Nov 13th 2014

The Ethics of Fighting Ebola

PRINCETON – It may, in the end, turn out to be fortunate that a handful of people in developed countries – four in the United States and one in Spain – have contracted Ebola. Tragic as this was for Thomas Duncan, the only one of these patients who has died, if all of the more than 13,000 cases and nearly 5,000 deaths had occurred in Africa, Ebola would never have aroused nearly as much attention in rich countries.

In this respect, Ebola is – or, rather, was – an example of what is sometimes referred to as the 90/10 rule: 90% of medical research is directed toward illnesses that comprise only 10% of the global burden of disease. The world has known about the deadly nature of the Ebola virus since 1976; but, because its victims were poor, pharmaceutical companies had no incentive to develop a vaccine. Indeed, pharmaceutical companies could expect to earn more from a cure for male baldness. 

Government research funds in affluent countries are also disproportionately targeted toward the diseases that kill these countries’ citizens, rather than toward diseases like malaria and diarrhea that are responsible for much greater loss of life.

But the tiny number of Ebola cases in rich countries – and the ensuing panic-inducing headlines and quarantine measures – have brought home the global nature of infectious disease today. Mass travel has made effective containment of epidemics extremely difficult. 

The best defense against an infectious disease is to fight it where it originates, and that requires good health services. Ebola appears to have been eradicated from Nigeria, in no small part because that country had a Gates Foundation-supported hospital with personnel trained and equipped to control infectious diseases. If, over the past decade or two, affluent countries had done more to assist Liberia, Sierra Leone, and Guinea, the current Ebola outbreak could have been minimized, if not prevented.

But now it is too late for that, and scientists are rushing to find both a vaccine and an effective treatment for Ebola. What ethical considerations should guide them in their search? 

The standard way to judge the efficacy of a vaccine is to conduct a trial in which those who could benefit are randomly assigned to two groups, one of which receives the potentially beneficial vaccine, while the other receives a substance with no active ingredients, known as a placebo. To avoid possible confounding factors, such as greater risk-taking by those who know they have been vaccinated, or the desire of those conducting the trial to show that the vaccine works, the study is “double blind”: Neither the subjects nor those administering the trial and collecting the data know who got the vaccine and who got the placebo. Only an independent group examining the data sent in from the field has that information.

Without such a trial, the appearance of efficacy may be an illusion, because other factors would have led to a lower rate of infection anyway. Yet if a promising vaccine is available – and if safety trials in healthy human volunteers who are not at risk of infection demonstrate that it does no harm – to deny it to those who are tending to the sick and dying, at great risk to their own health, seems unethical. 

That question will soon need to be answered, because both the pharmaceutical giant GlaxoSmithKline (in conjunction with the US National Institute of Allergy and Infectious Diseases) and the Public Health Agency of Canada have candidate vaccines in development.

At a recent World Health Organization meeting in Geneva, Ripley Ballou, the head of GlaxoSmithKline’s program to develop a vaccine, argued that a randomized controlled trial comparing a potential Ebola vaccine with a vaccine that protects against another virus would be the most ethical way to assess efficacy. Depending on the outcome, results could be available within three months, allowing production and distribution to go ahead with greater confidence. 

Representatives of Médecins Sans Frontières (Doctors without Borders), which has more than 3,000 staff members combating Ebola in the most affected countries, strongly opposed giving placebos to anyone at high risk of contracting the disease. But Ballou appears to have persuaded many of the participants at the meeting that his proposal will save more lives in the long run. If that is true, a randomized controlled trial could be the most ethical option.

When it comes to treatment, the situation is different. In a letter published last month in The Lancet, doctors, scientists, and bioethicists from a wide range of countries – including Guinea, Ghana, Nigeria, and Senegal, as well as Britain, France, Hong Kong, and the United States – argued that a randomized trial is justified only when there is “equipoise,” or balance, between the two options offered. This can happen when doctors do not know whether a proposed treatment will do more harm than good, or when they are in doubt about which of two treatments is more likely to cure the patient. 

