1 ethical issues in epidemics

7/27/2019 1 Ethical Issues in Epidemics

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Ethical Issues in Epidemics

KUSWANDEWI MUTYARA


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Ethical Issues in Epidemics

Doctors must be prepared to face epidemics withits ethical problems that might occur, such asconflict between individuals and society relatedto reportable disease, also how the managementof epidemics in many countries which sometimesmight be regarded as disrespectful, toobureaucratic, or even breaching human rights.Therefore, students will be introduced to the

tendency of individuals and institutions in facingepidemics, through the perspective of medicalanthropology.


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Infectious disease should be recognized as atopic of primary importance for bioethics received relatively little attention incomparison with things like abortion,euthanasia, genetics, cloning, stem cellresearch, and so on.


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The Black Death eliminated one third of theEuropean population during the 14 th Century;

The 1918 flu killed between 20 and 100 million

people; and, in the 20 th Century Smallpox killed perhaps three times more people

than all the wars of that period. In the contemporary world, epidemics (of AIDS,

multi-drug resistant tuberculosis, and newly emerging infectious diseases such as SARS)continue to have dramatic consequences.


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Infected individuals can threaten the health of otherindividuals and society as a whole, for example, publichealth care measures such as surveillance, isolation, andquarantine can require the infringement of widely acceptedbasic human rights and liberties.

An important and difficult ethical question asks how tostrike a balance between the utilitarian aim of promotingpublic health, on the one hand, and libertarian aims of

protecting privacy and freedom of movement, on the other,in contexts involving diseases that are to varying degrees contagious, deadly, or otherwise dangerous.


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their burden is most heavily shouldered by thepoor (in developing countries), infectiousdiseases deeply involve issues of justice which should be a central concern of ethics.

the paramount ethical importance of infectious diseases is illustrated by the factthat their consequences have been, and willlikely continue to be


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SITUATION Infectious diseases are currently the worlds

largest killer[s] of children and young adults. They account for more than 13 million deaths

a year one in two deaths in developingcountries.

In 2004, 3 million people died from AIDS, and

5 million people were newly infected with HIV. At the end of 2004, an estimated 39 million

people were living with HIV


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One third of the worlds population is infectedwith the latent form of the disease; and, atenth of these are expected to develop active

illness. It is estimated that between 2000 and 2020,

nearly one billion people will be newlyinfected, 200 million people will get sick, and35 million will die from TB if control is notfurther strengthened.


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ISSUES Isolation, quarantine, travel advisories, travel restrictions, and related public health measures

were put into effect; and the economic impact

The public health measures required to protect otherindividuals and society from contagion (again,depending on the disease) might sometimes involvesurveillance, mandatory testing, mandatoryvaccination or treatment, notification of authorities orthird parties, isolation (of individuals), quarantine (of entire regions), or travel restrictions.


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Infectious disease should be recognized as a crucial topic forbioethics because the topic of infectious disease is closelyconnected to the topic of justice.

Bad nutrition, dirty water, crowded living conditions, pooreducation, lack of access to basic medicines, disempowerment of women, and a complex host of other factors combine to make thepopulations 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. In developing countries, about one third of the population 1.3

billion people live on incomes of less than $1 a day. Almost one in three children are malnourished. One in five are not immunized by their first birthday. And over one third of the worlds population lack access to

essential drugs


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This situation is not merely unfortunate suffer social and political injustice


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Public-health decisions commonly involveconflicting and ambiguous ethical principles.Ideas like efficiency, human rights, culturalrespect, equity, and individual choice arecommonly invoked but rarely analysed inpublic-health debates.

Yet how these concepts are understood andused can lead to quite different policies.


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Decision makers had to balance individualfreedoms against the common good, fear forpersonal safety against the duty to treat sickpeople, and economic losses against the needto contain the spread of a deadly disease.

Such decisions have to be guided by bothscientific knowledge and ethicalconsiderations.


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A framework for looking at the ethicalimplications of the outbreak, identifying 10key ethical values, and five major ethicalissues faced by decision makers.


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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


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Ten substantive values to guide ethicaldecision-making for a pandemic


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Five procedural values to guide ethical decision-making for a pandemic


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4 Key Ethical Issues:Ethics of quarantine

A medical clerk is asked by public healthofficials to remain at home in quarantine for 10 days because of possible exposure to SARS.She wants to comply but fears this could cost both her job and her apartment.


