Polio, AIDS, and Ebola: A Recurrent Ethical Dilemma

During the 2014 West African outbreak, a dilemma emerged about the ethics of conducting randomized placebo-controlled trials in the midst of a rapidly spreading, devastating epidemic for which there was no effective treatment. The dilemma has in fact has deep historic roots; it has appeared in several previous fearsome epidemics-during the poliomyelitis epidemic in the 1930s-1950s, and again during the AIDS epidemic in the1980s-1990s. Moreover, ethical and social questions characterizing each of these epidemics-the increased risks of withholding potentially life-saving drugs for people assigned to a control arm and the damaging effect on eroding community trust-were conceptualized beforehand in the 1925 novel Arrowsmith. A historical analysis both reaffirms that rigorous placebo-controlled trials remain indispensable tools in epidemic settings and also provides guidance on how to approach the ethical and social issues that will likely arise when these trials are carried out in future epidemic emergencies.