Keywords

Public Health Ethics Issue

Ethicists like Rita Charon have popularized fictional narrative as a teaching tool that offers a unique approach to exploring ethical considerations (2002). For ethical issues in public health, novels about devastating epidemics which threaten all or part of humanity exemplify the power of storytelling. By allowing readers to learn from and identify with fictional characters, such stories can help readers play out how they would respond in a real-life situation. The two best-selling novels discussed below illustrate how a good story and a coherent plot can explore difficult ethical choices that arise during an outbreak or epidemic. Steven King’s The Stand, published in 1978 and Michael Crichton’s The Andromeda Strain, published in 1969, examine the impact of life-devastating microbial outbreaks introduced as the result of government activities. The Stand portrays an outbreak that impacts the lives of all Americans, while The Andromeda Strain focuses on just the two remaining residents of a small town in Arizona. By dramatizing the difficult ethical choices which an outbreak forces upon us, both novels compel the moral imagination of readers to respond.

Mortimer (2003, 447) has argued that an outbreak, like a story, needs a coherent plot in order to ascribe meaning to a random event that creates chaos within peoples’ lives. By imposing order upon the unordered, the creation of a narrative allows individuals or communities to cope with uncertainty and loss of control. Similarly, in the wake of disasters that devastate electrical power and transportation infrastructure, public health officials attempt to restore order in practical ways. Public health officials must address mass injuries and death, inadequate food and water supplies, loss of homes, disease outbreaks, and other urgent matters. Gathering useful information about a disaster to create “situational awareness” must be a priority in managing a public health crisis. Sharing this information is both a challenge and a necessity, analogous to the structural coherence a story needs to be successful. Disseminating information can calm a community threatening to unravel under extreme duress. Chaos can only be avoided, however, if citizens trust their government is working on their behalf. Transparency, trust and effective information dissemination—key components of emergency response—lay the groundwork for a coherent strategy that can keep panic at bay.

An effective way to calm the public and build trust is to establish collaborations that focus on ways to mitigate harm. Awareness that experts are working together to solve problems, both anticipated and unanticipated, can reduce panic. Sharing information and building collaborations are mutually reinforcing. Ensuring that collaborations and effective networks are in place to resolve problems can in turn encourage the collection and dissemination of appropriate information. King and Crichton highlight the importance of sharing information and building public trust, especially as the governments in their respective novels directly or indirectly have precipitated the outbreaks.

Background Information

Making key decisions depends on timely and relevant information, which is why its absence cripples decision-making. However, collecting and disseminating such information during emergencies raises several challenges, both logistical and ethical.

Disasters can destroy critical communication infrastructure yet demand a coordinated response from entities unused to communicating with each other while posing a serious logistical challenge for emergency response. The non-hierarchical character of the U.S. public health system only magnifies the challenge. Our decentralized public health system comprises a loosely organized network of about 3000 local, state and federal health agencies (Hearne 2007, 185). Accurately communicating information not only among these U.S. health agencies, but also to millions of American citizens, poses a daunting challenge during a response.

Especially daunting, although rare, are those scenarios where governments or their citizens intentionally create and expose residents to deadly microbes. While the viruses created in these two novels involve fictional events, there are only a handful of times where governments or individuals have deliberately exposed the public to a virus. These include the Sverdlosk anthrax exposure in 1970s Russia, the Raneeshee cult salmonella incident in Oregon in the 1980s and the U.S. anthrax exposure immediately after 9/11 where a few politicians and members of the media were exposed.

Collecting and disseminating public health surveillance information, while necessary during a response, raises ethical concerns. Continued surveillance reveals the extent of an epidemic and whether interventions have been effective. However, the process of screening and testing for a disease, as well as collecting and disseminating this information, poses risks to vulnerable individuals. Living in countries that lack discrimination protection could expose individuals to psychological trauma and economic harms such as loss of employment, insurance, and housing (Gostin and Berkman 2007, 82). The COVID-19 pandemic has raised issues such as the inappropriate use of contact tracing apps for purposes such as the gathering and storage of personal data not needed for health purposes (Xafis et al. 2020, 74–5).

