Reiheld, Alison

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Ethics, Pandemics, Duty to TreatRemembering the “Pan’’in “Pandemic’’: Considering the Impactof Global Resource Disparity on a Dutyto TreatAlison Reiheld, Michigan State UniversityWhile Malm and colleagues (2008) do a fine job of consid-ering the limits and merits of a duty to treat in the face ofpandemic disease, they do so in the developed-world con-text. Developing world healthcare providers face infectiousdiseases as virulent as anywhere else in the world, often be-ing on-site for initial outbreaks of global and regional pan-demics. They do so with fewer resources and at greater riskto themselves, a fact I contend must be accounted for inany formulation of pandemic duty to treat whether or notit alters that duty. Here, I introduce some of the salient con-ditions resulting from global resource disparity and offer abrief consideration of how they might affect formulations ofa duty to treat.Consider the following case. In December of 2007, anoutbreak of Ebola occurred in Uganda. Its epicenter wasthe town of Bundibugyo, a city to which there is only oneroad, which has no electricity, and in which the hospitaltreats 65,000 patients per year on a budget of only $250,000.By December 11, 2007, 18 people were dead, four of whomwere healthcare personnel at the hospital (Ehrenkranz 2007).This is hardly surprising as healthcare providers are mostlikely to have direct contact with the virus-bearing bloodof Ebola patients, nor is it surprising given the lethality ofEbola: the least lethal of the Ebola subtypes, EBO-S has amortality range of 41%–65%; EBO-Z, the most lethal, canrange as high as 89% (King 2008). In short order, the Ugan-dan Medical Workers Union (UMWU) (Uganda) advisedtheir people in Bundibugyo to vacate their hospital jobs.But this was no simple failure to fulfill a duty to treat,and was very different from the failure of some Torontohealthcare workers with access to modern infection con-trol procedures to show up for work during the severeacute respiratory syndrome (SARS) outbreak (Malm et al.2008). Why? Because workers were willing to return to workeven while the disease still raged unabated. The UMWUhad very simple conditions for doing so: better protectionand sanitary measures (Ehrenkranz 2007). Conditions stan-dardly available in the developed world are simply absentin a region where hypodermics can rarely be fully ster-ilized, individual isolation of patients from each other isAddress correspondence to Alison Reiheld, 35 East Holmes Hall, Lyman Briggs College, Michigan State University, East Lansing, MI48825-1107. E-mail: reiheld@msu.edunot physically possible, and universal precautions such asdouble-gloving and eye protection are prohibitively expen-sive. While the risks for Toronto healthcare works werehigh—Malm and colleagues (2008) point out that approx-imately 50% of Toronto SARS infections were in health-care workers, three of whom died—they are far higherin places where resource disparity leads to poor infectioncontrol.Just how bad is access to such protections? So badthat the medical system, itself, is a major site for trans-mission. Unsterilized needles and syringes are frequentlyreused in administering treatment and commonly drawfrom multi-dose vials, thereby contaminating the vials suchthat even subsequent use of sterile equipment will conveycontaminated medicine (Peters 2005). The conditions on theground and the shortages of supplies mean that ostensiblydisposable plastic equipment, which has prevented cross-contamination in the developed world, is being reused. Thishas proven to be worse for the developing world than oldermedical supplies such as glass syringes which can be heatsterilized: easily-melted disposable plastics are usually sim-ply rinsed and reused. Where sterilizable sets of syringesand needles are available, they may be hard to come by andclosely rationed.This is only one way in which the resource disparitybetween the developing and the developed world changesthe face of pandemic disease for healthcare providers. Otherbasics of infection control such as barriers are also in seriousshortage, resulting in inadequate use by nursing and otherstaff: “Gloves are used only rarely—often not even duringsurgical procedures—and gowns are not commonly avail-able. Thus, hospital personnel often bear the brunt of theseepidemics and participate in the dissemination of disease”(Peters 2005, 2572). Such infection control procedures andindividual use of gowns, gloves, masks, and goggles arerecommended by the World Health Organization for infec-tious diseases and Ebola, in particular, without any regardfor how resource-poor regions are to acquire them. Com-pare this with the experience of hospital staff in the devel-oped world where adequate resources mean that nurses andAugust, Volume 8, Number 8, 2008 ajob 37The American Journal of Bioethicsphysicians rarely have unprotected contact with infected pa-tients.1.There are many ways to account for these facts when for-mulating a duty to treat. Let us consider the following two:we can maintain that the duty to treat is an absolute moralimperative, or we can allow that it is narrowly defeasible.Viewing the duty to treat in an epidemic or pandemicas an absolute duty from which there can be no exceptionsis appealing as it sets clear standards for behavior in a timewhen medical care may be all that stands between a pan-demic