Surviving SARS, Preparing for Pandemics: Ethics, Infectious Diseases and Modern Health Care Organizations

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Surviving SARS, Preparing for Pandemics Ethics,
Infectious Diseases and Modern Health Care
Organizations

• Ross E.G. Upshur,
• BA(HONS), MA, MD, MSc, CCFP, FRCPC
• Director, Joint Centre for Bioethics
• Canada Research Chair in Primary Care Research
• University of Toronto

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Objectives

• In the aftermath of SARS and in anticipation of
  an influenza pandemic
• Appreciate ethical principles and concepts
  relevant to understanding infectious disease
  outbreaks in modern health care organizations,
• Understand the complex relationship between self
  and other regarding acts in the care of patients
  with infectious diseases,
• Understand the silences and gaps in current codes
  of ethics in setting expectations for health care
  professionals in infectious disease outbreaks.

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Overview of Presentation

1. The past and present context
2. Ethics and Infectious Diseases
3. The Challenges of the Duty to Provide Care During
   Infectious Disease Emergencies
4. Preparing for the Pandemic
5. Conclusions

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Plague of AthensThucydides

• Neither were the physicians at first of any
  service, ignorant as they were of the proper way
  to treat it, but they died themselves the most
  thickly, as they visited the sick most often nor
  did any human art succeed any better.
  Supplications in the temples, divinations, and so
  forth were found equally futile, till the
  overwhelming nature of the disaster at last put a
  stop to them altogether.

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Prayer of Separation

• I forbid you to ever enter a church, a monastery,
  a fair, a mill, a market or an assembly of
  people. I forbid you to leave your house unless
  dressed in you recognizable garb and also shod. I
  forbid you to wash your hands or to launder
  anything or to drink at any stream or fountain,
  unless using your own barrel or dipper. I forbid
  you to touch anything you buy or barter for,
  until it becomes your own. I forbid you to enter
  any tavern and if you wish for wine, whether you
  buy it or it is given to you, have it funneled
  into your keg. I forbid you to share house with
  any woman but your wife. I command you, if
  accosted by anyone while travelling on a road, to
  set yourself down-wind of them before you answer.
  I forbid you to enter any narrow passage, lest a
  passerby bump into you. I forbid you, wherever
  you go, to touch the rim or the rope of a well
  without donning your gloves. I forbid you to
  touch any child or give them anything. I forbid
  you to drink or eat from any vessel but your own.

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The Plague DiariesDaniel Dafoe

• So the plague defied all medicines the very
  physicians were seized with itmen went about
  prescribing to others and telling them what to
  doand they dropped down dead, destroyed by that
  very enemy they directed others to oppose. This
  was the case of several of the most skilful
  surgeons.

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Fumigation box for treatment of syphillis
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Ellis Island Quarantine Station
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• WHO head warns of incalculable' suffering
• Monday, November 7, 2005

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Romania
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Why are infectious diseases important to ethics?

• Long time neglect of ID issues by ethicists
• Of historic and future significance
• Challenge traditional and familiar concepts (e.g.
  autonomy)
• Cross borders from personal to global ethics
• Universal vulnerability

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Why have infectious diseases been neglected by
ethicists?

• Infectious Diseases no longer considered relevant
• Ethics concerned with high technology
• The other
• Complexity

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Complexity

• Microbiology
• Immunology
• Clinical medicine
• Epidemiology
• Zoology
• Geography

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Integration of Levels of Ethical Reflection

• Personal Ethics
• Clinical Ethics
• Professional Ethics
• Organizational Ethics
• Public Health Ethics
• Global Health Ethics

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The Duty to Care

• Health care workers duty to care, and the duty
  of institutions to support them

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SARS AND HEALTH CARE WORKERS IN TORONTO

• 40 of probable cases in Toronto outbreak were
  health care workers
• 2 nurses and one physician died
• Hundreds in quarantine
• Psychological impact substantial
• 45 of nurses in one survey scored above the
  GHQ-12 cut point for psychological stress
• 65 of respondents report SARS related concerns
  for personal or family health
• In aftermath many considering alternative careers

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Case

• Mary, works in a pediatric ICU, caring for
  patients with serious respiratory diseases.
• During an outbreak of serious respiratory
  illness, her husband asks her to call in sick, as
  the mother of 3 small children she should not to
  risk giving them the illness.
• Mary feels torn between the need to protect her
  children, husband and self from infection her
  commitment to her patients, colleagues and
  profession.

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Nightengale

• Her heart it means good for no bounty shell
  takeShed lay down her life for the poor
  soldiers sake,She prayd for the dying, gave
  peace to the brave,She felt that a soldier had a
  soul to be savedThe wounded they lovd her, as
  it has been seen,Shes the soldiers preserver
  they call her their queen.May God give her
  strength, her heart never fail,One of heavens
  best gifts is Miss Nightingale.

