– – – The patient’s Covid-19 result isn’t back yet, but they have to assume she has the infection, given the fever and breathing difficulties. She lies in a side-room, conscious, panting, waiting. The young doctor and a single nurse don their personal protection equipment – gloves, apron, surgical mask. The doctor, a trainee, three years out of med school, cannot stop himself flattening the surgical mask to his face. He inhales, and cannot help visualising infectious particles in the air. He doesn’t want to be here. He doesn’t want to breathe the virus in, he doesn’t want to take it home. The nurse is waiting. But he, the doctor, is reluctant to enter. Yet he must. He cannot excuse himself. It is his duty. – – –
Healthcare workers (HCW) are worried, and some are afraid (as this testimony confirms). But very few will refuse to see patients, even though many if not all would rather not. The Covid-19 pandemic is the first time for generations that HCW in the UK have felt endangered on a large scale. The HCW’s duty to care during epidemics of dangerous infectious disease has long been a subject of inquiry, and many of the conclusions drawn appear relevant to today’s great challenge. In this post I am going to summarise a few stand out papers.
Going back to 1980’s, a fascinating paper in by Zuger et al in JAMA (1987) recount the behaviour of doctors during historical epidemics, from Athenian plagues to HIV. It starts with an apparently hyperbolic analysis (given the progress we have made in anti-retroviral treatment) – ‘Beneath all its layered horrors, the acquired immunodeficiency syndrome (AIDS) epidemic—that Pandora’s box of the 20th century—has left us with one small gift. It has forced our attention toward issues that, over the last century, we have grown unaccustomed to facing; it is making us relearn lessons we had almost forgotten.’
We ‘relearn’ that ‘Galen himself had admitted to fleeing from Rome when plague struck that city in 166 AD’, and that ‘nearly all physicians withdrew out of fear and terror’ during a Venetian plague. During the Great Plague of London in 1665, ‘Great was the reproach thrown on those physicians who left their patients during the sickness, and now they came to town again nobody cared to employ them. They were called deserters…’ (Daniel Defoe). The paper goes on the explore the different ethical constructions that may underpin a modern HCW’s behaviour – ‘rights’ based, ‘contract’ based or ‘virtue’ based.
The virtue-based approach is the one we are accustomed to apply in modern medicine, and is described as ‘an ethic of virtue requires a virtuous moral agent whose character can be nurtured and trained and who can be held morally accountable for his/her actions’. It ‘mandates, as well, that because of their prior voluntary commitment to the professio of healing, physicians are obliged to undertake the officia of caring for these patients. Individual physicians who decline to perform these officia are falling short of an excellence in practice implicit in their professional commitment.’
Daniel Sokol, a barrister and ethicist who will be well known to readers of the BMJ, wrote directly to this topic in 2006, shortly after Severe Acute Respiratory Syndrome (SARS, caused by SARS-COV) had killed over 700 people in 17 countries, with an estimated 9% fatality rate. Sokol conceded that a HCW, ‘by accepting a post, is usually aware of the perils of treating infected patients’ and ‘by entering into a specialty, doctors implicitly consent to a range of risks and responsibilities associated with the job.’ This suggests that HCW make a deal early in their careers, aware that they will be exposed to certain risks, analogous perhaps to risks encountered in other jobs such as diving, flying, the armed forces, or law enforcement. However, ‘the appearance of an exotic, highly virulent disease […] challenges […] their interpretation of the duty of care, in particular, its limits.’ He differentiates between different types of HCW, for instance the infectious disease specialist and the dermatologist: the former, one can argue, has made a conscious decision to study and treat diseases that are inherently more dangerous. We are happy to accept the dangers of being with ill people in general, but grow uncomfortable when approaching the ‘the outer limit of acceptable personal risk’.
Sokol is clear about the balance between a HCW’s duty to provide care at such a time, but equally clear about their employer’s duty to protect them as much as possible. For employer, we should probably substitute the ‘state’. This is a contentious point at the moment, with many being concerned that insufficient equipment is available in the UK. In Italy, where the crisis escalated beyond all imagination, outstripping resources and capacity, there were tragic outcomes among HCW, as the Tweet below illustrates.
Such cases beg the question – what are expectations during times of crisis? Is selfless heroism required? Sokol is very clear on this. ‘Should doctors do everything in their power to benefit their patients?’ he asks. ‘The answer, surely, is no.’ This question was approached empirically by Kpanake et al (J Med Ethics, 2017) in relation to the Ebola epidemic. The authors presented 54 scenario cards to over 220 HCW and 252 lay people in Guinea. They were asked to rate how acceptable it was, from 0 to 10, for the HCW to leave a patient unattended, with factors such as working conditions, risk of being infected and family commitments varying across the scenarios. The strongest influence in this study was working conditions, the ‘acceptability of refusal’ to treat rising to an average of 8.5/10 when conditions were ‘poor’. [Interestingly, ‘Lay people (42%) were significantly more likely to be members of this cluster than nursing staff (28%). Atheists (67%), also, were significantly more likely to endorse this position than Christians (32%) or Muslims (37%).’]
