Ethics of the Ebola Crisis
REFERENCES Best, M., and D. Neuhauser. 2004. Ignaz Semmelweis and the birth of infection control. BMJ Safety & Quality in Health Care (British Medical Journal) 13(3): 233–234. Available at: http://dx.doi.org/ 10.1136/qshc.2004.010918 Borten, C., and M. Wallack. 2013. Dallas buyers club. Directed by J.M. Vallee. Produced by Truth Entertainment Voltage Pictures. Performed by Matthew McConaughey, Jennifer Garner, and Jared Leto. Focus Features (US). Centers for Disease Control and Prevention. 2014a. Interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. December 24. Available at: http://www. cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-per sons-with-exposure.html (accessed 3 January 2015). Centers for Disease Control and Prevention. 2014b. Post-treatment Lyme disease syndrome. August 11. Available at: http://www. cdc.gov/lyme/postLDS/ (accessed 3 January 2015). Fauci, A. S. 2012. Emerging ethical issues over the course of the AIDS pandemic. Public Health Reviews 34(1): 1–6. Jena, A. B., V. Prasad, D. P. Goldman, and J. Romley. 2015. Mortality and treatment patterns among patients hospitalized
with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Internal Medicine (American Medical Associaton) 175(2): 237–244. doi: 10.1001/ jamainternmed.2014.6781. Langer, E. 2013. Edmund D. Pellegrino, prominent bioethicist, dies at 92. The Washington Post, June 19. Available at: http://www. washingtonpost.com/local/obituaries/edmund-d-pellegrino-prei minent-bioethicist-dies-aat-92/2013/06/19/34a3e97a-d82f-11e29d14-895344c13c30_s (accessed 5 January 2015). Mormile, R., I. Quadrini, and U. Squarcia. 2013. Milestones in pediatric cardiology: Making possible the impossible. Clinical Cardiology 36(2): 74–76. Available at: http://dx.doi.org/10.1002/ clc.22087 National Center on Complementary and Alternative Medicine. 2014. NIH National Center on Complementary and Integrative Health. Available at: http://www.nccam.nih.gov (accessed January 6, 2015). Shah, S. K., D. Wendler, and M. Danis. 2015. Examining the ethics of clinical use of unproven interventions outside of clinical trials during the Ebola epidemic. American Journal of Bioethics 15(4): 11–16.
Infection Control Measures and Debts of Gratitude Diego S. Silva, Medizinische Hochschule Hannover, St. Michael’s Hospital, Toronto, and University of Toronto A. M. Viens, University of Southampton Health care workers (HCWs) returning home from Ebolainfected regions are subject to various infection control measures (ICMs), including investigative, diagnostic, and liberty-restricting measures. Public health laws justifying the use of ICMs, such as quarantine, have been invoked in recent cases involving HCWs returning home from areas affected by Ebola, such as for Maine nurse Kaci Hickox. Upon her return to the United States, Hickox was issued with a 21-day quarantine order by the Maine Department of Health and Human Services (Temporary order 2014), which she successfully challenged in court. In the final court order on the matter, Judge LaVerdiere acknowledged that while protecting others from harm can serve as a justification for the use of quarantine in such cases, the fact that Hickox had been asymptomatic, and hence unlikely to infect others with Ebola, rendered such measures illegitimate (Order pending hearing 2014). This was an instance where, as Steven Miles (2015) notes in his
article, “a government motivated by antiscience, irrational fear, or politics attempts to abuse public health laws to infringe on civil liberties” (18). Instead, the court held that the proportionate response would be for Hickox to comply with direct active monitoring (DAM), which provides public health authorities with the ability to conduct the requisite surveillance activities in a way that would not violate her civil rights. Interestingly, in his order, Judge LaVerdiere claimed that “we owe her and all professionals who give themselves [to fighting Ebola] a debt of gratitude” (Order pending hearing 2014, 3). On what basis and in what ways does one exactly discharge a debt of gratitude in the case of Hickox and other professionals who are fighting Ebola? There are many facets to both questions, but we argue that making progress on them depends on distinguishing between two senses of gratitude and understanding how each sense impacts the legitimacy of using ICMs.
