Introduction
The Ebola virus disease (EVD) epidemic originating in West Africa has, as of May 31, 2015, seen 27,181 patients and 11,162 deaths in nine countries (1). These deaths, overwhelmingly concentrated in Guinea, Sierra Leone, and Liberia, signal a disease outbreak more deadly than all other EVD outbreaks combined since the virus’ emergence in 1976 (1). The current outbreak has been complicated by a novel geographic spread, and the virus’ flourishing in urban environments. However, behind these novel issues, familiar themes from past outbreaks carry through to the present day: severe resource deprivation in those counties most affected by the outbreak, underfunded global health infrastructure, and an often lethal distrust of health care workers (HCWs) (2). As the outbreak subsides, medical and public health professionals should reflect on the lessons provided—often at considerable cost—by the outbreak and use them to inform future outbreak responses. This need to adapt has gained significance given the recent outbreak of Middle Eastern respiratory syndrome coronavirus in South Korea, infecting 182 and involving the contact tracing of thousands (3).
HCWs represent a small but significant number of infections and deaths from EVD. According to recent World Health Organization (WHO) reports, of 869 HCWs contracting EVD in the three worst affected countries, 507 have died: a proportion of fatal cases among HCWs of 58.34%. This figure is, thus, significantly higher than the base population proportion of fatalities reported by the WHO for this outbreak of 41.5%. Although the absolute number of HCW infections of EVD is small, a back of the envelope calculation indicates that the odds of dying after contracting EVD are almost two times that of non-HCWs (odds ratio, 1.90; 95% confidence interval, 1.65 to 2.19) (1). Although it is likely that the true proportion of fatalities in the general population is likely higher and thus, the odds ratio for HCWs is lower, this is a compelling indication of the kind of danger in which HCWs find themselves in the context of the outbreak.
Developed countries present a frightening, albeit empirically divergent picture of the outbreaks. The infection of two nurses at Texas Health Presbyterian Hospital in Dallas, Texas after the exposure of 76 staff to EVD (4) illustrated the vulnerability of HCWs to EVD in a resource-rich setting. These two pictures, although worlds apart, have created a justified concern about the considerable risks that HCWs can take in treating patients with EVD.
Spurred by these concerns, the author was invited to present at an ad hoc panel on EVD preparedness at the American Society for Nephrology (ASN) Kidney Week 2014 meeting in Philadelphia, Pennsylvania to outline the ethical considerations informing a physician’s duty to treat patients with EVD. It was argued that, as professionals in service of providing a moral public good (health care), physicians and other HCWs had particular professional duties—to patients, colleagues, and community—that may produce conflicts between professional duties or as professional duties intersect with more general duties to one’s own wellbeing or family. The argument was given that, despite these conflicts, there is a general presumption in favor of treating patients with EVD and that strategies exist to enable HCWs to better respond to these crisis moments in ways that align with a professional’s various duties.
What follows is a summary of those arguments. First, we delineate what constitutes an epidemic and why they have special ethical significance in terms of patient care. Second, an account of profession role morality is given along with the kinds of conflicts between professional and other duties that may arise in the context of HCWs responding to a public health emergency, such as an epidemic. Third, strategies to design ethics into professional roles and institutions are given to prevent or mitigate the effects of conflicts between the duty to treat and other professional and personal commitments in future outbreaks.
Epidemics and Emergency Health Care
Severe infectious disease epidemics are a paradigm of a public health emergency. Epidemics are, in the broadest of terms, disease events clearly in excess of the expected incidence of disease occurring from a single or propagated source (5). Public health emergencies are understood in a variety of ways; the most salient definition in the context of the 2013–2015 EVD epidemic is the Public Health Emergency of International Concern (PHEIC), which is “an extraordinary event which is determined, as provided in the International Health Regulations, 2005: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordinated international response” (6).
Not all epidemics are public health emergencies, and certainly, they are not all PHEICs: the recent measles outbreak in the United States is concerning (7) but not an emergent event requiring a coordinated international response. Not all public health emergencies, moreover, need be epidemics—the PHEIC declared around the violent resistance to polio vaccination in Pakistan, hindering the eradication of the disease, concerns an endemic disease. At the intersection of these two phenomena, however, is emerging infectious disease outbreaks that threaten national, regional, and potentially, even global health security. The EVD outbreak is one such example.
Public health emergencies are immensely and tragically disruptive events. Public health and safety services are depleted past their breaking point. Social mistrust becomes rife, and the morale and mental health of community members suffer, particularly as political measures to break disease transmission, such as isolation and quarantine, are used (8). The effects of unexpected ancillary disruptions, such as natural disasters, power outages, or civil unrest, are exacerbated by public health emergencies. Also—potentially more deadly than the emergency itself—endemic illnesses in a community afflicted by a public health emergency can rage through populations as subepidemics.
