Every decade or so, a new or exotic infectious disease boards a flight and lands at a Western hospital, and suddenly ethical questions of risks to health care workers and “duty to treat” are front and centre.
In the 1980’s and 90’s it was HIV/AIDS. In 2003 it was SARS. Today it’s Ebola.
There is no question the current Ebola outbreak has put health care workers at risk: As of October 15th, about 420 health care staff have been infected globally and more than 230 have died. All but three of those cases have been in Western Africa. While we can assume many of the doctors and nurses in Ebola zones in Africa did not always have access to state-of-the-art personal protective equipment, there are conflicting stories about whether the nurses affected in Dallas contracted Ebola despite wearing full personal protective equipment .
Our front line health care workers in North America are pushing for public health agencies and hospital managers to provide more training in personal protective equipment, more surveillance so Ebola patients don’t land in our waiting rooms without warning, and more guarantees that the risks are indeed as low as claimed.
Those are appropriate demands.
But many of us work in hospitals that cared for some of the sickest SARS patients in Toronto, where about 30% of all cases were in health care workers. Physicians, respiratory therapists, but most often nurses, were infected as they heroically rushed to perform emergency intubations or other high risk procedures. Many worried they would bring the virus home to their children, although thankfully this never happened. During SARS, a small minority of health care workers in Toronto refused to show up to work and it’s not unreasonable to think the same might happen if we see Ebola cases in Canadian hospitals.
Is this a violation of a code of ethics that medical personnel accept when they work in a health care setting, especially in high-risk fields like infectious disease, critical care and emergency medicine?
In Canada, it seems not. Although it is generally assumed that health care workers will care for patients with transmissible diseases, this “duty to care” or “duty to treat” is not explicitly spelled out in the codes of ethics of either the Canadian Medical Association (CMA) or the Canadian Nurses Association (CNA).
The CMA, which revised its code of ethics in 2004, a year after the SARS outbreak, offers doctors no direct guidance on whether they have an obligation to care for patients in an infectious disease outbreak. As Upshur and colleagues have noted,
“The key revision in the 2004 edition of the CMA Code was the addition of the following item to the ‘Fundamental Responsibilities’ section: “Consider the well-being of society in matters affecting health”. This addition, however, does little to address, in any substantively meaningful way, the duty to care obligations of health care professionals in the context of an infectious disease outbreak. Does the addition of this responsibility obligate physicians to provide treatment even when doing so would put their own health in peril? The wording is too vague to be of any significant guidance in clinical practice.”
Similarly, the CNA issued a position paper in 2008 titled “Nurses’ Ethical Considerations in a Pandemic or Other Emergency” that states:
“During a natural or human-made disaster, including a communicable disease outbreak, nurses have a duty to provide care using appropriate safety precautions.”
The code also explains that “a duty to provide care refers to a nurse’s professional obligation to provide persons receiving care with safe, competent, compassionate and ethical care. However, there may be some circumstances in which it is acceptable for a nurse to withdraw from providing care or to refuse to provide care”.
While health care professionals have an ethical obligation to care for their patients, they also have obligations to their families and to themselves. They should (and do) expect some level of risk on the job, as do firefighters, construction workers and miners. Still, are there some diseases and procedures that require risk that is unreasonable, even for those who pride themselves on delivering life-saving medical treatment?
Clark has argued that health care professionals, and especially physicians, having freely chosen this line of work, have a greater obligation to care for patients in a pandemic than other members of society. Along with the voluntary nature of the choice of profession, Clark argues that health care professionals are the only ones with the knowledge and skills to provide this care, and in countries like Canada with publicly funded health care systems, they have a social contract with the population to step up in these types of emergencies.
