose sight of ethical principles. Bringing the ethical issues of an epidemic to public discourse is crucial to our management of outbreaks. With all of the resources the developed world can—and presumably will—bring to bear on Ebola, we cannot ignore the common responsibility to do our best to assist those in need. Lackluster responses to even the first Ebola deaths in Africa have been the greatest ethical pitfall of the outbreak thus far. Looking toward the future, it is imperative that the worldwide response avoids repeating mistakes already made and works to overcome dilemmas already foreseen.

Jackson Allen ’18 is currently a freshman.

Works Cited

1. Sixty Days To Beat Ebola, United Nations Warns. Sky News. 15 October 2014.
2. I. Meltzer, C. Y. Atkins, S. Santibanez, B. Knust, B. W. Petersen, et al., Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015. Centers ford Disease Control and Prevention. Morbidity and Mortality Weekly Report 63(03); 1-14. 26 Sept. 2014.
3. Fink, Cuts at W.H.O. Hurt Response to Ebola Crisis. New York Times. 03 Sept. 2014.
4. Dyxon, Africans, three Ebola experts call for access to trial drug. Los Angeles Times. 06 Aug. 2014.
5. Dickenson, The Ethics of Ebola. Project Syndicate. 03 Sept. 2014.
6. Report: Armed men attack Liberia Ebola clinic, freeing patients. CBS News. 17 Aug. 2014.
7. Beds scarce, staff scarcer, in Liberia’s overrun Ebola wards. Agence France-Presse. 28 Sept. 2014.
8. Guinea. The CIA World Factbook. 22 Jun. 2014.
9. Questions and Answers on Experimental Treatments and Vaccines for Ebola. Centers for Disease Control and Prevention. 29 Aug. 2014.
10. Doucleff. No, Seriously, How Contagious Is Ebola? National Public Radio. Shots: Health News from NPR. 2 Oct. 2014.