Public health officials have an obligation to “inform and educate the public about health issues and functions” (American Public Health Association2019, 16). However, inadequate or inaccurate dissemination of information by the media or other sources during a disaster raises distributive justice concerns. Those with few resources have less reliable access to sources of credible information and therefore lack of credible information has the greatest potential to harm them (Gostin and Powers, 2006, 1058). Historical data confirm that poorer countries fare far worse in pandemics (Faden 2007, 178). To address these justice concerns, health officials, other governmental representatives, and the media need to distribute accurate information in ways that can reach even the most disadvantaged communities.

One important set of decisions during an emergency response involves resource allocation. These decisions raise important justice considerations relating to how to best balance utility and equity. Public health officials may—at times--need to allocate resources based on equity and not equality; that is, it may be necessary to provide a greater share of resources to those especially vulnerable. Doing so, however, may not result in the greatest utility in terms of efficient use of limited resources. To be effective and sustainable, health interventions for marginalized groups facing health inequities must address the root causes of the inequities. This will often necessitate that systemic change be put in place prior to an emergency, such as law reform or drastic changes in economic or social relationships (World Health Organization2016; Xafis et al. 2020). In an era of global interdependence, trade, and travel, illnesses and epidemics can spread much more quickly than in the past. Health officials in each country may need to exercise their authority to limit the freedom to travel or to import products that pose health risks. Success in imposing restrictive measures depends on a community that trusts its public health officials, but trust does not develop overnight. Transparency helps to build trust, but transparency mandates that decisions be made openly and communicated to everyone impacted by a decision, that is, the stakeholders. Ensuring that stakeholders generally have a voice in decision-making will enhance the probability of compliance with short-term limits on freedoms. However, emergency response often requires expedited decisions without immediate stakeholder engagement. To build trust, then, public health officials must engage stakeholders in preparations well before an emergency event takes place.

International bioethics mandates a culturally sensitive approach. For instance, individual autonomy must often cede to the welfare of the community (Battin et al. 2009, 8–9). Practitioners from Western countries that prioritize individual rights may face challenges when working in locales where a communitarian approach is more common. These practitioners need to be prepared to place the importance of community health and welfare above individual autonomy and beneficence. It is worth adding that imposing liberty-limiting measures also invokes the primacy of the community when the exercise of individual freedom could harm the public during an emergency. However, imposing liberty limiting measures in a society that privileges liberty will be more difficult. Nevertheless, the larger point is that emergency situations underscore the need for public health officials to collaborate with communities and focus on their welfare.

Approach to the Narrative

This section contains brief excerpts from The Andromeda Strain and The Stand that deal with information collection and sharing and with collaboration. I used the 1993 version of The Andromeda Strain since it was readily available. I used the 1990 complete and uncut edition of The Stand since it is King’s preferred version of the novel and contains material that was removed from the original 1978 novel. These excerpts illustrate the importance of these activities to the ethical practice of public health, especially during emergency events. Both novels address the role of information in public health decision-making and how teamwork and collaboration can better inform the decision-making process. Although fictional, these stories nevertheless raise many issues that likely would arise in real-world scenarios. I will explore how the two novels demonstrate the need for appropriate information and for collaboration, how each author addresses ethical issues, and how these issues are, or are not, resolved.

