Bioethicists call for greater first-world response to Ebola outbreak
Amid recent discussion about the Ebola crisis in West Africa, Penn Medicine physicians say that high-income countries like the United States have an obligation to help those affected by the outbreak and to advance research to fight the deadly disease—including in the context of randomized clinical trials of new drugs to combat the virus. The two new editorials, which will appear "online first" in JAMA on September 11th, are written by faculty members in the Perelman School of Medicine at the University of Pennsylvania and the Department of Social Science, Health and Medicine at King's College London.
The first paper, co-written by Ezekiel J. Emanuel, MD, PhD, Penn's Vice Provost for Global Initiatives, the Diane v.S. Levy and Robert M. Levy University Professor and chair of the department of Medical Ethics and Health Policy, and Annette Rid, MD, PhD, at King's College London, contends that there are three independent reasons why high-income countries should "help the affected countries combat the Ebola outbreak and strengthen their health systems and infrastructure in the longer term." These reasons include: "the duty to provide humanitarian assistance; obligations of global justice to ensure, at least, that people everywhere can lead a minimally decent life; and the ethical requirement to provide fair benefits from any research conducted during the epidemic."
With no specific treatments or preventative measures available, and striking in some of the poorest countries with weak health systems, the ongoing Ebola outbreak in West Africa has claimed the lives of almost 2,300 people. More people have now died in the 2014 Ebola epidemic than in all previous outbreaks combined.
Rid and Emanuel's editorial states that everyone has an obligation to help others if the cost or imposition is minimal—the Good Samaritan notion—pointing out that effective help for Ebola, including containment measures and universal precautions such as gloves and masks, are available at relatively minimal cost for high-income countries like the U.S. In addition, they say that in the interest of global justice, these same countries have obligations to meet the basic needs of people living in extreme poverty, especially because we live in an increasingly interconnected world. Rid and Emanuel also argue that as part of conducting any research in these impoverished countries, it's imperative to ensure that the communities actually receive fair benefits from the research—such as strengthening of their health systems.
The second paper, authored by Steven Joffe, MD, MPH, Vice Chair of the Department of Medical Ethics and Health Policy, outlines the considerations and implications of using scarce new Ebola treatment agents in the midst of the epidemic. He looks at how research of these agents can be conducted with an eye towards preventing "the maximum number of deaths during the current outbreak," while calling on policymakers to "seek to optimize knowledge gained for use in confronting future Ebola epidemics."
"Scientifically and ethically justified use of scarce new agents in the midst of the Ebola epidemic, or any other epidemic for which novel agents hold promise, requires reflection on the understandable desire to rescue imminently dying patients," writes Joffe. "Clinicians, investigators and policy makers must deploy novel agents in ways that address pressing scientific questions, prioritize research in populations that will be most scientifically informative as well as most likely to benefit, ensure valid answers through the use of supportive care controls, and protect critical clinical and public health resources from diversion to longer-term aims. By doing so, they can both maximize lives saved in the present epidemic and ensure knowledge gains for the next."
Joffe's editorial asserts that randomized clinical trials are the best way to conduct this research, especially since the supplies of the treatment agents currently under study are so scarce that limited numbers of patients will receive access regardless of the study design. He also cautions against diverting attention or resources from proven therapeutic and public health measures, as doing so could actually increase, not reduce, the death toll.