By Daniel Sokol
Are healthcare workers ever justified in abandoning their patients during epidemics of severe disease?
Sars put Canadian health workers at potential risk
On 4 June 2003 outside a large hospital in Toronto, Canada, hundreds of nurses clamoured for better protection against the deadly Sars respiratory virus.
With high exposure and low protection, many of the victims of Sars were health care workers.
For a long time, health workers wore surgical masks that blocked only 50% of the airborne pathogen.
These were eventually replaced by N95 masks, which have a 95% filter efficiency.
The psychological impact of severe infectious diseases on medical staff is still poorly understood
In at least one hospital, the management told staff to remove their masks, on the grounds that they were unnecessary and frightened the public.
Deaths followed, and the masks were back, blocking the virus and angry, anxious faces.
A month later, I arrived in Toronto to work as an Intern in Clinical Ethics in a major hospital.
On the streets of the city, one could buy T-shirts saying "I survived Sars, West Nile, Mad Cow, Sars (again!)", alluding to recent epidemics and the two waves of the Sars outbreak.
Although the epidemic had just been declared over, two people died from the disease during my four-week stay in Toronto.
At the hospital, masked staff squirted alcohol gel on the hands of every visitor.
On each visit, I was subjected to a mini-interview ("how are you feeling today?") and the insertion of a thermometer in my ear. The spectre of Sars remained.
In an epidemic of infectious disease, the last place to be is in a hospital.
It is where most of the victims of Sars caught the virus.
Aware of this fact and of the possibly fatal outcome of infection, some health care workers experienced high levels of psychological stress.
Many were stigmatized in the community. Some were denied taxi rides by frightened drivers or were refused day care for their children.
The psychological impact of severe infectious diseases on medical staff is still poorly understood.
In 1976, in a London hospital, four doctors caring for an Ebola patient experienced 'phantom' symptoms.
They developed flu-like symptoms and stomach pains. Antibody studies revealed no infection.
Doctors and nurses have a special obligation to benefit their patients - but that this obligation has limits
In 2000, during an outbreak of Ebola in a leading hospital in Uganda, 400 health care workers mutinied and assembled in protest, calling for the closure of the hospital.
Dr Matthew Lukwiya, a medical director who later died of the disease, persuaded them to stay.
Yet he too was aware of the perils of working in such an environment, and his hospital colleague, junior doctor Yoti Zabulon, recalled an ominous conversation with Dr Lukwiya: "One time he told me 'my God, Dr Yoti, we're going to die on duty one of these days!'."
Dr Yoti told of the conditions in the isolation ward of the hospital: "You can imagine 69 people, seriously sick, some running up and down, bleeding, vomiting, having diarrhoea with high fever, crying with aches, and you are two doctors on duty, with less than ten nurses. It was so dramatic!"
In such chaotic and exhausting conditions, precautions are sometimes overlooked by medical personnel.
Doctors died during the Uganda ebola outbreak
Dr Lukwiya's death is believed to have occurred through an uncharacteristic lapse: on the night of November 20, he wore no protective goggles when caring for a heavily bleeding patient.
In the corridors of my Canadian hospital, posters praised the heroic work of the healthcare workers.
As I met doctors and nurses who had survived the disease, heard their stories of treating patients who only hours before had been colleagues, of the stigma and fear of infecting themselves and loved ones, of the refusal of some medics to go to work, I asked myself if doctors and nurses could ever justifiably forego their 'duty of care' and abandon their patients?
And, if so, in what circumstances is it acceptable? With the anticipated arrival of bird flu on our shores, these questions are as relevant as ever.
My answers to these questions were published earlier this month in Emerging Infectious Diseases, a journal published by the Centers for Disease Control in the United States.
I argue that doctors and nurses have a special obligation to benefit their patients - an obligation that the rest of us do not have - but that this obligation has limits.
It is not clear to me why their duties as a doctor should always trump their duties as a parent
A doctor has no obligation to donate one of his kidneys to a patient awaiting a kidney transplant, for example.
I suggest that the limits of the duty depend on the normal risk level of the healthcare professional's working environment.
A doctor working in Uganda might have to endure more risk than a doctor in a hospital in Devon.
Another factor is the healthcare worker's specialty.
During a Sars or bird flu epidemic, infectious disease specialists, as a result of their training and their implicit consent to deal with such diseases when entering the specialty, will have stronger obligations to treat than dermatologists.
The strength of the duty will be also be affected by how much good the healthcare worker can bring about (including reducing patients' pain or emotional distress) and the level of personal risk.
Doctors and nurses have multiple roles. They are not only healthcare professionals, but parents, spouses, siblings, and so on.
These roles also carry responsibilities which can impact on their duties as healthcare workers.
It is not clear to me why their duties as a doctor should always trump their duties as a parent.
Would trust go?
Finally, I address the question of trust.
Will patients lose trust if doctors abandon their patients? I suggest 'not necessarily'.
Imagine a lifeguard who spots a person drowning 20 metres away from the beach.
Clearly, we would expect the lifeguard to attempt a rescue. After all, that's his job.
Now, imagine he spots a person drowning 200 metres away and, to make matters worse, that this unfortunate fellow is surrounded by a school of man-eating sharks.
Does he have an obligation to dive in, even if there is a very slight chance of rescuing the drowning man?
Would the public lose trust if the lifeguard decided against the heroic feat? I believe not, and neither would we lose trust in doctors or nurses who abandon their patients in certain, exceptionally risky circumstances.
But the question remains: how risky is too risky?
The only way to address this thorny issue is for a dialogue between the public and the medical profession.
Daniel Sokol is a medical ethicist at the Imperial College Faculty of Medicine, London.
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