In the midst of an epidemic, HCWs experience the bulk of contact with patients, and thus, incur substantial risks. These risks were intensified by not only a relative shortage of HCWs in the context of the West African outbreak but also, an absolute scarcity of HCWs in the region: Guinea has 10 HCWs per 100,000 people compared with the United States, which has 245 HCWs per 100,000 people. Risks were further exacerbated by a lack of supplies, such as personal protective equipment (PPE), and basic resources, such as power or water. This led to staggering numbers of deaths and the depletion of a health care system that will scar Guinea, Sierra Leone, and Liberia for years to come. In particular, the loss of HCWs in these communities is particularly devastating, because there were so few to start.
In contrast, HCWs in resource-rich nations face different pressures. The treatment of patients suffering from EVD at Emory showed the plentiful resources at a medical team’s disposal when dealing with isolated patients. What it also showed, however, was the lack of knowledge about what works—and what does not—in determining an appropriate clinical response to EVD (M. Connor, personal communication). This and a lack of institutional capacity in large, complex health care systems to react to emerging infectious disease outbreaks leave HCWs vulnerable to illness through the treatment of patients.
Across the globe, albeit with different reasons, HCWs lack the training, equipment, people power, expert knowledge, and institutional capacity to respond to public health emergencies involving high–mortality infectious diseases (9,10). A question that arises in the context of this state of insecurity then is to what degree HCWs are obligated to treat patients suffering from highly virulent infectious diseases given the high risk to themselves and the relative and absolute shortage of HCWs in a public health emergency. This issue, known as the duty to treat, is a consistent theme when public health emergencies challenge conventional norms of health care. We identify the ethical foundations of the duty to treat in the status of HCWs as professionals (11) and develop the limits of the duty further in the next section.
This theme has appeared in the background of the dominant public health emergencies over the last 40 years. Most prominent were debates about a physician’s obligation to treat in the context of HIV/AIDS (12), Severe Acute Respiratory Syndrome (13,14), and pandemic influenza (15). In each case, an emergent infectious disease outbreak prompted HCWs and physicians in particular to question whether there was a duty to treat patients suffering from these illnesses.
However, in each of these cases, it was determined that there was a presumption in favor of a duty to treat. Emanuel (16), writing on the HIV/AIDS outbreak, noted that three factors determine the risk of infection of HCWs with HIV: “the risk of becoming HIV positive from a single contaminated needle stick, the proportion of patients treated who are HIV positive, and the frequency of needle-stick injuries and other exposures” (16). Emanuel (16) concludes that, under normal circumstances, the risks arising from these factors are marginal. Emanuel (16) notes, however, that there might be four general cases in which the duty to treat is limited by competing considerations: excessive risks, questionable benefits, obligations to other patients, and obligations to self and family. Emanuel (16) also notes that broader issues—for example, the number of patients with HIV/AIDS that an HCW treats over time—may generate competing considerations and that it is incumbent on society to mitigate the risks that HCWs face (16).
The accounts by Emanuel (16) and indeed, most others provide a plausible starting point for an inquiry into the duty to treat. The duty to treat exists, but it is not the only—or the most important—thing that matters. It may, thus, be outweighed by other competing ethical considerations.
We have reason to believe that—at least in resource-rich environments—nephrology procedures performed on individuals who present with EVD, on the face of things, can be made safe enough that the presumption of a professional duty to treat applies. The Centers for Disease Control (CDC) provide guidance on the safe use of acute hemodialysis, including specific methodologies, equipment, PPE, and disposal of waste products (17). In asking whether RRT could be provided to patients with EVD without infecting HCWs, Wolf et al. (18) noted that “although treatment of patients with EVD does entail inherent risk to health-care workers, meticulous training and adherence to protocol can allow health-care workers to provide effective care to patients with EVD while minimizing their own risk” (18). Connor et al. (19), likewise, note that RRT can be provided safely to patients as long as attention and care are paid to patient, HCW, and community safety. Although both leave open the possibility that some case could exist to outweigh the duty to treat, these works establish a strong presumptive case that RRT can be safely administered to patients with EVD given a sufficiently high standard of safety in treatment (18,19).
The conceptual basis for discussions on the duty to treat is the idea of a professional. The conceptual architecture of this idea is, however, often eschewed. Although basic considerations of risks are important, understanding the normative basis of the duty to treat allows us to better understand against what we are weighing risks. Professionals are first and foremost stewards and promoters of moral public goods—this generates their duty, their autonomy, and many of the conflicts that arise in emergent scenarios.
