Geneva, Tuesday, 23:15
This is a work of fiction.
Any resemblance to actual events or to real persons, dead or alive is, naturally, strictly coincidental.
17
Geneva
Tuesday, 23:15
“We should be guided by three basic principles when distributing the existing resources: efficiency, equity and accountability,” said the man sitting with his back to the door. He wore a Centres for Disease Control badge, and was one of three team leaders that the Director General entrusted with the delicate assignment of recommending operational plans for different pandemic scenarios.
The Director General’s face was expressionless, but he listened carefully. He sat in his large leather armchair, his back straight and his hands in his lap. Across from him, on a large sofa, sat Dr Wells. Next to him was an elegant, slender woman in her mid-thirties and another man, who hadn’t said a word since the consultation had started. On another chair, with his back to the door, sat the silver-haired man from the CDC. He did most of the talking.
“There are two main resources that may become scarce in the case of a pandemic,” he continued. “These are antiviral drugs and vaccines. For antivirals, we are of the opinion that people displaying symptoms should be given priority, even if those who aren’t showing any symptoms are at high risk.”
“Do you mean that doctors and nurses who are treating patients but not displaying symptoms will not be guaranteed access to antiviral drugs?” asked Dr Chi.
“It’s a hard one,” said the slender woman, brushing an invisible speck off her black skirt. “The problem may be determining who falls into what category, if certain groups are given priority over others. So really, it can be said that treating those who are ill or infected is the first priority for antiviral treatment. The second priority can be, for example, hospital staff.”
The man started talking again. “Of course, it may happen that we will not be able to treat all those who are ill. Then, we’ll have to further prioritize treatment. This is where the Fair Innings Principle comes into play as the solution that our team is suggesting.”
“There are many ethical and logistical problems with this Fair Innings idea. How can you suggest denying treatment from patients based on their age alone?” asked the woman.
“If you want to be really fair, the only solution is a lottery,” said the CDC man.
Everyone in the room fell silent. They looked at each other, too troubled to speak.
“You mean, a lottery to determine who has the right to be treated?”
It was Director General Chi who dared ask the question.
“It sounds outrageous, I know,” said the man. “But to be honest, this is the fairest solution. Especially if there is objection to the Fair Innings Principle.”
“What about giving lower doses to more people in cases of antiviral shortage, as an emergency solution?” asked Dr Wells. He was wearing the same suit for the fourth day in a row, and it now looked as if it urgently needed dry-cleaning.
“The problem is that it could lead to developing drug resistance, which would put us in even greater danger,” said the man.
“But it could buy us more time,” said Dr Wells. “What about vaccines, assuming we can actually isolate the strain of the virus and produce a vaccine in time? Who do you suggest should be vaccinated first?” he added, looking at both the CDC man and the woman sitting by his side.
“Our team thinks it would be unfair to completely exclude people who are at low risk, and to vaccinate only those at high risk,” said the slender woman. She looked at her palms, and sighed. “There is no simple solution, as you can imagine. We’ve spent the last three days weighing and considering all the ethical and legal aspects of the problem. There is nothing in international law that provides for a situation like this. There are only our moral and ethical considerations. The burden of these decisions is very heavy.”
“If I understand correctly, for vaccines, the Fair Innings Principle will justify vaccinating children and young adults. But they are not necessarily the ones at the highest risk of dying from an infection,” said Dr Wells.
“You are absolutely right,” said the CDC man. “As I said, there is no easy solution.”
“What does the Swiss National Advisory Commission on Ethics have to say about this?” asked the Director General.
The man in his mid-fifties, who was silent until now, opened his notebook. He looked at his notes, as if trying to decide whether to read from them or to speak without them. He decided on closing his notebook.
“Director General, distinguished colleagues. We think that all life is equal, whether young or old, rich or poor, female or male. The only two principles that guide us are minimizing the number of people infected, and saving as many lives as possible. We think that the first group that should get the vaccines is the one most likely to spread the infection.
These could be, for example, school children or those in contact with other large groups of population. The next group will be the one which becomes most endangered if they become infected, like the very young and the very old. The third group could be those who are maintaining public order. The remaining vaccines can be distributed among the rest of the population.”
“This is quite different from what our colleague from the CDC and his team have recommended,” said Dr Wells.
“It will be each country’s final decision how to act with its own population,” said the Director General. “But it is our job to draft the recommendations and guidelines.”
Everyone in the room was silent again.
“There is a big difference between the issue of vaccines and that of antiviral drugs,” said the silver-haired man from the Centres for Disease Control. “With vaccines, we would start from a position of scarcity, and as we produce more, there will be larger quantities available. With antivirals to treat the symptoms, it would be exactly the opposite. At the moment, there may be enough to treat everyone displaying symptoms. But if this turns into a true pandemic, there may be a shortage of antivirals. Of course, if the virus develops resistance to drugs, we will be in even bigger trouble, because we’ll have to develop different antiviral drugs.”
“Thank you for this clarification, Dr Stanley,” said the Director General. He took a deep breath and looked at the notes in front of him.
“May I conclude that there will be two different phases? The first would be where antivirals will be given to all those who need them, and vaccines will be given to the most vulnerable.”
Everyone around the room looked at each other.
“Is that acceptable to you?” asked Dr Chi, looking into the eyes of each person present. Everyone nodded.
“Good, now we are getting somewhere,” said Dr Wells. “We get dozens of calls from health centres around the world, asking for our position, our recommendations. We must provide some kind of guidelines, otherwise it may lead to chaos.”
“The second phase, if I understand correctly, will be where antivirals are distributed only to those whose life is most in danger,” said Director General Chi. Everyone nodded again.
“If it becomes impossible to treat all those whose life is in danger, then treatment will be given to those who have the highest chance of survival,” he continued.
“At this stage, if the chances are that certain patients will not survive even if they are treated with scarce antivirals, then they should not be administered antivirals,” said the Swiss Commission representative.
“This is a harsh recommendation, which will not stand legally,” said the woman in black.
“Even so, we may have to make it, if it comes down to it,” said Director General Chi.
“We strongly object to the Fair Innings Principle,” said the Swiss man. “We see it as unfair and unjustified. The ideal is to find certain priorities that will be acceptable even to those excluded from medical treatment. People with children may accept the Fair Innings Principle, because they may choose saving their children’s lives over saving themselves. But what about childless people? They are much less likely to agree to it.”
“We can’t talk about any kind of ‘fair’ system in a situation like this,” said Dr Wells. “It’s better to talk about the least unfair system.”
“What about private stockpiling of antiviral drugs?” asked the Director General. “Can it be rendered illegal?”
“I’m afraid not,” said the woman. “We can’t implement any form of punishment against those who stock up on drugs privately.”
“We have to conclude that those who can afford to do so probably will, and there is no way we can prevent them from stockpiling privately,” said the Director General.
“Except by making a prescription obligatory,” said Dr Wells.
“There will always be some kind of black market,” said the CDC representative.
“Lady and Gentlemen, it is nearly midnight,” said the Director General. “Let’s conclude this consultation for today. I believe we have initial guidelines for health institutions seeking our advice. Are you satisfied with this committee’s work for tonight, Dr Wells?”
“Yes, thank you everyone. Now the SHOC can be of more help to those calling in need of guidance.”
“The only point I am not comfortable with so far, from a legal point of view, is the Fair Innings idea,” said the woman, “and yet it comes up again and again.”
“We’ll have to find a way to deal with it, one way or another,” said Director General Chi. “I just hope that the virus will give us enough time.”
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