The document summarizes ethical issues that arise in treating patients with Ebola virus disease. It discusses principles of medical ethics like utilitarianism and deontology. It describes the author's experience working in an Ebola treatment unit in Sierra Leone. Key issues discussed include health worker safety, patient selection and triage if resources become overwhelmed, experimental treatments, and stigmatization of survivors.

1. Ebola virus disease:
Ethical issues
Matthew Rollosson, RN, MPH&TM, BSN
26 January 2015

2. Introduction
• Registered Nurse, 1992 – present
• Master of Public Health & Tropical Medicine
• Clinical experience
• Neurology/neurosurgery
• Critical care
• Previous volunteer work
• Ethiopia
• New Orleans
• Tanzania
• Maforki Ebola Treatment Unit
• Port Loko, Sierra Leone
• November – December 2014

3. Preface
• “And I am the worst sinner of all.”
• 1 Timothy 1:15
• “This class intends to develop students'
tolerance for the considered opinions of others
as well as promote students' autonomy in
decision making and shaping their own values.”
• PHIL 223 syllabus

4. Deontology

5. Utilitarianism
• Prevent transmission
• Case management
• Isolation
• Treatment
• Contact tracing
• Prophylaxis
• Monitoring
• Quarantine

6. Altered standards of care
• Mass casualty events
• Overwhelm local resources
• Allocate equipment, personnel, and supplies in
order to save the greatest number lives
• Identify and reserve treatment for individuals who
are most likely to survive
AHRQ 2005

7. Ebola virus disease
• Preferred over “Ebola hemorrhagic fever”
• Most people with EVD do not have hemorrhagic
symptoms
• Disseminated intravascular coagulation
• Thrombocytopenia
• Non-specific symptoms
• Fever, headache, body aches
• Profuse vomiting and diarrhea
† Fluid and electrolyte loss
• Treatment: aggressive rehydration and
electrolyte replacement

8. Transmission
• Direct contact with blood or body fluids of a
symptomatic patient
• There is little or no evidence that human
ebolaviruses are transmitted
• through contact with inanimate objects
• via airborne route
• at onset of symptoms

9. References
• Bausch, D. G., Towner, J. S., Dowell, S. F., Kaducu, F., Lukwiya, M., Sanchez, A., et al. (2007). Assessment of the risk of
Ebola virus transmission from bodily fluids and fomites. Journal of Infectious Diseases, 196(Supple. 2), S142-S147.
• Blumberg, L., Enria, D., & Bausch, D. G. (2014). Viral hemorrhagic fevers. In J. Farrar, P. J. Hotez, T. Junghanss, G. Kang, D.
Lalloo, & N. J. White (Eds.) Manson's tropical diseases, 23rd Ed. [Electronic version]. Elsevier.
• Chertow, D. S., Kleine, C., Edwards, J. K., Scaini, R., Giuliani, R., & Sprecher, A. (2014). Ebola virus disease in West Africa
– clinical manifestation and management. New England Journal of Medicine, 371(22), 2054-2057.
doi:10.1056/NEJMp1413084.
• Fowler, R. A., Fletcher, T., Fischer, W. A., Lomontagne, F., Jacob, S., Brett-Major, D., et al. (2014). Caring for critically ill
patients with Ebola virus disease. Perspectives from West Africa. American Journal of Respiratory and Critical Care
Medicine, 190(7), 733-737. doi:10.1164/rccm.201408-1514CP.
• Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser
(Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version].
Elsevier.
• Hartman, A. L. (2013). Ebola and Marburg virus infections. In, A. J. Magill, D. R. Hill, T. Solomon, & E. T. Ryan (Eds.)
Hunter's tropical medicine, 9th Ed. [Electronic version]. Elsevier.
• Hoenen, T., Groseth, A., Falzarano, D., & Feldman, H. (2006). Ebola virus: unravelling pathogenesis to combat a deadly
disease. TRENDS in Molecular Medicine, 12(5), doi:10.1016/j.molmed.2006.03.006.
• Kortepeter, M. G., Bausch, D. G., & Bray, M. (2011). Basic clinical and laboratory features of filoviral hemorrhagic fever.
Journal of Infectious Diseases, 204(Supple. 3), S810-S816.
• Schieffelin, J. S., Shaffer, J. G., Goba, A., Gbakie, M., Gire, S. K., Colubri, A., et al. (2014). Clinical illness and outcomes in
patients with Ebola in Sierra Leone. New England Journal of Medicine, 371(22), 2092-2100.
doi:10.1056/NEJMoa1411680.
• Towner, J. S., Rollin, P. E., Baucsh, D. G., Sanchez, A., Crary, S. M., Vincent, M., et al. (2004). Rapid diagnosis of Ebola
hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a
predictor of outcome. Journal of Virology, 78(8), 4330-4341. doi:10.1128/JVI.78.8.4330–4341.2004.
• Yamin, D., Gertler, S., Ndeffo-Mbah, M. L., Skrip, L. A., Fallah, M., Nyenswah, T. G., et al. (2015). Effect of Ebola
progression on transmission and control in Liberia. Annals of Internal Medicine, 162(1), 11-17. doi:10.7326/M14-2255.

