• BIOETHICS FORUM ESSAY

Report from China: Ethical Questions on the Response to the Coronavirus

Published on: January 31, 2020
Published in: Global Health, Hastings Bioethics Forum, Public Health

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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  1. Kathryn Foxhall on

    The U. S. badly need to look at its own lack of transparency.

    My letter to the Washington Post Editorial Board is below

    To the Washington Post Editorial Board:
    Regarding your editorial: “China tried to keep a lid on the coronavirus. It put everyone at risk.”
    Your statements about the risk of China’s secrecy and media censorship are extremely frightening. That’s both because the U.S. has harsh, pervasive controls on the press and because the editorial illustrates our absolute determination not to recognize them.
    As journalists you are officially prohibited from communicating with anyone in CDC and other federal agencies without the oversight of censors: much to our discredit we call them, “Public information officers.” Reporters also usually can’t walk into the buildings and there are often no systems for credentials.
    Usually the prohibitions hold: agency staff people don’t talk without the censors.
    Beyond that, often reporters are just not allowed to communicate with the person they request or to anyone at all, in HHS and other federal agencies.
    These restrictions have surged in the U.S. over the last 25-30 years, to the point they are almost a cultural norm. Society of Professional Journalists’ surveys show they are pervasive in federal, state and local governments, scientific organizations, educational institutions and police departments.
    The many thousand people in HHS, including those with the best knowledge of the current crisis, are effectively silenced, even after unenlightened news articles are published. There are many things hidden because we can’t talk to people without reporting to the authorities. Those unmentioned things might be about budget constraints or political pressures. They may well be something you and I can’t imagine.
    Under such restrictions, for journalists to just believe the official story, or believe whatever we can get from whoever will talk, is incredibly reckless, similar to what you castigate China for.
    During the early AIDS years I was reporting for public health professionals. It was before the imposition of this “Censorship by PIO.” I found out that the official story was so controlled it was life threatening–and there were millions of lives at stake. Journalists having conversations without the knowledge of the authorities—routinely—is critical for ethical journalism.
    The press puts many lives at risk by acquiescing to the constraints. The FDA’s apparent lack of competence on drug manufacturing safety (“Bottle of Lies” is on 2019 best book lists, but it took 10 years to write) and the opioid epidemic are two examples where agencies successfully controlled press access as situations quietly turned disastrous. After CDC was found to be mishandling pathogens, the investigating commission said the staff was scared to tell their supervisors. Of course, talking to the press was prohibited.
    Please see in particular the letter 28 journalism and other groups sent to Congress last fall on this.
    Also, note that an extensive legal review has concluded these constraints are unconstitutional. SPJ’s press release, with other links, is below. My essay for “Censored 2020” is attached.
    Will you take responsibility for examining these restraints and explaining them to the public?
    May I or other people active on this issue talk to the editorial board about this?
    Thank you,
    Kathryn Foxhall

    000000
    Review of legal cases says much of ‘media policy’ censorship is illegal

    CONTACT:
    Patricia Gallagher Newberry, SPJ National President, 513-702-4065, pattinewberryspj@gmail.com
    Jennifer Royer, SPJ Director of Communications and Marketing, 317-361-4134, jroyer@spj.org

    INDIANAPOLIS – In an important turn in the fight against the severe controls on reporters trying to communicate with public employees, the Brechner Center for Freedom of Information has presented a “roadmap” for journalists to legally challenge that censorship.

    Attorney Frank LoMonte, head of the center, says, “Wholesale prohibitions on unapproved contact with journalists, or with the general public, have long been recognized as unconstitutional, and remain so even after Garcetti,” the 2006 Supreme Court decision often cited by agencies claiming they have the right to prohibit employees from talking to the press or forcing them to get prior approval from someone, often a public information officer.

    In the newly released article in the Kansas Law Review, LoMonte says that employees are highly unlikely to bring a suit in order to speak to the media, but recent court cases indicate news organizations and even journalism membership groups should be able to litigate the issues around these workplace gag orders.

    The article is a broader discussion of what appeared in the Brechner Center Issue Brief released in October. LoMonte is a member of the SPJ Foundation Board of Directors.