But, when facing a disease that kills up to 70% of those who are infected, and no accepted treatment yet exists, patients could reasonably refuse consent to a trial in which they might receive a placebo, rather than an experimental treatment that offers some hope of recovery. In such cases, it might be more ethical to monitor carefully the outcomes of different treatment centers now, before experimental treatments become available, and then compare these outcomes with those achieved by the same centers after experimental treatments are introduced. Unlike in a randomized trial, no one would receive a placebo, and it should still be possible to detect which treatments are effective.


Copyright: Project Syndicate, 2014.
www.project-syndicate.org




     

 


This article is brought to you by Project Syndicate that is a not for profit organization.

Project Syndicate brings original, engaging, and thought-provoking commentaries by esteemed leaders and thinkers from around the world to readers everywhere. By offering incisive perspectives on our changing world from those who are shaping its economics, politics, science, and culture, Project Syndicate has created an unrivalled venue for informed public debate. Please see: www.project-syndicate.org.

Should you want to support Project Syndicate you can do it by using the PayPal icon below. Your donation is paid to Project Syndicate in full after PayPal has deducted its transaction fee. Facts & Arts neither receives information about your donation nor a commission.

 

 

Browse articles by author

More Current Affairs

Mar 19th 2019
Last week, a far-right extremist killed at least 50 people – including a three-year-old child – worshiping at two mosques in the New Zealand city of Christchurch. Neither white supremacy, nor racially motivated terrorist attacks carried out in its name, are new phenomena. Yet the response to far-right terrorism remains thoroughly insufficient.
Mar 12th 2019
Allegations of Russian meddling in the affairs of Western countries have been a persistent feature of Western politics since the Cold War. Claims of Russian interference in the 2016 US presidential election are only the most recent in a long series of suspected conspiracies across the past century or so. But Russian political discourse is also riddled with conspiracy theories. Everything bad that happens in Russia is traced back by some to one or another anti-Russian plot hatched in the West.
Mar 10th 2019
My Soviet school built a mesh fence around its yard. Every week, tardy kids who wanted to cut through the yard tore a hole in the fence. Every weekend, the administration fixed it. But the hole would reappear the morning after. This went on forever. I wish US President Donald Trump, the fence builder of the West, had gone to my school. The Soviet Union was a country of fences, barriers, and walls. Everything was prohibited, locked, and guarded. Warning signs were phrased in no uncertain terms: “Do Not Enter: Death!” “Strangers Are Forbidden.” “The Border Is Closed.” Barriers didn’t stop people from ignoring the warnings. But they complicated things.
Mar 8th 2019

 

WASHINGTON, DC – It seems that every time I write about Donald Trump’s presidency, I pronounce it to be in more trouble than ever. This time is no different: he and his presidency are indeed in more trouble than ever. And yet that may not prevent him from winning again in 2020.

