Ethical Dilemmas for Healthcare Professionals: Can We Avoid Influenza?
Ethical Concerns and an Influenza Pandemic
Who will be first to receive the new H1N1 influenza A (swine flu) vaccine when it is ready? Who will get antiviral medication if supplies run low? Does the government have the right to restrict individual liberties to contain the spread of a flu virus?
These are a few of the ethical questions that arise fast on the heels of an emerging influenza pandemic. For physicians, nurses, and other healthcare professionals (HCPs), the questions continue:
How much personal risk am I expected to assume in caring for influenza patients?
Should I risk bringing the influenza virus home to my children?
Could I lose my job or my license if I refuse to take care of influenza patients?
Will I have to work in unfamiliar areas or provide care for which I have not been trained?
When is it OK to say no?
When it's business as usual, we pretty well understand our ethical and moral obligations as professionals. But a pandemic flu is not business as usual. Widespread sickness among HCPs could result in staffing shortages, particularly among frontline staff who are the first to come into contact with infected patients. Shuffling of staff and new responsibilities are distinct possibilities. Managing the incoming influenza patients on top of our regular workload could lead to shortages of the supplies and equipment that we are accustomed to having. With a sudden or prolonged onslaught of infected patients, personal protective equipment and antiviral medication could become scarce in some areas, increasing the healthcare worker's level of risk.
Physicians, nurses, and other HCPs work hard to achieve a balance between the duties to provide care to patients and to care for self and family. In a situation like the current one, HCPs may fear that exposure to influenza could place at risk not only their own health, but also that of their children, spouses, or elderly family members. Those who are pregnant may worry about exposing their unborn children to the virus or whether they can take antiviral medication during pregnancy. HCPs who also suffer from chronic conditions that affect their ability to fight infection, be vaccinated, or take antiviral medication may face greater personal risks.
The adequacy of safeguards and conflicting obligations are the primary concerns of HCPs when considering their role in a pandemic. Another issue that may present an ethical quandary is the need to operate under different standards of care during a pandemic. Despite whether these concerns are legitimate, they could influence HCPs' decisions to go to work or stay at home during a pandemic.
Who Will Come to Work During a Pandemic?
In 2006, the US Department of Homeland Security estimated that up to 40% of the general workforce could be absent from work for periods lasting up to 2 weeks during the height of a pandemic wave. Some of these workers will be ill themselves, some will be caring for ill family members at home, some will be under voluntary home quarantine because of exposure to influenza, and others will stay at home out of concern for their own safety.
Although these estimates pertain to all US workers and not just healthcare workers, we do not have any more reliable estimates of how many healthcare workers might be absent from the workplace for similar reasons during a pandemic. Researchers have begun to specifically examine the question of whether healthcare workers would continue to perform their jobs during an influenza outbreak, and if not, why not? Some surveys have further explored whether incentives might change the HCP's mind about coming to work.
In a recent survey of 169 hospital employees (equally divided among physicians, nurses, and other hospital workers) a hypothetical question was posed to participants: In the event of a pandemic influenza involving this institution, would you report to work as usual? Half of the respondents said yes, 42% maybe, and 8% no, even if it meant loss of job. Physicians were most likely to indicate that they would go to work (74% yes) and nurses were most likely to indicate that they would not (15% no). Being married or having children did not influence the response. In regard to incentives (What would it take to change your mind?), 52% indicated that during an influenza with a 50% (very high) mortality, they would come to work for triple pay, while for 19% of survey respondents, financial incentives had no effect on the decision to stay home from work.
Other research supports the conclusion that roughly 50% of healthcare workers might have reservations, based on personal safety concerns, about showing up for work during a pandemic.[4-7] In a random survey of US physicians, although 80% indicated their willingness to treat patients during an outbreak of an unknown but potentially deadly illness, only 55% agreed that physicians had an obligation to care for such patients even if it endangered the physicians' health.
Hypothetical situations don't always translate to the real world. Asking HCPs how they are likely to act in a given situation could prompt primarily socially desirable responses. Individuals could act quite differently during a real pandemic.
