Upon the completion of this chapter and with further self-directed learning you are expected to be able to:
Identify at least five ‘whole-of-world’ scenarios that are going to give rise to ethical challenges for nurses and that will extend ‘beyond the bedside’.
Discuss critically the moral challenges posed respectively by:
public health emergencies
antimicrobial resistance (AMR)
inequities in health and health care.
Discuss critically how, if at all, the nursing profession can be appropriately prepared to respond justly and effectively to the moral challenges posed by ‘whole-of-world’ scenarios such as those listed above.
Explore and describe the kinds of strategies the nursing profession could develop and / or contribute to in order to ensure that, when faced with public health emergencies or health care disasters, the needs of society are upheld in a just, accountable and transparent manner.
Nursing has long been positioned as a profession on which society depends. In keeping with this stance it is appropriate that nurses, both individually and collectively, take time to reflect on the kinds of ethical problems they will be likely to encounter in the future and on whether they are as adequately prepared as they need to be in order to be able to respond ethically to what lies ahead.
As I have argued previously ( Johnstone 2009b ), past futurist thinking about nursing ethics futures has tended to focus on conventional issues such as the expansion of medical knowledge and developments in medical technology, continued health care reform, and the transformation of the profession in relation to these developments. Issues typically identified have included:
advancing patients’ rights in health care
ongoing cultural shifts and changes in attitude towards end-of-life care (e.g. ‘Not For Treatment’ directives, euthanasia / assisted dying, advance care planning)
the growth and use of technology in caring
‘genomic’ medicine – often accompanied by alarmist warnings of threats to the privacy and confidentiality of genetic information, and of genetic discrimination and exclusion of people from society and health care (i.e. in a manner such as that portrayed in the 1997 US science fiction movie Gattaca ( Johnstone 2009b )).
The identification of these and related issues has typically been followed by a rehearsal of the ‘usual’ arguments about professional accountability and responsibility. Although these issues are important, they will not be the most pressing issues that nurses will have to grapple with over the next few decades. As this chapter will attempt to show, there will be other (more) pressing ethical issues that the nursing profession will face in the future and that need to be anticipated. Of particular concern are the health-care-related ethical issues raised by public health emergencies, which may be driven by the threats to public health posed by climate change, pandemic influenza and antimicrobial resistance, and the sobering problem of local and global inequities in health and health care. Also of concern is whether conventional nursing ethics will be up to the task of guiding and motivating nurses to behave in ways that meet society’s needs. It is to briefly considering these issues and their possible moral implications for the nursing profession that this final chapter will now turn.
Public health emergencies 1
A public health emergency is defined by the World Health Organization (WHO) as:
an occurrence or imminent threat of an illness or health condition, caused by bio terrorism, epidemic or pandemic disease, or (a) novel and highly fatal infectious agent or biological toxin, that poses a substantial risk of a significant number of human fatalities or incidents or permanent or long-term disability. ( WHO (nd) www.who.int.easyaccess1.lib.cuhk.edu.hk/hac/about/definitions/en/ – current 10 June 2018)
For a public health emergency to ‘exist’, government authorities must formally declare ‘a state of public health emergency’ so that state regulations can be suspended and the functions of state agencies changed so that appropriate responses can be operationalised.
‘Emergency preparedness’, in turn, is defined as consisting of:
all activities taken in anticipation of a crisis to expedite effective emergency response. This includes contingency planning, but is not limited to it: it also covers stockpiling, the creation and management of standby capacities and training staff and partners in emergency response. ( Inter-Agency Standing Committee 2007 : 40)
Over the past decade, questions concerning the ‘emergency preparedness’ of countries, communities and citizens have received increasing attention as the lessons learned from an array of widely reported public health emergencies (e.g. those caused by hurricanes, bush fires, catastrophic flooding, earthquakes, tsunamis and the unprecedented outbreak in 2014 of the Ebola virus disease in western Africa) have highlighted ‘gaps in ethics guidances’ on how best to decide and act in emergency ultra-scenarios.
