- BIOETHICS FORUM ESSAY
Report from China: Ethical Questions on the Response to the Coronavirus
Hegel says, “We learn from history that we do not learn from history.” The recurrence of the coronavirus epidemic in China proves his insight to be right.
Sixteen years ago, the SARS pandemic was ravaging mainland China and spreading beyond the border to cause global catastrophe. Now we have a SARS cousin, the novel coronavirus (2019 n-Cov). As of January 31, according to the National Health Commission, there were 9,720 confirmed cases and 15,238 suspected cases in China; 213 people have died, and 175 have recovered. The majority of the cases are in Hubei Province. [See updated statistics here.] On January 30, the WHO (World Health Organization) decided that the epidemic of 2019 n-Cov is a public health emergency of international concern, based on the increase of confirmed cases in the countries and regions outside China.
There are many scientific questions, including whether the virus came from the South China Seafood Market in Wuhan or elsewhere. And there are ethical questions about the response to the spreading virus.
In an interview on CCTV with Dr. Feng Zijian, the deputy director of China’s Centers for Disease Control, the anchorman asked a question that all Chinese people want the answer to: what is causing the rapid increase in confirmed cases? The first case was reported on December 8, 2019, and it took more than 40 days to surpass the 500th case; there were 571 cases on January 22. Just two days later, there were 1,000 cases. By January 27 there were more than 2,800 confirmed cases. The news anchor asked, “What do you think of the rapid change in the data? What does it mean?”
Dr. Feng said that the transmission capacity of the new virus is stronger than that of SARS. He attributed the rapid spread of the virus during this period to the Spring Festival (January 25-February 2), when as many as 3 billion people travel and can be exposed to, and transmit, the virus. However, we argue that other factors made the growth in cases plateau before January 17 and rise sharply afterward.
Lack of Transparency
In the efforts to control the epidemic, transparency is a key principle to let citizens know how to protect themselves and to let medical and public health personnel know which effective and appropriate interventions should be taken. Now, the National Health Commission updates data on the epidemic every day. There are timely briefings at press conferences in Beijing and other cities to report the updated information on the spread of the virus and interviews with epidemic experts on TV. It is good that the ethical principle of transparency is being followed now. However, there was a lack of transparency earlier in January.
On January 28, a special report titled “The Puzzle of No New Case for 12 Days after 6 January,” published in the online journal YiMagazine, said that, strangely enough, from January 11 to 16, the number of confirmed cases in Wuhan remained unchanged at 41. The lack of reported new cases raised the suspicion that true information was being hidden, and that the public was misled and missed the opportunity to control the spread of the virus.
The author reported that two meetings were held in Wuhan: the Hubei Provincial People’s Congress on January 7 to 10 and the Political Consultation Conference on January 11 to 17. This is the time to sing the praise of the government’s achievement, not to deal with problems and expose mistakes. Hubei Daily published a special report with 12 pages to praise the province’s achievement. In the lower corner of the last page, there was information on the epidemic issued by the Wuhan Municipal Health Commission. During this period, information on the epidemic was not reported every day, and there was no report from January 6 to January 9. The Wuhan Health Commission’s notifications made only the following points: All patients were receiving isolation treatment in medical institutions, no clear evidence of human-to-human transmission was found, and no medical staff members were infected.
On January 21 and 23, Hubei provincial and Wuhan municipal authorities organized largescale gatherings and artist performances to celebrate the Spring Festival, with the presence of the leaders of Hubei Province and city of Wuhan These activities conveyed a misleading message to the public that the epidemic was not a serious problem.
The omission of updates on the epidemic and faked, misleading information shifted the public’s attention from the epidemic and inhibited the efforts by medical and public health staff to control it. This is a case in which public health intervention was devastatingly compromised by the politics. It violated Article 37 of the Law on Infectious Diseases, which stipulates that the relevant departments of the people’s government shall not conceal, make false reports, or delay the report of the epidemic situation of infectious diseases. The provincial officials should be legally liable.
Isolation and Quarantine
In an epidemic without effective drugs or a vaccine, isolation and quarantine may be the only effective interventions. There are various forms of isolation and quarantine in China:
- Community prevention and control: measures include prohibiting public gatherings to reduce personal contacts and detect infected patients as early as possible.
- Self-quarantine for 14 days: people who work in Wuhan or throughout Hubei Province are required to stay home for 14 days without going out in public except for essential shopping; they must wear face masks when shopping.
- Isolation treatment: suspected and confirmed cases should be isolated and treated in designated hospitals.
- Quarantining cities: Wuhan and other cities in Hubei Province are quarantined, meaning that the residents cannot go to other places in China.
Under China’s Law on Infectious Diseases, the government can seal off, or quarantine, the serious epidemic area. What is controversial is whether the decision is ethically justified. In our opinion, it is ethically justified if it is effective in controlling the epidemic, it is proportional to the severity of the epidemic, it is necessary for controlling the epidemic, it is taken with minimal infringement on individual freedom and rights, and it is transparent to the public. Sealing off Wuhan and other cities roughly meets these conditions. Before Wuhan was sealed off, 5 million people living there traveled outside the city. The largest number of confirmed and suspected cases in all other areas of China are people who had traveled to Wuhan or were in contact with people from Wuhan. Sealing off Wuhan may reduce the spread of the virus.
Ethical Issues to Be Addressed
Some decisions made by the government have been beneficial to controlling the epidemic: All medical (inpatient and outpatient) costs for confirmed cases and for outpatient services to suspected cases are covered by the government; the Spring Festival will be prolonged by three days, and the start of the spring semester for school will be no earlier than February 17 to reduce the flow of travel and the spread of the virus; and the central government banned all forms of trade in wild animals until the end of the epidemic. But there are several ethical issues that need to be addressed.
We knew from the SARS epidemic that using wild animals for food may promote the spread of the virus to people. Why did we continue permitting markets and restaurants to provide food from wild animals? Should we change traditional cultural customs to prevent future epidemics? Should the temporary ban on wild animal trade be permanent?
As early as November 2019, some patients in Wuhan were detected with an unidentified pneumonia-like illness. Why didn’t the local health officials report these cases to the central center for disease control and try to isolate the pathogen from the biological samples of these patients and identify its nature?
Why, at the beginning of the epidemic, did the Wuhan Health Commission characterize the infection as mild, treatable, and under control? Why did the commission say, without adequate supporting evidence, that there was no transmission from human to human?
Was the information about the epidemic disclosed to the Chinese public and international community adequate, complete, and faithful, without any cover-up?
Are the cases of isolation and quarantine that are in effect ethically justifiable and proportionate? Do these interventions minimize the infringement upon individual freedom?
Isolation treatment unavoidably leads to the shortage of drugs, equipment, and medical staff. How do we ensure equitable access to and fair allocation of these resources?
Which interventions should we take to effectively prevent and fight discrimination against the people from Wuhan or those infected with the virus?
Do medical staff have a moral responsibility to treat patients infected with the virus? Do health administrative departments and the government have a responsibility to provide extra support to medical staff who stick to their posts?
We hope China can learn from the latest coronavirus epidemic and reform policy and law to improve transparency, require accurate and timely updates, and address the many ethical questions that an epidemic raises to prove that what Hegel says is not all correct: We can learn a little bit from history after paying extraordinarily great and painful costs.
Ruipeng Lei, a Hastings Center Fellow, is Professor and Executive Director Center for Bioethics Huazhong University of Science & Technology. Renzong Qiu, a Hastings Center Fellow, is Professor and Director, Institute of Bioethics, Center for Ethics & Moral Studies, Renmin University of China.
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