Others may argue that Ebola presents a special case. Sokol has defended doctors and nurses who abandoned their Ebola patients in the 1995 Kikwit (Democratic Republic of Congo) outbreak, where protective equipment was scarce, the chance of infection was high, and the benefit of treating the sick was mostly “trivial”. In addition, Sokol contends that “virtuous patients” would not expect doctors or other health care professionals “to transcend the bounds of reasonable risk.” But health care professionals who have recently published their 2014 experiences working in Ebola clinics in West Africa say the mortality rate can be improved by providing basic supportive care such as IV fluids and acetaminophen. It is unthinkable that anyone would advocate the abandonment of these patients, whether they are stricken in Liberia, Spain or the US.
We should salute those Canadian medical personnel who have and still are volunteering in West Africa, working under unspeakable conditions to care for Ebola patients. It is worth emphasizing that the risk of a health care professional contracting Ebola in Canada remains very low, but not impossible. Hospitals should act quickly to provide health care professionals with equipment and training, and have plans that minimize the number of workers who will be asked to provide care. Emergency department staff and even family doctors must be on high alert, but as the Dallas cases show, those most at risk will be intensive care nurses and physicians who are looking after patients when they are at their sickest and most contagious. If a few health care professionals stay home when the virus turns up in their workplace, that may be unfortunate, but we can probably handle Ebola without them. In the meantime, our professional associations, bioethicists and the public should address the issue of “duty to treat” with specifics rather than vagueness before the next pandemic, when we’ll need every single health care professional to show up to work.
The comments section is closed.
Correction to post by Edward on October 28, 2014. The sentence ‘This is vastly different from, and much higher than SARS and other illnesses’ should read:
‘This is vastly different from, and much higher than SARS once appropriate PPE measures were implemented. In Kikwit, there was no such option. However, during the current outbreak in West Africa, PPE availability in treatment facilities and the community is now improving.’
Dear Maureen,
Thank you for your thoughtful essay on this pressing topic. Thankfully, I have not heard a single person advocating the abandonment of Ebola patients or refusing to work with one. These reactions are a testament to the education and preparation being implemented through hospitals, clinics, and public health offices in Canada.
Discussion of the moral issues relating to Ebola care is necessary, however, comparing the obligations (or comments about obligations) of a physician in the developed world with one in a developing setting can be misleading. Clark and Sokol are likely writing about different contexts. In the 1995 Kikwit epidemic, evidence exists that physician attack rates were over 30%. This is vastly different from, and much higher than SARS and other illnesses.
We must remember that Ebola clinics in West Africa today, under-resourced as they are, are still probably much better equipped than the hospital in Kikwit. Especially in the earlier Ebola outbreaks, saline, sterile IV catheters, gloves, or bleach may not have been available. Moreover, the death of medical personnel in a system with many fewer healthcare workers than developed countries could leave entire villages or regions with no healthcare workers. That would severely impact the treatment of patients with malaria, HIV, TB, pneumonia, meningitis or other serious illnesses.
Lastly, the sad truth is that Ebola outbreaks have been limited in the past due to lack of contact with medical personnel. Nosocomial spread due to lack of PPE, lack of lab tests, and lack of sterilization equipment is a massive and overlooked threat.
I agree with you that the justifications advanced by Sokol do not apply to a Canadian context. We are fortunate to work in a medical system of altruistic professionals. The main difference is that we have the advantage of being well-trained, well-equipped, and forewarned. As you have said, we must share this advantage with the hardest affected in West Africa.
Thank you Maureen, for your insights and advocacy.
Edward Xie
Maureen thank you for this very thoughtful and well written piece. As a Emergency physician I stand shoulder to shoulder with you and other health care workers on the front-line. I had my introduction to health care during the peak of the SARS outbreak and what served us well then was education, research, stringent infection control policies and straight forward communication. While it is likely impossible to remove all risk to health care providers, we can do much to mitigate risk through the use of proper personal protective equipment. I truly admire the courage of those health care workers in West Africa and elsewhere who have had to make the decision to show up for work to care for a patient stricken with Ebola. My hope is that with continued attention to this most pressing global health issue we can begin to contain Ebola and drive down the case fatality rate through the provision of effective supportive care. In time I hope that scientists and clinicians will be able to develop and deploy vaccines or treatments for this menace as we have historically during similar outbreaks of infectious diseases.