Medical Professionals and the Duty to Treat
The literature on professional ethics is vast, and its connection to bioethics is long standing (20). Here, we present a particular account of what and who professionals are in virtue of their relation to a social institution with a particular moral end. Unlike some accounts of professions, which define professions in relation to a particular set of internal characteristics (21), this account defines professions in terms of the externally imposed ends on a group of individuals who occupies roles of special moral importance to a community (11). This model of professions has been defended elsewhere for scientists (as academic researchers) (22) and warfighters (in the “profession of arms”) (23); physicians are less controversial examples of profession, and therefore, we present this account of professionals without excess justification.
The clergy is, arguably, the original profession, and although the church’s influence in the context of important social institutions (a single statewide religion) has waned, their position inspired conceptual models of professions. Physicians and lawyers were the next groups to occupy professional roles. Most recently, engineers and architects have argued for professional status.
Five conditions describe professionals:Physicians, on this account, are not the only professionals who promote the public good of health. Registered nurses, Emergency Medical Technicians, and laboratory technicians are all (under this account) professional. That is because they occupy roles within the health care community that are necessary components of the social institution dedicated to promoting health as a public good, where autonomy and expert knowledge are part of the job and institutional frameworks exist to regulate the training and authorization of these professionals.
- (1) They promote some public good.
- (2) The public good in (1) cannot be reliably secured through market transactions.
- (3) They require expert knowledge to promote this public good.
- (4) They are granted significant autonomy in performing their roles.
- (5) They exist within an institutional framework that furthers the end of promoting some public good and authorizes (including training) professionals to carry out their autonomous work (11).
A central aspect of the ethics of professionals is professional autonomy. HCWs are, in virtue of their expert knowledge and roles, able to exercise autonomy over valuable courses of treatment, selecting diagnostics to produce useful information and choosing between different clinical interventions to promote health and health care. Although qualified by the rights and autonomy of patients, this kind of professional autonomy is very different from strictly market–based enterprises, where consumer preference—largely independent of other factors—is the single deciding factor.
The counterpoint to professional autonomy is professional duty. Professional duties arise in the context of the autonomy possessed by professionals in aid of promoting some important collective good, such as health. These duties are incurred, because unlike goods promoted in market-based organizations, professionals are obliged to promote a public good as part of their role. These duties include a duty to treat patients and promote their health, a duty to the integrity of the social institutions that promote health in the community, and a duty to their colleagues as fellow occupants of a morally valuable institution.
Conflicts of Duty: Professional and Personal
Professional duties are not absolute; no single duty of an HCW as a professional is more important than any and all other considerations. Contrary to stereotypes about doctors, HCWs are not ethically obligated to spend all of their waking lives at work or act solely in the interests of their profession. They have other important duties that arise simply as humans engaged in social interactions: to family or anyone else with whom they possess a close and intimate relationship and to the world at large. These duties can and do conflict with a professional’s special duties. Moreover, one’s right to be free from harm—a right to welfare (24)—may be infringed on if undue risks are placed on HCWs.
Three general conflicts arise between the duty to treat and other concerns. The first and most common concern is when the duty to protect infringes on the right of HCWs as humans to be free from undue risk. As discussed, there is general agreement that HCWs, in virtue of their professional status, must incur some risk as a professional obligation. In a case, however, where individual HCWs are subject to excessive risks by being unable to access appropriate PPE (where such PPE is otherwise obtainable), we might think that there is an undue and avoidable amount of risk placed on HCWs. The obligation to accept risk as part of one’s professional role is not a sanction for just any degree of risk to be undertaken.
Clear-cut cases tend to belie complex details on the ground. The duty to treat a patient is clearly not tenable if expressed as you must treat a patient with EVD even if you lack sufficient PPE with which to perform your job. No one would expect, for example, a nephrologist at Emory to treat a patient suffering from EVD without the appropriate protective equipment. In fact, we could arguably say that it is unethical to do so given the risks of transmission.
A second concern is that, in resource-poor scenarios, individual duties to patients conflict with not only personal safety but special duties to promote the collective public good that medicine and health care provision supply to a community. In public health emergencies, resources are often highly limited, in both areas that have an absolute resource deprivation, and areas with capacity that cannot adjust to the relative increase in demand that a public health emergency places on health care.
Here, professional duties to promote the health and welfare of an entire community may conflict with duties to treat individuals. In other emergent situations, such as war, the rule of salvage—prioritizing care to those who can return to the front lines—provides a normative basis for assessing conflicts between duties of care and the larger objectives of war (25). In public health emergencies, the objectives may change, but the normative basis remains familiar: the need to balance the (legitimate) aims of response to a public health crisis with the norms that require HCWs to treat on the basis of need.
The need to respond to and resolve a public health emergency highlights a final concern, which is the effect that the exceptional circumstances of public health emergencies have on public trust. Sokol (26) gives us the example of 30 patients suffering from EVD in 1995 in the Democratic Republic of the Congo (formerly Zaire) left alone to die in an abandoned hospital. In the example by Sokol (26), the loss of public trust that emerged through HCW absenteeism was devastating to the community and the response effort. HCWs exist within a framework of social trust, and the breaking of this trust can break a response effort as surely as disease itself.