From an ethical standpoint, public health emergencies are challenging because they call into question and contradict ‘many of the values we hold dearest, such as providing each patient with the best available care’ ( Stroud et al 2010 : 51). Accordingly, fundamental ethical guidances and preparedness for dealing with ethical issues that may arise during public health emergencies are required. This is because, as Stroud and colleagues explain:
if we don’t act in accordance with our ethical principles, the repercussions both for individuals and the society after the fact will be enormous. They are fundamental because our ethical principles serve as the foundation of our laws. They are fundamental because people will only act and sacrifice if they believe they are operating in an ethical system, and that individuals are being treated with fairness and transparency in the full view of the law. In addition, they are fundamental, quite frankly, because many of the decisions contemplated will be made with imperfect information – they will be best guesses. Those guesses, in the absence of firm evidence, will need to be made based on a shared ethical construct. ( Stroud et al 2010 : 51)
The outbreak in 2003 of the severe acute respiratory syndrome (SARS), the 2009 swine flu epidemic and the 2014 outbreak of the Ebola virus disease in western Africa have each served to provide an important catalyst for raising probing questions about how prepared the world is to respond ethically to what has been termed in the public health literature the ‘three Rs’ of public health emergencies – notably: rationing (e.g. of vaccines, medications), restrictions (on people’s liberties / access to and from health care services) and responsibilities (of health care professionals to continue providing care and treatment even when doing so places them, their families and others close to them at risk) ( Wynia 2007 ; see also Reid 2005 ; Singer et al 2003 ). They also provided a catalyst for reflecting on the ‘tragic choices’ encompassing the ethical tradeoffs that will invariably have to be made in ‘ultra-scenarios’. As Campbell and colleagues have warned, when disaster strikes:
At progressively more extreme levels, the decisions will be increasingly harsh; morally agonizing to those who must make and execute them – but in the end, morally deadening. ( Campbell et al 2007 : 77)
There are at least three looming scenarios which are posing threats and challenges to the public’s health and health security but which authorities and the health professions (including nursing) have yet to substantively prepare for from an ethical standpoint: climate change, pandemic influenza and the ‘slow pandemic’ of antimicrobial resistance (AMR), which some scientists regard as being more threatening than climate change ( Telegraph Reporter 2014 ). Adding to the complexity of these scenarios and compounding their harmful impact is the problem of health inequalities, particularly those associated with the immediate and long-term impact of the austerity measures imposed on countries following the global financial crisis circa 2007–09. These will each be considered under separate subheadings below.
Climate change 2
Images of the catastrophic damage left in the wake of widely reported extreme weather events across the globe stand as graphic harbingers of what lies ahead as the world’s climate changes. Regardless of the political disagreements over what ‘the’ ultimate cause of climate change is, there is a near-global consensus among the world’s scientists that the climate is warming and that this change in climate involves harm – to human beings, to other species (many of which face being wiped out) and to the environment. It is the harms (preventable and otherwise) that are projected to occur in the near and distant futures (and that are already occurring) that place climate change firmly within the domain of ethics. Moreover, as Gardiner (2010 : 87) correctly points out, ‘at a most general level […] we cannot get very far in discussing why climate change is a problem without invoking ethical considerations’. He further contends:
If we do not think that our own actions are open to moral assessment, or that various interests (our own, those of our kin and country, those of distant people, future people, animals, and nature) matter, then it is hard to see why climate change (or much else) poses a problem. ( Gardiner 2010 : 87)
Some might counter that ‘science has all the answers’ and that it is ‘drawing a long bow’ characterising climate change as an ethical issue, or that the ethical dimensions of climate change are serious enough to warrant attention. Such a stance is, however, misguided. As the discussion in the previous chapters of this book has shown, ethics as a discipline fundamentally involves concern for others and, in particular, the prevention of harm and suffering to innocent others. Climate change at its most basic level threatens preventable harm to many entities. Although scientific research can tell us what is going on, it cannot tell us what we should do about it. This is because deciding what we ‘should’ do requires not only a grasp of the facts of the matter, but also a grasp of the values pertinent to the decisions that will ultimately need to be made – including what we value, what we think is ‘right’, how we justify our judgments of right and wrong, whose interests should count, who we are and who we want to be ( Gardiner 2010 , 2011 ; Garvey 2008 ).