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Protecting the public from harm caused by the uncontrolledmovements of

people who may be infectious. Under the value of proportionality,authorities exercising public health powers should do so in a waythat is relevant, legitimate, and necessary.

They should use the least restrictive methods that are reasonablyavailable to limit individual liberties and should apply restrictionswithout discrimination.

The value of transparency requires stakeholders to be fullyinformed about issues, including the risks and benefits, particularlyif they affect their health, wellbeing, and personal liberty. Finally,the value of reciprocity requires society to ensure that thosequarantined receive adequate care and do not suffer unfaireconomic penalties

P i f l i f i d


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Privacy of personal information andpublic need to know

A nurse at a hospital affected by SARS feelsunwell 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, the nurse takes a commuter trainto work. She is later found to have SARS.Medical officials choose not to name the nursebut use the media to warn people who may have been on her train that they should betested for SARS.


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Although the individual has a right to privacy, thestate can over-ride this right if it would greatlyhelp protect the public from serious harm.

In the initial stages of the outbreak, authoritiesnamed the woman who carried SARS to Canadafrom China, and her son, with the familys

consent, because they believed it would provideadditional public health benefit.


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Proportionality requires that private informationbe released only if there are no less intrusivemeans to protect the public health.

For example, naming an individual or releasing aphotograph could be justified if that personviolates a quarantine order.

Transparency can be achieved without namingindividuals or communities.

Indeed, the need to protect communities fromundue stigma is an important lesson for futureepidemics.


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Duty of care

An intensive care nurse is afraid of contractingSARS at work and infecting her husband and three small children. She feels torn between

the potential danger posed to her family and her professional duties. Dozens of healthcare workers, many of them

nurses, were infected with SARS because of their work. Some infected their families, andtwo died


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Healthcare workers were forced to weigh serious andimminent health risks to themselves and their familiesagainst their duty to care for the sick.

This duty is mainly determined by professional ethics. By analogy, firefighters do not have the freedom to

choose whether to face a particularly bad fire andpolice officers do not get to select which dark alleysthey walk down.

Measures such as an insurance fund to coverhealthcare workers who become sick or die throughwork should be considered for future epidemics.


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Collateral damage

Surgery for a patient with breast cancer is postponed during the SARS outbreak,increasing the anxiety of the woman and her

family about the spread of her disease.


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Severe restrictions on entry to hospitals affected by SARS in theToronto area meant that thousands of people were denied medicalcare, sometimes for severe illnesses such as cancer and heartdisease.

Some of these patients died before receiving treatment. Those who

were admitted, with or without SARS, suffered loss of contact andemotional support from family and friends as hospitals closed theirdoors to visitors.

Authorities in the Toronto region had to make hard choices aboutwhich medical services to maintain and which to place on hold.

They had to weigh risks, benefits, and opportunity costs. How suchdecisions can best be made needs thorough re-evaluation.


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SARS in a globalised world

In Guangdong province in rural China a farmer develops a severe respiratory infection.Normally, the disease would have stayed inthe community, but family travels begin achain of events that takes SARS around theworld. The World Health Organization issues

travel warnings for areas with large numbersof cases.


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Public-health decisions commonly involveconflicting and ambiguous ethical principles.Ideas like efficiency, human rights, culturalrespect, equity, and individual choice arecommonly invoked but rarely analysed inpublic-health debates.

Yet how these concepts are understood andused can lead to quite different policies.


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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, development, social & politicalorganizations, religions, languages, art &artefacts


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Medical Anthropology

A branch of social and cultural anthropology It is concerned with a wide range of biological

phenomena, especially in relation to health and disease

Definition according to Foster and Anderson: Abiocultural discipline concerned with both the biological and sociocultural aspect of human behaviour, and

particularly with the ways in which the two interacted

throughout human history to influence health and disease


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Medical Anthropology (cont) Anthropologists studying the socio-cultural in all human

societies, 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 waysin which people have become recognized as ill

Anthropologists are particularly interested in the group of healers (special social group; their selection, training,concepts, value, and internal organization)

Healers play roles beyond their healing functions and usuallytheir focus on his ill family, community, village not individual


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Main Tasks of Medical Anthropology

How individuals in a particular society perceive andreact to ill health and the types of health care that theyturn to, to know something about both the cultural andthe social attributes of the society in which they live

It is possible to link medical sciences (microbiology,biochemistry, genetics, parasitology, pathology,nutrition, and epidemiology), social and cultural factorsfor explain the cause of illness

1 ethical issues in epidemics

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