Physicians, nurses, and respiratory therapists are not the only healthcare workers at risk during an influenza pandemic. Many other healthcare workers -- both professional and nonprofessional - come into close, or even closer, contact with patients. The laboratory technician, the nursing assistant, the admissions clerk, and the pastoral care provider, to name a few, all face increased risk as a consequence of their interactions with infected patients, and all of these individuals are vital to an effective pandemic response.
The Professional's Duty During a Pandemic
In 2003, an infectious disease specialist was consulted about a patient with an unusual influenza-like illness. The specialist, Dr. Carlo Urbani, evaluated the patient and subsequently helped the hospital deal with what appeared to be an epidemic of similar patients infected with an unknown virus. Within a few weeks, Dr. Urbani and 5 colleagues were themselves victims of SARS, a much deadlier virus than the H1N1 virus that is responsible for the current influenza epidemic. What happened to Dr. Urbani and others who lost their lives after caring for influenza patients illustrates the difficulty of attempting to base the HCP's duty to treat on the level of anticipated risk. The risk to HCPs is often unknown when a novel virus or unidentified illness appears. By the time data regarding virulence and mortality rate are known, many HCPs have already been exposed.
HCPs who are on the fence about how much personal risk they will accept during an influenza pandemic might find it useful to review their professional codes of ethics. These codes address the duty to care or treat when the HCP perceives elevated risk to their own health. For example, the American Nurses Association (ANA) states that:
Nurses are obligated to care for all patients; however, in certain situations the risks of harm might outweigh a nurse's moral obligation or duty to care for a given patient. There are limits to the personal risk of harm nurses can be expected to accept. Accepting personal risk exceeding the limits of duty is not a moral obligation; it is a moral option. 
Furthermore, according to the ANA, the nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety. To resolve this, the nurse must engage in critical thinking and ethical analysis. For example, caring for a patient with an infectious disease that may place the nurse at risk for harm is a moral duty rather than a moral option if all of the 4 following criteria are met: (1) the patient is at significant risk for harm, loss, or damage if the nurse does not assist; (2) the nurse's intervention or care is directly relevant to preventing harm; (3) the nurse's care will probably prevent harm, loss, or damage to the patient; and (4) the benefit that the patient will gain outweighs any harm that the nurse might incur and does not present more than an acceptable risk to the nurse. The nurse must base the assessment of risk on objective, current, and scientifically sound information.
The American Medical Association (AMA) updated its code of ethics in 2004:
National, regional and local responses to epidemics, terrorist attacks and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future. 
Admittedly, professional codes can be ambiguous and open to various interpretations and may fail to offer the guidance sought by the HCP.[13,14] Codes of ethics can't factor individual or unique circumstances into the equation. Employment contracts may be no better if they don't specifically address emergency situations such as an influenza pandemic. Sokol believes that the phrase duty to care is too vague because its limits are undefined. It is also ethically dangerous, for it could be used to pressure healthcare workers into working in circumstances that they consider morally, psychologically, or physically unacceptable. Moreover, it is likely that no single, accepted view of duty to care exists.
The time to decide one's level of commitment in the face of threats to personal safety is not during a public health emergency but before such an emergency occurs. A "conscientious objection" to caring for certain patients must be communicated in advance and in time for alternate arrangements to be made for patient care. The professional is obliged to provide for the patient's safety, to avoid patient abandonment, and to withdraw only when assured that alternative sources of care are available to the patient, for if the HCP steps out in a time of crisis, who will step in? Who will be able to? The risks will rise -- both for the individual who lacks the proper education and skill to provide care, as well as for the patient who needs care.
Besides professional codes and employment obligations, HCPs have what amounts to a "social contract" to provide care to the public in times of emergency.[10,16-18] This unwritten understanding with society is what makes nursing and medicine professions rather than jobs. Nancy Berlinger, PhD, Deputy Director and Research Scholar at the Hastings Center, a bioethics research institute, reminds us that we freely chose to become health professionals. We acquired the education, training, and experience that now place us in the position of competent caregivers, and society expects us to fulfill this role. That our abilities are well beyond those of the general public increases this obligation to provide care in a crisis situation, and the more unique our knowledge and skill, the more important it is for us to become involved. It is this very act that engenders the high level of trust and respect that society holds for HCPs.