Address correspondence to Diego S. Silva, Institut f€ ur Geschichte, Ethik und Philosophie der Medizin, OE 5450, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany. E-mail: [email protected]
April, Volume 15, Number 4, 2015
ajob 55
American Journal of Bioethics
GRATITUDE, RISK, AND LOSS We may have different emotions, such as admiration or inspiration, toward HCWs who help fight Ebola. We might also feel gratitude, since many of these HCWs have voluntarily left non-Ebola-affected countries, thereby putting themselves at increased risk of harm and suffering losses for the benefit of others. Gratitude can be understood as an attitude of feeling grateful toward persons for their actions or for something received. There seems to be, primarily, two things for which people may feel grateful toward Hickox. First, we can imagine Americans would be grateful that HCWs would take on risks to reduce the global burden of Ebola and, in turn, reduce the risk of Ebola-infected individuals landing in the United States. Second, we can also imagine that Americans, and especially Mainers, would feel grateful for Hickox’s compliance with ICMs, in this case DAM, because of its contribution toward protecting the broader public upon her return. Both these actions would likely solicit feelings of gratitude for different reasons. While both considerations concern Ebola and the harm associated with it, there are, at least, these two distinct senses of gratitude in operation. The feeling of gratitude, however, may take on a normative force, too, namely, in the form of a debt of gratitude. In other words, we might argue that our feeling grateful toward Hickox morally demands that we show her gratitudinous thankfulness in a concrete way.1 The justification for the debt of gratitude can be grounded in the notion of reciprocity. Reciprocity “demands an appropriate balancing of the benefits and burdens of the social cooperation necessary to obtain the good of public health” and “requires that one return the good one has received, or responds to harms performed, in a fitting manner” (Viens, Besimon, and Upshur 2009). Therefore, one might argue that we can have a debt of gratitude toward Hickox in two senses. On the one hand, we can have a debt of gratitude predicated on the risk she took in order to help persons suffering from Ebola. On the other hand, we can also have a debt of gratitude predicated on the risk she is limiting by voluntarily incurring a loss by complying with ICMs that seek to prevent the spread of Ebola. How the debt of gratitude is fulfilled would seem to differ based on which sense of gratitude is being considered. In the first instance, we owe a debt of gratitude because Hickox is an HCW, which might require providing hazard pay or perhaps public displays of gratitude (e.g., a parade for her and other HWCs who chose to
1. It would seem that the debt of gratitude would, in this instance, be discharged by the state. Perhaps individual persons may also wish to show gratitude, e.g., sending her “thank-you” cards, but it seems less likely that one would claim individuals have an obligation to discharge gratitude in this particular case since the benefit is at the population level, not directed toward any one individual. For more about this topic, and related issues regarding reciprocity see Becker (1986).
56 ajob
work in Ebola-affected countries). In the second instance, a debt of gratitude is owed for abiding by DAM or other ICMs, which may require ensuring that Hickox has the necessary resources to fulfill her public health obligations so that she is not unduly burdened.
BALANCING GRATITUDE-BASED REASONS The two senses of gratitude help explain why we owe HCWs a debt of gratitude and how we should discharge this debt when these individuals are subject to ICMs, like quarantine and DAM. It also gives rise to a related issue concerning how these gratitude-based reasons shape our judgments about the legitimacy of ICMs. In particular, it is unclear how reasons predicated from these two senses of gratitude should be balanced. In the case of Hickox, for instance, we have gratitudebased reasons both because she is a HCW and because she incurred a loss by abiding by ICMs. Should both gratitudebased reasons be treated additively (a C b D c) or do these reasons operate independently of each other (a C b D a C b)? If it is the former, then it would seem that we have more reason—at least on the basis of gratitude—to mitigate the losses suffered by HCWs compared to nonHCWs, even if both suffer the same loss through ICMs. That is to say, if gratitude-based reasons are to be treated additively, then the greater the debt of gratitude we have toward someone, the greater is our obligation to minimize or prevent loss associated with ICMs. We can imagine, however, why such a view may be problematic. If what we care about when it comes to ICMs concerns preventing potential infection exposure and transmission, and showing gratitude to those who voluntarily comply with ICMs, then why should it matter how someone was exposed to the virus? If what really matters is showing gratitude to those individuals who voluntarily contribute to risk-minimization activities, then we should think that the gratitude-based reasons we have toward Hickox should be treated nonadditively. It is also possible to see why this would raise a parallel question about how culpability for exposure or infection should impact on how we respond to individuals subject to ICMs. Even if we maintain that there is an additional, gratitude-based reason when it comes to HCWs, like Hickox, since they knowingly and voluntarily placed themselves at higher risk of exposure or infection, how should this impact how we respond to them? Does voluntarily exposing oneself to increased risk of harm—especially a risk of harm that will present an increased risk of harm to others—reduce the level of gratitude that should be shown? We often think that responsibility-based considerations should temper what we owe other people, so why should it be different in these cases? Should the good intentions of HCWs who expose themselves to Ebola negate any diminution of gratitude compared to someone who was accidently and involuntarily exposed through no fault of their own?
