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Was it ethical for missionaries to be treated for Ebola before the Liberians they were serving?

Players of the ''L'Etoile de Guinee'' football team poses with a sign reading ''Stop to the ebola epidemic'' prior to a football tournament gathering youth from Guinea near the Koumassi sports center in Abidjan on August 10, 2014.
Players of the ''L'Etoile de Guinee'' football team poses with a sign reading ''Stop to the ebola epidemic'' prior to a football tournament gathering youth from Guinea near the Koumassi sports center in Abidjan on August 10, 2014.
(Sia Kambou/AFP/Getty)

As my colleague Julia Belluz pointed out, the recent Ebola outbreak in Africa has forced the global medical community to face thorny ethical questions. Doctors have had to grapple with what it means to give patients experimental treatments, and who should get priority.

But there's a separate ethical conundrum facing religious scholars: what does it mean for two Christian missionaries to receive treatment that the people they traveled to Africa to serve couldn't access?

The Americans who received treatment were not tourists on vacation; they were Christian mission workers charged with the responsibility of carrying out the Christian mandate to serve the unserved, the have-nots, and the physically ill. They were missionaries with the Christian organization SIM USA. Though not affiliated with one particular branch of Christianity, SIM affirms that each of its missionaries is "committed to the essential truths of biblical Christianity." (Here is a link from their website where they explain what they mean by that.) SIM also affirms its first commitment to "Respond to Need" of all kinds, wherever they find it:

Our goal is to meet people's physical needs as we also share how Jesus can meet their spiritual needs. Help and relief come in many forms. Whatever the need, we are compelled to respond with the love of Jesus.

When seen in this light, then, the ethical conundrum raised by the Ebola outbreak is this: Does receiving treatment that could potentially be used for another Ebola patient somehow come into conflict with the missionaries' religious commitment to serving those patients? If Jesus commanded his followers to put the needs of others before their own — "whoever would be great among you must be your servant" — then should the missionaries have turned down the treatment?

Of course, the problem with framing the question this way is that it presumes that the Americans were the ones deciding who the drugs would go to. They weren't. The FDA made that decision — the Americans only agreed to it. But what if the Americans had turned down the treatment?

"It isn't clear to me that if the Americans refused the drugs that they would then go instead to the people who they were serving," says Charles C. Camosy, associate professor of christian ethics at Fordham University. In other words, he said in an email, at the time the missionaries agreed to treatment, the choice seemed to be either (1) the missionaries get the drug, or (2) no one does. "I can understand why someone would be hesitant, but my instinct would be to say that it is not wrong for [the missionaries] to choose (1) over (2)."

According to Celia B. Fisher, another bioethicist at Fordham, the fact that the Ebola epidemic is affecting many people changes the moral question significantly. The question, then, isn't "whether or not a missionary has a moral obligation to prioritize one other person's health over his own," but rather "which choice has the greater possibility of preventing the spread of disease across many people."

If a missionary's goal is curing Ebola in every infected patient, then yes, taking one of the available treatments might be at odds with that goal. But if, however, she is concerned with decreasing the overall length or force of the epidemic, then agreeing to a trial of an experimental drug might be more in line with her goal as a missionary.

"Another issue unique to the current Ebola crisis," noted Fisher, "is that the effectiveness and side effects of the medication are unknown." When the missionaries agreed to take the medication, they, along with the health professionals who administered it to them, were unsure of whether the treatment would work or not. Until it is approved, ZMapp provides "no guarantees and some risks" to those who agree to its use in treatment, said Fisher. In fact, Miguel Pajares, the Spanish missionary who was given the drug, ended up dying. Instead of asking if it's ethical to give limited medications to Americans before Liberians, ethicists need to ask if it's ethical to give potentially harmful medications to Liberians before Americans.

As Fisher notes, previous clinical trials that administered experimental drugs to individuals living in low-resource countries were criticized for treating those individuals like "guinea pigs." There might be a case to be made, then, that agreeing to the unapproved drugs was the altruistic choice for the Americans to make since it may end up providing valuable information to Western doctors as they continue to search for a cure.

Once the missionaries have recovered, Fisher said, they might be able "to motivate the [infected] community to adopt health measures that will stem the disease — a skill the other Ebola patients may not possess." She added: "the most life-saving steps are those that guide the community in public health safety procedures."