Designing Ethical Practice
There will be cases where the professional duties and personal commitments of HCWs will conflict. Given that we know that conflicts may occur, however, we are in a place to design ethics into our institutions to prevent or mitigate conflicts of duties (27).
A range of interventions exists to reduce the risks to HCWs and the community and help balance our ethical commitments should conflict arise when treating patients with EVD. The most pressing and actionable of these interventions is education. Ensuring that individuals are well prepared to react to patients with emergent infectious disease will substantially reduce the risks of caring for patients. For nephrologists, professional associations, such as the American Medical Association, the CDC, and the ASN, have produced guidance on the appropriate use of PPE should patients present with EVD and specific guidance for the use of techniques, such as RRT (28). These guidelines should be studied, and the health care community should be proactive in developing the skills to respond safely and efficiently to emerging infectious diseases. Moreover, the recent publication of experiences and clinical modalities for the administration of RRT (18,19) can provide a basis on which to inform clinical decision making.
This, however, is far from sufficient. Institutions need to prepare their staff for the potential arrival of a patient suffering from EVD. Although the US Government has now specified a series of 55 Ebola Treatment Centers that will act as points of care from patients suffering from EVD (29), it is far from known where a patient infected with an infectious disease will become clinically ill. As such, hospitals should prepare HCWs for response to patients who have EVD if only to develop institutional capacity against future emerging infectious diseases. Avoiding a case like the one in Dallas should be a priority for hospitals, and the best and most justified way of doing so is to prepare staff.
The creation of dedicated points of care can be replicated on the microlevel by developing dedicated response areas and personnel within hospitals and other care facilities in the event of the presentation of an individual with EVD. For nephrologists, this introduces a new consideration: the allocation of dialyzing devices to patients with EVD. Infection control guidelines require these devices to be stationed within treatment rooms away from other patients. The time during which these units will need to be isolated, moreover, will depend on the speed with which devices can be used and decontaminated. The maximum number of devices that can and should be assigned in the event of an EVD outbreak or other public health emergency should be considered.
Finally, duties to one’s colleagues mean that, where possible, HCWs should practice appropriate self-care. This includes monitoring oneself and others for signs of fatigue that could lead to lapses in infection control protocol or patient management. Professionals should also be prepared to engage with their institutions to ensure that personnel numbers and shift length are such that a balance is found between limiting the number of potential exposures to infected patients and preventing avoidable accidents through understaffing, overworking, and excessive time spent in energy–intensive, high–containment PPE.
Conclusions and Implications
One of the valuable aspects of a conceptual framework, such as professionalism, is that it can shed light on the implications of our strongly held moral commitments. This enables practitioners and policymakers to determine the right course of action, even if it is not immediately obvious. Given the manageable risks to HCWs who follow internationally recognized guidelines, there exists a strong professional duty to treat patients with EVD, including dialyzing those patients who suffer from AKI as a result of their illness.
Public health emergencies, like wars, exist in a theater: the geographic context in which an event takes place. For American or other HCWs residing in resource-rich countries, it is highly unlikely that EVD will cause a public health emergency in that theater. One patient with EVD does not a public health emergency make, and there are time and resources enough to develop coordinated responses that minimize HCW risk while maximizing patient outcomes. The conflicts that arise in emergent clinical situations within a public health emergency are not immediately applicable to other scenarios just in virtue of that emergency existing somewhere.
In resource-poor theaters, conflicts of duties can occur, but the overwhelming basis for this is likely to be the tenuous nature of public trust and institutional capacity and the overwhelming need to resolve a public health emergency. Individual HCWs are likely to find themselves in untenable positions, where their rights to welfare are overshadowed by the compelling need to treat patients and respond to an outbreak. The right to welfare means little, even to the most self–interested person, if absenteeism only risks the individual more through the continuation of an emergency.
However, health care is a public good and in the age of rapid mass transit, an increasingly global public good. As the EVD outbreak wanes, the recent jump of Middle Eastern respiratory syndrome coronavirus from the Middle East to the Republic of South Korea has once more shown how quickly an outbreak can move. This means that HCWs have a duty incumbent on them to respond to public health crises a world away if they have the skills. Being a professional entails duties to one’s fellows; the HCWs of Guinea, Sierra Leone, and Liberia have been neglected in the course of this epidemic. This has cost them and their patients their lives and jeopardized the health and safety of millions. HCWs in the United States have a duty to support their colleagues abroad and make sure that the risks that any one professional takes are not fatal.
Disclosures
None.
Published online ahead of print. Publication date available at www.cjasn.org.
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