Ethics and severe pandemic influenza: maintaining essential functions through a fair and considered response

The response to severe pandemic influenza will be managed by experts in public health and infectious disease and by government officials to whom the public will turn for information and direction. Nonetheless, there remain important ethical considerations that can shape what goals are given priority, how scarce resources are distributed, how the public is included, and how we treat the most vulnerable in our response to a pandemic. This article assumes that the secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself. Response plans, then, must consider threats to societal as well as medical infrastructures. While some have suggested that scarce medical countermeasures be allocated primarily to first responders and then to the sickest, we suggest that an ethical public health response should set priorities based on essential functions. An ethical response also will engage the public, will coordinate interdependent sectors as a core preparedness priority, and will address how plans affect and can be understood by the least well off.     

Allocation of scarce resources in Africa during COVID‐19: Utility and justice for the bottom of the pyramid?

The COVID‐19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub‐Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high‐income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID‐19 pandemic in low‐income countries suffering from chronic shortages in health care resources, and chronic high morbidity and mortality from non‐COVID‐19 causes. A parallel is drawn between the distribution of severity of COVID‐19 disease and the classic “Fortune at the bottom of the pyramid” model that is relevant in SSA. Focusing allocation of resources during COVID‐19 on the ‘thick’ part of the pyramid in Low‐to‐Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post‐COVID‐19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID‐19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non‐pandemic times.     

The moral importance of selecting people randomly

This article discusses some ethical principles for distributing pandemic influenza vaccine and other indivisible goods. I argue that a number of principles for distributing pandemic influenza vaccine recently adopted by several national governments are morally unacceptable because they put too much emphasis on utilitarian considerations, such as the ability of the individual to contribute to society. Instead, it would be better to distribute vaccine by setting up a lottery. The argument for this view is based on a purely consequentialist account of morality; i.e. an action is right if and only if its outcome is optimal. However, unlike utilitarians I do not believe that alternatives should be ranked strictly according to the amount of happiness or preference satisfaction they bring about. Even a mere chance to get some vaccine matters morally, even if it is never realized.     

Ethical reasoning in pandemic preparedness plans: Southeast Asia and the Western Pacific

The emergence of H1N1 in 2009 shows that it is a mistake to regard the scenario of having to implement pandemic plans as merely hypothetical. This recent experience provides an opportunity to inquire into the current state of pandemic preparedness plans with regard to their ethical adequacy. One aspect that deserves consideration in this context is the disclosure of ethical reasoning. Accordingly, the following is an analysis of examples of pandemic plans and drafts of plans from Southeast Asia and the Western Pacific. It is an analysis of the occurrence of explicit ethical reflection in these documents as well an inquiry into the related question of how ethical reflection can be understood as a constitutive element of ethical pandemic preparedness. In the analysis, different fields of ethical consideration concerning equity, personal rights and accountability are distinguished. There are both pragmatic and genuinely ethical reasons to explicitly address issues of these types in pandemic plans. The extent to which ethical language appears in the national plans in South East Asia and the Western Pacific suggests that there is limited awareness of ethical considerations, or at least insufficient ethical substantiation of pandemic action. The aim of the analysis is to show that further inclusion of ethical considerations into pandemic plans is ethically demanded. It is of particular significance that these considerations are formulated and remain discernible as instances of ethical deliberation.     

道德规范与动物学

道德规范教育如今已经提升到了专业的水平。因此在专业领域里 (例如工程学和医学 ) ,道德规范教育应作为必修课程。但至今很多理科课程仍没有把它列为必修课。这就给我们提出了一个疑问 :理科是专业课程吗 ?如果是的话 ,那么科学家例如动物学家需不需要熟悉他们职责范围内的道德准则和尺度呢 ?动物学家对医学上暴露的一些问题很敏感———包括我们怎样对待动物以及我们怎样或者是否开展基因工程。但是从道德观念上来看 ,道德规范教育的实行是比这两件事更实际的。这篇论文就以上观点进行了进一步的论述 ,并且对把道德规范教育加入理科课程的需求和可能性做了评估。在现实社会里 ,动物科学家是被敬重的专业人士。他们每天面对着许多极可能影响我们生活环境的决策。有鉴于此 ,动物科学家必需掌握道德规范的标准 ,并且有能力做出与此相符合的决策。这才能使我们在动物学的教学过程中确保动物学家持续稳定的专业发展方向     