Mar 7th 2019
The Brexit process has exacerbated many of the disunities within the UK’s territorial constitution................polling in England suggests that many people think breaking up the UK is perhaps a price worth paying to deliver Brexit.......... At the referendum, only two of the four component parts of the UK – England and Wales – voted to leave the EU. This was enough to swing an overall UK-wide majority in favour of leave, but it went against the will of the Scottish and Northern Irish electorate. In both these parts of the country, significant majorities voted to remain – 62% and 55.8%, respectively.
Mar 6th 2019
Watching Michael D. Cohen, US President Donald Trump’s former lawyer and self-described “fixer,” testify to the House Committee on Oversight and Reform was a remarkable spectacle to behold. Here was a man who was hired by Trump to behave like a gangster. And he did that to perfection. When The Daily Beast was about to report on allegations by Trump’s first wife, Ivana, that her husband had raped her, Cohen barked at the journalist working on the story: “So I’m warning you, tread very fucking lightly, because what I’m going to do to you is going to be fucking disgusting. You understand me?” That journalist was hardly alone. Cohen’s job was to threaten anyone who got in the way of his old boss. He lied to congressional committees, paid off prostitutes to stop them from talking about their affairs with Trump, and much else. Cohen, who will soon begin serving a three-year prison sentence, has become what Mafiosi (and Trump) call a “rat.”
Feb 27th 2019
Extracts: "Some political catastrophes come without warning. Others are long foretold, but governments still walk open-eyed into disaster. As the possibility of a no-deal Brexit looms, most analysts agree that there will be severe economic and political consequences for the UK and the EU. And yet a no-deal Brexit still remains an option on the table....." ".......Although the consequences of a no-deal Brexit will be much less terrible, there are similarities in certain patterns of thinking and political behaviour, from the few who embrace disaster to the systemic pressures which prevent compromise. Avoiding disaster in 1914 would have required framing the stakes of the July crisis in less zero-sum ways and refusing to rationalise a general European war as an acceptable policy option. It required leaders with enough courage to compromise, even to accept defeat, and for states to offer rivals the prospect of long-term security and future gains in exchange for accepting short-term setbacks."
Feb 25th 2019
US President Donald Trump’s administration has underestimated China’s resilience and strategic resolve. With the Chinese economy slowing, the US believes that China is hurting and desperate for an end to the trade war. But with ample policy space to address the current slowdown, China’s leadership has no need to abandon its longer-term strategy. While a cosmetic deal focused on bilateral trade appears to be in the offing, the sharp contrast between the two economies’ fundamental underpinnings points to a very different verdict regarding who has the upper hand.
Feb 21st 2019
Extracts: "......after three years of referendum-induced turmoil, there is finally a new move, a brave move, by the eight Labour MPs and three Conservative MPs (and counting)......There are no policy announcements, no real statement of principles, and there is no leader or political platform. And yet, this policy-free political movement is of incredible political importance........this is an act of direct action, based on the concept of prefiguration. That is, the actual policy statement at the heart of the formation of this movement is the formation of the movement itself. There is no need for grand policy statements right now."
Feb 21st 2019
There is a fascinating chapter toward the end of Alexis de Toqueville’s Democracy in America titled “What Kind of Despotism Do Democratic Nations Have to Fear?” in which the author attempted something truly extraordinary – to describe a social condition which humankind had never before encountered. We find him trying to put his finger on something which does not yet exist, but which – in his extraordinary political imagination – he was able to foresee with startling clarity.
Feb 20th 2019
From Trump’s very inauguration day speech, written for him by the fascist gadfly Steve Bannon and man still without a prom date Stephen Miller, it was apparent that the 45th president was a constitutional crisis waiting to happen. And now, without our realizing it for the most part, the constitutional crisis is here.
Feb 11th 2019
The first step to defending Europe from its enemies, both internal and external, is to recognize the magnitude of the threat they present. The second is to awaken the sleeping pro-European majority and mobilize it to defend the values on which the EU was founded. Otherwise, the dream of a united Europe could become the nightmare of the twenty-first century.
Feb 7th 2019
Watching a sophisticated democratic society knowingly walk into a predictable and avoidable national disaster is a rare and alarming experience. Most British politicians are well aware that leaving the European Union with no agreement on the post-Brexit relationship will cause enormous damage to their country. They are not sleepwalking into the abyss; their eyes are wide open. A minority of deluded ideologues doesn’t mind the prospect of Britain crashing out of the EU with no deal. A few chauvinist dreamers on the right, egged on by sections of the press, believe that the bulldog spirit of Dunkirk will overcome early setbacks and Great Britain will soon rule the waves again as a great quasi-imperial power, albeit without an empire. Neo-Trotskyists on the left, including Jeremy Corbyn, the leader of the main opposition Labour Party, seem to think that catastrophe will spur the British people to demand true socialism at last.
