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Ethics during epidemics: Old lessons get new look
Balancing personal protection with professional duty
Last year’s worldwide outbreak of a deadly new virus, severe acute respiratory syndrome (SARS), made health systems around the world re-examine their preparedness to deal with a sudden epidemic of infectious disease.
But in addition to designing new methods for detecting outbreaks and improving measures to prevent spread, health care providers again must look at the complex ethical issues that epidemics pose to society, experts say.
Prior to the emergence of HIV and AIDS in the late 1980s, many in the health care community assumed that large outbreaks of infectious disease were no longer a problem for the developed world, says Matthew Wynia, MD, MPH, director of the Institute of Ethics of the American Medical Association (AMA) in Chicago.
As a consequence, they never expected to face many of the ethical dilemmas of their older counterparts, he says. Questions such as when and how patients with a communicable illness should be quarantined, and whether health care providers have a duty to provide care, even at risk to their own safety, must be re-examined.
"It has sort of been forgotten now that it has been dangerous in the past to be a doctor, or a nurse, or a health care professional of any type," Wynia says. "In the early part of the 20th century, it was [a] well-known and well-accepted part of what it meant to be a doctor. More than 20% of each year’s medical class would get active tuberculosis [and], some people would die. It was very common in the 1940s and 1950s, before the age of antibiotics, for health care workers to become ill because of the work they did."
In 1847, when the AMA was formed, part of the group’s code of professional conduct stated that physicians would continue to care for patients "when pestilence prevails," Wynia says. But by the 1970s and 1980s, some medical leaders were talking about removing that statement because epidemics were thought to be on their way out.
Many of today’s physicians were trained in an age when infectious disease was not thought to be a major concern.
"When the HIV epidemic came along, there was a great deal of controversy about the role and rights of health care providers — there were a lot of doctors who wanted to debate whether it was an ethical obligation to take care of patients with HIV infection," Wynia says. "It took four or five years for us to finally resolve it and say that, in fact, it was an ethical obligation."
The recent federal plan to prepare for a possible bioterrorist attack with weaponized smallpox, the anthrax attacks two years ago, and the SARS outbreak, have all refocused attention to these concerns, he adds.
Wynia and other experts in medicine and ethics recently participated in a conference at Union College in Schenectady, NY, titled "Ethics and Epidemics: An International Conference on the Ethical Dimensions of Epidemic Control."
"We talked quite a lot about the fundamental ethical issue in terms of being prepared for bioterrorism or epidemic disease. What if there is an epidemic and health care professionals don’t show up?" Wynia says. "In every hospital that dealt with SARS, they had problems with this — every single one. And the applications to medical school and nursing programs in Toronto are way down this year."
As part of their bioterrorism and epidemic preparedness activities, hospitals should consider some amount of education about ethical responsibilities to care for patients during epidemics.
The September issue of the journal Health Affairs contains a report of a survey of physician willingness to treat patients with infectious illnesses. "Approximately 80% said they would [continue to care for patients in the event of an unknown, potentially deadly illness], and 20% said they would not. As the estimates of risk to the health care providers increased, the number of physicians who would agree to continue treating patients decreased," Wynia explains.
Only about half of the respondents said there was a professionwide duty to treat patients during epidemics.
Access to care
Participants at the conference also discussed the possibility of improving access to primary care as a function of national bioterrorism preparedness efforts, Wynia says.
"People who don’t have ready access to care now, [such as] undocumented immigrants or the uninsured, could prove to be vectors for a new epidemic — either natural or man-made," he explains. "There are lots of reports of multidrug-resistant tuberculosis spreading in uninsured populations, and then eventually spreading and infecting others in the community."
Because people without insurance and those who are in the country illegally might avoid seeking treatment, the emergence of a new epidemic could go undetected for some time.
"Using some of the money dedicated to bioterrorism preparedness to improve access to basic primary care would not only improve the health of the community, but it would also improve the success of the current surveillance and detection systems," Wynia says. "There have been moves on the part of some states to compel physicians and nurses to turn in their patients who are here illegally. First of all, it is abhorrent to fundamental principles of medical ethics. It also seems really dumb in terms of preventing future epidemics."
Hospitals also will have to consider how to allocate scarce resources, both in terms of personnel, equipment, and medicine, says Michael Olesen, an infection control specialist with St. Cloud (MN) Hospital.
Many health systems already are struggling to take care of the patients they currently see, with their current levels of resources. If a large-scale disaster were to occur, many fear they wouldn’t have the "surge capacity" (extra personnel, equipment and funds) to cope.
Last year’s influenza season for example, notably strained emergency medicine resources in a number of cities, with many hospitals reporting shortages in medicine attributable to the outbreaks and increased incidences of ambulance diversions due to overwhelmed emergency departments.
Working with a regional planning group on epidemic and bioterrorism planning issues, Olesen also decided to investigate whether the area would have enough ventilators if a large outbreak of SARS or another severe respiratory ailment occurred.
"While I was doing education on SARS in our facility, I did a ventilator national surge-capacity assessment," Olesen explains. "Given that an estimated 10%-20% of patients with SARS will require ventilators, I calculated that we would hit national capacity to deal with SARS once we had 40,000-80,000 concurrent cases. This represents just about 0.001%-0.003% of the U.S. population."
By comparison, he notes, on any given day, an estimated 0.4%-0.8% of the population has influenza.
"This was rather shocking to me, and I realized that SARS could easily overwhelm our ICUs if it were to become established," Olesen notes. "I spoke with our ethics committee about beginning a discussion on distributional justice around medical devices. Who gets ventilators when we run out? Do we remove it from someone with a low chance of recovery to give it to someone with better chances?"
The committee still is examining the issue and, at this point, has a lot of questions and few answers, he says.
They also realize that ventilators won’t be their only concern.
In doing bioterrorism preparedness planning at his facility, Olesen bases calculations on the assumption that, as Wynia indicated, many health care workers will refuse to come to work.
"Even if we did have enough ventilators, would we have the staff to operate them?" he says. "If you look back, historically, when there have been large outbreaks at hospitals, you really can count on a range of from 30%-80% of people disappearing from your staff if things are really ugly. I kind of steer doing planning around the assumption that 50% of the staff is gone either because they are scared or because they are sick. If you loose that many staff, getting more [ventilators] isn’t going to help."