- Dena Hsin-Chen Hsin
China Medical College, Taiwan
91 Hsueh-Shin Road, Taichung 40421, Taiwan
& Doctoral Program in Life and Environmental Sciences, University of Tsukuba, Tsukuba Science City, 305-8572, Japan

E-mail: hschin@hotmail.com

Eubios Journal of Asian and International Bioethics 13 (2003), 107-8.

In late April, I came back from Tsukuba. At that time, people were quiet and calm as usual in Japan. You couldn't feel the threat of SARS. However; as soon as I arrived in Taipei airport; I felt a different atmosphere. First, I saw almost everyone had a mask; and people avoided speaking to each other. In front of the immigration counter, I took off my mask to let them check my passport photo. The immigration officer didn't ask any questions but only responded by eye contact. The next procedure was to have one's temperature checked at a counter. I was a little bit nervous for I was thinking what would happen to me if my temperature suddenly rose? Will I be isolated for several days that I couldn't rush back to my lovely sons and husband? I must have worried too much. My temperature was all right and I passed the luggage counter without a minute's delay. I noticed that people tried to avoid unnecessary physical contact. . Inside the bus, people were all wearing masks; and they were alert to any noise of coughing. I then put a tablet into my mouth to prevent my sensitive throat from making any cough response that I supposed might result in the critical gaze of other passengers. And I tried to make them realize that I came back from Japan, not Mainland China or Hong Kong. I did not expect that Taiwan would soon become an affected area itself, sooner than we could imagine.

Although SARS was reported to have a relatively low mortality rate, it attacks the young and healthy as well as the old and frail. Moreover, this is a totally new disease, we know very little about it. There are no adequate therapies and no adequate vaccines. Since the pathways of spreading are still unknown and under investigation; this has made control of the epidemic very difficult. Early diagnosis is essential to halt the spread of SARS; however, at the moment, clinical syndromes or laboratory evidence can't identify the cases precisely. People who have fever, who exhibit respiratory infections and who have contact with known cases are all regarded as important discriminators to diagnose potential SARS cases. If people were diagnosed to be suspect or probable cases, all the people around them may as well be suspected of having been contaminated by them. Consequently, the persons they have been in close contact with; for example, families, colleagues or schoolmates should be isolated ideally to avoid further possible spread of the disease. So much home isolation has caused serious influences and great losses. Nevertheless, nothing appears worse than the mass panic that may be triggered at any moment. In carrying out the responsibility of reporting the truth, the media has been urged to stop creating SARS panic.

In Taiwan, the epidemic situation has been getting worse since the end of April, up to now we have 499 suspected cases and 344 probably case followed with 40 victims.(as of May 19, 2003). The first case was a business man who traveled frequently to China; he then infected his wife and son. All of them were cured after respirator therapy in the National Taiwan hospital. However; another major event that has been verified was not so lucky. It happened in early April, a Hong Kong resident who came to Taiwan to visit his younger brother was supposed to be forced to be under home isolation in Hongkong due to the spread of the disease in his apartment building, Amoy Garden. Nevertheless, he travelled to Taiwan for the yearly ceremony of ancestors, going against the rules. His brother was infected by him and was the first fatality in Taiwan. One woman, who took the same train with him, was highly suspected to be the source of a major hospital outbreak. At first, the doctors weren't sensitive about her case since she had no contact history to match the susceptive criteria for SARS. Thus, she spread SARS in the hospital before she was diagnosed.

Many hospital staff, patients and patients' families were infected at the same time. The hospital was able to detect this spread and sealed its premises entirely without good preparation. Four thousand people were locked inside the building to prevent further spread of the disease; and more than thirty thousand people were isolated in their homes. This strong measure resulted in a mass panic. But it was too late. The numbers of infected cases increased exponentially. Nurses and doctors have also sacrificed their lives in taking care of SARS patients.

From those narratives reported by media, the mass panic caused by SARS has changed the relationships between people. In the sense that people in society have low spirit in considering others and doing good. To my worry, if not guided properly, it will be a huge barrier to achieve the value of human glory to help each other in this critical period of combating SARS.