Preparing for an influenza pandemic: ethical issues

In the near future, experts predict, an influenza pandemic will likely spread throughout the world. Many countries have been creating a contingency plan in order to mitigate the severe health and social consequences of such an event. Examination of the pandemic plans of Canada, the United Kingdom and the United States, from an ethical perspective, raises several concerns. One: scarcity of human and material resources is assumed to be severe. Plans focus on prioritization but do not identify resources that would be optimally required to reduce deaths and other serious consequences. Hence, these plans do not facilitate a truly informed choice at the political level where decisions have to be made on how much to invest now in order to reduce scarcity when a pandemic occurs. Two: mass vaccination is considered to be the most important instrument for reducing the impact of infection, yet pandemic plans do not provide concrete estimates of the benefits and burdens of vaccination to assure everyone that the balance is highly favorable. Three: pandemic plans make extraordinary demands on health care workers, yet professional organizations and unions may not have been involved in the plans' formulation and they have not been assured that authorities will aim to protect and support health care workers in a way that corresponds to the demands made on them. Four: all sectors of society and all individuals will be affected by a pandemic and everyone's collaboration will be required. Yet, it appears that the various populations have been inadequately informed by occasional media reports. Hence, it is essential that plans are developed and communication programs implemented that will not only inform but also create an atmosphere of mutual trust and solidarity; qualities that at the time of a pandemic will be much needed.     

AFRICAN AND WESTERN MORAL THEORIES IN A BIOETHICAL CONTEXT

The field of bioethics is replete with applications of moral theories such as utilitarianism and Kantianism. For a given dilemma, even if it is not clear how one of these western philosophical principles of right (and wrong) action would resolve it, one can identify many of the considerations that each would conclude is relevant. The field is, in contrast, largely unaware of an African account of what all right (and wrong) actions have in common and of the sorts of factors that for it are germane to developing a sound response to a given bioethical problem. My aim is to help rectify this deficiency by first spelling out a moral theory grounded in the mores of many sub-Saharan peoples, and then applying it to some major bioethical issues, namely, the point of medical treatment, free and informed consent, standards of care and animal experimentation. For each of these four issues, I compare and contrast the implications of the African moral theory with utilitarianism and Kantianism, my overall purposes being to highlight respects in which the African moral theory is distinct and to demonstrate that the field should take it at least as seriously as it does the Western theories.     

Uncertainties about 'painless' animals

Macer explores whether it is possible to genetically alter animals to reduce or eliminate their capacity to feel pain, whether it would be ethical to do so, and how we would regard animals that do not feel pain. A possible use for such animals would be as subjects for laboratory research. Among the scientific, philosophical, and ethical uncertainties of pain that Macer considers are: can we define pain? how do we measure pain and anxiety? is pain always related to suffering? what is the minimum level of pain that a being must be able to feel before we reach the conclusion that it should not be used by other beings? are we justified in using beings that do not feel pain when we would not be if they did feel pain and suffer from it?     

The anticipated severity of a "1918-like" influenza pandemic in contemporary populations: the contribution of antibacterial interventions

Recent studies have shown that most of deaths in the 1918 influenza pandemic were caused by secondary bacterial infections, primarily pneumococcal pneumonia. Given the availability of antibiotics and pneumococcal vaccination, how will contemporary populations fare when they are next confronted with pandemic influenza due to a virus with the transmissibility and virulence of that of 1918? To address this question we use a mathematical model and computer simulations. Our model considers the epidemiology of both the influenza virus and pneumonia-causing bacteria and allows for co-infection by these two agents as well as antibiotic treatment, prophylaxis and pneumococcal vaccination. For our simulations we use influenza transmission and virulence parameters estimated from 1918 pandemic data. We explore the anticipated rates of secondary pneumococcal pneumonia and death in populations with different prevalence of pneumococcal carriage and contributions of antibiotic prophylaxis, treatment, and vaccination to these rates. Our analysis predicts that in countries with lower prevalence of pneumococcal carriage and access to antibiotics and pneumococcal conjugate vaccines, there would substantially fewer deaths due to pneumonia in contemporary populations confronted with a 1918-like virus than that observed in the 1918. Our results also predict that if the pneumococcal carriage prevalence is less than 40%, the positive effects of antibiotic prophylaxis and treatment would be manifest primarily at of level of individuals. These antibiotic interventions would have little effect on the incidence of pneumonia in the population at large. We conclude with the recommendation that pandemic preparedness plans should consider co-infection with and the prevalence of carriage of pneumococci and other bacteria responsible for pneumonia. While antibiotics and vaccines will certainly reduce the rate of individual mortality, the factor contributing most to the relatively lower anticipated lethality of a pandemic with a 1918-like influenza virus in contemporary population is the lower prevalence of pneumococcal carriage.     

