Cui bono? Ebola crisis brings black-and-white question into focus
One of the issues raised by the ongoing Ebola outbreak in West Africa runs to the core of medical ethics: how to decide who should benefit from a limited medical resource – and one that has not been rigorously tested, to boot.
With no proven specific treatment and no vaccine available to counteract Ebola, focus shifted to an experimental serum, reportedly with just eight doses available, that had shown striking results when tested in Rhesus monkeys within hours of their exposure to the haemorrhagic virus.
Samaritan’s Purse, the charity that deployed two American missionaries who contracted the virus in Liberia, heard about the serum and arranged for three doses to be flown to West Africa. Two doses were given to a female healthcare worker, while an infected doctor received one dose; significantly, he also received blood transfusions from a 14-year-old survivor he had treated.
Specialist isolation unitThe experimental treatment ZMapp is an enhanced version of an antibody cocktail called MB-003. It consists of three monoclonal antibodies that researchers have shown is capable of both deactivating the Ebola virus and tagging it for attack by the victim’s immune system. ZMapp is made by inserting modified genes into the cells of tobacco plants whose cells then become mini-factories of the antibodies. In an ironic aside, the facility where this happens is owned by cigarette maker RJ Reynolds.
Now in a specialist isolation unit in Atlanta, the doctor in particular is making a good recovery. Meanwhile back in Sierra Leone, Liberia, Nigeria and Guinea, the number of cases of and deaths from Ebola continues to rise. Local healthcare professionals account for about 10 per cent of fatalities.
Which raises some important ethical issues: who decided that two white American professionals should get the scarce treatment ahead of their black African medical colleagues? And is it acceptable to assume that poor African villagers have less rights to a limited resource than educated and well-connected Americans?
Experimental treatmentThe World Health Organization (Who) has responded by convening a panel of medical ethicists to explore the use of experimental treatment in the ongoing Ebola outbreak.
It reached an initial consensus that it is ethical to offer unproven interventions but that “ethical criteria must guide the provision of such interventions. These include transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community.”
Additional sensitivityThose who have read John Le Carré’s book The Constant Gardener will be aware of an additional sensitivity facing the Who: administering untested serum to an African population runs the risk of being accused of using black people as guinea pigs, as happened during meningitis treatment trials in Nigeria in 1996.
Another key ethical issue that arises is whether a person who has never heard of the concept of informed consent can consider fully the implications of taking a drug such as ZMapp.
Does the patient understand the unproven drug might not work, while exposing them to side-effects? Is it in some way more ethical to have offered the scarce treatment to American professionals on the basis that they would more fully understand the risks of an untested medicine?
Preferentially offering the drug to the missionaries seems to violate the principle of distributive justice: the benefits of the drug are being inequitably distributed, with skilled professionals more likely to benefit. On what ethical basis does a doctor’s role increase their value and dictate they should be given a preferential chance to survive?
Patients are commonly prioritised on the basis of need; does the person’s capacity to benefit from treatment add to that need?
Beyond clinical ethics, perhaps the core issue is not that two white people got an untested serum, but that the deaths of so many black people were ignored until two white people got sick.