Climate change is a ‘burgeoning public health concern’ that is already contributing to health disparities in vulnerable populations ( Kreslake et al 2018 ). As noted by Kreslake and colleagues (2018) , climate change has serious and significant implications for ‘chronic health conditions; nutrition and food security; food, water, and vector borne diseases; and social disruption, injuries, displacement, and death associated with extreme weather’ ( Kreslake et al 2018 : 568). It is also raising the possibility of what Dyer (2008) has called ‘climate wars’ whereby regions and nations enter into a ‘desperate struggle for advantage and survival’ and are ultimately drawn into conflict over acute and permanent crises in food and water supplies. A major casualty of these events will undoubtedly be the health security of people and whole nations.
In response to growing local and global concerns about the public health impacts of climate change, the nursing literature and nursing organisations are increasingly giving attention to the issue, believing it to be ‘one of the largest threats to human health that the planet has ever experienced’ ( Sullivan-Marx & McCauley 2017 : 593; see also Adlong & Dietsch 2015 ; Anderko 2017 ; Angelini 2017 ; Australian Nursing and Midwifery Federation (ANMF) 2015 ; Leffers & Butterfield 2018 ; New Zealand Nurses Organisation (NZNO) 2016 ). This has included drawing attention to the issue of ‘climate justice’ – a notion that refers to ‘the ethical and human rights issues that occur as a result of climate change’, including the unequal distribution of the burdens of climate change (e.g. in terms of health, food and water security) imposed on vulnerable populations ( Nicholas & Breakey 2017 : 609). A notable example of this emerging trend can be found in the publication of a collection of essays in the November 2017 special issue of Image: Journal of Nursing Scholarship (the official journal of the Sigma Theta Tau International (STTI) Honor Society of Nursing) in which critical attention is given to addressing the issue of ‘Climate change, global health, and nursing scholarship’ ( Sullivan-Marx & McCauley 2017 ). Despite this emerging trend in the nursing literature, important questions remain such as: ‘Is nursing ethics up to the task of guiding what Garvey (2008 : 114) terms a “morally adequate” response to the moral challenges posed by climate change?’, ‘Or will nursing ethics, like other ethical perspectives, require a fundamental paradigm shift in order to cope with the moral demands that lay ahead (after Jamieson 2010 )?’
The nursing profession has yet to make more than a rhetorical response to the ethics of climate change, the window of opportunity for which is narrowing. Responding to the ethics of climate change will, however, not be easy on account of its involving what Gardiner (2011) has famously termed ‘the perfect moral storm’ (after the Hollywood film of the same title), which he describes as involving the unusual convergence of a number of serious, and mutually reinforcing, problems (or ‘storms’) that undermine our ability to behave ethically ( Gardiner 2011 : 77). The intersecting ‘storms’ in this instance include: (i) a serious global asymmetry of power whereby some (i.e. the more powerful) may take undue advantage of others; (ii) an intergenerational power imbalance whereby current generations may affect the prospects of future generations, but not vice versa; and (iii) the problem of theoretical inadequacy whereby conventional moral theories are simply ill-equipped to deal with the kinds of problems posed by long-term futures ( Gardiner 2011 ).
The nursing profession has the intellectual and emotional resources to ‘unpack’ the issues at stake and to develop a robust understanding of and a nursing-focused response to each of the three intersecting problems which Gardiner has described. Using an adaption of Garvey’s (2008 : 114–18) ‘criteria of moral adequacy’, the profession can begin by collectively examining and describing its:
historical responsibility (encompassing consideration of nurses’ individual and collective responsibilities locally and globally, to current and future generations, to other species and to the environment)
present capacities (including an honest analysis of the role of nurses and what is required in prudential and ethical terms for the sustainable delivery of essential nursing services)
sustainability (taken as implying ‘meeting the needs of the present without compromising the ability of future generations to meet their own needs’)
processes for procedural fairness (these must minimally be reasonable, open and transparent, inclusive, responsible and accountable).