April, Volume 15, Number 4, 2015
Ethics of the Ebola Crisis
CONCLUSION It is permissible to subject individuals who present an actual risk of harm to others through the potential exposure or transmission of an infectious disease to control measures that are proportionate to the kind and level of harm threatened. The legitimacy of such ICMs, however, depend on how we respond to individuals who are subjected to such measures. One of those ways includes reciprocally responding with gratitude for the risks taken on and/or the losses incurred by these individuals. Reciprocally responding with a debt of gratitude can be understood in two senses: (i) showing gratitude to those who voluntarily take on additional, self-imposed risks for the benefit of others and (ii) showing gratitude to those who voluntarily subject themselves to loss-imposing ICMs that seek to limit harm to others. The ways in which these gratitude-based reasons interact and are balanced against each other raise important and interesting questions concerning
whether and why we should treat HCWs and non-HCWs differently in the application of ICMs. &
REFERENCES Becker, L. C. 1986. Reciprocity. New York, NY: Routledge & Kegan Paul. Miles, S. H. 2015. Kaci Hickox: Public health and the politics of fear. American Journal of Bioethics 15(4): 17–19. Order pending hearing. 2014. Mayhew v. Hickox, Docket No. CV2014-36 (Maine District Court, October 30, 2014). Temporary order. 2014. Mayhew v. Hickox, Docket No. CV-2014-36 (Maine District Court, October 30, 2014). Viens, A. M., C. M. Bensimon, and R. E. G. Upshur. 2009. Your liberty or your life: Reciprocity in the use of restrictive measures in contexts of contagion. Journal of Bioethical Inquiry 6: 207–217.
Health Communication, Public Mistrust, and the Politics of “Rationality” Sara M. Bergstresser, Columbia University Miles (2015) appears to conclude that either governmental action can be populist, catering to the irrational fears of the masses, or it can be rational, scientific, and presumably therefore more ethical. I suggest that this dichotomy fails to capture the full complexity and broader implications of the U.S. reaction to the Ebola epidemic. While the case of Kaci Hickox has certainly galvanized many parties and arguments about the limits of civil rights versus the “police power” of quarantine, the most important lessons here are not to be learned from the legal details of her case, but rather from within the context of a broader national failure of public health communication. There is a basic lack of trust in information that is disseminated through official sources, and this has troubling implications for the future of public health in the United States and beyond. Trust in medicine and medical institutions is tied to attitudes and behaviors at many levels, having consequences for everything from national vaccination campaigns to doctor– patient relationships, care seeking, information disclosure, treatment adherence, and even the placebo effect (Hall 2005). In this commentary, I argue that our attentions should shift away from the case itself and toward the reestablishment of trust in public health. An October 2014 New York Times article addressed public health leaders’ reliance on statements of scientific
expertise to justify ongoing action, saying that this approach had been mainly ineffective in quelling public alarm over Ebola (Perez-Pe~ na 2014). Though this anxiety was taken up as fodder for partisan strife, the broader phenomenon of public mistrust is more alarming because it extends across political boundaries. There is a growing resentment of messages that are perceived as condescending. Hansen (2009) suggests that the initial triumph of the Salk vaccine marked the end of widespread popular enthusiasm for medical advances. In contrast, the current era is marked by widespread mistrust of vaccines. In the intervening decades there have been many ethical failures, from the abuse of research subjects to tainted pharmaceuticals, many of which also played a role in the advent of contemporary bioethics (De Vries and Kim 2008). These failures have also become part of the public consciousness. The polarizing discourse surrounding Ms. Hickox and her case exemplifies the damaging dynamic of mistrust in health and scientific institutions that pervades the United States. Those who champion her case as a fight for rationality present the image of a valiant and heroic victim of injustice. On the other hand, many general public perceptions focus on an image of someone who appears flagrantly unconcerned for the health and safety of her neighbors. This dichotomization has spawned a larger
