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The Ethical Analysis of Treating and Preventing Ebola
Matthew Kuntz
Concordia University- MPH 560
October, 2014
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The Ethical Analysis of Treating and Preventing Ebola
Introduction
For many years in the past, public health professionals have had the task of treating,
controlling, and preventing infectious diseases. Recently, however, a new focus determining our
health status has become the issue of chronic diseases due to the unhealthy habits of many
different cultures around the world. Even with this new focus, though, there are still many
infectious diseases that continue to cause trouble and wreak havoc for many people. Some of
these infectious diseases include HIV/Aids, Lyme disease, malaria, flu, pneumonia, and Ebola.
When treating and preventing these diseases, many issues and implications can arise.
Specifically, as rules, regulations, and policies to combat Ebola are introduced and implemented,
policymakers must battle moral dilemmas, ethical issues, and personal values to decide what is
best for the general public.
In the case of treating and preventing the Ebola outbreak of 2014, there is no exception.
Some of these ethical issues and implications that public health officials around the world are
dealing with include violating human rights and social justice, using humans for
experimentation, unfair treatment, and not obtaining informed consent. As Ebola has managed to
infiltrate United States ground, one of the biggest ethical implications of treating and preventing
Ebola has been giving out experimental treatments that have not passed its full experimental
process. Even though many of these issues seem to be unethical and against what many people
believe, these policymakers making these important decisions must always keep the general
public’s best interest in mind and rely on public health’s three core functions of assessment,
policy development, and assurance to treat Ebola patients and prevent its ongoing spread (“Core
Functions of Public Health”, 2011).
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Background and Significance
When moral and ethical issues arise, one of the first three things people want to know is
what is it, why is it so important, and how does it personally impact them. In order to answer
these questions, we need to understand what Ebola is and how serious the disease can actually
be. Originally “discovered in 1976 near the Ebola River in what is now the Democratic
Republic”, Ebola has been problematic in many parts of Africa, Guinea, Sierra Leone, Liberia,
and Nigeria (About Ebola Virus Disease, 2014). Previously known as Ebola hemorrhagic fever,
this virus is a severe and often times fatal illness in humans that is thought to be “transmitted to
people from wild animals and spread in the human population through human-to-human
transmission” (Ebola virus disease, 2014). Like many other infections, this disease is spread
when contact is made through broken skin or mucous membranes. Although it cannot be spread
through the air or water, Ebola is primarily found in “blood or body fluids (including but not
limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who has been
infected (Transmission, 2014). Other means of transition may include needles, infected animals,
and raw meats that are primarily found in Africa. Aside from those means of transmission,
research is ongoing to determine if Ebola can be spread in other ways that are not known. This
point is very significant because researchers have not yet gained a full handle on this disease.
The significance of this disease affects many people because of who can become infected
with Ebola. This disease does not pick and choose who to infect, although, there is one particular
population most at risk. The healthcare population and anyone associated with healthcare
workers are most at risk of contracting Ebola as these people are the first line of defense. This
population includes doctors, surgeons, nurses, lab technicians, janitorial services, and any other
occupation in a healthcare setting. These healthcare workers are the lucky individuals treating
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infected patients, who are in close contact with many bodily fluids, and who may not have or
may not use proper protective gear when handling bodily fluids. The CDC says “exposure to
Ebola can occur in healthcare settings where hospital staff are not wearing appropriate protective
equipment, including masks, gowns, and gloves and eye protection” (Transmission, 2014).
Sanitation is also very important. If proper measures are not taken to sanitize healthcare settings,
Ebola is very likely to spread very fast. Once Ebola infiltrates these weaknesses in protection,
anyone associated with healthcare workers put themselves at a higher risk of infection.
Because Ebola is spreading through multiple cultures and countries at the same time, its
nature is relatively unknown. Public health officials are dealing with language barriers,
communication issues, sanitary deficiencies, education gaps, and financial discrepancies that put
us at a disadvantage. Because of these shortcomings in preventing diseases, this Ebola outbreak
we are currently living though is the “largest and most complex Ebola outbreak since the Ebola
virus was first discovered in 1976” (Ebola virus disease, 2014). Not only is this outbreak the
largest and most complex, it has moral, value, and ethical implications that have caused many
people to become outraged toward public health officials due to the ways they are dealing with
preventing and treating this deadly disease.