Narrative

Need for the Collection and Sharing of Appropriate Information

First, consider the need to base public health programs on appropriate information. Characters in both novels operate in a constant environment of fear. Information is a tool, perhaps the best tool available, to control fear. Public health officials use scientific information to determine which intervention is best to combat the public health crisis. Is contact tracing appropriate? Should quarantine be considered? Should travel restrictions be imposed? While there may not be enough information for public health officials, scientists and others to make informed decisions, especially early in a pandemic, they often must act, even with inadequate information. In Michael Crichton’s 1969 novel, The Andromeda Strain, a military satellite returns to the United States and lands near a small town in Arizona. When military officers attempt to retrieve it, they find that virtually all residents of the small town have died. The town members appear to have been struck down immediately as radios and televisions are still turned on and appliances are still running. Only an elderly alcoholic man and an infant are left alive. They are taken by government scientists along with the satellite to a remote research facility in an attempt to find out why these two have survived and to investigate bacteria found on the satellite. The town is cordoned off. Scientists have a limited amount of time to save these two survivors and determine how to destroy the bacteria which appears to be the source of the epidemic. Since virtually the entire town’s population has died, the operation is aptly called Wildfire, after a fire which burns out of control and threatens to destroy everything in its path. The scientists do not yet realize, however, that the population of the planet may be in jeopardy in just days. Only the judicious exercise of scientific knowledge will prevent Wildfire from destroying more lives.

A character in The Andromeda Strain alludes to scientific errors that follow The Rule of 48, which states simply: “All Scientists are Blind” (Crichton1993, 125). The name of the rule refers to scientists who routinely accepted that humans possessed 48, not 46 chromosomes, despite over a decade of evidence to the contrary. Scientists, then, can collectively ignore clear evidence staring them in the face. The Wildfire team was aware that the bacteria were both mutating and reproducing at a rapid rate, but somehow the evidence did not register with them. If the team had been more attentive to the evidence and considered why these two extraordinary characteristics of the bacteria were occurring, the solution might have been revealed days earlier. “[S]pace could affect reproduction and growth. And yet no one in Wildfire paid attention to this fact, until it was too late” (Crichton1993, 128). As it turns out, the version of the bacteria mutated by the satellite trip to space will endanger virtually every human on earth.

Later in the novel, even certain biological assumptions are called into question, including the definition of life (Crichton1993, 194). One scientist recalls a famous seminar where a well-known researcher persuaded others present that a black cloth, a watch and a piece of granite all met the definition of life (Crichton1993, 195–6). He makes such compelling arguments that each of the three inanimate objects are, in fact, alive that audience members reluctantly conclude that he may be correct. Similarly, in order to resolve the conundrum presented by the bacteria from space, the researchers will need to think in new and original ways to solve the very complex problem confronting them. Leavitt, one of the key scientists on the Wildfire team, recalls this lesson and endeavors to remain flexible in his approach to the problem and not jump to conventional conclusions despite the fact that two lives and ultimately—millions—depend on a swift resolution to the problem. And yet, errors are inevitable on any path to discovery when, “despite the individual brilliance of team members, the group grossly misjudged their information at several points” (Crichton1993, 237). Their errors, in retrospect, were inevitable, according to the scientists in the novel. “What they did not anticipate was the magnitude, the staggering dimensions of their error. They did not expect that their ultimate error would be a compound of a dozen small clues that were missed, a handful of crucial facts that were dismissed” (Crichton1993, 237). The scientists created a chain of causal inferences; reasoning correctly but from false premises, the errors cascading as they added new false premises. Unfortunately, the correct premises, the crucial facts upon which sound reasoning must rely, are often overlooked, appearing crucial only in retrospect.

The emphasis in The Stand is on the information—or lack thereof—available to community members, not scientists and researchers. In Steven King’s 1990 novel, the survivors gather into one of two camps, those who dream of MotherAbagail (the good) and those following Randall Flagg (the evil). In this dystopian future, survivors soon find themselves drawn to one of the two leaders. While the camps of both Flagg and MotherAbagail offer little order, at least at the beginning, those drawn to the prior world of law and order are at home with MotherAbagail, while the false promise of technology—the source of the virus—appeals to the follows of Flagg. Only a few characters waver; most know where they belong.

King imagines that not only this virulent strain of influenza, but also human greed and suspicion, would likely undermine the cooperation survivors need in order to survive. Even some characters who survived the deadly flu cannot survive their neighbor’s selfishness. While there are many characters, the novel focuses on three. Fran is a young woman who is pregnant. Stu is her new partner and fellow survivor who becomes the reluctant leader of the new community drawn to MotherAbagail. Finally, there is Harold, who loves Fran, but ends up joining the camp of Randall Flagg when Fran chooses Stu for her partner.

