Ethical Issues in Epidemics

KUSWANDEWI MUTYARA

Ethical Issues in Epidemics
• Doctors must be prepared to face epidemics with its ethical problems that might occur, such as conflict between individuals and society related to reportable disease, also how the management of epidemics in many countries which sometimes might be regarded as disrespectful, too bureaucratic, or even breaching human rights. Therefore, students will be introduced to the tendency of individuals and institutions in facing epidemics, through the perspective of medical anthropology.

• Infectious disease should be recognized as a topic of primary importance for bioethics  received relatively little attention in comparison with things like abortion, euthanasia, genetics, cloning, stem cell research, and so on.

multi-drug resistant tuberculosis. epidemics (of AIDS. • In the contemporary world. . and. in the 20 th Century • Smallpox killed perhaps three times more people than all the wars of that period. • The 1918 flu killed between 20 and 100 million people.• The ‘Black Death’ eliminated one third of the European population during the 14th Century. and newly emerging infectious diseases such as SARS) continue to have dramatic consequences.

on the one hand.• Infected individuals can threaten the health of other individuals and society as a whole. in contexts involving diseases that are – to varying degrees – contagious. . public health care measures such as surveillance. for example. • An important and difficult ethical question asks how to strike a balance between the utilitarian aim of promoting public health. deadly. and libertarian aims of protecting privacy and freedom of movement. or otherwise dangerous. isolation. and quarantine can require the infringement of widely accepted basic human rights and liberties. on the other.

• the paramount ethical importance of infectious diseases is illustrated by the fact that their consequences have been. infectious diseases deeply involve issues of justice – which should be a central concern of ethics. and will likely continue to be .• their burden is most heavily shouldered by the poor (in developing countries).

an estimated 39 million people were living with HIV .’ • In 2004. and 5 million people were newly infected with HIV. 3 million people died from AIDS.SITUATION • Infectious diseases are currently the world’s largest ‘killer[s] of children and young adults. • At the end of 2004. • They account for more than 13 million deaths a year – one in two deaths in developing countries.

and. nearly one billion people will be newly infected. 200 million people will get sick. a tenth of these are expected to develop active illness.• One third of the world’s population is infected with the latent form of the disease. • ‘It is estimated that between 2000 and 2020. . and 35 million will die from TB – if control is not further strengthened.

. • travel restrictions. or travel restrictions. and the economic impact • The public health measures required to protect other individuals and society from contagion (again. travel advisories. depending on the disease) might sometimes involve surveillance. mandatory vaccination or treatment. mandatory testing. and related public health measures were put into effect.ISSUES • Isolation. notification of authorities or third parties. isolation (of individuals). quarantine. quarantine (of entire regions).

• Almost one in three children are malnourished.• Infectious disease should be recognized as a crucial topic for bioethics because the topic of infectious disease is closely connected to the topic of justice. about one third of the population – 1. • And over one third of the world’s population lack access to essential drugs . • In developing countries. poor education. crowded living conditions.3 billion people – live on incomes of less than $1 a day. and a complex host of other factors combine to make the populations of developing nations especially vulnerable to infectious diseases: • Most deaths from infectious diseases occur in developing countries – the countries with the least money to spend on health care. dirty water. lack of access to basic medicines. disempowerment of women. • One in five are not immunized by their first birthday. • Bad nutrition.

dysentery. tuberculosis. broncho-dilators. analgesics. Relationships between poverty and disease • Most of the infected people who live in these countries have no access to new or existing drugs for HIV/AIDS. and typhoid fever. infectious diseases: 50% of people in developing nations do not have access to even basic medications. cholera. or diuretics . • But the problem of access to medications goes far beyond the HIV/AIDS pandemic: people in developing nations also cannot afford medications used to treat or prevent malaria. anti-inflammatory agents. meningitis. such as antibiotics. anti-coagulants. decongestants. • The affordability problem also extends beyond a lack of access to new drugs designed to treat devastating.

• This situation is not merely unfortunate  suffer social and political injustice .

equity. and individual choice are commonly invoked but rarely analysed in public-health debates. • Yet how these concepts are understood and used can lead to quite different policies. human rights. cultural respect. Ideas like efficiency. .• Public-health decisions commonly involve conflicting and ambiguous ethical principles.

• Such decisions have to be guided by both scientific knowledge and ethical considerations.• Decision makers had to balance individual freedoms against the common good. . and economic losses against the need to contain the spread of a deadly disease. fear for personal safety against the duty to treat sick people.

• A framework for looking at the ethical implications of the outbreak. identifying 10 key ethical values. . and five major ethical issues faced by decision makers.

Ten key ethical values • • • • • • • • • • Individual liberty Protection of the public from harm Proportionality Reciprocity Transparency Privacy Protection of communities from undue stigmatisation Duty to provide care Equity Solidarity .

Ten substantive values to guide ethical decision-making for a pandemic .