Treating and Preventing Ebola
Over the years, researchers have come up with vaccines and treatments to combat many
of the most severe infectious disease known to man. They have developed flu vaccines,
treatments for AIDs/HIV, eradicated smallpox, and controlled the spread of many other diseases
using medical technology. With the technology we currently have, combating Ebola should be
no different. Unfortunately, Ebola does not succumb to our most up-to-date prevention and
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treatment strategies. Because of this, many ethical concerns have developed as the current Ebola
outbreak has been concerning millions of people around the globe.
Unethical Treatment Concerns
Even though” public health focuses on preventing illnesses”, there are no prevention
vaccinations for Ebola (Schneider, 2011. p. 6). The only prevention measures that are available
are through limited prevention strategies that differ from country to country. If prevention
medication is out of the question and strategies have yet to work, then one would think treatment
is the next best solution. Unfortunately, there are no known treatment medications available
either. The CDC says “symptoms of Ebola are treated as they appear” and “no FDA-approved
vaccine or medicine (e.g., antiviral drug) is available for Ebola” (Treatment, 2014). Knowing
this, researchers and doctors needed answers fast. Using one of the main missions of public
health to guide them in their decisions, “the fulfilment of society’s interest in assuring the
conditions in which people can be healthy”, they turned to experimental drugs that have not yet
been cleared for use. (Schneider, 2011, p. 4) “As the death toll from the Ebola virus disease
continued to soar in several West African countries, an experimental drug called ZMapp was
administered to two U.S. missionaries who contracted the virus while working with Ebola
patients in Liberia” (Lewis, 2014). The drug seemed to work on those two patients but a third
patient who was given ZMapp ultimately died. Dr. Ezekiel Emanuel, the chair of the department
of medical ethics and health policy at the University of Pennsylvania's Perelman School of
Medicine said the problem with this information is “you have no idea whether the medication
worked or didn't work” (“WHO Experts Give Nod”, 2014). He concluded that we can’t really
know if the drug worked just by treating a small sample size.
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With this information at hand, the first and major ethical concern is raised. Why were
experimental drugs given to people who were infected with Ebola? If these drugs were not
properly tested, many things can go wrong. Kim Lewis says “Among the many risks of using an
untested drug to treat humans, there are the risks of unanticipated toxicities” (2014).
Furthermore, information is lacking in regards to when the drug should be administered, short
term side effects, long term side effects, who should administer the drug, dosages, efficiency,
and how to best administer the drug. Even if ZMapp was tested on “18 monkeys who were
exposed to a lethal dose of Ebola”, no other humans had been tested and many negative
outcomes could occur (Pollack, 2014). Moreover, by administering these experimental drugs, a
trickle down affect has transpired. Many other ethical concerns have been raised strictly due to
the process of administering these experimental drugs.
First, who should be among the initial people to get this new medication and how do we
decide who follows in line? This drug is already exhausted and production takes a long time.
Deciding who gets treated first causes a huge ethical debate. According to our human rights,
everyone should have fair access to this medication and we should all obtain equal rights to be
treated. With shortages of this drug already distinguished, what makes the first people treated so
worthy of the treatment? Should people who are the sickest get treatments first or should the
people doing the treating get treatment first? If no fair way of determining order is manufactured,
maybe a lottery system is the best answer. Regardless of how this is decided, many people will
go unhappy. Second, who will make this decision on the order of treatments? Would it be one
person, a panel, Americans, a combination of all 4 infected countries, or the leaders of each
country? Regardless of who makes the decision, ethical concerns are raised because the people
making this decision have the opportunity to be partial to one group based on their link to that
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infected population. In a perfect world, we would hope that sound moral reasoning will be used
and not just biased affinity for Americans by Americans (“WHO Experts Give Nod”, 2014).
Third, “how do you communicate the risks of an experimental drug to a poorly educated
inhabitant of a rural village” (“WHO Experts Give Nod”, 2014)? Communication is a key part of
this process. Doctors and researchers are already dealing with language barriers, adding
education gaps to the mix create a whole new mix of problems.
With education playing a critical rule in communication, the fourth ethical concern of
informed consent is presented. Do researchers actually receive informed consent from patients
being treated with this experimental drug? If public health officials are communicating through
language barriers and education gaps, ethical concerns of gaining full understanding is presented.
Without that full understanding, patients may be misled, uninformed, deceived, and unaware of
what is really happening when they receive ZMapp. Usually, when experimental treatments are
being tested, testing institutions must follow a strict procedure with rules and regulations to
eliminate any chances of wrong doing. Commonly known as the code of ethics, it states the
following.