When we became HCPs, we knew that the personal risks of our professions were greater than those of the many other professions we might have chosen. By becoming HCPs, we implicitly assumed these risks, whether or not we consciously considered them. "Health professionals can't be fair-weather carers," cautions Berlinger.
Some HCPs might argue that although they did accept a certain level of risk in choosing a health profession, they did not imagine that circumstances might deny them any choice about how much risk they would take. Others might argue that their personal situations have changed -- that when they became health professionals, they didn't have spouses, children, or elderly parents who depended on them. "Everyone has competing interests," acknowledges Berlinger. "But when personal considerations such as family conflict with professional responsibilities, it would be very precarious for society if health professionals always chose their personal interests over society's."
Is the "social contract" still applicable in a world where heretofore unimagined acts of terrorism, extreme natural disasters, and emerging infectious diseases pose such frequent and novel risks to HCPs? Shouldn't the social contract be reevaluated and renegotiated from time to time? Public expectations must be realistic if we are to be able to convince young people to pursue careers in the health professions. Otherwise we will need new models of healthcare for disasters and emergencies, in which responders, treaters, and caregivers willingly accept and are compensated for the considerably higher risks that they incur. In the military, this is known as combat pay.
Doing the Right Thing During a Pandemic
Loss of job and disciplinary action by regulatory agencies are 2 of the possible consequences of refusing to care for or treat influenza patients, and both occurred in the wake of the SARS epidemic. Health professionals who have employment obligations can't expect to walk off the job with impunity. Legal enforcement, however, is not the preferred way of encouraging courageous action. Fortunately, the threat of sanctions probably won't be necessary to keep most HCPs working during a pandemic. On the contrary, altruism, solidarity, and the social rewards of knowing that they risked their own health to save patients and to support their coworkers have proved, in the past, to be sufficient inducement for most professionals.
History indicates that far more HCPs run toward danger than away from it, even when running away might be ethically justifiable. Matthew K. Wynia, MD, MPH, FACP, Director of the AMA Institute for Ethics, believes that "ultimately we can rely on people to do the right thing for their communities. With a 50% mortality rate, most people still went to work during the SARS epidemic. On 9/11, we were inundated with calls from healthcare professionals who wanted to help -- more than we could possibly use. In extraordinary situations, people tend to pitch in and do whatever they can."
How about the nurse who fears being required to pitch in on an unfamiliar floor, with unfamiliar types of patients and treatments? Should he or she be worried about being sued if a mistake is made? "We can never be 100% certain that people won't sue," acknowledges Wynia. "But there isn't a jury in the country that would convict a health professional who made a good faith effort to help in a crisis, particularly when the situation would have been worse without the health professional's actions. Some states have Good Samaritan laws that specifically protect health professionals under these circumstances."
Berlinger agrees. "You might be asked to do your job differently during an emergency, but no one is going to put you in a situation where you don't have the necessary skills." She often hears this type of question from nurses. "They tend to imagine the scariest thing that could possibly happen and put themselves into that situation. They need to have confidence that the institution has a plan to handle the crisis."
Reciprocal Responsibilities: Employer and Employee
The world has been anticipating and planning for a pandemic influenza for some time now, as evidenced by numerous articles and scores of pandemic influenza plans created over the past 5-10 years. It is inconceivable that HCPs in current practice could fail to be aware of the potential for a major infectious breakout or of the increased risk that they will probably have to shoulder if one occurs. Knowing this, HCPs should have considered issues related to personal risk long before the first case of illness caused by H1N1 virus was confirmed last month. The good news is that today's HCPs have more knowledge and personal protections at their disposal than at any other time in history; being forewarned is being forearmed.