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Five procedural values to guide ethical decisionmaking for a pandemic .

She wants to comply but fears this could cost both her job and her apartment. .4 Key Ethical Issues: Ethics of quarantine A medical clerk is asked by public health officials to remain at home in quarantine for 10 days because of possible exposure to SARS.

including the risks and benefits. Under the value of proportionality. legitimate. wellbeing. and necessary. the value of reciprocity requires society to ensure that those quarantined receive adequate care and do not suffer unfair economic penalties . • The value of transparency requires stakeholders to be fully informed about issues. authorities exercising public health powers should do so in a way that is relevant. • They should use the least restrictive methods that are reasonably available to limit individual liberties and should apply restrictions without discrimination. Finally.• Protecting the public from harm caused by the uncontrolled movements of • people who may be infectious. and personal liberty. particularly if they affect their health.

the nurse takes a commuter train to work. Medical officials choose not to name the nurse but use the media to warn people who may have been on her train that they should be tested for SARS. She is later found to have SARS. .Privacy of personal information and public need to know • A nurse at a hospital affected by SARS feels unwell and has a fever. After weighing the risk of having the disease against losing income and placing a burden of extra work on her colleagues.

• Although the individual has a right to privacy. because they believed it would provide additional public health benefit. the state can over-ride this right if it would greatly help protect the public from serious harm. with the family’s consent. and her son. • In the initial stages of the outbreak. authorities named the woman who carried SARS to Canada from China. .

• Transparency can be achieved without naming individuals or communities. • Indeed. • For example.• Proportionality requires that private information be released only if there are no less intrusive means to protect the public health. the need to protect communities from undue stigma is an important lesson for future epidemics. . naming an individual or releasing a photograph could be justified if that person violates a quarantine order.

• Dozens of healthcare workers. were infected with SARS because of their work. and two died . many of them nurses. She feels torn between the potential danger posed to her family and her professional duties. Some infected their families.Duty of care • An intensive care nurse is afraid of contracting SARS at work and infecting her husband and three small children.

• This duty is mainly determined by professional ethics. firefighters do not have the freedom to choose whether to face a particularly bad fire and police officers do not get to select which dark alleys they walk down.• Healthcare workers were forced to weigh serious and imminent health risks to themselves and their families against their duty to care for the sick. . • Measures such as an insurance fund to cover healthcare workers who become sick or die through work should be considered for future epidemics. • By analogy.

. increasing the anxiety of the woman and her family about the spread of her disease.Collateral damage • Surgery for a patient with breast cancer is postponed during the SARS outbreak.

• Authorities in the Toronto region had to make hard choices about which medical services to maintain and which to place on hold. suffered loss of contact and emotional support from family and friends as hospitals closed their doors to visitors.• Severe restrictions on entry to hospitals affected by SARS in the Toronto area meant that thousands of people were denied medical care. and opportunity costs. benefits. • They had to weigh risks. . sometimes for severe illnesses such as cancer and heart disease. Those who were admitted. with or without SARS. • Some of these patients died before receiving treatment. How such decisions can best be made needs thorough re-evaluation.

Normally. The World Health Organization issues travel warnings for areas with large numbers of cases. but family travels begin a chain of events that takes SARS around the world. .SARS in a globalised world • In Guangdong province in rural China a farmer develops a severe respiratory infection. the disease would have stayed in the community.

• Yet how these concepts are understood and used can lead to quite different policies. human rights. and individual choice are commonly invoked but rarely analysed in public-health debates. . Ideas like efficiency. cultural respect.• Public-health decisions commonly involve conflicting and ambiguous ethical principles. equity.

social & political organizations. languages. development. art & artefacts .Anthropology ~ the study of man  The most scientific of the humanities & the most humane of the sciences  Aim: the holistic study of humankind – its origins. religions.

Medical Anthropology • A branch of social and cultural anthropology • It is concerned with a wide range of biological phenomena. and particularly with the ways in which the two interacted throughout human history to influence health and disease . especially in relation to health and disease • Definition according to Foster and Anderson: A biocultural discipline concerned with both the biological and sociocultural aspect of human behaviour.

and internal organization) • Healers play roles beyond their healing functions and usually their focus on his ‘ill’ family.Medical Anthropology (cont) • Anthropologists studying the socio-cultural in all human societies. value. training. village not individual . their selection. community. beliefs and practices relating to ill health • Linked to beliefs about the origin of misfortunes • Necessary to examine the social organization of health and illness in that society (the health care system) include the ways in which people have become recognized as ill • Anthropologists are particularly interested in the group of ‘healers’ (special social group. concepts.

nutrition. genetics.Main Tasks of Medical Anthropology • How individuals in a particular society perceive and react to ill health and the types of health care that they turn to. and epidemiology). biochemistry. social and cultural factors for explain the cause of illness . pathology. to know something about both the cultural and the social attributes of the society in which they live • It is possible to link medical sciences (microbiology. parasitology.