Ethical issues in isolating people treated for EbolaBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h140 (Published 14 January 2015) Cite this as: BMJ 2015;350:h140
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Professors Devnani and Guo highlight the ethical challenge of balancing the rights of an individual against the collective interest in preventing spread of Ebola in a specific case in India. The challenge arises also on vast scale and with much greater potential infringement of rights in the countries most affected.
A particular concern relates to cohorting of patients with suspected Ebola virus infection in facilities that may be called “holding centres” or “community care centres”. This practice is substantially supported by the international community. As the presentation of EVD is relatively non-specific any cohort of people suspected of having Ebola virus infection on clinical grounds will include people who have and people who do not have Ebola virus infection. The non-infected and infected patients frequently share the cohort areas for days. During this time the cohort group may share washing and toilet facilities, they may sit together, eat together and in some instances some patients may become informal carers for other patients. The non-infected patients have no training, no personal protective equipment and frequently have not been clearly informed of the risks. Meanwhile any health care worker who enters the cohort area has been trained in self protection and is provided with comprehensive personal protective equipment (PPE).
The risk to non-infected patients that is inherent in this cohort process is exaggerated if the cohort areas are crowded, if cleaning is difficult, if the toilet and washing facilities are poor and there is no effective segregation of seriously ill /highly infectious patients (wet-patients) from those with less serious illness (dry patients). The risk is exaggerated if the case definition is not rigorously applied in relation to selection of suspect patients admitted to the cohort area and even more so if asymptomatic contact patients are admitted to the cohort area. The potential injustice is exaggerated if there is an element of social pressure or coercion of patients to request admission to the cohort area and if they are effectively denied the freedom to leave at will.
t seems unlikely that such a cohort system would be accepted in Europe. Is it acceptable in Africa ? One may argue that this system is justified as necessary to limit spread of EVD by removing infected patients from their community however subordination of the rights of the one (or the few) to the good of the many is not an ethical position that doctors usually sustain1. One may argue that uninfected cohort patients are at no greater risk than they would be at home. That is difficult to accept if they come from a household where no one is infected. Perhaps the most worrying thing is that there has not been enough argument. There was a 2 day global conference on the ethical and legal issues related to potential Ebola therapies but not much about this much more fundamental issue.2 In addition to the concern for individual rights is the possibility if non-infected people acquire infection in a cohort area and then go home the cohort process may not only risk harm to the individual but also potentially fuel the outbreak. Has the global response to EVB subordinated the rights of the poor and sick to the fears or the affluent well? If so, has this been counterproductive in terms of disease control?
1. World Medical Association International Code of Medical Ethics.
2.WHO Consultation on potential Ebola Therapies and Vaccines
Competing interests: I worked as consultant for an international agency in Sierra Leone from November 9 to December 10 2014. Travel costs and per diem expenses were paid by the agency.
Really an eye opener.
Being as ignorant as other general public and the enforcing authorities, no wonder there is no hue and cry when such knee jerk and over-reactive measures are taken without any scientific evidences for the same.
We as citizens are taken for granted and we presume that whatever measures have been taken are scientific and based on proven facts.
It also sends wrong message in the community adding to the scare already created. Probably the immaturity of the enforcing authorities and safe playing medical advisors are responsible for the same.
Competing interests: No competing interests