Intended for healthcare professionals

Education And Debate

Ethics and SARS: lessons from Toronto

BMJ 2003; 327 doi: (Published 04 December 2003) Cite this as: BMJ 2003;327:1342
  1. Peter A Singer, Sun Life financial chair and director1 (,
  2. Solomon R Benatar, visiting professor2,
  3. Mark Bernstein, professor3,
  4. Abdallah S Daar, director, programme in applied ethics and biotechnology1,
  5. Bernard M Dickens, Dr William M Scholl professor of health law and policy4,
  6. Susan K MacRae, deputy director1,
  7. Ross E G Upshur, director, primary care research unit5,
  8. Linda Wright, bioethicist1,
  9. Randi Zlotnik Shaul, bioethicist1
  1. 1University of Toronto Joint Centre for Bioethics, 88 College St, Toronto, Canada M5G 1L4
  2. 2Department of Public Health Sciences, University of Toronto
  3. 3 Division of Neurosurgery, University of Toronto
  4. 4Faculty of Law, University of Toronto
  5. 5Sunnybrook and Women's College Health Sciences Centre, Toronto
  1. Correspondence to: P A Singer
  • Accepted 15 September 2003

The SARS epidemic showed how easy it is for infectious diseases to spread round the world. Ethical as well as clinical issues need to be resolved to improve the response to the next epidemic

The outbreak of severe acute respiratory syndrome (SARS) in the Toronto area earlier this year forced medical and government workers to make hard choices, often with limited information and short deadlines. Healthcare providers were on the firing line, and were the people most affected by the disease.1 Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat sick people, and economic losses against the need to contain the spread of a deadly disease. Such decisions have to be guided by both scientific knowledge and ethical considerations. The SARS outbreak showed that Canadian society was not fully prepared to deal with the ethical issues.

Evaluating ethical issues

We formed a working group to identify the key ethical issues and values most important for an analysis of ethical dimensions of the SARS epidemic. The final list of issues and values was agreed by a consensus process and found to have face validity and credibility. We then developed a framework for looking at the ethical implications of the SARS outbreak, identifying 10 key ethical values relevant to SARS (box), and five major ethical issues faced by decision makers.

We examined the underlying ethical values for the five major issues and drew lessons from how each was tackled. The following case studies illustrate the issues and are an amalgam of our experiences.

Ethics of quarantine

A medical clerk is asked by public health officials to remain at home in quarantine for 10 days because of possible exposure to SARS. She wants to comply but fears this could cost both her job and her apartment.

Five …

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