Feb 4th 2019
We’re off to the races - the 2020 presidential races, that is. Since the beginning of the year, at regular intervals, new candidates have been coming forward to announce their intention to compete for the presidency. Some are interesting and/or exciting, while others frankly leave me scratching my head and asking “What are they doing? How on earth do they think they’re going to be elected?”      
Jan 29th 2019
Extract: "As it happens, on that Friday night when Trump buckled, I was at a restaurant where Pelosi and her husband, Paul, were dining with another couple. When the House Speaker left her table, customers and staff alike applauded her. A waitress standing beside me was nearly in tears. She choked out, “We need someone who will fight for us.” "
Jan 28th 2019
Recognizing that opinion in Parliament is moving strongly against leaving the EU on the terms proposed by May, with a growing number of members even in favor of a second referendum to test whether we should leave at all, some right-wingers have flirted with the idea of trying to close down the House of Commons for a time. They want the government to be able to get its own way without any democratic opposition. It is a sign of their desperation to get Britain out of the EU whatever the constitutional or economic cost. Is May prepared to get to grips with this? If she runs away from the task, despite growing Parliamentary unease about the path we are on, Britain is in big trouble.
Jan 25th 2019
At the end of last year, Russian President Vladimir Putin announced that Russia had completed final testing of an “invincible” new hypersonic nuclear-capable missile, the “Avangard,” calling it “the best New Year gift” for his country. With Putin seeming to up the ante on his increasingly frequent doomsday rhetoric, should the world be bracing itself for a nuclear conflict?................In recent months, popular support for Putin in Russia has declined sharply, with his approval rating falling from over 76% to 66% in the second half of last year. At the same time, a kind of neo-medieval thinking, focused on the restoration of autocratic monarchy and the supremacy of the Orthodox Church, has been gaining prominence in Russia. Putin’s fire-and-brimstone rhetoric may actually reflect the mindset of these fundamentalists, who view nukes as a “practical solution” to the world’s problems.
Jan 24th 2019
Over the past three decades I wrote more than two hundred articles about Israel, envisioning it to be a democratic state, independent and free, a champion of human rights, a force of unity for world Jewry, united in its citizenry, admired by its friends, envied by its detractors, and above all at peace with the Arab states and especially with the Palestinians. My vision about Israel was founded on my deep sense of the Jews’ turbulent and tragic history and their yearning for a home of their own in which to live in peace and security. As the years went by, I became increasingly disillusioned with Israel’s endemic political disunity, its inability to resolve the conflict with the Palestinians, the growing public complacency, the loss of the country’s unity of purpose, and the abandonment of its moral responsibility.
Jan 22nd 2019
China’s strategy for economic growth has been a work in progress since Deng Xiaoping launched the country’s “reform and opening up” in 1978. While the last 40 years of reform have been far from error-free, the government has displayed a willingness to adapt, as well as a capacity for navigating complex transitions, supported by a healthy internal policy debate. But how is China’s development model likely to evolve in the future, as external conditions pose new challenges to economic growth? A defining feature of China’s four decades of reform has been the state’s evolving role in the economy, about which there is still significant domestic disagreement. Some argue that the state – and, by extension, the Communist Party of China (CPC) – must retain a prominent role, in order to uphold the social stability needed to sustain economic development. Others claim that spurring the innovation needed to reach high-income status requires the state to be less like a market participant and more like a referee, regulator, and arbiter of economic and social priorities.
Jan 16th 2019
Consumer studies academics have been picking up on changing habits for a number of years. This includes an increased ambivalence towards consumption itself: people are buying less often and less overall. This is particularly true in the clothing industry, where research shows that millenials are especially unforthcoming – even after you factor in the shift to online retail. A lack of bricks and mortar did not, for instance, prevent online fashion retailer Asos from shocking the City with a profit warning shortly before Christmas. The American car industry is another harbinger of generational change: sales are stalling because younger people seem less interested in ownership. The average age of a new car buyer in the US was 50 in 2015. Or to give one more example, witness Apple’s recent trading problems. People are not only opting for cheaper smartphones, but they are keeping them for longer. If the world’s first company to pass the trillion dollar value mark is showing signs of struggling, we ought to take note.