The race is on to find a treatment for coronavirus. This race is split between two approaches: the trialling of pre-existing drugs used for similar diseases, and the hunt for a vaccine. In both instances, important ethical decisions must be made. Is it OK to reassign a treatment that comes with side-effects? And with thousands dying from coronavirus every day, is it acceptable to cut corners in the search for a vaccine?
Last Friday, the World Health Organization announced the launch of Solidarity, a worldwide trial of the four most promising candidate treatments for Covid-19: remdesivir, an antiretroviral treatment for Ebola; chloroquine and hydroxychloroquine, both antimalarials; ritonavir, an HIV treatment; and interferon, a treatment for hepatitis C. Both Kaiser Permanente Washington Research Institute in Seattle and China’s Academy of Military Medical Sciences last week announced the start of human trials for new possible vaccines. Around 30 other research groups worldwide are working on vaccines.
But the WHO estimates that a vaccine won’t be ready until June 2021. There are requirements that have to be observed. The gold standard for this kind of research is the clinical trial – administering the vaccine to a large number of people in controlled conditions and measuring its effect. Usually scientists wait 14 months to monitor effectiveness and possible side-effects – which is why we may have to wait until next summer. Coronavirus vaccine trials face the following dilemma: we need treatment quickly but we also need to know it will work. The worst outcome for the medical industry would be a vaccine that either did not work or, worse, was harmful or had side-effects. Globally, faith in vaccines is already at an all-time low.
Decisions are taken by governments, in tandem with ethics committees. Every day they delay the development or introduction of an intervention found to be effective, a growing number will die. There have so far been 19,603 deaths, with 12% of those deaths occurring in a single day – yesterday (Tuesday 24 March). The economic devastation being wrought must also be considered – this will cost lives through depression, suicide and other effects of deprivation. In a pandemic, time is not only money. It is lives. Many lives.
Yet even promising possible treatments can prove to be ineffective or even harmful. Remdesivir, chloroquine, ritonavir and interferon all have serious side-effects, including heart arrhythmias and possibly death. Indeed, a man in Arizona died after ingesting chloroquine, believing it would protect him from Covid-19.
In terms of vaccine discovery, there are plenty of ways authorities could speed up the process. One is a human challenge study. This involves deliberately infecting a person with coronavirus to look at how the virus behaves and using that evidence to find the most promising vaccines. Today, healthy people are deliberately infected with flu, common cold, typhoid, malaria, dengue fever and streptococcal infections to study the disease, and more rapidly develop vaccines and treatments.
Challenge studies have been proposed in Covid-19. Hvivo, a clinical research group in London, has attracted more than 20,000 volunteers willing to be infected with a milder coronavirus that does not cause serious symptoms. They will each be paid £3,500. However, the utility of studying a related virus may be limited. There have been suggestions of challenge studies infecting younger participants at lower risk of complication with Covid-19. This comes with dangers and profound ethical implications – but could save thousands of lives. Another alternative would be to conscript low-risk people likely to be exposed to Covid-19 anyway to vaccine trials. A benefit of this would be to accrue a large sample group, so helping to indicate whether treatments could be rolled out to large populations. It is notable that China’s vaccine testing will occur within a military installation: the suggestion is that trials may be conducted on soldiers without consent.
This war will require lines to be drawn: what level of uncertainty to accept, whether research can be done on unconscious patients without consent, what level of risk is justifiable, and so on. Currently these decisions are usually made by ethics committees using guidelines developed for non-pandemic situations. We require leadership from the government to push ahead scientific research around all treatment options, while ensuring reasonable risks. In my opinion, a failure by government to support this research is as wrong as implementing harmful policy.
How quickly we develop a treatment or a cure will depend on the risks we are prepared to take. So far, western countries have given greater priority to liberty and rights than eastern countries in responding to coronavirus, leaving them less able to secure public health. It is now, most likely, too late to eliminate the virus with isolation and quarantine. Scientific research looks the most promising option for a resolution to this pandemic.
We need to run the race by the rules in order to sufficiently protect human participants. But there is a balance to be struck: let’s not run it with one hand tied behind our back.
• Julian Savulescu is chair of the Oxford Uehiro centre for practical ethics and director of the Oxford Martin programme on collective responsibility for infectious disease at the University of Oxford
