Emergency department clinicians faced unique ethical challenges during the 2014 Ebola outbreak. A recent position paper provides clinicians with guidance on the following:
Clinicians were torn between obligations to patients and their own well-being.
Clinicians feared exposing their families to Ebola.
Facilities need to prepare for ethical challenges of future emerging infectious diseases.
Sangeeta Lamba, MD, associate professor of emergency medicine and surgery at Rutgers New Jersey Medical School in Newark, says Ebola was one of the biggest systemwide ethical challenges she’s seen in her career. “Nothing has challenged us more in emergency medicine, in the ethical realm, than Ebola,” she says. Lamba and colleagues will be leading a national session on the unique ethical and moral challenges of healthcare workers caring for dying patients with highly contagious diseases.1
In this scenario, clinicians are torn between obligations to patients and obligations to their own families. “When you do patient care, you have an obligation to do the right thing by the patient — it’s a very clear construct,” says Lamba. “But what about when your own life or loved one’s life may be at stake?”
At Newark-based University Hospital, clinicians expressed conflict and moral distress regarding care for patients with Ebola symptoms. This was something Lamba had never seen with outbreaks of drug-resistant tuberculosis, methicillin-resistant Staphylococcus aureus, or even with the threat of smallpox. “With everything else, you put on a mask and went in — there was no argument. In emergency medicine, we are trained to deal with crises, not to avoid crises,” she says.
The difference with Ebola is that healthcare workers across the country felt their primary responsibility to their families was conflicting with their obligation to care for patients. “With Ebola, people were afraid of what implications it would have for their family, who didn’t sign up for this job,” Lamba explains.
Widespread fear among the general public was another factor. “Media coverage of the negative public reaction to healthcare workers with suspected Ebola, such as a New York City physician, did not help,” says Lamba.
NEW GUIDANCE FOR CLINICIANS
A position paper from the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine provides guidance on how to approach the ethical dilemmas posed by the Ebola outbreak.2
At the time the paper was being developed, “Ebola was on the front pages of virtually every news source in America, and a lot of it had to do with the handling of Ebola patients in the ED,” says Arvind Venkat, MD, who coordinated the project. Venkat is system ethics committee chair at Allegheny Health Network in Pittsburgh, and an ethics consultant at Allegheny General Hospital.
Multiple ethical issues arise with any emerging infectious disease, says Venkat. These include staff involvement, facility preparation, staff preparation, and what to do if patients’ needs go beyond the institution’s capabilities.
These ethical concerns are not unique to Ebola, according to Venkat. “Whenever we have an emerging infectious disease where there is little known about how we can control its spread, these same issues arise,” he says. Venkat saw the same issues — the fear of the unknown, and the obligations of healthcare providers — come up during the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) epidemics.
Venkat says that at his institution, he didn’t encounter staff refusing to care for potential Ebola patients. “But certainly across the country, especially in cities where there were potential cases, healthcare providers were saying, ‘I don’t want to do this,’” he says.
Healthcare providers generally have an obligation to care for patients despite potential risks, says Venkat, “but the obligation is not absolute. There is an ethical principle of reciprocity.”
The guidelines acknowledge that while healthcare workers have an obligation to care for patients, society has an obligation to healthcare workers as well. “When we sign up as healthcare providers, we need to be prepared for this. But institutions — and society — also have to be prepared,” says Venkat. “We all want to be altruistic, but none of us are suicidal.”
Venkat says the ethical framework outlined in the guidelines are applicable to future emerging infectious diseases. “We are not at the end of emerging infectious diseases in this country,” he says.
Allegheny Health Network’s policy states that if healthcare providers have moral or ethical reasons not to follow a treatment pathway, they can make that known to their supervisor. “But oftentimes, these are emergency situations,” notes Venkat. “The question become, how do you approach those situations?”
The key is for institutions to prepare in advance. “On the logistics level, we need more drills, equipment, and preparedness for various types of infectious disease agents based on their mode of transmission,” says Venkat.
Discussion from an ethical perspective should be built into policies. “Institutions need a plan in place so that when these scenarios come up, staff is supported, and there is adequate staff to deal with patients that may arrive,” says Venkat.
At University Hospital, volunteering for the role worked well when there was an occasional person under quarantine. “As screenings increased, there was a heightened level of anxiety and stress amongst staff,” recalls Lamba. Having a separate area removed from the main ED for screening patients, as well as having a central person in charge to manage assignments, answer queries, and train personnel and organize flow worked well, she reports.
In the ED, clinicians routinely see patients who pose unknown risks. “If you put a policy in place saying no ED provider can ever recuse themselves from a population, no one would work in EDs,” says Venkat.
Venkat feels a better approach is to find ways to demonstrate support for staff. “Carrots are better than sticks. There might be forms of compensation, not necessarily financial in nature, offered to staff,” he says. For instance, staff might feel more comfortable caring for potential Ebola patients if they had assurance that if they or their family members became ill, they’d get access to the best available treatments. “It’s a very fine line,” Venkat says.
Lamba S, Goett R, DeSandre P, et al. Dying alone: End-of-life care of the quarantined patient. Concurrent didactic session. American Academy of Hospice and Palliative Medicine Annual Assembly, Chicago, IL, March 11, 2016.
Venkat A, Wolf L, Geiderman, JM, et al. Ethical issues in the response to Ebola virus disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine. J Emerg Nurs 2015; 41(2):e5-e16.
Sangeeta Lamba, MD, Associate Professor of Emergency Medicine and Surgery, Rutgers New Jersey Medical School, Newark. Phone: (973) 972-4823. Fax: (973) 972-6035. Email: [email protected].
Arvind Venkat, MD, Vice Chair for Research and Faculty Academic Affairs, Department of Emergency Medicine and System Ethics Committee Chair, Allegheny Health Network, Pittsburgh, PA. Phone: (412) 359-6180. Fax: (412) 359-8874. Email: [email protected].