Address correspondence Sara M. Bergstresser, Columbia University, Program in Bioethics, 2970 Broadway, 504 Lewisohn Hall, New York, NY 10027, USA. E-mail: [email protected]
April, Volume 15, Number 4, 2015
ajob 57
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES Best, M., and D. Neuhauser. 2004. Ignaz Semmelweis and the birth of infection control. BMJ Safety & Quality in Health Care (British Medical Journal) 13(3): 233–234. Available at: http://dx.doi.org/ 10.1136/qshc.2004.010918 Borten, C., and M. Wallack. 2013. Dallas buyers club. Directed by J.M. Vallee. Produced by Truth Entertainment Voltage Pictures. Performed by Matthew McConaughey, Jennifer Garner, and Jared Leto. Focus Features (US). Centers for Disease Control and Prevention. 2014a. Interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. December 24. Available at: http://www. cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-per sons-with-exposure.html (accessed 3 January 2015). Centers for Disease Control and Prevention. 2014b. Post-treatment Lyme disease syndrome. August 11. Available at: http://www. cdc.gov/lyme/postLDS/ (accessed 3 January 2015). Fauci, A. S. 2012. Emerging ethical issues over the course of the AIDS pandemic. Public Health Reviews 34(1): 1–6. Jena, A. B., V. Prasad, D. P. Goldman, and J. Romley. 2015. Mortality and treatment patterns among patients hospitalized
with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Internal Medicine (American Medical Associaton) 175(2): 237–244. doi: 10.1001/ jamainternmed.2014.6781. Langer, E. 2013. Edmund D. Pellegrino, prominent bioethicist, dies at 92. The Washington Post, June 19. Available at: http://www. washingtonpost.com/local/obituaries/edmund-d-pellegrino-prei minent-bioethicist-dies-aat-92/2013/06/19/34a3e97a-d82f-11e29d14-895344c13c30_s (accessed 5 January 2015). Mormile, R., I. Quadrini, and U. Squarcia. 2013. Milestones in pediatric cardiology: Making possible the impossible. Clinical Cardiology 36(2): 74–76. Available at: http://dx.doi.org/10.1002/ clc.22087 National Center on Complementary and Alternative Medicine. 2014. NIH National Center on Complementary and Integrative Health. Available at: http://www.nccam.nih.gov (accessed January 6, 2015). Shah, S. K., D. Wendler, and M. Danis. 2015. Examining the ethics of clinical use of unproven interventions outside of clinical trials during the Ebola epidemic. American Journal of Bioethics 15(4): 11–16.
Infection Control Measures and Debts of Gratitude Diego S. Silva, Medizinische Hochschule Hannover, St. Michael’s Hospital, Toronto, and University of Toronto A. M. Viens, University of Southampton Health care workers (HCWs) returning home from Ebolainfected regions are subject to various infection control measures (ICMs), including investigative, diagnostic, and liberty-restricting measures. Public health laws justifying the use of ICMs, such as quarantine, have been invoked in recent cases involving HCWs returning home from areas affected by Ebola, such as for Maine nurse Kaci Hickox. Upon her return to the United States, Hickox was issued with a 21-day quarantine order by the Maine Department of Health and Human Services (Temporary order 2014), which she successfully challenged in court. In the final court order on the matter, Judge LaVerdiere acknowledged that while protecting others from harm can serve as a justification for the use of quarantine in such cases, the fact that Hickox had been asymptomatic, and hence unlikely to infect others with Ebola, rendered such measures illegitimate (Order pending hearing 2014). This was an instance where, as Steven Miles (2015) notes in his
article, “a government motivated by antiscience, irrational fear, or politics attempts to abuse public health laws to infringe on civil liberties” (18). Instead, the court held that the proportionate response would be for Hickox to comply with direct active monitoring (DAM), which provides public health authorities with the ability to conduct the requisite surveillance activities in a way that would not violate her civil rights. Interestingly, in his order, Judge LaVerdiere claimed that “we owe her and all professionals who give themselves [to fighting Ebola] a debt of gratitude” (Order pending hearing 2014, 3). On what basis and in what ways does one exactly discharge a debt of gratitude in the case of Hickox and other professionals who are fighting Ebola? There are many facets to both questions, but we argue that making progress on them depends on distinguishing between two senses of gratitude and understanding how each sense impacts the legitimacy of using ICMs.