Sokol and co-author Simonds address the duty of the employer to optimise working conditions in a later paper (written on the brink of an avian flu epidemic). They call this principle Reciprocity. This is reiterated in the document ‘Ethical considerations in developing a public health response to pandemic influenza’ published by the World Health Organisation (WHO) in 2007, but is well summarised in a panel from the Simonds/Sokol paper.
The first item is perhaps the most challenging (logistic wrinkles around PPE excepted) – to be clear about what is expected. Such conversations tend to occur after the infection has taken off, when people are anxious and maybe a little paranoid. But Simonds and Sokol urge psychological preparedness: ‘In light of [ ] historical precedents, hospitals may want to inform prospective staff members of what is expected in crisis situations before, rather than in the midst of, an emergency’ and ‘however difficult the task, these issues should best be tackled now, in times of relative calm, rather than in times of pandemic turbulence.’ Wise words, presaged by Camus who wrote in The Plague, ‘There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.’
Should we really engage our high school students in this discussion, so that they can consider the risk of being a HCW before they commit? Or during medical school, when they still have the opportunity to back out? Young people feel immune to danger. And there are other dangers – assault, suicide (statistically speaking), and various blood borne infections. To paint medicine as a high risk occupation seems over the top, and anyway, such conversations are unlikely to change career decisions. But surely it would seem wise to put time aside during induction into a new hospital or Trust so that a general overview could be given.
A paper by Singer et al (BMJ, 2003) identified the key ‘ethical values’ or considerations for HCW involved in a health emergency (in the box below).
The authors imagined a HCW like the one I my scenario, uncertain, worried about taking the infection home. They could not reach a consensus on what the ‘correct’ course of action would be, or what varieties of response were defensible. The ethical values listed above are competing, individual liberty to choose not to treat being the most contentious. ‘Healthcare workers were forced to weigh serious and imminent health risks to themselves and their families against their duty to care for the sick. This duty is mainly determined by professional ethics. By analogy, firefighters do not have the freedom to choose whether to face a particularly bad fire and police officers do not get to select which dark alleys they walk down.’ Again, comparisons with other professions are made. I wonder if the duty to proceed down dark alleys, or the duty to enter a unstable buildings, are discussed explicitly with trainee police and firefighters. If it is, we may have something to learn from them in medicine.
Ruderman et al (BMC Med Ethics, 2006) reflected on the SARS epidemic, commenting that although the response from HCW ‘was generally regarded as exemplary’, ‘some baulked at providing care to those infected with the unknown virus’, and as a consequence ‘the risk that was faced during SARS was not distributed equitably, and those HCPs who volunteered to provide care faced the greatest exposure.’ The authors agreed that HCW have ‘special obligations’, but were concerned that ‘many current professional codes of ethics fail to provide explicit guidance sufficient to set policy or assure the public in the event of an infectious disease outbreak.’ So should there be rules, or a contract? Would people stick to it? They conclude, ‘In our view, health care codes of ethics should speak specifically to this issue in order to guide professional behaviour during infectious disease outbreaks. Indeed, the time to address the ethical duty to provide care is at hand – before the arrival of the next public health emergency.’ Well, that emergency has happened.
The final paper is by Maunder et al (CMAJ 2003), and it focuses on the psychological morbidity of HCW involved in the SARS emergency, recognising that they were affected disproportionately. Self-protection from infection was a large issue. ‘The perception of personal danger was exacerbated by uncertainty. Modification of infection control procedures and public health recommendations day by day, and sometimes hour by hour, increased uncertainty.’ Then, echoing present concerns: ‘The perception of personal danger was heightened by the known lethality of the syndrome and intense media coverage of the outbreak and its effects (e.g., “Hospital masks are in short supply”).’ The tension between professional duty and the risk of taking the infection home was well articulated – ‘Many expressed conflict between their roles as health care provider and parent, feeling on one hand altruism and professional responsibility and, on the other hand, fear and guilt about potentially exposing their families to infection.’ These tensions can be managed, through clear explanation, through reassurance, and through preparation. Pandemics occur, yet, as Camus wrote, we always seem to be surprised.
What is our young doctor to do, standing outside the side-room? Should we discipline him, if he turns around saying, ‘No thanks, not me, I’ve got family at home to look after.’ Should he be taken away from the front line like an unreliable soldier, to be dealt with later when the battle is over? My feeling is that his doubts, fears and questions should have been explored much earlier. As the epidemic took hold, if not before, he should have been told what might be expected, and asked to share his concerns. The effectiveness of his personal protection should have been explained, and the risks of infection (low in this scenario) quantified. When PPE policies were changed to what less effective surgical masks and basic plastic aprons, there should have been clear communication. If HCW are now feeling profound fear as they approach patients, we have not prepared them well enough. This is part of ‘reciprocity’. So as we work through the Covid-19 pandemic, sharing our anxieties and supporting each other, let us commit to making sure we are ready for the next, not just materially, but psychologically.
“I have no idea what’s awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.”
― Albert Camus, The Plague