Pandemic Ethics

When the poison is the antidote: risky disaster research

A recent report by Lipsitch and Galvani warns that some virus experiments risk unleashing global pandemic. In particular, there are the controversial “gain of function” experiments seeking to test how likely bird flu is to go from a form that cannot be transmitted between humans to a form that can – by trying to create such a form. But one can also consider geoengineering experiments: while current experiments are very small-scale and might at most have local effects, any serious attempt to test climate engineering will have to influence the climate measurably, worldwide. When is it acceptable to do research that threatens to cause the disaster it seeks to limit?

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US Congress shutsdown CDC, also other unimportant agencies

So the US government is likely being shutdown, which will suspend the work of many government agencies, including the Center for Disease Control (CDC). But, fair citizens, I reassure you – in its wisdom, the US Congress has decided that the military’s salaries will be excluded from the shutdown.

With all due respect to military personnel, this is ludicrous. The US military is by far the world’s largest, there is little likelihood of any major war (the last great power war was in 1953), and no sign of minor wars starting, either. Suspended salaries may be bad for morale and long term retention, but they aren’t going to compromise US military power.

Contrast with the CDC’s work. The world’s deadliest war was the second world war, with 60 million dead, over a period of years (other wars get nowhere close to this). The Spanish flu killed 50-100 million on its own, in a single year. Smallpox couldn’t match that yearly rate, but did polish off 300-500 million of us during the 20th century. Bog standard flu kills between a quarter and a half million every year, and if we wanted to go back further, the Black Death wiped out at least a third of the population of Europe. And let’s not forget HIV with its 30 million deaths to date.

No need to belabour the point… Actually there is: infectious diseases are the greatest killers in human history, bar none. If any point needs belabouring, that’s one. And a shutdown would have an immediate negative impact on public health: for instance, the CDC would halt its influenza monitoring program. Now, of course, this year’s flu may not turn out to be pandemic – we can but hope, because that’s all we can do now! And if we have another SARS starting somewhere in the United States, it will be a real disaster.

We’re closing our eyes and hoping that the greatest killer in human history will be considerate enough to not strike while we sort out our politics.

Experimenting with oversight with more bite?

It was probably hard for the US National Science Advisory Board for Biosecurity (NSABB) to avoid getting plenty of coal in its Christmas stockings this year, sent from various parties who felt NSABB were either stifling academic freedom or not doing enough to protect humanity. So much for good intentions.

The background is the potentially risky experiments on demonstrating the pandemic potential of bird flu: NSABB urged that the resulting papers not include “the methodological and other details that could enable replication of the experiments by those who would seek to do harm”. But it can merely advice, and is fairly rarely called upon to review potentially risky papers. Do we need something with more teeth, or will free and open research protect us better?

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Ferretting out fearsome flu: should we make pandemic bird flu viruses?

Scientists have made a new strain of bird flu that most likely could spread between humans, triggering a pandemic if it were released. A misguided project, or a good idea? How should we handle dual use research where merely knowing something can be risky, yet this information can be relevant for reducing other risks?

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Would the End of the World really be so Bad?

As always, we sentient beings on earth are at risk of being wiped out by some global catastrophe. Some of the risks – diseases or meteorites – are old; others – nuclear weapons or global warming – are more recent. They are discussed very well in Nick Bostrom and Milan Cirkovic’s edited collection Global Catastrophic Risks:

http://ukcatalogue.oup.com/product/9780198570509.do?keyword=bostrom&sortby=bestMatches

In one sense, a catastrophe is just major systematic change. It needn’t be bad. But of course many people believe that the ending of sentient life on this planet would be a catastrophe in the evaluative sense. It would be very bad for most of the sentient beings living at the time of the catastrophe, and bad in some more impersonal sense since it would prevent many potential sentient beings from becoming actual.

Clearly the ending of sentient life isn’t the worst outcome imaginable. That would involve the existence of sentient beings, in great agony. But the question remains whether this kind of catastrophe would be worse than its not happening, with things continuing much as they are.

It’s at least arguable that it would not be worse. Most would accept that it could be good for some individuals – perhaps those with only a short time of intense agony left. But they would also think that the overall suffering in the world is counterbalanced by the good things in the lives of sentient beings, considered as a whole.

