Ethical Issues in Epidemics

1. Ethical Issues in Epidemics KUSWANDEWI MUTYARA

2. 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.

3. 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.

4. The ‘Black Death’ eliminated one third of the European population during the 14th 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.

5. Infected individuals can threaten the health of other individuals and society as a whole, for example, public health care measures such as surveillance, isolation, and quarantine can require the infringement of widely accepted basic human rights and liberties. • An important and difficult ethical question asks how to strike a balance between the utilitarian aim of promoting public 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.

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

7. SITUATION • Infectious diseases are currently the world’s largest ‘killer[s] of children and young adults. • They account for more than 13 million deaths a year – one in two deaths in developing countries.’ • 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

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

9. 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 other individuals and society from contagion (again, depending on the disease) might sometimes involve surveillance, mandatory testing, mandatory vaccination or treatment, notification of authorities or third parties, isolation (of individuals), quarantine (of entire regions), or travel restrictions.

10. 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. • Bad nutrition, dirty water, crowded living conditions, poor education, lack of access to basic medicines, disempowerment of women, 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. • 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 world’s population lack access to essential drugs

11. 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. • 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, tuberculosis, cholera, dysentery, meningitis, and typhoid fever. • The affordability problem also extends beyond a lack of access to new drugs designed to treat devastating, infectious diseases: 50% of people in developing nations do not have access to even basic medications, such as antibiotics, analgesics, broncho-dilators, decongestants, anti-inflammatory agents, anti-coagulants, or diuretics

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

13. Public-health decisions commonly involve conflicting and ambiguous ethical principles. Ideas like efficiency, human rights, cultural respect, 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.

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

15. 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.

16. 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

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

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

20. 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. She wants to comply but fears this could cost both her job and her apartment.

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

22. Privacy of personal information andpublic 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, the nurse takes a commuter train to work. She is later found to have SARS. 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.

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

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

25. Duty of care • An intensive care nurse is afraid of contracting SARS 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, and two died

26. Healthcare workers were forced to weigh serious and imminent health risks to themselves and their families against 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 and police officers do not get to select which dark alleys they walk down. • Measures such as an insurance fund to cover healthcare workers who become sick or die through work should be considered for future epidemics.

27. 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.

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

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

30. Public-health decisions commonly involve conflicting and ambiguous ethical principles. Ideas like efficiency, human rights, cultural respect, 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.

31. 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 & political organizations, religions, languages, art & artefacts

32. 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:A biocultural 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

33. 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 ways in 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 usually their focus on his ‘ill’ family, community, village not individual

34. 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, 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, biochemistry, genetics, parasitology, pathology, nutrition, and epidemiology), social and cultural factors for explain the cause of illness