Scoping the moral adequacy of the nursing profession’s response to the ethics of climate change will not only enable enlightened ethical reflection on the world’s current predicament, but will also assist nurses to identify what can and should be done in order to ensure the sustainability of essential nursing services, in both the immediate and the distant future.
In May 2009, the world awoke to the news that a ‘swine flu’ pandemic was possibly emerging. As the number of suspected and confirmed cases of the flu increased, so too did the levels of anxiety among governments and people as fears mounted that this could be the ‘ultra-scenario’ that pandemic influenza experts have been warning about for years ( McKibbin & Sidorenko 2006 ). Meanwhile, GPs and emergency departments were reportedly becoming swamped by people exhibiting flu-like symptoms. In some instances health services were stretched to capacity as health care professionals themselves had to be quarantined because either they or a close family member had come into contact with someone infected by the virus.
The recorded history of pandemic influenza dates back to the 5th century bc , with experts suggesting that there have probably been between three and ten human influenza pandemics since this time ( McKibbin & Sidorenko 2006 : 3). In the 20th century, virologically confirmed human pandemics of the disease were the Spanish H1N1 influenza pandemic (1918–19), the H2N2 Asian influenza (1957–58) and the H3N2 Hong Kong influenza pandemic (1968–69) ( McKibbin & Sidorenko 2006 : 4). A characteristic feature of all three pandemics was a shift in the age distribution of associated deaths; notably, the mortality rate tended to be higher among previously healthy young adults.
The Spanish influenza pandemic of 1918–19 (which killed more people than World War I) is regarded as being ‘the most deadly contagious calamity in human history’ ( Markel et al 2007 : iii). Reportedly over 500 million people (one-third of the world’s population) were infected, with an estimated 40–100 million people (3%–5% of the world’s population) dying from the virus – a rate that was 5–20 times higher than expected ( Johnson & Mueller 2002 ; Taubenberger & Morens 2006 ). To this day, the Spanish influenza pandemic stands as ‘an ominous warning to public health’ ( Taubenberger & Morens 2006 : 15), with experts cautioning that the big question is not if there will be another ‘ultra’ scenario pandemic (i.e. like the Spanish pandemic) but when . Warning of its inevitability, Taubenberger and Morens (2006 : 21) point out that:
Even with modern antiviral and antibacterial drugs, vaccines, and prevention knowledge, the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill > 100 million people worldwide. A pandemic virus with the (alleged) pathogenic potential of some recent H5N1 outbreaks could cause substantially more deaths.
Envisaging a range of possible scenarios (mild, moderate, severe and ultra), other experts warn that ‘even in a mild pandemic’ an estimated 1.4 million lives would be lost at a cost to the world’s economy and GDP of around 0.8% (or $US 330 billion); in the case of an ‘ultra’ scenario an estimated 142.2 million lives would be lost at a cost to the world’s economy and GDP of around $US 4.4 trillion ( McKibbin & Sidorenko 2006 : iii).
As it turned out, the emergence of swine flu epidemic did not become the ‘ultra’ pandemic scenario many feared it could become. Even so, it prompted a number of important questions: ‘ “What if” things had been worse?’, ‘What if swine flu had progressed rapidly to the “ultra-scenario” that experts have been warning about for years?’, ‘How prepared “really” are government agencies, the health care professions and the community at large for dealing not just with the practical aspects of managing a pandemic (e.g. keeping the infrastructure of society functioning), but also with the morally agonising choices that would have to be made?’ and, more importantly, ‘How prepared are individual countries and the world at large for dealing ethically with the consequences that are likely to arise from catastrophic disasters generally (whether of a natural, technological or human cause) and their implications for health care services?’
