With Zika, ethical and medical questions- and few answers
On January 23, as the cleanup from Winter Storm Jonas began outside of my apartment on the Upper West Side of Manhattan, a patient posed a seemingly straightforward question to me: Should I cancel my upcoming trip to Florida? This woman was concerned about potentially contracting the Zika virus — a mosquito-borne illness known to cause fever, rash, joint paints, and, it appears, a devastating birth defect called microcephaly.
In theory, I was the right person to ask. I’m an infectious disease specialist at New York-Presbyterian Hospital and my research focuses on the ethical implications of medical decision-making. But this case was tricky because the patient was in her first trimester of pregnancy, and more importantly, she happened to be my wife.
‘Is it worth it?’ she asked, as she curled up next to me on the couch.
Like most doctors in the United States, my experience with the Zika virus is minimal. It occasionally gets discussed on rounds when we see an unexplained fever in a patient returning from the Caribbean, but that’s about it. In those cases — the ones not involving a pregnant woman — the stakes are relatively low. The symptoms, like body aches and bloodshot eyes, are annoying, but they don’t carry any long-lasting effects.
This latest Zika outbreak is uniquely terrifying because of the rapid spread of the virus — the World Health Organization said it has ‘explosive pandemic potential’ — and because of the imagery: every Google search leads to a picture of a concerned mother holding an infant with an uncomfortably tiny head. That’s the tell-tale sign of microcephaly, which can lead to seizures, developmental delay, and a shortened life expectancy. So what do we do about it? And how do we decide where to travel?
Zika is problematic from a public health perspective because it leads to something harmless or disastrous, and that presents a unique ethical quandary for doctors and patients. When does a potential exposure to a possible teratogen become unacceptable? What degree of diagnostic uncertainty are we comfortable with? Almost every day I’m asked about Zika and my level of concern seems to change with the news cycle. I’ve also found that my professional notions of risk and volition are viewed differently through the lens of fatherhood. In some ways, my travel advice to my wife felt like my first act as a parent to our unborn daughter.
The virus has spread through more than twenty countries in the Americas, where contraceptive access is often limited and abortion laws are some of the most restrictive in the world. Some countries in the region, like El Salvador, have chosen to err far on the side of caution, recommending that no one in the country get pregnant until 2018. (Good luck with that.) Others, like Brazil, Colombia, and Ecuador, have also urged women to avoid getting pregnant, but haven’t put forth a timetable for this unprecedented recommendation. Still others in the region, like Haiti and Martinique, have not provided any guidelines. This patchwork approach has led to confusion, especially as the virus migrates north.
The Centers for Disease Control and Prevention have issued a travel alert for pregnant women, suggesting they postpone travel to the areas where Zika virus transmission is ongoing. Unfortunately, the situation on the ground is changing so rapidly that it can be difficult to determine exactly where that is. Jamaica reported its first case on Saturday and many experts (myself included) believe it will spread throughout the United States over the next few months. (Dozens of Americans in eleven states and Washington, DC, have already contracted the virus.)
Adding to the confusion, Zika virus often causes minimal (or no) symptoms in infected patients. Pregnant mothers don’t need to have symptoms to transmit the virus to their foetus, and there’s no reliable test, treatment or vaccine to combat the disease. In short, we’re all playing a bit of a guessing game when we advise patients on travel, especially to places where the virus isn’t yet circulating.
Taking all of this into consideration, I found the fundamental principles of moral decision-making — things like autonomy, proportionality, and beneficence — to be confusing and unhelpful as I tried to answer my wife’s question. On one hand, it seemed unwise to travel anywhere. The risk of microcephaly for my unborn child was far too great to justify any avoidable trip. On the other hand, I don’t want to live my life in fear. I’ve looked at the data and read the recommendations. So why not follow the evidence? Zika isn’t circulating widely in Florida, so why not go?
Across the country, patients are being told to consult their doctor when they have questions about Zika. But as my wife (also a doctor) quickly discovered, physicians don’t entirely know what to recommend. The CDC has created an algorithm for testing pregnant women, who may have been exposed to the virus, but it’s exceedingly complicated and, more troublingly, it may lead to the detection of microcephaly outside of the window of possible pregnancy termination. You might learn of a birth defect when it’s too late to do anything about it.
One of the more intriguing ethical issues that hasn’t been discussed involves adoption, particularly for parents who are planning to adopt a child from a country now affected by the outbreak. Should they view their roles any differently? Or attempt to intervene on behalf of their foetus? A generation of unborn children are suddenly at risk, and the ripple effect will extend far beyond the borders of the affected nations.
After much deliberation, my wife and I decided to take the trip to Florida. She wore long-sleeves and tried to avoid mosquitos, and as we walked in the sun, it felt like the right decision. But after one of our walks, I received a text from an old friend — an obstetrician who specializes in fertility. She was writing to congratulate us on our pregnancy and told us to avoid unnecessary travel, especially to places like Florida.
On February 1, the World Health Organization declared the Zika outbreak a ‘public health emergency of international concern.’ The designation fast-tracks aid and research to tackle the virus and puts it in the same category of concern as the Ebola virus. It also gives WHO decisions the force of international law. But at this point, even with growing attention, we’re left with more questions about Zika than answers. I still don’t know if the trip to Florida was misguided.
At times, Zika can feel far away — especially if you live in a place where mosquitos are uncommon. But the ethical questions surrounding the outbreak touch us all. There is now a groundswell of support in the medical community to wipeout the species of mosquito that carries the Zika virus, and, potentially, to bring back DDT to do it. Is this the right move?
The foundation of modern bioethics mandates a duty to protect, and in this case, it’s unborn children who need our help. As this story continues to evolve, we must ask ourselves: Are we doing enough to protect them?
Matt McCarthy is an assistant professor of medicine at Cornell and a staff physician at Weill Cornell Medical Center. He is the author of the memoir "The Real Doctor Will See You Shortly."