However, some pandemic influenza plans and strategies may have missed the boat when it comes to preparing healthcare workers for the psychological and emotional challenges of a pandemic. Although these plans usually involve educating staff about infection-control practices, it is unclear whether such education extends to open and honest conversations regarding the real risks that staff will be asked to face during a pandemic and the precise steps that will be taken to reduce these risks. If HCPs are questioning their role during a pandemic or expressing doubt about even coming to work, trust may be missing from the employer-employee relationship. There are indications that HCPs who are confident that their employers have a realistic grasp of the risks and are taking steps to minimize them have fewer reservations about responding to the call to duty during an influenza.
HCPs want assurance that the institution will take appropriate steps to protect and support them and that both the benefits and burdens will be shared equitably. Considerations include:
Sufficient supplies of effective personal protective equipment, such as properly fitting N95 respirator masks (or better filtering masks), goggles, the means to effectively isolate or cohort infected patients, hand hygiene supplies at point of care, and showering facilities;
Policies regarding handling of influenza patients;
Access to vaccination (when available) and antiviral agents active against the virus causing the pandemic for HCPs and their families; and
Treatment and care for HCPs if they become infected and also for family members to whom HCPs transmit the infection.
Hospitals and other facilities must also reassure HCPs with special vulnerabilities (comorbid/chronic illness, allergy to vaccine, contraindications to antiviral drugs) that these issues are recognized and will be taken into consideration. Pregnant women should follow the Centers for Disease Control and Prevention's Considerations for Pregnant Women
In turn, HCPs are responsible for understanding what is going on, separating fact from fiction, educating the public, and planning ahead so that their families are provided for in case a public health crisis requires them to be away from home. HCPs must also take responsibility for protecting themselves. Currently a mere 40% of HCPs get an annual influenza vaccine. Perhaps one positive outcome of the current influenza outbreak will be a higher rate of seasonal influenza vaccination among HCPs.
Standards of Care During a Pandemic
Most of the time, we regard standards of care as inflexible, and it is our duty to uphold them. An emergency such as a pandemic influenza, which can rapidly overwhelm healthcare resources, can necessitate operating under different standards of care, and this can present an additional ethical dilemma to healthcare providers. Under emergency conditions, if changes to usual operating procedures are not made, there could be even greater loss of life.
The framework for standard of care during an emergency can shift from one that focuses on the individual to one in which the clinical goal is the greatest good for the greatest number of individuals. During a bona-fide emergency with scarce resources, we might have to accept the concept of "sufficient care" in place of "quality care," a shift in thinking that may be difficult for some nurses. For example, during an emergency, we might have to delegate tasks to others (such as students or family members) that would ordinarily be the responsibility of the healthcare professional. Patients might be sent home who would normally be admitted for care. Ventilators and other equipment typically available to all who need it might be allocated to those with the greatest chance of survival.
The current epidemic of H1N1 virus is, so far, nowhere near as dangerous as the SARS epidemic of 2003, and today we are far better prepared to protect professionals and mitigate the effects of the virus than we were in 2003. Given what we do know about influenza viruses, it is too early to be certain of the outcome but we can't afford to become complacent. Influenza tends to occur in waves of approximately 6 weeks, and even if this wave appears to fizzle, it could come back with greater virulence.
HCPs who are considering not working (and who have this option) during an influenza breakout need to realize that their absence from work, and possible lack of income, could be prolonged. It makes far more sense to go to work and take all necessary precautions to protect oneself from influenza. Staying away from the hospital or clinic only reduces part of the individual's risk of contracting influenza.
The H1N1 virus is just the latest in a long list of threats to the well-being of HCPs. The next communicable disease outbreak could be much worse than this one, but hopefully we are learning from every new infectious disease and will find more ways to decrease the risk to HCPs. In the meantime, the only way to avoid all risk in healthcare is to change careers.
Healthcare Professionals and Influenza: The Bottom Line
Without HCPs, the current influenza outbreak might already have evolved into a pandemic. By virtue of their specialized knowledge and training, physicians, nurses, and other professionals have an obligation to respond to public health crises like influenza, and history suggests that most will fulfill these obligations. After all, physicians, nurses, and other HCPs have family members and friends who might also become infected and would certainly want these individuals to be properly cared for should the need arise. Treating and caring for influenza sufferers poses increased risk to the health of professionals, but ultimately the level of acceptable risk is a matter of personal choice.
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