medical surgeons performing surgery

Bioethics Forum Essay

Responding to Ebola: Health Care Professionals’ Obligations to Provide Care

As health care institutions in the United States prepare for Ebola patients, many have adopted the policy that those providing hands-on care should come from a pool of volunteers. Given the mixed history of health care providers’ willingness to care for patients during epidemics and pandemics, and the need for additional training in personal protective equipment for Ebola, this may be the most pragmatic response. However, worries about the risk of transmission of the virus to those coming in contact with infectious bodily fluids may lead to insufficient personnel coming forward, putting hospitals in a position to require some professionals, including doctors, nurses, and respiratory therapists, to care for Ebola-infected patients.

Many academic medical centers have formulated policies about who might be required to participate in the care of Ebola patients and who might be exempt. In many centers, medical and nursing students have heard that they will not provide care to Ebola patients. In some centers, other trainees, such as residents and fellows, have also been excluded.

These policies raise two important questions. First, what is the obligation of health care professionals to assume personal risk? When we look at what history shows, we find the original American Medical Association Code of Ethics, written in 1847, stated “. . . it is their duty to face the danger, and to continue their labours for the alleviation of the suffering, even at the jeopardy of their own lives.” Interestingly, this section was removed in the 1960s when the Surgeon General declared the threat of infectious diseases to be a problem of the past. Multidrug resistant tuberculosis, HIV, SARS, and now Ebola suggest the Surgeon General’s opinion might have been premature. The American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine, jointly authored Medical Professionalism in the New Millennium: A Physician Charter in 2002 to reaffirm the medical community’s commitment to serve others and to re-inspire public trust.  It has been adopted by over 130 organizations worldwide.  The Charter asserts that being a professionalmeans,in part, putting aside self-regarding interests in order to serve those in need.

Professionals acquire specialized knowledge and skills that others do not and cannot have. Having these skills creates a presumptive obligation to use them. However, such an obligation is tempered by the likelihood that intervention will actually benefit patients by either curing them or relieving pain and suffering. The extent of professionals’ duty to assume risk must take into account the rights of the providers to receive appropriate training and resources to protect themselves.

Second, is it ethical to adopt policies that systematically exclude or include classes of professionals from participating in especially risky care? We believe one can reasonably include or exclude professionals on the basis of theirrelevant clinical experience.  Students have relatively little related experience. However, by the end of several years of postgraduate training as residents or fellows, many, though not all, physicians and surgeons, even those still in formal training programs, have sufficient clinical experience to competently learn and use Ebola precautions.

The exclusion of students seems morally and clinically justifiable–very few, if any, have had adequate experience to either meaningfully help desperately ill patients or protect themselves. By contrast, blanket exclusion of postgraduate medical trainees from caring for Ebola patients unfairly privileges them as deserving of protection when other health care professionals, namely, nurses, and respiratory therapists of similar ages and similar time in the clinical workplace, may be compelled to work. In previous epidemics, in the absence of adequate volunteers, nurses and other staff have been required to provide care or risk disciplinary action, including the loss of their jobs. Such a stance seems particularly problematic when advanced physicians-in-training have exemptions but can look forward to substantially greater future income and social status than their colleagues in nursing and the allied health professions. This disparity, it has been argued, affirms “how ethical issues embedded in power and systemic politics go unrecognized within bioethical principlism.”

Relevant clinical experience and not one’s professional degree or job title should determine one’s obligations. So, for example, neither psychiatric nurses nor psychiatrists (whether residents or experienced professionals) would have an obligation to provide hands-on care of patients with Ebola. They do not have to deal with infection precautions often enough to have the appropriate muscle memory and habits needed for Ebola prevention. On the other hand, all doctors and nurses with several years of experience, perhaps four or more, in emergency medicine or intensive care should be expected to participate, assuming they get the additional necessary training regarding the use of personal protective equipment for Ebola.

If institutions do not have adequate numbers of volunteers to fulfill our collective obligation to provide care to Ebola patients, they will have to make difficult choices.  Some situations warrant respecting informed professionals’ choices to opt out of caring for patients with or at-risk for Ebola. For example, clinicians who have increased vulnerability to infection because of medical conditions or immunosuppressive treatment could reasonably refuse to assume the risk. Pregnant women who might pass the virus onto their fetuses should also have the option of declining participation. Within these categories, competent adults could choose to opt in and participate in the care of these patients, provided they do so knowingly and voluntarily, understanding the risks and benefits, and being reassured that no penalties would accrue from a decision to opt out.

Beyond these categories, however, permission to decline duty assignments among those with the requisite experience inevitably raises issues of fairness among “competing” groups. Many of us have dependents and partners, some of us may be single parents or nursing mothers, and others may care for aging parents. These are all important reasons to demand appropriate training and resources for self-protection; but none should be singled out as adequate justification for exclusion from patient care. Penalties could be justified for those who refuse, but, again, equity would require similar treatment across disciplines.

The Ebola crisis reminds us about individual vulnerability. It also provides us with an opportunity to fulfill our ethical duties to help those unable to help themselves.

Joel Frader, MD, MA is the division head of Academic General Pediatrics and Primary Care at the Ann & Robert H. Lurie Children’s Hospital of Chicago, director of the Bridges Pediatric Palliative Care Team, and a professor of medical humanities and bioethics at Northwestern University Feinberg School of Medicine. Lainie Friedman Ross, MD, PhD, is the Carolyn and Matthew Bucksbaum Professor of Clinical Ethics, a professor in the departments of pediatrics, medicine and surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Posted by Susan Gilbert at 11/07/2014 11:39:35 AM |

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