This seems very plausible as a claim about the lives of some such beings. But some individuals have lives of an extremely low quality, consisting sometimes of nothing much more than great agony over a fairly protracted period. How are we to weigh the value of all these different lives against one another?

In his An Analysis of Knowledge and Valuation (1946), the American philosopher C.I. Lewis suggested that we might attempt such comparisons by imagining that we ourselves have to live the lives of all those concerned, in series. It might seem that such a comparison relies on some controversial theory of personal identity. But it need not. Imagine that by some means your own life could be extended hugely, and that you would then be plugged into some machine that would ‘play back’ into your consciousness all the experiences of all sentient beings until there were no more left.

Of course, many of these experiences would be wonderful. But many of them would be very bad indeed. It’s not clear to me that this stream of experiences would overall be better for me than no experiences at all, since the amount of suffering would be so great that perhaps no amount of good experience could counterbalance it. If this is the right view, then a global catastrophe might be something to be welcomed, at least from the impartial or moral point of view.

The ethics of prescribing antibiotics

Antibiotics are overprescribed. That is, they are given out in many cases where they will achieve little or nothing for the patient. On its own, this would merely be wasteful, but usage of antibiotics increases the development of antibiotic resistant organisms and this is bad for everyone. Today's Guardian has an article suggesting that antibiotic resistance could become a *very* big problem, with all major antibiotics becoming ineffective within a couple of generations (see also the original research in the Lancet). This leads to some very interesting questions concerning the ethics of prescribing antibiotics.

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The ventilator lottery: rolling the dice in the face of difficult choices

As the winter approaches there has been a surge in the number of cases of swine flu, as well as a number of recent deaths in the UK. Although there is hope that the new vaccine will reduce the impact of the pandemic a number of countries including Canada the UK and the  United States have had to face the possibility that health services will not be able to accommodate the predicted surge in demand. Officials have been contemplating guidelines for deciding who should be prioritised for receiving life saving mechanical ventilation. The hope is that such guidelines will enable doctors to save the greatest number of lives in a pandemic.

But one concern about these guidelines is that they are unfair. Should scarce medical resources such as ventilators be allocated using a lottery instead?

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The party line and the flu-line

It has emerged over the weekend that the UK government ignored the advice of a key panel of scientific advisors in the formulation of its pandemic response. The panel advised against the mass prescription of antivirals (Tamiflu) because of the fear that this would accelerate resistance of the virus (see also this previous post in the pandemic ethics series). An expert in influenza, Hugh Pennington, has even called for the national flu hotline to be shut down. It appears that the government may have been influenced in its pandemic response by political sensitivities.

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Pandemic ethics: Mild flu and Tamiflu – the patient’s dilemma

In recent days there have been reports of a jump in the number of cases of H1N1 influenza (swine flu) in the UK. There have been 29 deaths associated with pandemic influenza in the UK, and there are 652 people in hospital in England with the flu. Faced with the prospect of primary health care services becoming overwhelmed, the government has set up a telephone hotline to allow those affected by the flu to access antiviral drugs (for example oseltamivir or Tamiflu) without needing to see a doctor. But there are also suggestions that not all patients with flu-like symptoms should be treated. Patients with mild or vague symptoms of the flu, without other medical conditions that put them at particular risk, may not be given medication.

This sets up a problem for patients who develop mild flu-like symptoms. Although there is only a small chance of them becoming seriously ill or dying from the flu it is possible that early treatment with anti-virals would reduce that risk. (Antivirals were only effective in trials if given in the first 48 hours of illness) Should they demand treatment from their doctor in the hope of avoiding a serious complication of influenza? Should they exaggerate their symptoms? If the doctor refuses, should the patient self-treat with medications that they have obtained privately (for example over the internet)? There is a form of the classic prisoner’s dilemma involved in such questions.

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Pandemic Vaccination: Who to Vaccinate?

Fears of the spread of pandemic influenza in the UK continue to grow. Three apparently previously healthy patients have died here. There are now plans for widespread immunisation later in the year – though initially this is likely to be restricted to those at highest risk, and those in 'vital' professions.

Who should be vaccinated? This is a question of distributive justice.

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