An early passage in The Stand dramatically foreshadows the possibility of citizens seizing control of a radio station or newspaper in an effort to learn the truth or distribute the limited information they have available (King1990, 214–30). As governmentofficials have been withholding information, most Americans never learn about the cause of the outbreak or its impact as it spread throughout the country. Often, they first encounter the pandemic through the death of immediate family members. It should not be surprising, then, that survivors distrust the U.S. government and turn to each other in order to survive. All efforts to obtain information end badly, as the government shuts down media outlets and kills those trying to ascertain the truth and distribute information. Even the President of the United States shares blatant lies in a misguided attempt to calm the American public (King1990, 229). Without access to knowledge and information, the remaining survivors face a vacuum of fear and uncertainty.

After learning that Stu appears to be immune to the virus, government officials involuntarily hold him at a research facility in Vermont to take blood samples to use for development of a possible vaccine. During this time, information is withheld from him, both about the work being done at the lab and the spread of the pandemic. With nearly everyone at the facility dead, Stu must kill an official in self-defense to enable his own escape. His experience there echoes the prevailing sentiment that, with no help coming, individuals must save themselves. After his escape, Stu tells his friends that reliance on traditional social institutions is no longer an option. In the following passage, Stu shares with his friends his uncertainty about the future, while the reader learns that all the traditional social structures that we have taken for granted no longer exist. Imagine a world where science, medicine, journalism, education and everything we depend on are gone.

  • Assume that the age of rationalism has passed. I myself am almost positive it has. It’s come and gone before, you know; it almost left us in the 1960s, the so-called Age of Aquarius, and it took a damn near permanent vacation during the Middle Ages. And suppose…suppose that when rationalism does go, it’s as if a bright dazzle has gone for a while and we could see…” He trailed off, his eyes looking inward.

  • “See what?” Fran asked.

  • He raised his eyes to hers; they were gray and strange, seeming to glow with their own inner light.

  • “Dark magic,” he said softly (King1990, 742).

When rational explanations fail to comfort survivors, then magic, even the appeal of black magic—or evil—offer some appeal. Randall Flagg offers empty promises, tempting each character by offering what each needs to be happy in this new and irrational world. Those who remain with MotherAbagail are realistic enough to know that their new world requires that they depend on each other to face the many challenges ahead.

Both novels raise similar issues regarding the need to base public health responses on appropriate information. The media, including social media, play a significant role in distributing information. Today, even though Americans have access to more information, that information may not be of high quality. Similarly, though it has become easier to verify information by checking reliable news sources, many people cannot determine which sources are reliable (Rampersad and Althiyabi 2020). As a result, finding appropriate information today is harder than it should be. Deliberately sowing misinformation exacerbates these difficulties and can eventually undermine confidence in the media. History teaches us that when governments hide information, it almost always harms public health efforts and contributes to the spread of disease (Markel 2007, 50). Moreover, lack of transparency and giving out misinformation destroys trust, which undermines the willingness of the public to share critical but sensitive information with all levels of government.

Developing and using good communication systems is vital in multiple ways. They are essential for transparency both at the bottom and at the top of the chain of command (Battin et al. 2009, 325). A government-initiated public health program will be less effective if it withholds information or is perceived to be sharing inaccurate or dubious information. Conversely, citizens more consistently comply with instructions when they understand their purpose. If vital information is unavailable, citizens drift along without guidance or direction and become prey to their emotions. As Reynolds has noted, the importance of consistent, timely and meaningful messages issued after a public health emergency cannot be underestimated. Exhibiting both competence and empathy—while emphasizing the likelihood that our knowledge about the health issue and instructions for the public are likely to change as public health officials and physicians learn more about the illness—is crucial to the success of policies developed by governmentofficials’ (Reynolds 2005, 48–51).

