As the death toll from coronavirus tops 2,600, the global community continues to grapple with urgent medical questions: How do we stop its spread? What treatments will save the most lives?
But the health crisis has spawned an equally pressing ethical debate: Who should be treated first? Do travel bans harm more than they help? What research should be top priority? How should unaffected nations offer support for hard-hit countries?
Western bioethicist Maxwell Smith is on the frontlines of that decision-making as one of the World Health Organization’s top experts.
“Ethics comes into play throughout the process. You really need to start with ethics to set your priorities, and then set the right course of action in response,” said the Health Studies professor who serves as Co-director of Western’s Health Ethics, Law, & Policy (HELP) Lab.
Smith was one of 300 global experts the World Health Organization (WHO) invited to a two-day forum in Geneva last week to identify gaps in knowledge and response and reach a consensus on research priorities.
The forum was convened in line with the WHO R&D Blueprint, a strategy for developing drugs and vaccines before epidemics and accelerating research and development while they are occurring.
Smith described the sessions as a “research roadmap to guide scientists moving forward…We have a lot of researchers who are trying to generate this information as quickly as possible – but we need somewhere to pool that information and make some coordinated decisions about it.”
SMITH
An ethics-informed response includes asking, What research should be a priority? That answer, however, needs to balance the immediate need to develop treatments with the longer-term importance of vaccine development – and who should conduct that work.
It also means embedding ethical considerations in every approach, such as when and how to fast-track research studies and reviews.
“There’s not necessarily a need for Canadian scientists, for instance, to be running clinical trials for the development of a vaccine on Canadians when only four or five Canadians have the virus,” Smith said.
That doesn’t mean Canada can just wash its hands of the problem, he added. That’s where it’s essential the global community work together.
“Viruses don’t respect borders. A virus emerging in a country where there’s a weak health system is just as much our problem as it is anybody’s problem. That’s another ethical issue – figuring out what Canada’s obligations are to other parts of the world to make sure that we can contain these global pandemics as quickly as possible.”
More than 73,000 cases of coronoavirus (recently renamed new COVID-19 disease) have been lab-confirmed or clinically confirmed in 29 countries and territories since the start of this year. Most cases and deaths are in mainland China, where the outbreak started.
Canada has emerged as an important player in the field of infectious diseases because of hard-earned experience here in containing and learning from the SARS outbreak of 2003.
That’s when Smith first came to the attention of WHO while he was a PhD student in Toronto working on the ethics of disease outbreaks with public-health specialists, physicians and ethicists.
In countries where medical resources are overburdened, for example, ethical questions and answers are foundational in determining who is first in line for care.
“You need to make certain decisions about how you set priorities for who gets treatment, who gets a hospital bed, who gets a ventilator. Some people could say, ‘Maybe we should treat the sickest people first.’ But some people might see that as a waste of resources and might say, ‘Maybe we should treat first the people with a higher possibility of surviving.’ Some people think we should treat health-care workers first because they’re on the frontline and if we can get them healthy again then they can treat the people who are sick.”
He continued, “There’s a lot of scientific information that can tell us which of these would be effective and to what end. But you’re also making value judgments about who we think deserves treatment in each of these settings.”
Another consideration in any outbreak includes the concern that forcibly quarantining people, infected or uninfected, can violate individual liberties. Unless it’s in a health-care setting or nursing home, getting the flu usually doesn’t prompt a mandatory quarantine.
“But because of the unknown nature of this (COVID-19) virus and the need to curb it from becoming a pandemic, then we feel a bit more justified in putting in quarantine measures or isolation measures.
“We really need to exercise caution in how we implement those various measures and usually ethics is the instrument we use to think about what is the right way and what is the wrong way to do that.”
Aggressive counter-measures that include travel bans to or from countries can also have negative consequences that outweigh the benefits, he said.
WHO has determined such travel restrictions are ineffectual at containing the spread of disease and specifically recommended countries not put those restrictions in place. More than 70 countries have done so, however.
In those instances, families are separated from each other and from support systems; aid doesn’t reach patients in a timely way; food shortages jeopardize overall health; economies are thrown into turmoil; stigma and discrimination increase.
“It impacts trade, it impacts a whole bunch of other things so even that decision to put in restrictions is a huge ethical issue.”
Even after COVID-19 has moved off the world stage, it will have provided more scaffolding to deal with the next outbreak, Smith said.
Canada’s experience makes us more prepared than most. But the worldwide community, the global north and south and east and west, must also listen to each other’s needs and work together on a co-ordinated response.
“With climate change and the development of resistance to antibiotics, it’s only more likely that we see these infectious diseases emerge and create these outbreaks that will require this concerted effort to think through these issues.”