Public health strategies for distribution of influenza vaccine during an influenza pandemic

In order to consider the ethical issues around vaccine distribution during an influenza pandemic, it is critical to have an understanding of the role of influenza vaccine in a pandemic, the rate at which vaccine is likely to be come available, who will likely produce and "own" the vaccine, how vaccine distribution and administration might be accomplished, and which are the groups that might be deemed highest priority to be vaccinated against influenza. The United States and Connecticut have been considering the more challenging of these issues and have learned from Canada, which previously discussed and made decisions on the challenges related to vaccine distribution. Although there is still some critical advance thinking that needs to be done, planning for the response to an influenza pandemic is now at an advanced stage. The keys to preparedness at this stage are to be aware of the vaccine distribution options, to know the benefits and limitations of each option, and to be flexible but nimble in dealing with a real pandemic.     

Global Mapping of Ecosystem Disservices: The Unspoken Reality that Nature Sometimes Kills us

Increasingly, we view nature through a utilitarian lens that leads us to attempt to measure and manage the services that species, habitats and ecosystems provide. Surprisingly, we have tended to consider only the positive values of ecosystems, their ecosystem services. In addition to providing our food and water, Nature also kills us, primarily through disease. If we are to effectively manage the terrestrial Earth, we need to also manage species, habitats and ecosystems so as to minimize such ‘ecosystem disservices’. I consider what we know about the spatial pattern of one disservice, pathogen prevalence and how changes in habitat influence it. I consider the effects of habitat changes on pathogen prevalence and, consequently, ecosystem disservices. In the end, we need to weigh both the costs and the benefits of particular ecosystems, habitats and species – to consider the bad with the good. Doing so requires that we learn much more about the biota than we currently know.     

Pharmacogenomics and personalized medicine: wicked problems, ragged edges and ethical precipices

In the age of genomic medicine we can often now do the genetic testing that will permit more accurate personal tailoring of medications to obtain the best therapeutic results. This is certainly a medically and morally desirable result. However, in other areas of medicine pharmacogenomics is generating consequences that are much less ethically benign and much less amenable to a satisfactory ethical resolution. More specifically, we will often find ourselves left with 'wicked problems,' 'ragged edges,' and well-disguised ethical precipices. This will be especially true with regard to these extraordinarily expensive cancer drugs that generally yield only extra weeks or extra months of life. Our key ethical question is this: Does every individual faced with cancer have a just claim to receive treatment with one of more of these targeted cancer therapies at social expense? If any of these drugs literally made the difference between an unlimited life expectancy (a cure) and a premature death, that would be a powerful moral consideration in favor of saying that such individuals had a strong just claim to that drug. However, what we are beginning to discover is that different individuals with different genotypes respond more or less positively to these targeted drugs with some in a cohort gaining a couple extra years of life while others gain only extra weeks or months. Should only the strongest responders have a just claim to these drugs at social expense when there is no bright line that separates strong responders from modest responders from marginal responders? This is the key ethical issue we address. We argue that no ethical theory yields a satisfactory answer to this question, that we need instead fair and respectful processes of rational democratic deliberation.     

What does an African ethic of social cohesion entail for social distancing?

The most prominent strand of moral thought in the African philosophical tradition is relational and cohesive, roughly demanding that we enter into community with each other. Familiar is the view that being a real person means sharing a way of life with others, perhaps even in their fate. What does such a communal ethic prescribe for the coronavirus pandemic? Might it forbid one from social distancing, at least away from intimates? Or would it entail that social distancing is wrong to some degree, although morally permissible on balance? Or could it mean that social distancing is not wrong to any degree and could, under certain circumstances, be the right way to commune? In this article, I defend the latter view. I argue that, given an independently attractive understanding of how to value communal relationship, distancing oneself from others when necessary to protect them from serious incapacitation or harm can come at no cost to right action. However, I also discuss cases in which social distancing would evince a lack of good character, despite being the right thing to do.     

