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This post originally appeared on the SAGE Journals Blog.

By Farirai Mutenherwa

As we commemorate the "Ethics Awareness Month," I thought it best to reflect on COVID-19 and highlight some of the ethical challenges that might need attention. With its origins in China, the virus has spread to 170 countries and territories, leaving more than 8,000 dead. It has been declared a public health emergency of international concern and there are no signs of a cure at the moment. As a global emergency, a swift and aggressive approach is needed to contain further spread and to ensure that patients are treated and cured. All these approaches require adherence to some minimum ethical standards and careful reflection on previous epidemics.

The role of research is paramount in global emergencies. A therapeutic drug and vaccine should be developed with urgency, taking into consideration potential ethical dilemmas. It is encouraging to note that already over 100 clinical trials are underway. But lest we forget, experiences with the Ebola outbreak taught us some valuable lessons which should inform current efforts to control the pandemic. Thankfully, the Nuffield Council on Bioethics recently published a document that provides an ethical roadmap and compass to navigate the ethical issues in the context of global health emergencies. Hopefully, states and relevant institutions will be guided accordingly. 

Experts say it will take more than a year to develop and deploy the much-needed vaccine for the virus. Who knows? By that time, the worst of the outbreak could be over. In haste for a quick solution, ethical norms and standards should not be compromised, but non-expedited review procedures should be accelerated. Questions about whether and to what extent the principle of clinical equipoise should be addressed. Furthermore, scientific standards for vaccine development should be met. There are also issues around health equity. Will pregnant women get an opportunity to participate in such trials, or will the historical exclusionary approaches to their participation in vaccine trials persist? As occurred during the Ebola outbreaks, excluding pregnant women will prevent them from accessing potentially life-saving vaccines. Their inclusion in vaccine trials is, therefore, an ethical imperative. 

If the vaccine is finally developed, there are critical post-trial ethical considerations and obligations that states should address. Unlike the Ebola outbreak, which was confined to one region, demand for COVID-19 vaccines is likely to be global. Conversations about mechanisms for the equitable distribution of the vaccine should start in earnest, with non-producing low and middle-income countries in mind. Many of them cannot produce their own vaccines and already have strained healthcare systems characterized by erratic drug supplies. Besides the vaccine, how will health facilities allocate to patients other scarce medical resources critical for therapeutic success? These questions are no longer abstract as health institutions become increasingly overburdened.  

Lack of transparency and openness around the COVID-19 outbreak is a grave concern. There is some evidence that the Chinese government knew about the outbreak long before it became public and deliberately withheld vital information. A whistle-blower, who wanted to warn colleagues and others about the outbreak, was gagged. Sadly he died from the infection. Had the world known earlier about the outbreak, people would have known about the virus sooner and taken earlier measures to prevent further spread. Many lives could have been saved.

COVID-19 has brought to the fore the long-standing debates in public health ethics - the balance between individual privacy versus public good. Coercive and intrusive measures are being implemented as efforts to contain the pandemic intensify. Travel bans, mandatory cancellations of public events, quarantine, and contact tracing are commonplace. Although used since medieval times, the effectiveness of these measures remains controversial. Some have criticized these measures as a violation of civil liberties with minimum benefit. But in the middle of a global pandemic, what should be prioritized? 

A more holistic approach, which involves the development of a sustainable and resilient health system, might be more effective in responding to future epidemics while simultaneously managing existing health needs. More attention should be given to strengthening health governance, the establishment of robust disease surveillance, supported by functional laboratory systems, and trained and motivated health personnel. 

About

Farirai Mutenherwa is a PhD student at the University of KwaZulu-Natal and hold a Master’s degree in Health research ethics with support from the South African Research Ethics Training Initiative. My research focuses on the ethical, legal and societal issues associated with the design of, conduct in, and use of results from HIV molecular epidemiology.