Medicine's duty to treat pandemic illness: Solidarity and vulnerability

Hastings Center Report

Volumn 39, Issue 1, 2009, Pages 40-48

  Brody, Howard ^a   Avery, Eric N ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH PRACTITIONER; HOSPITAL SERVICE; HUMAN; HUMAN IMMUNODEFICIENCY VIRUS INFECTION; INSTITUTIONAL CARE; MEDICAL ETHICS; MEDICAL PROFESSION; PANDEMIC; PROFESSIONAL PRACTICE; PUBLIC HEALTH SERVICE; REVIEW; SOCIAL PSYCHOLOGY;

DISEASE OUTBREAKS; HEALTH PERSONNEL; HUMANS; MORAL OBLIGATIONS; REFUSAL TO TREAT; SEVERE ACUTE RESPIRATORY SYNDROME; SOCIAL VALUES;

EID: 59949088138     PISSN: 00930334     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (55)

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2. B. Reilley, M. Van Herp, D. Sermand, and N. Dentico, "SARS and Carlo Ur- bani," New England Journal of Medicine 348 (2003): 1951-52.
3. E.D. Pellegrino, "Toward a Reconstruction of Medical Morality: The Primacy of the Act of Profession and the Fact of Illness," Journal of Medicine and Philosophy 4 (1979): 32-56;
4. H. Brody and EG. Miller, "The Internal Morality of Medicine: Explication and Application to Managed Care," Journal of Medicine and Philosophy 23 (1998): 384-410.
5. EG. Miller and H. Brody, "The Internal Morality of Medicine: An Evolutionary Perspective," Journal of Medicine and Philosophy 26 (2001): 581-99.
6. Miller and Brody, "The Internal Morality of Medicine: An Evolutionary Perspective." The discussion in that article is restricted to therapeutic medicine and excludes medical research and public health. Our main focus in this article is the duty to treat among physicians (and other health care practitioners) involved in the clinical care of individual patients. Naturally, in a pandemic situation, public health efforts will play a very important role, and cleanly distinguishing the therapeutic from the public-health roles of physicians and nurses will be difficult.
7. The wide range of workers involved is suggested in a recent report by the U.S. Occupational Safety and Health Administration (OSHA): "The delivery of healthcare services requires a broad range of employees, such as first responders, nurses, physicians, pharmacists, technicians and aides, building maintenance, security and administrative personnel, social workers, laboratory employees, food service, housekeeping, and mortuary personnel. Moreover, these employees can be found in a variety of workplace settings, including hospitals, chronic care facilities, outpatient clinics (e.g., medical and dental offices, schools, physical and rehabilitation therapy centers, health departments, occupational health clinics, and prisons), free-standing ambulatory care and surgical facilities, and emergency response settings." Occupational Safety and Health Administration, U.S. Department of Labor, Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employees (OSHA 3328-05, 2007), 5, http://www.osha.gov/Publica-tions/OSHA- pandemic-health.pdf.
8. L.B. McCullough, "The Physician's Virtues and Legitimate Self-interest in the Patient-Physician Contract," Mount Sinai Journal of Medicine 60 (1993): 11-14.
9. A.R. Jonsen, A Short History of Medical Ethics (New York: Oxford University Press, 2000), esp. p. 46;
10. A. Zuger and S.H. Miles, "Physicians, AIDS, and Occupational Risk. Historic Traditions and Ethical Obligations," Journal of the American Medical Association 258 (1987): 1924-28;
11. D.M. Fox, "The Politics of Physicians' Responsibility in Epidemics: A Note on History," Hastings Center Report Special Supplement 18, no. 2 (1988): S5-S10.
12. Fox, "The Politics of Physicians' Responsibilities."
13. J.H. Kim and J.R. Perfect, "To Help the Sick: An Historical and Ethical Essay Concerning the Refusal to Care for Patients with AIDS," American Journal of Medicine 84 (1988): 135-38. It seems evident today that the unwillingness of many physicians to treat AIDS victims in the 1980s actually had little to do with the statistical risk of infection, and much more to do with the social stigma attached to the groups among which the victims were disproportionately found. We will not address this aspect of the historical record. The ways in which diseases like SARS and influenza spread tend to minimize the element of social stigma in the public response to an epidemic, but we should not underestimate the tendency of a society under threat to degenerate into stigmatization and ostracism, as evidenced by recent calls in the United States to exclude illegal immigrants as a potential source of infection.