Some Ethical Issues

I want to consider briefly some ethical issues as follows:

Label and Stigma

With the panic of being infected, people are very alert to the suspicious sources around. The certain relative objects were labeled to be the unwelcome group. For example; people working in the hospital or occasionally entering and coming back from China or Hong Kong, suspicious SARS patients and their family; or even those with very common syndromes of cold (cough, fever.....) are psychologically and socially isolated by their friends and relatives. In the early time of breakout, SARS fears sparked protest in some places of Taiwan. Viewing violent images through the TV screen left a huge impression to lots of people, and most people wondered how humans could be so selfish in neglecting others. We do not know how far this over reaction will go to harm the compassion among people. The distance caused by masks, and mutual suspicion could be a fatal point to weaken the collaboration of fighting SARS.

Humanity and Home Isolation

At the moment, with the limited awareness of the pathway of infection, personal isolation of the possible contact cases is though to be the only way to cut off the spread. However; with the stigma of SARS, people tend to hide the facts that might lead to them being recognized as a close contact with a SARS infected person. In the early stage, some people intentionally neglected the rules under the emotion of denying the possibility of SARS to themselves though they were forced under home isolation. It has resulted in many serious events. For example, one high school boy who was forced to have home isolation because his mother worked as a nurse in that hospital with outbreak SARS denied the possibility and kept on his course in extension classes secretly. People found that out only when he got fever and diagnosed as a probable case. It has resulted in further 400 students' home isolation. The boy's mother died of SARS recently; he alone was hospitalized to combat with the disease, in the mean time he has to suffer from self-guilt and public blame. It is quite cruel to a teenager, however the public are too strained to show any kindness to him. While we are thinking about the efficacy of home isolation, could we maintain a proper relationship of our society to avoid ruthless treatment like this when people made mistakes?

Professional Donation But Not Sacrifice

Universal precaution is the ideal procedure to prevent infection for the health profession. To face the unknown severe breakout like SARS, this is obviously not enough to guarantee the safety of frontline workers .Up to now, in Taiwan four nurses and two doctors have sacrificed their life in taking care of SARS patients. A doctor died from giving airway intubations to a terminal old woman even with the protection of masks and glove; he was so young to graduate from medical school a few months ago and got married only 4 months before. A nurse died with her 7 months fetus just because of a short contact with an undiagnosed SARS patient in the emergency room. Those scary stories are repeated and repeated, can medical ethics overcome their withdrawal of emotions? The selfless dedication of our frontline medical practitioners should be respected, nevertheless we should expect too much from them before the physical compartment can prevent the possible infection definitely.

Repel and discriminate against people from affected areas - a Global policy to stem SARS?

To have less ethical concern and isolationism is a practical self defense to stem the immigration of SARS from affected areas. The tourism, economic and academic activities among countries have all slowed down for the policy of "better safe than sorry" . The loss of profit is not now being considered as we expect the international collaboration will enhance in combating the crisis. Since SARS had potential to spread globally, it has become a major health threat all over the world. A global battle against SARS has just began; so do we think there is any reason to exclude any area or political object no to join the WHO to share the experience as well as to help each other during the SARS crisis? Taiwan desired assistance from WHO when the disease was first reported, but it was disappointed by political factors. If we may realize SARS has been affecting all of alike then each of use should be in the same boat of the global community to respect human life as well as to achieve the goal of health for all. The political status of Taiwan should not have been the major concern of WHO in delaying help.

From Victim to Criminal

To cope with the serious spread of SARS, China has announced tough penalties for "SARS crimes", people busting out of quarantine are given harsh prison sentences. Similarly in Taiwan, those who break this rule will be punished by imposing a fine. Those people were victims of SARS are now being accused of hindering the prevention or treatment of sudden disease outbreaks. IF there is no time to deliberate why quarantine has caused fears, and why people lose their patience and self-restraint, we should at least assume that those people were originally infected by others. And that they should be taken care better than being restricted to inflict harm on others. With the policy of respecting human nature, a lot of people will be motivated not just to protect themselves, but to contribute to the macro well-being of the society.

The Ethical Relationships with Animals and Using Animals As Food

Many experts believe that SARS, a novel coronavirus, probably came from an animal. One even speculated the germ might have come from some wild bird captured in Southern China. Some experts suspected because it didn't cause disease in the animal, but may have jumped to humans by chance contact or by mutation that allowed it to infect human tissues, such as lung tissue. The most likely way of getting infected from animals is by living in close contact with infected creatures or slaughtering or butchering them.

That information reminds us to face nature with humility. Human beings are but one of the species of nature, neither the center nor the master of the world. To maintain a proper relationship with other organisms (including animals) is essential to keep everything going round under natural law.