    Patricia Gallagher Newberry, Society of Professional Journalists national president, said, “Censorship has stalked a horrific path through history. This is another instance. It is heartening to find another way to fight this trend toward silencing public employees, which SPJ has identified as a grave risk to public welfare.”

    Paul Fletcher, chair of the SPJ Freedom of Information committee, an attorney and publisher of Virginia Lawyers Weekly, said, “The thoroughness of LoMonte’s research is groundbreaking. Journalists everywhere must recognize that despite their hard work and impressive reporting, these pervasive practices of silencing or putting censors on people inevitably keep much from the public. Our fight for the whole truth must include the fight against these dangerous barriers.”

    The 70-page review analyzes dozens of cases from the Supreme Court and other federal courts. It says that despite the fact journalists should be able to challenge restrictions that deny their access to desired sources, there is no record of them having done so. Thus the “overbroad” restraints are unenforceable constitutionally, “yet still proliferate and still exert a powerful influence on the way employees behave.”

    The article explains that the U.S. Supreme Court strongly disapproved of government policies that discourage employees from sharing their expertise with the news media in a 1995 case, United States v. National Treasury Employees Union. The Court’s later employee-speech cases – primarily its 2006 ruling in Garcetti v. Ceballos – created some confusion over the level of First Amendment protection that applies in the government workplace. But the Court clarified that government employees still have legally protected rights to discuss work-related matters with the public in a 2014 ruling, Lane v. Franks. In the Lane case, the court clarified that, saying, “the mere fact that a citizen’s speech concerns information acquired by virtue of his public employment does not transform that speech into employee—rather than citizen—speech.”

    After examining cases since Lane, LoMonte said, “In short, there is no indication that federal courts widely understand Garcetti to have legitimized broadly worded prohibitions against discussing workplace matters,” calling such polices “constitutionally infirm and vulnerable to factual challenge.”

    The article also gathers examples of questionably legal gag policies from agencies throughout the country, to illustrate how pervasively government gatekeepers at all levels are policing their employees’ interactions with the news media.

    SPJ and other journalism and open government groups have been speaking out against the controls for close to a decade. Coalitions of up to 60 organizations have sent letters to the Obama Administration, the Trump Administration and Congress. Seven surveys sponsored by SPJ over five years showed these censorship practices have become pervasive in state and local government, schools, science organizations and police departments.

    Further information on media policy censorship:
    • Other resources, including SPJ’s surveys, are on SPJ’s web page on the issue.
    • On Oct. 17 the House Science Space and Technology Committee voted to kill proposed provisions that would have given federal scientists the right to speak to reporters without prior permission from the authorities in their agencies. Science Magazine reported on the mark-up.
    • In its most recent resolution on the issue, the SPJ says the constraints are authoritarian and the public has a right to be dubious of statements from organizations in which employees can’t speak without guards.
    • On Nov. 6, SPJ and 28 more journalism and open government groups sent a letter to every member of Congress calling for support of unimpeded communication with journalists for all federal employees.
    • An essay in the book, “Censored 2020,” published in October, (attached) says this trend puts the entire public at risk: See “Censorship Through Public Information Officers.”

    Reply
    • Jon on

      Freedom of press and a fair and justice system for America, France, Brazil, Nigeria, Nicaragua and every other country are of course important, but unrelated to the topic of the article. This article is about China’s response to the coronavirus.
      I’m not sure why you felt the need to post this here.

      Reply
  2. Daniel R Black on

    Transparency? Truth? Faith? Righteousness? Honor? Integrity? Being an Infectious Disease geek and in Medicine for more than 30 years, “Ethics” seniors some golden rule. Not so, there are no clear roads through Moral and social dilemmas. Conflict of more and morals with social norms and lack of resources/controlled assets, etc, lead us down the rabbit hole. But, right and wrong are not so obvious and hind sight is 20/20. So, to take a closer look at Western Medicine: I suggest several books to your readers; The Coming Plague, Wrong, Bitten, The Hot Zone. Throwing stone in glass house, and the bugs have been here a billion years before our species. What about the Malthusian theories. The real prob is population Density and expansion into the woods for food. Enough, early morning coffee musing. Thx for your ear.

    Reply

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