The Moral Questions of Influenza
The term influenza comes from the Italian word for "miasma", or
"bad air." It would indeed be an ill wind blowing over humanity
if Avian Flu, or another variety, mutates to allow itself to
spread from person to person. Mankind has experienced 31
influenza pandemics since 1580, or about one every 14 years. The
last one occurred in 1968. We're due.
The natural reaction is to prepare ourselves. Vaccines,
anti-viral medications, hospital and medical facilities, public
health infrastructure and the like are at the forefront of any
preparation discussion. What often gets only nominal attention,
however, are questions of morality and ethics. Decisions made
early in the epidemic will affect the lives of millions of
people. Scientists, doctors, and public health officials are
best equipped to advise us on the mechanics of disease avoidance
and therapy, but there are many perplexing questions on how to
implement them. The best time to solve them is before the
emergency strikes.
Influenza is a chameleon among viral pathogens. It is an RNA
virus whose genome copying enzymes are actually designed by
nature to make mistakes. The wrong amino acid is often inserted
into a protein. Most of these copying errors are harmless. Some
cause death to the virus. But a few profoundly change the virus'
antigenic makeup enabling it to infect at a higher rate and
avoid the immune system. In preparing for a viral attack, we
have no way of knowing precisely which enemy we are facing, what
vaccine will work, and what anti-viral medicines will be
effective. Even in the best of circumstances we can expect a
shortage of medications for global use. What we have at the time
will need to be rationed. The choices on how best to use them
will be difficult, controversial, and challenging to our moral
conscience. Some that immediately come to mind: If influenza
breaks out on a massive scale in a developing country, do we
send them some of our limited medications, or do we reserve what
we have for our own use? Should travel restrictions be placed
on an entire country if a serious type of influenza is found
there? If so, who declares the quarantine, and who enforces it?
How? If we do send medical supplies to a poor country, how do
we ensure that a corrupt government doesn't use the material for
its own monetary or political benefit?
The best treatment for any infectious disease is to avoid
getting it in the first place. The correct vaccine is very
effective in preventing influenza. Unfortunately, given the
virus's ability to change its identity, we don't now know what
the correct vaccine is. Preparing an influenza vaccine by
traditional methods takes time. The virus has to be cultivated
in hens' eggs, incubated for several months, harvested, killed,
and made safe for human injection. If we knew the structure of
an infecting virus and started on a vaccine today with
traditional methods, it would be 4 or 5 months before a product
would be ready for use. That's too much time.
Much work is being done on newer formulations of influenza
vaccine. Many involve taking a part of an influenza virus,
inserting it into another organism, and producing the specific
vaccine that way. It's basic genetic engineering. The catch, of
course, is that these newer methods of vaccine production, while
able to produce a product more rapidly, are not proven in a
large number of people. Even the safest vaccines have side
effects. They directly affect the immune system, and each
person's immune system is unique. Most of us can eat a full bag
of peanuts and not have a problem. But a few people can just
touch a peanut and go into a hyper-immune state called
anaphylaxis and nearly die. Any vaccine given to millions of
people can cause several to have very serious immunologic
complications. At what point in an influenza threat do we
decide to vaccinate millions of people? Should we use one of
the newer, perhaps unproven, formulations of vaccine production,
or wait for the more traditional one? Many people will refuse
to be vaccinated. Should they be subject to any sort of
quarantine or travel restrictions? How do we identify them?
Influenza can be treated with several anti-viral drugs that
directly inactivate the virus. One of them is called
oseltamivir, also known by its trade name Tamiflu. This drug
inactivates the protein called neurominidase that the virus uses
to escape from the human cell. Neurominidase is the N in H5N1.
But just like the rest of the virus the N can change by genetic
mutation. So while Tamiflu may work today, the virus of tomorrow
may be resistant to it. Should we stockpile hundreds of
millions or billions of dollars worth of Tamiflu today,
realizing that it may be useless when we need it? Like any
medication Tamiflu has an expiration date. Expiration dates are
conservative estimates of a product's shelf life. If a product
outdates on November 2nd, is it all that bad on November 3rd?