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Archilocus

• Some Saian mountaineer
• Struts today with my shield.
• I threw it down by a bush and ran
• When the fighting got hot.
• Life seemed somehow more precious.
• It was a beautiful shield.
• I know where I can buy another
• Exactly like it, just as round.

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Infectious Diseases and Duty to Care Sources of
Guidance

• Codes of Ethics
• Professional Standards
• Virtue Ethics
• Contract Law
• Public Expectations

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Do We Expect Heroism?

• "...when pestilence prevails, it is their
  (physicians') duty to face the danger, and to
  continue their labours for the alleviation of
  suffering, even at the jeopardy of their own
  lives". 1922 CMA Code of Ethics
• 2004 CMA Revision silent on the issue.
• Other codes of ethics from other health care
  professions similarly offer no direction.
• What about non-professional health care providers?

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Duty to Care Ethical Values

• duty to care
• Principles autonomy and beneficence
• virtue ethics
• Reciprocity/relationality
• society, institutions
• necessary supports
• no penalization
• transparency

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Duty not to harm others by communicating
diseases. Harris and Holm BMJ 1995

• The moral duty to behave responsibly and not
  knowingly put other people at risk is not a duty
  that is confined to HIV infection or to other
  life threatening diseases.
• It is a duty which all people with communicable
  diseases have. It is, however, also a duty which
  we can expect people to discharge only if they
  live in a community that does not leave them with
  all the burdens involved in discharging this
  duty.

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Traditional Principles

• Autonomy
• Beneficence
• Non-maleficence
• Justice

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Autonomy

• Autonomy is a form of personal liberty of action
  where the individual determines his or her course
  of action in accordance with a plan chosen by him
  or herself.

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AutonomyLeslie Francis

• Infectious disease reminds us that we are
  related in our vulnerability.
• In the case of infectious diseases agency is not
  isolated but inherently relational

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The issue of autonomy

• Infectious diseases challenge notions of autonomy
• Victim and vector

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Do public expectations matter?

• Health professionals self-regulated
• Health care a public good
• Do we know what the public expects?

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What standard do we wish to uphold?

• Supreme Samaritan
• Good Samaritan
• Minimally Decent Samaritan

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Duty to Care Lessons Learned

• health care professionals have an obligation to
  care for
• the sick
• themselves in order to care for the ill
• their families
• limit to personal risk is unclear

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Duty to Care Lessons Learned

• institutions have a reciprocal duty to support
  and protect health care workers, and to help them
  cope with very stressful situations
• need for clear expectations of employees
• reward, not penalization for following safe
  practices
• recognition of heroism by the public
  institutions

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Recommendations

• Professional colleges and associations should
  provide, by way of their codes of ethics, clear
  guidance to members in advance of a major
  communicable disease outbreak, such as pandemic
  flu. Existing mechanisms should be identified, or
  means should be developed, to inform college
  members as to expectations and obligations
  regarding the duty to provide care during a
  communicable disease outbreak.
• Governments and the health care sector should
  ensure that
• care providers safety is protected at all times,
  and providers are able to discharge duties and
  receive sufficient support throughout a period of
  extraordinary demands and
• disability insurance and death benefits are
  available to staff and their families adversely
  affected while performing their duties.
• Governments and the health care sector should
  develop human resource strategies for
  communicable disease outbreaks that cover the
  diverse occupational roles, that are transparent
  in how individuals are assigned to roles in the
  management of an outbreak, and that are equitable
  with respect to the distribution of risk among
  individuals and occupational categories.

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WHO Consultation

• How useful are these recommendations at the
  global level?
• How to manage systems that cannot assure
  protection to HCWs?
• Does the absence of this reciprocity absolve
  HCWs of their obligations to care?
• What about sanctions?

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Conclusions

• Infectious diseases pose important challenges to
  traditional medical ethical frameworks
• Professional codes of ethics are of limited value
  in providing limits to risk in care for patients
  with infectious diseases
• Need for global response based on solidarity

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Thanks to

• Solomon R. Benatar
• Mark Bernstein
• Abdallah S. Daar
• Bernard Dickens
• Sue MacRae
• Peter A. Singer
• Linda Wright
• Randi Zlotnik Shaul
• Tarif Bakdash
• Amy Haddad
• Shari Gruman

• Jennifer Gibson
• Alison Thompson
• Karen Faith
• Kumanan Wilson
• Shawn Tracy
• Laura Hawryluk
• Bob Williams
• Cecile Bensimon
• Chris McDougall
• Marian Adly
• Wayne Gold
• Rima Styra

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Acknowledgements

• CIHR
• Canada Research Chair
• City of Toronto Public Health

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Links

• Joint Centre for Bioethics Report
• Stand on Guard for Thee
• http//www.utoronto.ca/jcb/home/news_pandemic.htm
• Ontario Pandemic Plan
• http//www.health.gov.on.ca/english/providers/prog
  ram/emu/pan_flu/pan_flu_plan.html

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