14. We are grateful to Laurence McCul- lough for stressing this point in a personal communication.
15. L.O. Gostin, R. Bayer, and A.L. Fairchild, "Ethical and Legal Challenges Posed by Severe Acute Respiratory Syndrome: Implications for the Control of Severe Infectious Disease Threats," Journal of the American Medical Association 290 (2003): 3229-37.
16. C. Ruderman, C.S. Tracy, CM. Ben- simon, et al., "On Pandemics and the Duty to Care: Whose Duty? Who Cares?" BMC Medical Ethics 7, no. 1 (2006): E5;
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18. S.E. Straus, K. Wilson, G. Rambaldini, et al., "Severe Acute Respiratory Syndrome and Its Impact on Professionalism: Qualitative Study of Physicians' Behavior During an Emerging Healthcare Crisis," BMJ 329 (2004): 83;
19. D. Godkin and H. Markwell, The Duty to Care of Healthcare Professionals: Ethical Issues and Guidelines for Policy Development (Toronto, Ontario, Canada: University of Toronto Joint Centre for Bioethics, December 2003);
20. G.C. Alexander and M.K. Wynia, "Ready and Willing? Physicians' Sense of Preparedness for Biotetror- ism," Health Affairs 22 (2003): 189-97;
21. S. Huber and M.K. Wynia, "When Pestilence Prevails ⋯ Physician Responsibilities in Epidemics," American Journal of Bioethics 4, no. 1 (2004): W5-W11;
22. P.A. Singer, S.R. Benatar, M. Bernstein, et al., "Ethics and SARS: Lessons from Toronto," BMJ 327 (2003): 1342-44;
23. R. Jones, "Declining Altruism in Medicine" (Editorial), BMJ 324 (2002): 624-25;
24. M.W. Chaffee, "Making the Decision to Report to Work in a Disaster: Nurses May Have Conflicting Obligations," American Journal of Nursing 106, no. 9 (2006): 54-57;
25. D.K. Sokol, "Virulent Epidemics and Scope of Healthcare Workers' Duty of Care," Emerging Infectious Diseases 12 (2006): 1238-41.
26. Pandemic Influenza Working Group, Stand on Guard for Thee: Ethical Considera tions in Preparedness Planning for Pandemic Influenza (Toronto, Ontario, Canada: University of Toronto Joint Centre for Bioethics, November 2005), http://www.utoronto.ca/jcb/home/documents/pandem- ic.pdf;
27. L. Reid, "Diminishing Returns? Risk and the Duty to Care in the SARS Epidemic," Bioethics 19 (2005): 348-61.
28. See also University Health Network, University of Toronto, "SARS Key Learnings from the Perspective of the University Health Network: Notes for the Campbell Commission," http://www.uhn.ca/About-UHN/what-is-UHN/docs/ campbell-presenta- tion-100103.pdf (accessed June 2, 2007). The entire Campbell Commission report on the Canadian SARS experience can be found at http://www.sarscommission.ca/report/index.html.
29. Solidarity as a value might also be characterized as an alternative to an exclusive focus on individual rights and choices; see, for example, S.R. Benatar, A.S. Daar, and PA. Singer, "Global Health Ethics: The ationale for Mutual Caring," International Affairs 79 (2003): 107-138.
30. While quarantine may be the first disease containment strategy that comes to mind, experts on emerging infections such as avian influenza argue that generally more effective strategies might be decreased social mixing and increased social distancing, such as closing large public gathering places, schools, and so forth. Civil confinement, including quarantine, would be a more intrusive measure to be restricted to special needs. See, for example, L.O. Gostin, "Public Health Preparedness and Ethical Values in Pandemic Influenza," in The Threat of Pandemic Influenza: Are We Ready? Workshop Summary, ed. S.L. Knobler, A. Mack, A. Mahmoud, and S.M. Lemon (Washington, D.C.: National Academies Press, 2005), 357-71.
31. Singer et al., "Ethics and SARS"; Sokol, "Virulent Epidemics"; E.J. Emanuel, "Do Physicians Have an Obligation to Treat Patients with AIDS?" New England Journal of'Medicine 318 (1988): 1686-90.
32. Reid, "Diminishing Returns?" Reid herself speaks less of "solidarity" and more of broad vs. narrow social contracts, virtues, and just systems. Nevertheless, we believe that the term is apt.