10. Holly and Andrew

11. No secondary cases among contacts of
U.S. health workers with EVD

12. Ebola epidemics 1976 - 2013
CDC 2015

13. Timeline of current epidemic
• West African Ebola epidemic traced to a 2-year-
old child in Guinea who died from the disease
December 6, 2013
• March 10 2014: World Health Organization
notified of an outbreak of an unknown infectious
disease characterized by fever, vomiting, and
diarrhea in Guinea
• Ebolavirus identified in blood from patients who
were hospitalized with the disease
• First outbreak of EVD in West Africa
Baize et al. 2014

14. Timeline
•…modest further intervention efforts
at that point could have achieved
control.”
- WHO Ebola Response Team
• Epidemic spreads to
• Liberia in March
• Sierra Leone in May
• Nigeria in July

15. Timeline
• August 8, 2014: WHO declared the Ebola
epidemic in West Africa a Public Health
Emergency of International Concern
Cases Deaths
Guinea 495 367
Liberia 554 294
Nigeria 13 2
Sierra Leone 717 298
Totals 1,779 961

16. Timeline
• By the end of August, the total numbers of EVD
cases and deaths exceeded that of all previous
Ebola epidemics combined
CDC 2015

17. Health workers
• Frequently infected
• Illness not recognized
as EVD
• Lack of appropriate
PPE
• Fewer health care
workers available
• Death
• Flee out of fear of
infection

18. Personal protective equipment
• Increases the risk
of heat-related
illness
• Limits the amount
of time spent in
patient care areas
• Greatest risk of
infection is during
doffing Partners In Health

19. Doffing

20. Safety
•Health worker safety is the priority
• Infected health workers
• Negative public perception of relief efforts
• Liability for the organization
• Discourages other health workers from
volunteering

21. Safety

22. My approach to patients with EVD
1. Can I care for this person without jeopardizing
my safety?
2. Can I improve this person’s chance of survival?
• If not,
• What can I do to relieve this person’s
suffering?
• What can I do to preserve this person’s
dignity?

24. Maforki Ebola Treatment Unit

25. Maforki Ebola Treatment Unit

26. Maforki Ebola Treatment Unit

27. Admission

28. Enter suspect ward

29. Suspect ward

30. Confirmed ward, PPE doffing area

31. Discharge
• Asymptomatic for 3 days
• Negative PCR
• Both confirmed and suspect cases

32. Photo: Martha Phillips

33. Stigmatization
• Survivors
• Loss of employment, family, home, property
• Harassed
• Victims of violence
• Health workers
• Unnecessary quarantine
• Confidentiality
• Names, personal information, photographs of
survivors in the media/social media

34. Other ethical issues
• Interruption of routine health care
• Obstetric care denied
• Maternal-child health
• Immunizations
• Schools closed
• Economic impact
• Businesses closed
• Unemployment
• Trade restricted

35. Other ethical issues
• Experimental treatments
• “Promising” results from animal trials
• No clinical trials
• Data sharing
• Scarce supplies
• Patient selection
• Compassionate use
• Randomization
• Diverting resources

36. Randomized controlled trial
Population
New treatment Current treatment
Randomization
Gordis 2004

37. Alternative therapies

38. Cumulative cases and deaths

39. Recommended reading
• Davtyan, M., et al. (2014). Addressing Ebola-
related stigma: lessons learned from HIV/AIDS.
Global Health Action, 7(26058).
doi.org/10.3402/gha.v7.26058.
• Rid, A. & Emanuel, E. J. (2014). Why should high-
income countries help combat Ebola? JAMA,
312(13). doi:10.1001/jama.2014.12869.
• Joffe, S. (2014). Evaluating novel therapeutic
during the Ebola epidemic. JAMA, 312(13).
doi:10.1001/jama.2014.12867.

40. References
• Agency for Healthcare Research and Quality. (2005). Altered standards
of care in mass casualty events.
http://archive.ahrq.gov/research/altstand.
• Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L.,
Magassouba, N., et al. (2014). Emergence of Zaire Ebola virus disease in
Guinea. New England Journal of Medicine, 371(15),1418-1425.
doi:10.1056/NEJMoa1404505.
• Blumberg, L., Enria, D., & Bausch, D. G. (2014). Viral hemorrhagic fevers.
In J. Farrar, P. J. Hotez, T. Junghanss, G. Kang, D. Lalloo, & N. J. White
(Eds.) Manson's tropical diseases, 23rd Ed. [Electronic version]. Elsevier.
• Centers for Disease Control and Prevention. (October 3, 2014). Ebola
virus disease outbreak – Nigeria, July-September, 2014. Morbidity and
Mortality Weekly Report, 63(39), 867-872.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm.
• Centers for Disease Control and Prevention. (November 20, 2014).
Interim guidance for healthcare workers providing care in West African
countries affected by the Ebola outbreak: limiting heat burden while
wearing personal protective equipment (PPE).

41. References
• Centers for Disease Control and Prevention. (2015). 2014 Ebola
outbreak in West Africa – cumulative reported cases in Guinea, Liberia,
and Sierra Leone. http://www.cdc.gov/vhf/ebola/csv/graph1-
cumulative-reported-cases-all.csv.
• Centers for Disease Control and Prevention. (2015). Outbreaks
chronology: Ebola virus disease.
http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.
• Gordis, L. (2004). Epidemiology, 3rd Ed. Philadelphia: Elsevier
• World Health Organization. (March 30, 2014). Ebola virus disease in
Liberia. http://www.who.int/csr/don/2014_03_30_ebola_lbr/en.
• World Health Organization. (May 26, 2014). Ebola virus disease, West
Africa – update. http://www.who.int/csr/don/2014_05_28_ebola/en.
• World Health Organization. (August 8, 2014). Ebola virus disease update
– West Africa. http://www.who.int/csr/don/2014_08_08_ebola/en.
• World Health Organization Ebola Response Team. (2014). Ebola virus
disease in West Africa – the first 9 months of the epidemic and forward
projections. New England Journal of Medicine, 371(16), 1481-1495.
doi:10.1056/NEJMoa1411100.

42. Questions?

43. Questions?