2018 marked the 100th anniversary of the Spanish influenza pandemic (circa 1918–19). This anniversary prompted experts in the field to reflect on how well prepared (if at all) the world is for the next influenza pandemic ( Belser & Tumpey 2018 ; Medina 2018 ; Zhang & Webster 2017 ). Of particular concern were the characteristic features of influenza pandemics – notably their capacity to emerge suddenly, unexpectedly and with little warning ( Belser & Tumpey 2018 ; Medina 2018 ), the capacity of the viruses responsible to ‘rapidly acquire mutations that evade our most recent vaccine formulations’ ( Belser & Tumpey 2018 : 255), and the inability of scientists to predict ‘if and when a particular viral subtype will acquire pandemic ability’ ( Zhang & Webster 2018 : 111). Scientists also reflected on the processes compounding the continuous and real threat of a new influenza pandemic emerging – namely: the growth in human population, the rapid development of megacities in the developing world, and the ‘unprecedented level of global trade and travel’ – all of which will enable the rapid and wide transmission of the disease ( Osterholm 2017 ). Global travel is a particularly worrying factor. For example, it has been estimated that there were more than 4 billion international travellers in 2017, with global air travel expected to double by 2036 ( www.travelpulse.com/news/airlines/global-air-passenger-traffic-soared-in-2017.html ).
In addition to the above, scientists have reflected on the moral as well as the practical lessons learned from the recent outbreaks of other highly contagious and dangerous diseases such as those caused by the Ebola, Chikungunya and Zika viruses ( Gostin & Ayala 2017 ) and the risk of what Quick and Fryer (2018 : 57) have described as ‘the triple threat: bioterror, bio-error and Dr Frankenstein’, described below.
Bioterror, which involves the deliberate and malicious use of harmful microbial agents as a terrorist weapon, is defined by the US Centers for Disease Control and Prevention (CDC) as the use of biological agents (microbes or toxins) ‘as weapons to further personal or political agendas’ ( CDC 2017 ). The CDC (2017) further explains that acts of bioterrorism can ‘range from a single exposure directed at an individual by another individual to government-sponsored biological warfare resulting in mass casualties’. Bioterrorism is not a new phenomenon and has been used as a weapon of war throughout history, with one of the earliest recorded events dating back to ad 1155 ( Quick & Fryer 2018 : 60).
Bio-error refers to the mistakes and accidents that can and do occur even in the world’s highest-level biosafety laboratories, including research laboratories that hold repositories of highly dangerous and deadly organisms ( Quick & Fryer 2018 : 67). As these laboratories are not ‘fool proof’ and human beings are prone to error, mistakes can be made with catastrophic consequences to both individual and public health.
Finally, there are the risks associated with scientists playing ‘Dr Frankenstein’ (i.e. ‘playing God’), particularly those involved in genetic sequencing ( Quick & Fryer 2018 : 69). On this issue, Quick and Fryer (2018 : 71) ask: ‘What kind of research jumps over the line of acceptability?’ and conclude, ‘It’s a stop-and-think question, and an old one’ for which security checks may not be the answer.
Reflecting on the outbreaks of Ebola, Chikungunya, Zika and other diseases caused by these viruses, Gostin and Ayala (2017 : 3) provide the sobering reminder that while scientists ‘cannot tell us which epidemics will strike […] they can predict with assuredness that dangerous infectious disease threats will materialize, based on historical trends and currently circulating pathogens’. They go on to contend that ‘despite the certainty and magnitude of the threat, the global community has significantly underestimated and underinvested in avoidance of pandemic threats’ ( Gostin & Ayala 2018 : 3). There is scope to add that authorities have also significantly underestimated the ethical issues that will arise during pandemics and have underinvested in anticipating and developing a sound ethics framework for dealing with the quandaries that will inevitably emerge.
Antimicrobial resistance (AMR) is a broad term that refers to the ‘resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it’ ( WHO 2014e : 1). Resistant microorganisms include bacteria, fungi, viruses and parasites that are no longer susceptible to antimicrobial drugs, such as antibacterial drugs (e.g. antibiotics), antifungals, antivirals and antimalarials ( WHO 2014e , 2014f ). When people become infected with microorganisms resistant to antimicrobial drugs, they are unable to be treated with standard treatments since these will not be effective. Moreover, if infection persists, there is a risk of this spreading to others thereby exacerbating the incidence and impact of antimicrobial resistance.