brushfire and a pandemic conflagration, and whenpersonnel shortages are already likely. However, this im-poses a disproportionate burden on people whose workconditions and resources intrinsically put them in greaterdanger than those with access to adequate supplies andequipment. What’s more, those bearing this burden tendto live in the lower-latitude developing countries with lim-ited disease monitoring from which infectious diseases mostcommonly emerge (Jones et al. 2008). Such regions therebysuffer a triple cocktail that affects both the duty to treatand the likelihood of a pandemic escaping early detectionand early response: poor disease monitoring, inadequateresources for infection control, and an increased likelihoodof emerging infectious diseases. An absolute duty to treatthus demands more of those who have less. Equally trou-bling, this demand disproportionately benefits those whohave more: because emerging infectious diseases are liableto emerge in resource-poor areas, those who are being askedto take the greatest personal risks will potentially be stop-ping the pandemic at a regional level or at least slowingit down before it goes global. The result of their sacrificemay be to prevent the well-equipped personnel from tap-ping out or even using their resources. This rather appallingscenario—that the poor would die to preserve the wealthyand be more likely to do so precisely because they are poor—may be both regrettable and acceptable on a strictly utilitar-ian basis of considering the good of the many to outweighthe good of the few, but is on its face so unjust as to bemorally undesirable and to render questionable an absoluteduty to treat.This leads me to consider a second way to account forresource disparities when formulating a duty to treat: Wemight say that a duty to treat is not absolute, but is defea-sible by particular narrow circumstances. I have in mindcircumstances such as an inability to effectively treat com-bined with a high risk to the care provider’s own safety,though this is only a preliminary proposal. This seems to be1. It should be noted that the scarcity typical of developing coun-tries could occur even in developed world clinical settings duringa pandemic with high incidence and prevalence; this scenario of aresource-rich system overwhelmed by demand for care is depictedby Malm and colleagues (2008).the case in Bundibugyo with Ebola, though not everywherewith all infectious diseases. Recall the high mortality ratesof Ebola. These are not due to lack of treatment, but rather toineffectiveness of treatment. Most commonly, only support-ive care can be offered (Peters 2005). These may be preciselythe kind of conditions in which a duty to treat is defeasible,conditions in which the little treatment that can be offered islargely futile for anything except the patient’s comfort andthe care provider is at high risk of becoming infected andthus both dying and serving as a vector. Yet hospitalizationis a key part of infection control, isolating infected personsfrom the general population if not from other patients, and isdifficult in the extreme without hospital personnel in place.In such situations, more likely to obtain for those healthcarepersonnel who lack resources but possible in any setting, istreating infected patients no longer a duty but above andbeyond duty? Whatever circumstances we might delineatefor a defeasible duty to treat, we must be cautious that we donot thereby universally eviscerate a duty to treat in preciselythe circumstances where it is most necessary such as pan-demics where healthcare personnel in short supply mightdesire not to report for work.I do not have the scope, here, to settle this issue. Butwe must consider the possible effect of resource disparitieson a pandemic duty to treat lest we forget that in a globalpandemic, everyone is involved and not everyone will beequally affected by implementing duties of care. Whetherwe formulate a duty to treat as an absolute or as defeasi-ble under particular narrow circumstances, it would be amoral failure to give no account at all of the impact of globalresource disparity on such a duty. REFERENCESEhrenkranz, A. December 11, 2007. Ebola epicenter: An on-scenereport from the Ugandan town hit hardest by the latest outbreak ofthe deadly virus. Newsweek . Available at: http://www.newsweek.com/id/76935 (accessed April 21, 2008).Jones, K. E., Patel, N. G., Levy, M. A., et al. 2008. Global trends inemerging infectious diseases. Nature 51: 990–994.King, J. W. 2008. Ebola virus. eMedicine. April 2. Available at: http://www.emedicine.com/MED/topic626.htm (accessed April 29,2008).Malm, H., May, T., Francis, L. P., Omer, S. B., Salmon, D. A., andHood, R. 2008. Ethics, pandemics, and the duty to treat. AmericanJournal of Bioethics 8(8): 4–19.Peters, C. J. 2005. Marburg and Ebola—Arming ourselves againstthe deadly filoviruses. New England Journal of Medicine 352(25):2571–2573.World Health Organization. 2007. Ebola haemorrhagic fever. Avail-able at: http://www.who.int/mediacentre/factsheets/fs103/en/(accessed April 18, 2008).38 ajob August, Volume 8, Number 8, 2008

Remembering the “pan” in “pandemic”: Considering the impact of global resource disparity on a duty to treat

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Remembering the “pan” in “pandemic”: Considering the impact of global resource disparity on a duty to treat

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