How about December 2nd? The drug doesn't just go bad overnight.
Months or even years after expiration there is still some
activity left. What do we do with outdated Tamiflu? Is it OK to
give to someone who would otherwise get nothing with the hope
that it will still do some good? How do we decide who gets the
fresh stuff and who gets the outdated?
The Swiss pharmaceutical company Roche holds a patent on
Tamiflu. Should they be compelled to allow other companies to
make the product? What is fair compensation to Roche? Tamiflu
is no panacea. If you take it after you come down with influenza
you don't get cured right away. You just don't get as sick. It
works very well, though, in preventing you from getting the
disease after you have been exposed to the virus. If Tamiflu is
still effective against the virus, but in short supply, should
we use it more for therapy in those already sick, or reserve it
for contacts of infected people to prevent the spread of the
virus?
Newer anti-virals such as peramivir and A-315675 are in
development. They seem to work on strains of virus that are
resistant to Tamiflu. Usually new medications have to undergo
rigorous testing before being allowed on the market. If we get
into a real bind of Tamiflu resistant influenza, should these
newer medications be allowed to be used before undergoing the
usual scrutiny? If so, should anyone be held liable if something
goes wrong?
When we become seriously ill, the first place most of us head
for is the nearest hospital. Unfortunately, we don't have any
hospitals just sitting there waiting for the next flu pandemic.
They are busy places even in times of no influenza. During a
pandemic hospitals, and the communities they serve, will face a
number of hard choices. The numbers of ill will exceed the bed
capacity. The disease is highly infectious and staff and
existing patients will be at risk of contracting the disease.
Many people will show up in the emergency room to be tested,
even if they simply have a common cold, overwhelming the staff.
Should we designate a few hospitals in the community to become
acute respiratory hospitals? If so, how do we decide which
one(s)? Where do we put people who need hospitalization when no
beds are available? Should hospital visitation rights be
severely restricted to prevent the introduction of the virus
into the hospital? Many people don't have health insurance. Do
they receive the same level of care as those who do? How will
the doctors and hospitals be compensated?
Most of us get our information through the news media. With the
current system news goes through several reporters and editors
before reaching us. Should the government or some other agency
be allowed to dictate the news about influenza, or should the
current system be left alone? How do we correct misinformation?
Should the news media be subject to some sort of oversight to
prevent unnecessary panic? If conflicting opinions within the
medical and public health community arise, what is the news
media's role in reporting it?
In this country we highly value our individual rights. During a
severe epidemic, however, some of those rights must be suspended
for the good of the community. Self-quarantine, travel
restrictions, closure of schools and certain recreation and
entertainment businesses will probably be necessary. What is the
best way for law enforcement and public health officials to
enforce these restrictions? Who decides which enterprises to
close down and for how long? Should those businesses and
communities that are the hardest hit by these rulings (think Las
Vegas) be compensated for their economic loss? If so, how much?
If essential business like grocery stores or pharmacies close
out of fear, should they be forced to stay open?
Those of us in the medical profession are very much aware of
the threat of lawsuits. Defensive medicine is an established
practice. How much laxity of current standards will be permitted
to cope with an influenza emergency? If someone is given Tamiflu
that is outdated and they die, can the hospital and the doctor
be sued? Should the doctor who fears a lawsuit be sued for not
cutting a corner or two?
Most people living in a developed country today have never
experienced a full-blown pandemic of influenza or anything else.
Our laws, medical practices and public behavior have all
developed assuming that infectious diseases are for the most
part controllable and manageable. But an influenza epidemic with
a death rate of 2.5% in a population with no immunity would
profoundly alter the status quo. Preparing for a pandemic is not
like retrofitting a bridge to meet earthquake standards. There
are too many variables and unresolved questions. Now is the best
time to consider not just the science, but also the ethics of
the next pandemic.