Of particular global concern in the 21st century are drug-resistant bacteria that cause common infections. In recognition of this, the WHO Assistant Director-General, Health Security, provides the following stark warning:
A post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century. ( Fukuda 2014 : ix)
For over six decades, antibacterial drugs have been the front-line defence against infections – irrespective of where they were acquired. However, due to their widespread acceptance and (mis)use in humans and non-humans over the decades, their effectiveness has gradually declined. Commensurate with this decline has been the failure, since the 1980s, to discover any completely new classes of antibacterial drugs to which most common pathogens are susceptible ( WHO 2014e , 2014f ).
Today patients with infections caused by drug-resistant bacteria are already at an increased risk of ‘worse clinical outcomes and death, and consume more health care resources, than patients infected with the same bacteria not demonstrating the resistance pattern in question’ ( WHO 2014e : xii). An everyday example of this can be found in the high percentage of hospital-acquired infections caused by the highly resistant bacteria methicillin-resistant Staphylococcus aureus (or MRSA) or other multidrug-resistant Gram-negative bacteria ( WHO 2014e : 1). These bacteria are responsible for the global incidence of such common drug-resistant infections as urinary tract infections, pneumonia and bloodstream infections. Another increasingly worrying trend is the emergence of multidrug-resistant tuberculosis – both as a primary and as an opportunistic disease (e.g. in people whose immune system is already compromised, such as with HIV / AIDS, rendering them more susceptible to the disease). For example, WHO (2018d) reported that in 2016 there were approximately 600 000 new cases of multidrug-resistant tuberculosis (MDR-TB), with 117 countries worldwide reporting at least one case of extensively drug-resistant tuberculosis (XDRTB) at the end of 2015 ( Chan 2017 ; WHO 2016 ). Other ‘apocalyptic’ bacteria (first seen in India in 2009) are the carbapenem-resistant Enterobacteriaceae (or CRE), a group of gut bacteria (including the common microbe Escherichia coli ) that are resistant to carbapenems – the ‘antibiotics of last resort’ to treat severe community-acquired and hospital-acquired infections ( WHO 2014d : xi).
The WHO has designated AMR as a ‘political priority’ alongside climate change and air pollution ( Chan 2017 : 140). In 2016 the UN General Assembly held its ‘first high-level meeting on antimicrobial resistance and adopted a far-reaching political declaration’ aimed at mobilising a global effort to combat the problem ( Chan 2017 : 142). In addition, WHO has assumed a proactive role as a ‘guardian of public health’ regarding this issue. This role, as described by the WHO, involves ‘tracking rapidly evolving threats, quantifying the harm to health, and sounding the alarm’ ( Chan 2017 : 136). In keeping with this role, WHO also works ‘to raise political awareness and extend advice on the best protective strategies for safeguarding public health’, which often requires establishing collaboration with multiple non-health sectors ( Chan 2017 : 136).
The emergence and spread of drug-resistant bacteria and other microbial organisms has drawn attention to the ‘three Rs’ of public health emergencies referred to above. In particular, it raises profound moral questions about: rationing (of antibiotics and other antimicrobial drugs to those who ‘really’ need them and in whom they are most likely to be effective), restrictions (on people’s liberties / access – noting that, as in the case of influenza pandemics, ‘coercive social distancing’ may be necessary – i.e. isolating patients and contacts, closing schools, and closing some businesses in order to prevent the spread of cross-infection; third-party notifications may also be required ( MacKenzie 2009 ; Selgelid 2008 )), and responsibilities (e.g. health care professionals’ ‘duty to treat’ at the risk of acquiring occupational AMR infections; the ‘responsible’ prescription, administration and monitoring of antibiotics and other antimicrobial drugs; avoiding ‘medically futile’ treatment) ( Marcus et al 2001 ).
The problem of drug-resistant bacteria and other microbial organisms is now recognised as a major public health issue. Although not as acute as an influenza pandemic, the moral quandaries associated with this global problem are much the same. In recognition of this, the World Health Organisation (WHO), 2014e, World Health Organization (WHO), 2014f has called for concerted and coordinated action to help minimise the spread of drug-resistant antibiotics and to tackle generally microbial resistance. Of particular note is its call to ‘preserve the efficacy of existing drugs’ and ‘prescribing and dispensing antibiotics only when they are truly needed ’ ( WHO 2014e : 1).