Swine flu outbreaks and the ethics of being sick.

Like a lot of other people, I'm watching the swine flu outbreaks unfold with some interest. As they do, I can't help but think about the ethical dimensions of our interactions with other humans, since it's looking like any of us could become a vector of disease.

There are some fairly easy ethical calls here -- for example, if you're sick and can avoid spreading your germs, you should avoid spreading them. But there are some other questions whose answers are not as clear.

Stay in bed or seek medical care?

Currently public health officials in Mexico and the U.S. are scrambling to determine how many cases of swine flu there actually are. There are confirmed cases, there are suspected cases, and there are untracked cases.

One wonders how many of these untracked cases are in people who, like me, have been trained not to go to the doctor unless the flu symptoms are so bad that you're pretty sure an organ is about to fail. When your symptoms convince you that death might be imminent, arguably you may have a duty to yourself to seek help.

Of course, there are plenty of people who catch colds, and plenty of people who come down with "flu-like symptoms" but who have not been infected with an influenza virus. But it is also the case that people who are infected with an influenza virus show some variation in the severity and duration of their symptoms. Surely not everyone who actually has swine flu has such a severe case that medical intervention is necessary. (This is what seems to be true of many of the confirmed cases of swine flu in the U.S. from the past few months.)

Given the state of affairs in the U.S., there are other issues besides the severity of symptoms that may play into whether people who are feeling flu-ish get to the doctor or stay in bed. These include whether there is a health care provider nearby, whether one has health insurance that will cover a visit to the health care provider, and whether one has a good way to get to the health care provider (since driving yourself or taking the bus may not be an option if you feel like you're on death's door, and you may need to find someone who can get off from work to give you a ride).

Seeking medical help when you need it is a good thing to do, as far as recognizing your duties to yourself. It may also be a good thing from the point of view of helping the public health officials who are doing disease surveillance put together an accurate picture of the incidence and virulence of the disease. Presumably a more accurate picture will help public health officials, health care providers, and even everyday people make more sensible decisions about how to deal with flu outbreaks.

Is there then a cost (in terms of accurate information that others could use) if you decide to tough out your flu in your bed rather than to hie yourself to the doctor's office or emergency room? Or, if you can tough it out on your own, is the loss of the tracking information you could be contributing by interacting with health care providers outweighed by the fact that you're not tying up medical resources that might be needed by a flu sufferer whose symptoms are much worse than your own? (Also, if you seek medical care but could ride out your flu without it, how likely is it that you could end up spreading the flu, whether to health care providers or other patients in the waiting room -- who, perhaps, will end up with a more serious case than your own?)

If your health care provider does triage over the phone (e.g., with an "advice nurse"), it's easier to feel like you're making the best decision about whether to come in or batten down. Otherwise, you may have to do a medical and ethical gut-check while you are puking your guts out.

Isolate yourself or get help?

If you're feeling sick enough that you've taken to your bed (rather than pretending you're still well enough to go to work or school and spreading your germs around there), you are in a position where you can slow down the transmission of the virus by staying put until you're no longer contagious. However, what's keeping you from spreading germs outside the house may also keep you from being able to drag yourself out of bed to secure food (if you can keep it down), fluids, tissues, fever medicine, and a sensible place to vomit.

You may, in other words, need someone to help you stay nourished, hydrated, and cleaned up enough to survive your flu. But unless that help is coming from a robot, there's a chance that the one helping you might come down with the flu, too.

I'm of the view that it's OK to ask for help when we need it. Needing help sometimes is part of the human condition -- it's how we come into the world, and if we live long enough, it's how we're likely to go out. But I don't think we can necessarily demand that others provide help, especially in situations where that help might endanger their own health -- or the health of others who haven't consented to undertake the risk. Rendering help without spreading the flu might require isolating oneself.

So, for example, if I were terribly sick with the flu and I asked a neighbor to take care of me -- and if that neighbor had a small child or immuno-compromised housemate -- that neighbor would be within his or her rights to decline my request.

Now, maybe face-masks and alcohol wipes would reduce most of the risk of transmission. But if the people the potential aid-giver might spread the flu to would be at very serious risk if they got the flu, those duties might take precedence.

Other duties besides keeping your germs to yourself.

Part of the reason that people haul themselves out of bed when they're feeling poorly is that they feel the pressure of other commitments. Not all of these are selfish commitments (like not wanting to miss that concert or that flight home). Sometimes you try to suck it up rather than convalescing because you promised to lead the review session, to drive the carpool, to throw the birthday party, to make dinner.

Maybe if you can manage to make good on these promises you're not so sick that spreading what you have will be a big deal. However, maybe it will. Your germs plus someone else's immune system might make for a much worse version of what you have. And in the big picture, does being better prepared for that final exam outweigh spending a few days hospitalized?

It probably depends on each person's interests and priorities. But we hardly ever have an explicit conversation about how our priorities (with regard to health and exams) mesh with those of the others with whom we interact. Once the germs have the potential to transmit something worse than a lingering head cold, I think we need to at least imagine having those conversations, rather than assuming that our own risk assessment will work for everyone in coughing range of us.

Now, I'm going to wash my hands and hope that these musings remain blissfully academic for all of you. Please take care of yourselves.

* * * * *

Just before posting, I got word from PalMD of recent words of advice from the Interim Director of the Centers for Disease Control and Prevention:

IF YOUâ²RE SICK, AND IF YOU HAVE A FEVER AND YOUâ²RE SICK OR YOUR CHILDREN ARE SICK, DONâ²T GO TO WORK AND DONâ²T GO TO SCHOOL. THAT CAN HELP REDUCE THE LIKELIHOOD THAT YOU WILL SHARE THAT INFECTION, BUT ITâ²S ALSO TIME FOR PEOPLE TO BE THINKING ABOUT,

WHAT WOULD I DO IF MY CHILDâ²S SCHOOL WERE CLOSED?

WHAT WOULD I DO FOR CHILD CARE?

WOULD I BE ABLE TO WORK FROM HOME?

ITâ²S TIME TO THINK ABOUT THAT SO THAT YOUâ²RE READY IN THE EVENT THAT THERE WERE A CASE IN YOUR CHILDâ²S SCHOOL. ITâ²S TIME FOR BUSINESSES TO REVIEW THEIR PLANS AND THINK ABOUT WHAT WOULD I DO IF SOME OF MY WORKERS COULDNâ²T COME TO WORK? HOW WOULD MY BUSINESS FUNCTION? THINK ABOUT THAT.

THEREâ²S BEEN TREMENDOUS PLANNING THATâ²S BEEN GOING ON AROUND THE COUNTRY OVER THE PAST NUMBER OF YEARS. ITâ²S TIME FOR PEOPLE TO REVIEW THOSE PLANS AND THINK ABOUT WHAT THEY WOULD DO.

The theme here seems to be: we're in this germ-pool together! Since what we do as individuals is going to have impacts on other individuals, we might as well start thinking about this as a community-level challenge.

In some ways, that's really what ethics is about.