Address correspondence to Diego S. Silva, Institut f€ ur Geschichte, Ethik und Philosophie der Medizin, OE 5450, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany. E-mail: [email protected]
April, Volume 15, Number 4, 2015
ajob 55
American Journal of Bioethics
GRATITUDE, RISK, AND LOSS We may have different emotions, such as admiration or inspiration, toward HCWs who help fight Ebola. We might also feel gratitude, since many of these HCWs have voluntarily left non-Ebola-affected countries, thereby putting themselves at increased risk of harm and suffering losses for the benefit of others. Gratitude can be understood as an attitude of feeling grateful toward persons for their actions or for something received. There seems to be, primarily, two things for which people may feel grateful toward Hickox. First, we can imagine Americans would be grateful that HCWs would take on risks to reduce the global burden of Ebola and, in turn, reduce the risk of Ebola-infected individuals landing in the United States. Second, we can also imagine that Americans, and especially Mainers, would feel grateful for Hickox’s compliance with ICMs, in this case DAM, because of its contribution toward protecting the broader public upon her return. Both these actions would likely solicit feelings of gratitude for different reasons. While both considerations concern Ebola and the harm associated with it, there are, at least, these two distinct senses of gratitude in operation. The feeling of gratitude, however, may take on a normative force, too, namely, in the form of a debt of gratitude. In other words, we might argue that our feeling grateful toward Hickox morally demands that we show her gratitudinous thankfulness in a concrete way.1 The justification for the debt of gratitude can be grounded in the notion of reciprocity. Reciprocity “demands an appropriate balancing of the benefits and burdens of the social cooperation necessary to obtain the good of public health” and “requires that one return the good one has received, or responds to harms performed, in a fitting manner” (Viens, Besimon, and Upshur 2009). Therefore, one might argue that we can have a debt of gratitude toward Hickox in two senses. On the one hand, we can have a debt of gratitude predicated on the risk she took in order to help persons suffering from Ebola. On the other hand, we can also have a debt of gratitude predicated on the risk she is limiting by voluntarily incurring a loss by complying with ICMs that seek to prevent the spread of Ebola. How the debt of gratitude is fulfilled would seem to differ based on which sense of gratitude is being considered. In the first instance, we owe a debt of gratitude because Hickox is an HCW, which might require providing hazard pay or perhaps public displays of gratitude (e.g., a parade for her and other HWCs who chose to
1. It would seem that the debt of gratitude would, in this instance, be discharged by the state. Perhaps individual persons may also wish to show gratitude, e.g., sending her “thank-you” cards, but it seems less likely that one would claim individuals have an obligation to discharge gratitude in this particular case since the benefit is at the population level, not directed toward any one individual. For more about this topic, and related issues regarding reciprocity see Becker (1986).
56 ajob
work in Ebola-affected countries). In the second instance, a debt of gratitude is owed for abiding by DAM or other ICMs, which may require ensuring that Hickox has the necessary resources to fulfill her public health obligations so that she is not unduly burdened.
BALANCING GRATITUDE-BASED REASONS The two senses of gratitude help explain why we owe HCWs a debt of gratitude and how we should discharge this debt when these individuals are subject to ICMs, like quarantine and DAM. It also gives rise to a related issue concerning how these gratitude-based reasons shape our judgments about the legitimacy of ICMs. In particular, it is unclear how reasons predicated from these two senses of gratitude should be balanced. In the case of Hickox, for instance, we have gratitudebased reasons both because she is a HCW and because she incurred a loss by abiding by ICMs. Should both gratitudebased reasons be treated additively (a C b D c) or do these reasons operate independently of each other (a C b D a C b)? If it is the former, then it would seem that we have more reason—at least on the basis of gratitude—to mitigate the losses suffered by HCWs compared to nonHCWs, even if both suffer the same loss through ICMs. That is to say, if gratitude-based reasons are to be treated additively, then the greater the debt of gratitude we have toward someone, the greater is our obligation to minimize or prevent loss associated with ICMs. We can imagine, however, why such a view may be problematic. If what we care about when it comes to ICMs concerns preventing potential infection exposure and transmission, and showing gratitude to those who voluntarily comply with ICMs, then why should it matter how someone was exposed to the virus? If what really matters is showing gratitude to those individuals who voluntarily contribute to risk-minimization activities, then we should think that the gratitude-based reasons we have toward Hickox should be treated nonadditively. It is also possible to see why this would raise a parallel question about how culpability for exposure or infection should impact on how we respond to individuals subject to ICMs. Even if we maintain that there is an additional, gratitude-based reason when it comes to HCWs, like Hickox, since they knowingly and voluntarily placed themselves at higher risk of exposure or infection, how should this impact how we respond to them? Does voluntarily exposing oneself to increased risk of harm—especially a risk of harm that will present an increased risk of harm to others—reduce the level of gratitude that should be shown? We often think that responsibility-based considerations should temper what we owe other people, so why should it be different in these cases? Should the good intentions of HCWs who expose themselves to Ebola negate any diminution of gratitude compared to someone who was accidently and involuntarily exposed through no fault of their own?
