- James Dwyer, Ph.D.
Associate Director of the Consortium Ethics Program at the University of Pittsburgh, University of Pittsburgh
Pittsburgh PA, 15260, USA
Email: jdwyer+@pitt.edu

E-mail: jdwyer+@pitt.edu

Eubios Journal of Asian and International Bioethics 13 (2003), 142-143.

SARS also tested our ethical principles, dispositions, and judgments. Here again, I think the results were mixed. Principled decisions and right conduct were mixed with ethical failings. I want to examine the ethical aspects of the public health response and offer an assessment. I shall examine the response in terms of honesty, the duty to treat, beneficence, individual liberty, and justice. These are not the only ethical categories that one could use, but they provide a good starting point.

Honesty. Today, more than ever, a good public health response depends on accurate and timely information. In the case of SARS, dishonesty and concealment were the key ethical failings. The lack of honest and prompt reporting meant that doctors couldn't diagnose the syndrome, infected patients weren't isolated, health care professionals didn't take proper precautions to protect themselves, contacts weren't traced and quarantined, laboratories couldn't begin work, and so on. The officials who failed to report the outbreak and extend of SARS ignored the well-being of millions of people. They followed a familiar pattern of bureaucratic secrecy and image management.

The lack of open and honest reporting eroded trust. The erosion of trust wasn't restricted to China. When the WHO lifted the travel advisory to Toronto, a number of people voiced the suspicion that the change had more to do with political lobbying than epidemiological reporting. I don't know the truth of the matter, but the suspicion itself shows how little trust was left.

The duty to treat. Outbreaks of infectious diseases often place health care workers at increased risk. This happened with plague, yellow fever, cholera, influenza, hepatitis, and HIV. And it happened with SARS. At least at the beginning of the outbreak, many of the people who became infected were health care workers. (Of course, with proper knowledge and equipment, health care workers were able to reduce their risk.) The ethical question is whether health care workers have a professional duty go to work, stay involved, and treat patients even at some risk to themselves. I think the answer is a qualified yes. Like firefighters and police officers, health care workers implicitly agree to accept a reasonable level of risk when they enter their profession.

Most health care workers lived up to their professional duties, but some doctors and nurses in Taiwan stayed away from work or resigned their positions. What should we think of their conduct? At worst, it is a failure to realize the ethical commitments that come with health care professions. At best, we can view their conduct as a social protest about the lack of infection control in hospitals, the way risks were distributed among staff, the social status of nursing, and even the lack of public support for their work.

Beneficence. A teacher of mine used to say that competence is the first virtue. He wanted to impress upon us the need to develop our knowledge and skill in order to truly benefit other people. But knowledge requires information, and information requires honesty. So maybe in a public health crisis, honesty is the first virtue. Once people had accurate information, many of them acted competently to prevent harm and benefit people. Indeed, some even acted courageously. But of course some people acted in ways that put other people at risk. Thousands of migrant workers and college students ignored public advice and fled Beijing. They could have carried SARS all over China.

The competence and beneficence of systems may be even more important than the behavior of individuals. I'm not sure how well the various systems would have functioned if they had gotten off to a better start. But some people have already suggested that the public health systems failed in a number of countries because they failed to curb individual liberty in the name of the public good.

Individual liberty. The classical problem in public health is how to balance the benefit to the overall population against the rights of individuals. This problem arises with respect to mandating the use of seat belts, restricting tobacco use, requiring vaccinations for children, and enriching food products. It arises most prominently with respect to infectious diseases. Here we can error in two ways. We can isolate, stigmatize, and deprive people of important rights when they pose no significant threat. Think of HIV-infected children who where barred from schools in the early years of that epidemic. But we can also error in the other direction. We can let people roam around who are exposing others to serious risks.

In the case of SARS, many countries adopted a well-balanced approach, but we need to keep in mind four things. First of all, this was a case in which coercion was justified. No one really questioned that. Second, when we have a choice among effective methods, we should adopt the method that is least restrictive of liberty. For example, if a person can be effectively quarantined at home, so much the better. Third, no amount of coercion will be effective unless a society can elicit the willing cooperation of most people. This is another reason why public trust and education are so important in public health. Lastly, society has an obligation to counteract prejudice.

Justice. Although it's too early to say with certainty, I think the SARS outbreak exposed a very serious ethical failing: a lack of justice and solidarity. Whereas beneficence is a matter of preventing harm and promoting good, justice is a matter of distributing benefits and burdens in a fair way. Some public health benefits may be indivisible and therefore evenly shared, but many benefits are divisible and quite unevenly distributed. The SARS outbreak highlighted this point. Public health officials were worried that that SARS would spread to the rural areas of China. There it would be hard to contain because public health resources are scarce and access to care is limited.

China is not the only country with a skewed distribution of health care resources. It's not prudent to leave disadvantaged groups without access to health care services. Diseases have a way of finding these groups. But it's not merely a matter of prudence. It's a matter of justice. Concern for the least advantaged is a mark of a just society. Universal programs that are truly inclusive are not merely convenient ways to pool risks. They are ways to promote justice and solidarity.

The Future. I want to reiterate two points because I think people have focused ethical attention in the wrong place. Many people have begun to discuss the trade-offs that sometimes arise between promoting the public good and protecting individual liberty. And some have urged us to shift the balance more in favor of the public good. But I think the real ethical problems are more insidious. If SARS was a test of our ethical readiness, then we need to focus attention on secrecy and injustice. SARS exposed how dependent we are on honest, prompt, and open reporting. SARS also exposed the health inequalities that exist within and between countries. To ignore these inequalities is neither prudent nor just.