The application of environmental ethics in biological conservation: a case study from the southernmost tip of the Americas

Biological conservation is not only about facts and technical measures concerning ecology, rather it must also consider values. This pertains to both the balancing of various human interests and also to the ethical evaluation of human actions towards nature. Here we discuss how environmental ethics can be incorporated into conservation decisions, and what implications the inclusion of ethical valuation has for the practice of conservation biology. While this is done mostly on a rather abstract level, we illustrate this here by applying ethical theory to a case study: the options for management of the introduced North American beaver (Castor canadensis) in the very south of Chile (Navarino Island). The beaver is an exotic species to the area and has substantially altered the ecological systems of the region. We discuss different options for dealing with the beaver (eradicate, control, tolerate, promote) from the viewpoint of anthropocentric environmental ethics and biocentric ethics. The results of our analysis demonstrate the value of ethical discussions in clarifying and underpinning arguments for and against specific actions. At the same time, they also show that ethical arguments do not decrease the need for sound scientific data but, on the contrary, may even increase this demand. We also highlight that the conclusions regarding adequate actions to be taken vary depending on the specific ethical theory embraced.

Consequentialism, reasons, value and justice

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources.     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Looking back, looking beyond: revisiting the ethics of genome generation

This paper will explore some of the ethical imperatives that have shaped strategic and policy frameworks for the use of new genetic technologies and how these play a role in shaping the nature of research and changing attitudes; with an attempt to conceptualize some theories of genetic determinism. I analyse why there is a need to put bioethical principles within a theoretical framework in the context of new technologies, and how, by doing so, their practical applications for agriculture, environment medicine and health care can be legitimized. There are several theories in favour of and against the use of genetic technologies that focus on genes and their role in our existence. In particular the theory of geneticisation is commonly debated. It highlights the conflicting interests of science, society and industry in harnessing genetic knowledge when the use of such knowledge could challenge ethical principles. Critics call it a ‘reductionist’ approach, based on arguments that are narrowed down to genes, often ignoring other factors including biological, social and moral ones. A parallel theory is that there is something special about genes, and it is this “genetic exceptionalism” that creates hopes and myths. Either way, the challenging task is to develop a common ground for understanding the importance of ethical sensitivities. As research agendas become more complex, ethical paradigms will need to be more influential. New principles are needed to answer the complexities of ethical issues as complex technologies develop. This paper reflects on global ethical principles and the tensions between ethical principles in legitimizing genetic technologies at the social and governance level.     

The ethics and obligations of long-term ethnographic relationships: revelatory moments and the concept of solidarity

This article reflects on an ethical and revelatory moment in the development of my long-term fieldwork relationships with people of the Lihir Islands in Papua New Guinea. Ethnographic research globally is now shaped through formal processes of ethical review, with the requirements for informed consent, privacy, and consideration of harm and beneficence. Researchers then have to put these procedures into practice, often encountering the need to weigh competing ethical principles, particularly when unforeseen events occur. Reflexivity has been argued to be crucial on these occasions. Yet both ethical codes and reflexivity fall short of managing ethical and relational implications of long-term field relationships. This article suggests that the concept of solidarity as theorized recently in bioethics may be helpful, particularly the discernment of three layers of relationship. What responsibilities might we as anthropologists have to the people we work with that go beyond procedural ethics? And how do moments such as the one described in this article shape ongoing field research?     

Parental virtue: a new way of thinking about the morality of reproductive actions

In this paper I explore the potential of virtue ethical ideas to generate a new way of thinking about the ethical questions surrounding the creation of children. Applying ideas from neo‐Aristotelian virtue ethics to the parental sphere specifically, I develop a framework for the moral assessment of reproductive actions that centres on the concept of parental virtue. I suggest that the character traits of the good parent can be used as a basis for determining the moral permissibility of a particular reproductive action. I posit three parental virtues and argue that we can see the moral status of a reproductive action as determined by the relationship between such an action and (at least) these virtues. Using a case involving selection for deafness, I argue that thinking in terms of the question ‘would a virtuous parent do this?’ when morally assessing reproductive action is a viable and useful way of thinking about issues in reproductive ethics.