In The Stand, crucial information is generally unavailable. Virtually everyone with key information about the outbreak has died; survivors must attempt to figure out the new world order on their own. Applying guesswork to the limited information available, they sometimes succeed and sometimes do not. Early in the novel, soldiers acting on government orders kill anyone attempting to provide information on the pretext that the information would incite panic. In The Andromeda Strain, the government deliberately withholds information until they can subdue the bacteria. This short-term gambit works without any backlash, since the scientists are able to subdue the bacteria. One can speculate, however, about potential long-term consequences of this lack of transparency and the damage to the trust in scientists it would have caused had their efforts failed and the incident became public.

The Need for Collaboration

The second public health issue addressed by both novels is that of the need to establish collaborations to build trust. The Andromeda Strain illustrates the point that working together to solve a common problem does not require everyone to like each other. Early in Crichton’s novel, we learn that “Manchek disliked Jaggers, who was effete and precious. But Manchek knew that Jaggers was good, and tonight he needed a good man” (Crichton1993, 16). Competence would prove crucial in order to achieve the common goal of defeating the bacteria before it overwhelms the planet. Whether the task requires technical knowledge or a social skill such as communication, the team must first trust that each team member is competent to complete the assigned task. Trusting each other will lead to a more effective collaboration.

In The Stand, the stress of the new world order causes the lives of the non-scientists to become complicated. The characters experience the emotional toll of “the tremendous, walloping psychological shock of the empty countryside” (King1990, 417). They all need to share their experiences (“They had stories to tell. All the stories were the same. Their friends and relatives were dead or dying.”) (King1990, 232). Unsurprisingly, they all entertain fears about the uncertain future (“…some leader or leaders who will start the whole thing again. Maybe a fear of technology in general.”) (King1990, 347).

In a thought-provoking exchange, Stu muses that Randall Flagg, who is drawing the evil survivors to his camp in Las Vegas, will probably collect most of the “techies,” since they are attracted to discipline and linear goals. The two new competing versions of society offered by MotherAbagail and Randall Flagg offer visions of a world which embraces different values. Flagg and his followers are choosing technology and science, ironically the source of the virus. MotherAbagail is choosing to create a democratic society that is necessarily messy and awkward at its inception. Flagg headquarters in Las Vegas, governing there with an authoritarian harshness that appeals to some, especially those seeking structure. To Harold, stung by Fran’s rejection, the dark order of Flagg and Las Vegas induces him to leave MotherAbagail and her followers. “The malignancy drew him in. It was a dark carnival—Ferris wheels with their lights out revolving over a black landscape, a never-ending sideshow filled with freaks like himself, and in the main tent the lions ate the spectators. What called to him was this discordant music of chaos” (King1990, p. 683).

Successful collaboration demands those with multiple skills be welcomed, whether the skills be technological or not. The need for different competencies may vary depending on the nature of the crisis, during which public health officials will need to tap a wide array of individuals. In The Stand, this is reflected by the need, at different times, for manual labor skills, high-tech skills and other specific competencies. At other times, those with high levels of ability in multiple areas may be needed.

In both novels, government’s role in the epidemic has made collaborations more challenging. In The Andromeda Strain, the U.S. government failed to protect Americans living in a small Arizona town from the bacteria collected on its satellite, ultimately causing the death of most of the town residents. In The Stand, the U.S. government’s experimentation with flu as a bioterrorism tool has accidentally made its way to the public. In the event of such a devastating accident, public official must be prepared to face a suspicious and wary public. As Harold tells Fran:

My dear child…sorry, Fran. Fran, it was the people in authority who did this…Your somebody in authority got a bunch of bacteriologists, virologists, and epidemiologists together in some government installation to see how many funny bugs they could dream up. Bacteria. Viruses. Germ plasm, for all I know. And one day some well-paid toady said, ‘Look what I made. It kills almost everybody. Isn’t it great?’ And they gave him a medal, and a pay-raise, and a time-sharing condo, and then somebody spilled it (King1990, 252).

