Some weeks ago I had reason to reflect on the professional obligation of doctors to treat and touch patients with possible Ebola virus infection. A man came in with a fever and diarrhoea, having returned just the day before from Africa. The scenario rang alarm bells, but the country from which he had travelled was not affected by Ebola, and a quick search on the internet combined with a call to the microbiologist reassured me and the clerking SHO (who had already seen him!) that the chances of infection were so low as to require no special measures. There was no reason to escalate, alert the rest of the department or hurry the patient into isolation.
But as I went to see him, and as I touched him, I wondered – What if this is the first case to come from ______; what if, within the conurbation where he was doing business, contact was inadvertently made with someone who had travelled from an area with a heavy burden of infection? What if?
Since that encounter (which came to nothing), the reality of meeting a patient with early or established Ebola infection has become more tangible. It seems inevitable that somewhere in this country a nurse, a doctor, or a member of non-clinical staff, will meet such a person. This leads me to wonder how strong our professional duty is to become involved in their care. It is a pertinent question – nurses in Liberia have threatened to strike unless ‘danger money’ is paid.
I found a document from Rhode Island which makes explicit the duty of licensed healthcare professionals to treat patients with Ebola. Not to do so is regarded as a dereliction of duty, and is punishable. It begins with the question,
But what if the healthcare provider is at risk of harm from the patient? May a licensed healthcare provider refuse to treat a patient? A patient, say, with Ebola?
The risk of disease transmission – in and of itself – does not provide grounds for the relaxation of a provider’s duty to help a patient, especially because the risk is understood and readily mitigated.
A parallel is then drawn with HIV, which caused similar panic and concern. Then, the document states –
In Rhode Island, licensed healthcare professionals in active practice are obliged to treat and/or care for Ebola patients, while minimizing the risk of Ebola transmission to self and others. Failure to do so is a potential breech of Rhode Island’s licensing laws for healthcare professionals, and warrants thorough investigation and potential sanctions. Therefore, healthcare providers must reflect very carefully before refusing care to a patient.
Lastly, the ‘spirit of Emory [University Hospital, Atlanta]’ is described, where,
…staff members volunteered to care for Ebola patients; some staff members voluntarily cancelled vacations to do so. This spirit reflects the best attributes of those who share our professions.
This is the ideal, and it is impressive. But… when faced with the situation, I wonder if the sense of duty, or even the fear of punishment, would fade into insignificance compared to the instinct for self-preservation.
Many of the medics representing this nation in the fight to control Ebola at source are from the armed forces, where duty is more rigidly imposed. Perhaps one advantage of utilising the military resource, aside from its logistical efficiency and well practised ability to arrive in strange places and set up hospital and clinics, is the fact that individuals are far less likely to waver in their duty at such times. In the US,
Several soldiers said their families were concerned about the deployment, and unlike past ones, they got little advance warning. Some said they felt better after the training, feeling they would be safe. But it left others unnerved.
Maj. Jim Wade, who has two young kids, said he was confident he could remain safe. Despite the dangers, he said, “it’s our job.”
What of the rest of us, the everyday doctors and nurses who work quite happily among the sick, but very rarely put ourselves in danger? Are we going to volunteer, are we going to step forward, to treat patients when the penny drops they might have Ebola? Or will we cite our inexperience, and purposefully leave the scene. Or rather reluctantly and trustingly proceed, rather like the US police deputy who entered an infected man’s vacated house? He is reported to have said,
“In my opinion, I think things could have … maybe taken a step back… In law enforcement, we ‘what if stuff’ all the time. If this happens, this is what we can do; if this happens, well this is our plan B. And so, maybe in a situation like this, it could have been a situation in which maybe we ‘what if it’ a little bit more and maybe plan a little bit better for things.”
Does being a healthcare professional necessarily require a greater than average predisposition to self-sacrifice? I have drifted into this subject before, in a post called ‘The needle and the damage done.’ There I describe the acute and damaging psychological impact of blood splashes and needle stick injuries. It is the uncertainty that does the damage. Knowing myself, I think I might not be the first to step forward. There is too much to lose, personally. Nurses in Spain have contracted the infection despite all sensible precautions. There are protocol ‘breaches’. I am human, I am selfish. But then again, if a patient was admitted under my care, I would have no choice as a caring professional but to become involved, and to do my level best to protect myself and others. To walk away would sow a seed of infinite regret, and a sense of cowardly shame.
As the possibility of meeting an Ebola patient becomes more real, we need to ask ourselves how we will respond, and, perhaps, make psychological preparations. To answer the question in an informed way we need to be reassured that the preventative systems in place are rigorous, and that their safe application is achievable by staff who have not had the benefit of rigorous training.