April, Volume 15, Number 4, 2015
Ethics of the Ebola Crisis
CONCLUSION It is permissible to subject individuals who present an actual risk of harm to others through the potential exposure or transmission of an infectious disease to control measures that are proportionate to the kind and level of harm threatened. The legitimacy of such ICMs, however, depend on how we respond to individuals who are subjected to such measures. One of those ways includes reciprocally responding with gratitude for the risks taken on and/or the losses incurred by these individuals. Reciprocally responding with a debt of gratitude can be understood in two senses: (i) showing gratitude to those who voluntarily take on additional, self-imposed risks for the benefit of others and (ii) showing gratitude to those who voluntarily subject themselves to loss-imposing ICMs that seek to limit harm to others. The ways in which these gratitude-based reasons interact and are balanced against each other raise important and interesting questions concerning
whether and why we should treat HCWs and non-HCWs differently in the application of ICMs. &
REFERENCES Becker, L. C. 1986. Reciprocity. New York, NY: Routledge & Kegan Paul. Miles, S. H. 2015. Kaci Hickox: Public health and the politics of fear. American Journal of Bioethics 15(4): 17–19. Order pending hearing. 2014. Mayhew v. Hickox, Docket No. CV2014-36 (Maine District Court, October 30, 2014). Temporary order. 2014. Mayhew v. Hickox, Docket No. CV-2014-36 (Maine District Court, October 30, 2014). Viens, A. M., C. M. Bensimon, and R. E. G. Upshur. 2009. Your liberty or your life: Reciprocity in the use of restrictive measures in contexts of contagion. Journal of Bioethical Inquiry 6: 207–217.
Health Communication, Public Mistrust, and the Politics of “Rationality” Sara M. Bergstresser, Columbia University Miles (2015) appears to conclude that either governmental action can be populist, catering to the irrational fears of the masses, or it can be rational, scientific, and presumably therefore more ethical. I suggest that this dichotomy fails to capture the full complexity and broader implications of the U.S. reaction to the Ebola epidemic. While the case of Kaci Hickox has certainly galvanized many parties and arguments about the limits of civil rights versus the “police power” of quarantine, the most important lessons here are not to be learned from the legal details of her case, but rather from within the context of a broader national failure of public health communication. There is a basic lack of trust in information that is disseminated through official sources, and this has troubling implications for the future of public health in the United States and beyond. Trust in medicine and medical institutions is tied to attitudes and behaviors at many levels, having consequences for everything from national vaccination campaigns to doctor– patient relationships, care seeking, information disclosure, treatment adherence, and even the placebo effect (Hall 2005). In this commentary, I argue that our attentions should shift away from the case itself and toward the reestablishment of trust in public health. An October 2014 New York Times article addressed public health leaders’ reliance on statements of scientific
expertise to justify ongoing action, saying that this approach had been mainly ineffective in quelling public alarm over Ebola (Perez-Pe~ na 2014). Though this anxiety was taken up as fodder for partisan strife, the broader phenomenon of public mistrust is more alarming because it extends across political boundaries. There is a growing resentment of messages that are perceived as condescending. Hansen (2009) suggests that the initial triumph of the Salk vaccine marked the end of widespread popular enthusiasm for medical advances. In contrast, the current era is marked by widespread mistrust of vaccines. In the intervening decades there have been many ethical failures, from the abuse of research subjects to tainted pharmaceuticals, many of which also played a role in the advent of contemporary bioethics (De Vries and Kim 2008). These failures have also become part of the public consciousness. The polarizing discourse surrounding Ms. Hickox and her case exemplifies the damaging dynamic of mistrust in health and scientific institutions that pervades the United States. Those who champion her case as a fight for rationality present the image of a valiant and heroic victim of injustice. On the other hand, many general public perceptions focus on an image of someone who appears flagrantly unconcerned for the health and safety of her neighbors. This dichotomization has spawned a larger
Address correspondence Sara M. Bergstresser, Columbia University, Program in Bioethics, 2970 Broadway, 504 Lewisohn Hall, New York, NY 10027, USA. E-mail: [email protected]
April, Volume 15, Number 4, 2015
ajob 57
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