This passage raises the issue of the obligations of scientists to the broader community and possibly future generations. Harold here also notes that science had an obligation to take action to protect the public from the harmful effects of an inadvertent release. Likewise, in The Andromeda Strain the fate of the world literally hangs in the balance due to research error. Both novels can be viewed as cautionary tales, offers a warning to the scientific community that they have an obligation to protect current and future generations from potential harms caused by their research.

Priscilla Wald, writing about outbreaks, points out that epidemics dramatize the need for regulation (Wald2008, 17). For instance, the increase of limb deformities among pregnant women who were prescribed thalidomide to prevent morning sickness in Canada, Europe and Africa, resulted in the United States passing the 1962 Kefauver Harris Amendment and the Food and Drug Act to strengthen the regulatory environment for new drugs (Rieder and Hawcutt 2016, 1308). Similarly, foodborne outbreaks have resulted in tightened agricultural regulations. Collaborations among individuals and organizations help to achieve the goal of regulation as a tool to address the source of the epidemic. In fact, national responses to epidemics and public health crises have helped define our modern understanding of not only public health but also the notion of a population itself. (Wald2008, 17–18, citing Rosen 2015). The two are interrelated; that is, a nation cannot develop its public health response without first understanding the population for whom the response is being readied. Wald even references the first chapter of The Stand, commenting that the spread of the virus through the most casual person to person contact, which will ultimately end the world as it currently exists, represents “the protagonists’ common humanity through their common susceptibility” (Wald2008, 54). Viruses and bacteria draw humanity together paradoxically by not respecting our borders. “Rats hop ships and spread the plague, mosquitoes stow away on airplanes or infest new regions as the climate warms, and birds migrate around the globe. Infections that emerge in one corner of the earth may cause deaths far away” (Battin et al. 2009, 38). Ironically, humanity might best address vectors and their disrespect for our borders and divisions, when nations and different sectors collaborate to fight them.

Collaboration is not mere massing. The establishment of a broad consortium of individuals involved in decision-making will ensure that diverse points of views and differing values are shared and heard. As global stakeholders, it is crucial that the views of representatives from all populations likely to be impacted by decisions are heard and respected. A more diverse array of potential solutions on the table increases the chance that decision makers will be able to avail themselves of an effective solution.

In summary, basing programs on appropriate information and establishing collaborations to build trust, are essential to any public health response to an epidemic. These twin efforts will ensure that all stakeholders will be heard and respected. Improving the health of a community is a broad and challenging goal that, just like a novel with a complex plot, has a compelling story at its heart, which can be a potent teaching tool.

Questions for Discussion

  1. 1.

    In The Stand, 99% of the population has already perished and the government does not want the remaining survivors to panic. Does this circumstance justify withholding information from the public? Why or why not? If not, would any circumstance justify withholding information from the public? What value or concern might outweigh transparency?

  2. 2.

    Are there any circumstances where it is justifiable for the government not to seek input from stakeholders before making a decision that impacts them? If not, why not? If yes, describe the circumstances and indicate what justifies the decision to not seek input.

  3. 3.

    In The Stand, Stu says “techies” would be drawn to those working to oppose public health officials attempting to restore order in the event of a life-changing public health crisis. Whether Stu’s view characterizes or caricatures techies, it suggests an opposition between the public and experts. Today, there is a growing lack of trust in expertise. Are there steps that public health officials can take now to counter the loss of trust in expertise?

  4. 4.

    In times of international crises, collaboration is essential, yet different countries will make different assumptions about values and concerns to prioritize. What measures can countries take in order to effectively collaborate during crises given these differences?

  5. 5.

    In both novels, the U.S. government bears some or all of the responsibility for the illness that killed many people. If this were to happen in a non-fiction setting, what obligation does the government have to address the harms they have caused during and after a public health crisis? If yes, how should this obligation be fulfilled?

  6. 6.

    Do these novels provide any lessons for responding to current or future public health emergencies, such as the COVID-19 pandemic?