1. Thomas, James C. PhD
  2. Miller, Reid MPH

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Nearly 10 years ago, when the world was preparing for an avian influenza pandemic, there was a flurry of preparation,1 including deliberation on the anticipated ethical challenges the pandemic would bring. Widespread infection with a highly pathogenic influenza virus would necessitate the allocation of scarce resources, such as antivirals, and the implementation of control measures, raising ethical concerns about who would receive the resources and who would be subject to isolation.


The United States' federal and state governments produced plans for responding to a surge in highly pathogenic influenza patients (available at Importantly, the federal plan did not guide states to prepare for decision making on issues with significant ethical implications.2 A review of the eventual state-level influenza plans revealed an absence of ethical language to guide decision making in the public health response2; a subsequent review showed little progress.3 A few states eventually deliberated on ethical issues, but most attention was given to the allocation of scarce resources, such as antivirals and respirators, whereas other ethical issues were addressed in a cursory manner.4 Moreover, the ethical deliberations were usually unconnected to the state plans and thus lacked official endorsement or a mandate for enforcement.


The Ebola epidemic's reach into the United States revealed that we remain unprepared to respond quickly and ethically to the ethical challenges of international transmission of a highly pathogenic disease. Guidelines for nonclinical actions, such as interactions with communities and structures for ethical decision making, are largely missing.


Ethical Challenges of the Ebola Epidemic

At present, more than 21 000 patients of Ebola hemorrhagic fever have been reported, spread over 8 countries on 3 continents. The vast majority of patients have been reported in Guinea, Sierra Leone, and Liberia. A little more than one-third have proved fatal. In the face of the growing crisis, how did we respond?


One of the first ethical concerns raised by the epidemic was the reluctance of resource-rich countries to become involved in the care of patients and the control of transmission in the affected West African countries.5 While the world deliberated in early 2014 on how to engage, patients on the ground quickly overwhelmed weak health infrastructures.


On September 30, 2014, when the first case on American soil was diagnosed in a West African who had recently returned from Liberia, Americans began paying closer attention. Against the backdrop of an impending national election, some politicians called for restrictions on flights from affected West African countries. Others countered that transportation restrictions would also limit the ability of Americans participating in the response to get to and from the places in need.


An asymptomatic nurse in the United States, quarantined in the absence of contact with the bodily fluids of an infected patient, threatened to sue the state of Maine for improper quarantine. Cases such as hers point to 2 ethical obligations: for health care workers to care for the sick, and for their employers and society to care for those interacting most closely with the sick.6 We cannot afford to lose the support of health workers in a public health crisis.


Additional ethical issues have included effective crisis communication (given the propensity for the media to incite fear), the inequities inherent in air-lifting American personnel but not local health providers to provide them with the best available care, and the use of untested medical treatments.7 With our knowledge of epidemic transmission, patterns of population movement, and technological developments, all of these issues are predictable.


Ethics Structures Needed

Ethics and thinking ahead are essential elements of public health preparedness. We cannot afford to rely on ethical lapses to raise the issues and then reactively determine the best practices. We must think globally and quickly. Had ethical guidelines prescribed international cooperation, for example, disease control assistance may have been offered sooner and the epidemic may not have reached its current magnitude.


However, public health institutions at all levels, ranging from the local to the global, lack an established infrastructure for ethical deliberation and prescription for actions. A system to guide ethical responses to fast-moving epidemics and pandemics must anticipate foreseeable events and make decisions quickly on unforeseen events. An infrastructure for this purpose might consist of a group of individuals already employed by a state health department who are trained and given the authority to create guidelines for the ethical implementation of existing or anticipated public health policies. National organizations, such as the Association of State and Territorial Health Officials, can recommend ethical standards and practices, but to be enforced, they will need to be integrated into governmental laws and policies.


Our ability to anticipate, prepare for, and prevent unethical actions in public health is an ethical obligation in itself. The code of ethics endorsed by the American Public Health Association states that public health institutions aim to "prevent adverse health outcomes" and "act in a timely manner on the information they have."8(p.1058) We suggest that preventing foreseeable ethical lapses is as important as preventing foreseeable adverse health outcomes, and the information we have from current and prior epidemics enables us to prepare for the next one. Instead of relying on the adrenaline rush of headlines to hold our attention and galvanize action, let's hold deliberations now to prepare us for ethical and more effective public health action before the next crisis.




1. World Health Organization. WHO Global Influenza Preparedness Plan: The Role of WHO and Recommendations for National Measures Before and During Pandemics. Geneva, Switzerland: Department of Communicable Disease Surveillance and Response, Global Influenza Programme; 2005. Accessed May 21, 2007. [Context Link]


2. Thomas JC, Desgupta N, Martinot A. Ethics in a pandemic: a survey of the state pandemic influenza plans. Am J Public Health. 2007;97(suppl 1):S26-S31. [Context Link]


3. Thomas JC, Young S. Wake me up when there's a crisis: progress in pandemic influenza ethics preparedness. Am J Public Health. 2011;101:2080-2082. [Context Link]


4. Minnesota Center for Bioethics and Minnesota Center for Healthcare Ethics. Minnesota Pandemic Ethics Project. St Paul, MN: Minnesota Department of Health; 2010. Accessed December 20, 2014. [Context Link]


5. Rid A, Emanuel EJ. Why should high-income countries help combat Ebola? JAMA. 2014;312:1297-1298. [Context Link]


6. Yakubu A, Folayan MO, Sani-Gwarzo N, Nguku P, Peterson K, Brown B. The Ebola outbreak in Western Africa: ethical obligations for care. J Med Ethics. 2014;10:1136. [Context Link]


7. Kass N. Ebola, ethics, and public health: what next? Ann Intern Med. 2014;161:744-745. doi:10.7326/M14-1864. [Context Link]


8. Thomas JC, Sage M, Dillenberg J, Guillory VJ. A code of ethics for public health. Am J Public Health. 2002;92:1057-1059. [Context Link]