The rules require that every research subject must be informed of the purpose of the study
and its risks, and benefits. The subjects must freely consent to participate. In addition,
any such study must be approved in advance by an institutional review board, a
committee that includes representatives of the community as well as other scientists, who
must agree that the study is well designed, that its benefits outweigh its risk, and that the
subjects are truly given the opportunity for informed consent (Schneider, 2011, p.88).
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Even with these current and strict regulations, other issues loom over these experimental trials.
Ethicists debate whether these trials should be conducted at all, who should be allowed to
participate, and whether unproven treatments should be available in the first place (Schneider,
2011). Finally, the last ethical concern stemming from the administration of an experimental
drug is about money. Would money be better spent on preventing the spread of Ebola verses
trying to create the treatment medication that may or may not work? Some people think that
preventing the disease through spending money on quarantine, sanitation supplies, and public
education better serves the general public than potentially wasting money on a “placebo
medication”. Regardless of where the money goes, the debate will be ongoing until researchers
prove ZMapp or any other treatment actually works.
If we do find that there actually is a treatment that works, the ethical debate will continue.
It doesn’t stop with who should be treated and who should not be treated. What happens if the
treatments are so good that public health officials make it mandatory for everyone to be either
medically treated for precautionary reasons to prevent the spread of Ebola or be medically
treated to relieve the symptoms of Ebola? Either way, if this happened, the ethical issues that
would ensue are endless. Mandatory vaccination and treatment goes against the human rights of
an individual. By making medications mandatory, personal freedoms of choice would be taken
away. Other ethical issues that would arise from this situation include breeches in confidentiality,
lack of respect of the infected person, and the lack of preservation of dignity and involvement in
the community (“Ethical considerations for use of unregistered interventions”, 2014). With these
ethical implications from mandatory treatments pending, one would think that more should be
done in the area of prevention. Even though prevention seems like a logical approach, ethical
issues will still prevail.
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Unethical Prevention Concerns
As already stated, preventing Ebola should garner more attention. If treatments strategies
are carrying the baggage of being unprepared, unapproved, inadequate, and unethical; why
shouldn’t we spend more time applying our knowledge and technology into preventing this
disease? Ethicists say that preventing the spread of this disease, as well as treating the disease,
will present ethical struggles along the way as well. Not having a vaccine for this disease sparks
a huge ethical debate. Where was money going since the last Ebola outbreak? If public health
officials knew Ebola was so bad, more money should have been allocated for Ebola research,
even if Ebola was not a problem for the United States. Money that is wisely spent is money that
is wisely saved. Many other humans were suffering from this disease and progress towards
preventing it was limited, and this is where a huge ethical problem lies.
Another one of the main ethical concerns in preventing this disease is our travel
regulations. As it stands, the United States is strengthening current travel regulations to prevent
Ebola from becoming an epidemic on our home turf. “Affected countries are requested to
conduct exit screening of all persons at international airports, seaports and major land crossings,
for unexplained febrile illness consistent with potential Ebola infection” (“Statement on travel
and transport”, 2014). Likewise, uninfected countries are subjected to requests as well. “Nonaffected countries need to strengthen the capacity to detect and immediately contain new cases,
while avoiding measures that will create unnecessary interference with international travel or
trade” (“Statement on travel and transport”, 2014). As it stands now, these requests seem to only
deter travelers and to only create an inconvenience. However, if travel regulations become
stricter, the ethical concerns then become more heated. Not allowing free will to international
travel, mandatory exit screening, mandatory entrance screenings, and full stoppage of trade
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would spark great debate. Other prevention debates that are equally important include mandatory
quarantine and not allocating money towards sanitation, education, safety gear, preparedness,
communication, and awareness. Mandatory quarantine inhibits human rights while money that is
being distributed incorrectly inhibits our ability to prevent Ebola from spreading. No matter how
we look at this issue, ethical issues will always be present. There are many people dealing with
this issue with many different ideas. When so many people get together and work on one issue,
ideas, opinions, values, morals, and priorities will always clash. When this happens, the ethical
debate takes full swing.
Discussion
The ethical issues of treating and preventing Ebola will be an ongoing process until a true
prevention or treatment shows success. The CDC has been working nonstop dealing with many
things that were known, many things that were not known, and many things that are yet to come.