33. Reid, "Diminishing Returns?" 359. The Canadian SARS Commission agreed: "The health system's capacity to protect its workers was in a state of neglect. ⋯ There was no system in place to prevent SARS or to stop it in its tracks. The only thing that saved us from a worse disaster was the courage and sacrifice and personal initiative of those who stepped up-the nurses, the doctors, the paramedics and all the others- sometimes at great personal risk, to get us through a crisis that never should have happened. Underlying all their work was the magnificent response of the public at large: patient, cooperative, supportive." SARS Commission Executive Summary: Spring of Fear, volume one, 2-3, http://www.sarscom-mission.ca/report/vl- pdf/Volumel.pdf (accessed June 2, 2007).
34. Reid, "Diminishing Returns?"
35. Pandemic Influenza Working Group, Stand on Guard for Thee.
36. Chaffee, "Making the Decision to Report"; B.P. Ehrenstein, E Hanses, and B. Salzberger, "Influenza Pandemic and Professional Duty: Family or Patients First? A Survey of Hospital Employees," BMC Public Health 6 (2006): 311.
37. McCullough, "The Physician's Virtues."
38. The OSHA report notes that current assumptions used for a national pandemic influenza strategy include a 30 percent attack rate across the United States. Of those who are ill, half will seek medical attention, and they will have a work absentee rate of up to 40 percent. The report seems to view the 40 percent absentee figure as applying to health care workers along with the rest of the population. OSHA, Pandemic Influenza Preparedness, 37-38.
39. Godkin and Markwell, The Duty to Care.
40. Huber and Wynia, "When Pestilence Prevails," W9.
41. Ibid.
42. M.A. Rothstein, M.G. Alcalde, N.R. Elster, et al. Quarantine and Isolation: Lessons Learned from SARS. A Report to the Centers for Disease Control and Prevention (Louisville, Ky.: University of Louisville School of Medicine Institute for Bioethics, Health Policy and Law, November 2003), http://louisville.edu/bioethics/public-health/SARS.pdf;
43. L.M. Hall, J. Angus, E. Peter, et al. "Media Portrayal of Nurses' Perspectives and Concerns in the SARS Crisis in Toronto," Journal of Nursing Scholarship 35 (2003): 211-16;
44. D. H-C. Hsin, "SARS: An Asian Catastrophe Which Has Challenged the Relationships between People in Society-My Experience in Taiwan," Eubios Journal of Asian and International Bioethics 13 (2003):106-8.
45. Reid, "Diminishing Returns?" 354.
46. Bellagio Group, "The Bellagio Meeting on Social Justice and Influenza. Bellagio Statement," (Baltimore, Md.: Johns Hopkins Berman Institute of Bioethics, July 2006), http://www.hopkinsmedicine.org/ bioethics/bellagio/statement.html.
47. D.P. Eisenman, K.M. Cordasco, S. Asch, et al., "Disaster Planning and Risk Communication with Vulnerable Communities: Lessons from Hurricane Katrina," American Journal of Public Health 97, Suppl. 1 (2007): S109-S115.
48. M. Shuchman, "Improving Global Health-Margaret Chan at the WHO," New England Journal of Medicine 356 (2007): 653-56, at 655.
49. J. Rawls, A Theory of Justice (Cambridge, Mass.: Harvard University Press, 1971), 75-83.
50. P. Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley, Calif.: University of California Press, 2003): 139-59.
51. Bellagio Group, "Bellagio Statement."
52. Pandemic Influenza Working Group, Stand on Guard for Thee.
53. American observers of the Canadian SARS experience have emphasized the importance of trust: "When containment measures such as quarantines must be put in place, establishing the trust of the public is crucial to their effectiveness. Social cohesion and compliance with the SARS quarantine in Toronto, for example, has been attributed in part to a combination of clear communication and practical guidance by public health authorities." Learning from SARS: Preparing for the Next Disease Outbreak. Workshop Summary, ed. S. Knobler, A. Mah- moud, S. Lemon, et al. (Washington, D.C.: National Academies Press, 2004), 207.
54. J. Kotalik, "Preparing for an Influenza Pandemic: Ethical Issues," Bioethics 19 (2005): 422-31.
55. Trust for America's Health, Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism (Washington, D.C.: Trust for America's Health, December 2006), http://healthyamericans.org/reports/ bioterror06/BioTerrorReport2006. pdf.