Because this disease is relatively unknown, there will be many bumps along the way. As this
process of fighting Ebola is taking shape, many people feel that the ones in charge have not been
handling this problem correctly. News stations across the globe have been discussing human
rights, fairness, equal rights to treatment, money allocation, prevention, and many other issues
with an ethical tone. While listening to these discussions, we hear many opinions and many
people becoming scared, afraid, hopeless, and uneasy. Regardless of who thinks what, though,
there should be a point when ethical issues are put aside and we allow the people in charge to do
their job. The real focus with Ebola should be figuring out how to prevent this disease from
spreading and treating the people that are infected. If we continue to focus on ethical issues,
moral codes, and personal values, finding an end to this disease will result in millions of sick
people and millions of deaths that could have been prevented.
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Recommendations
With Ebola harvesting such widespread news coverage, one cannot leave the house
without hearing someone offering ideas of how to fix this issue. If I had the chance of offer my
input, I would offer one piece of advice. The CDC and the people in charge need to be more
thorough in relaying information to the general public and they need to report everything that has
been done or will be done to combat Ebola. We hear many news accounts with many different
facts and opinions that all seem to conflict with each other. What we really need is for the CDC
or the President to address the public in a news conference so we all get the same information at
the same time. When the public is not informed, misinformed, or receives surprises, many
concerns start to spin out of control. If we were all informed of every aspect of this process, the
ethical concerns that this disease garners could be controlled before they got out of hand.
Summary
Ebola is a very serious disease that is relatively unknown and presents many problems for
everyone. Because of the way it is passed and the significance of not having treatments or
prevention strategies in place, many people have become indulged in the ever-changing news
articles that we hear every day. Whether people are scared, concerned, or just uneducated about
Ebola, issues have risen and people want answers. Since 1976, the first outbreak of Ebola, many
ethical and moral concerns pertaining to treatment and prevention has spiked many debates.
Issues like human rights, fairness, equal rights to treatment, informed consent, and travel
regulations have all been debated during this current outbreak of Ebola. Until researchers find
better ways to relay information, a treatment for Ebola, and/or a vaccine that prevents it, ethical
debates will be ongoing. If researches want to stop these debates, providing answers is a must.
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References:
About Ebola Virus Disease. (2014, October 3). The Centers for Disease Control and Prevention.
Retrieved October 5, 2014, from http://www.cdc.gov/vhf/ebola/about.html
Core Functions of Public Health and How They Relate to the 10 Essential Services. (2011). The
Centers for Disease Control and Prevention. Retrieved October 5, 2014, from
http://www.cdc.gov/nceh/ehs/ephli/core_ess.htm
Ebola virus disease. (2014). World Health Organization. Retrieved October 5, 2014, from
http://www.who.int/mediacentre/factsheets/fs103/en/
Ethical considerations for use of unregistered interventions for Ebola virus disease.(2014). World
Health Organization. Retrieved October 12, 2014, from
http://www.who.int/mediacentre/news/statements/2014/ebola-ethical-review-summary/en
Lewis, K. (2014, August 20). Ebola Drug Poses Question of Ethics in Treatment. Voice of
America. Retrieved from http://www.voanews.com/content/ebola-ethics-drug-untestedzmapp/2422021.html
Pollack, A. (2014). Experimental Drug Would Help Fight Ebola if Supply Increases, Study
Finds. The New York Times. Retrieved from
http://www.nytimes.com/2014/08/30/world/africa/study-says-zmapp-works-against-ebola-butmaking-it-takestime.html?module=Search&mabReward=relbias%3Aw%2C%7B%222%22%3A%22RI%3A12
%22%7D&_r=1
Schneider, M.-J. (2011). Introduction to Public Health (Third ed.). Sudbury, Massachusetts:
Jones and Bartlett
Statement on travel and transport in relation to Ebola virus disease (EVD) outbreak. (2014). The
World Health Organization. Retrieved October 12, 2014, from
http://www.who.int/mediacentre/news/statements/2014/ebola-travel-trasport/en/
Transmission. (2014, October 3). The Centers for Disease Control and Prevention. Retrieved
October 5, 2014, from http://www.cdc.gov/vhf/ebola/transmission/index.html
Treatment. (2014, October 3). Retrieved October 12, 2014, from
http://www.cdc.gov/vhf/ebola/treatment/index.html
WHO Experts Give Nod to Using Untested Ebola Drugs: MedlinePlus. (2014, August 12).
Retrieved October 12, 2014, from
http://www.nlm.nih.gov/medlineplus/news/fullstory_147811.html