Ethical Challenges in

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Ethical Challenges in Preparing for
Bioterrorism Matthew K. Wynia and Lawrence O.
Gostin
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HEALTH CARE AND CONTAGIONS

• Wynia and Gostin define health care system as
  those professionals (e.g. physicians and nurses)
  and institutions (e.g. hospitals and health
  plans) obliged to diagnose, treat, and care for
  individuals exposed to or infected with
  contagious diseases.
• The three main things that the health care system
  must do to protect the population from the spread
  of contagious diseases are identify threats of
  disease - detection prevent the spread of
  disease - containment and care for infected
  patients - treatment.

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DETECTION REPORTING I

• Early detection of a bioterrorist attack depends
  on the capacity for surveillance that a public
  health system has.
• Such surveillance relies largely on reports from
  health care professionals since persons with
  symptoms go to hospitals, clinics, and doctors
  offices.
• For this system to work properly ill people must
  have access to the health care system.

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DETECTION REPORTING II

• WG The health care system must improve its
  reporting performance.
• Such improvement includes making physicians aware
  of reporting requirements, making reporting
  easier, and making them understand the importance
  of reporting.
• Physicians also should receive feedback on how
  their reports are used to safeguard public
  health, since this will reinforce the value of
  the physician-public health partnership.

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DETECTION ACCESS I

• WG Strong ethical reasons have long been
  recognized as supporting universal access to a
  decent minimal set of health care services, yet
  our nation has been unable or unwilling to
  accomplish this.
• For WG, inadequate access to care poses a
  threat to national security.
• Perhaps we will have universal health care when
  politicians realize this.

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DETECTION ACCESS II

• WG In the United States, more than 40 million
  Americans lack health insurance, and this number
  is rising. (Many more are inadequately insured.)
• For WG, a problem with the uninsured seeking
  health in the event of a bioterrorist emergency
  is that uninsured patients discriminate poorly
  between appropriate and inappropriate care and
  tend to avoid both equally.
• If that is the case, then they may not seek even
  emergency room care if they are affected by an
  attack, in which case they may spread a
  transmissible disease.

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DETECTION ACCESS III

• WG Numerous studies demonstrate that the
  uninsured are more likely to present in an
  advanced stage of illness, and many die without
  ever being evaluated.
• Terrorists undoubtedly recognize that even a
  small-scale release of an infectious agent into a
  community with a high rate of uninsurance might
  be devastatingly effective given the capacity of
  the uninsured to spread disease throughout the
  population.

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DETECTION ACCESS IV

• WG Maintaining barriers to accessing health
  care in the face of todays threats should be
  unacceptable, morally and politically.
• This means that, in the event of a bioterrorist
  attack of a contagious illness, individuals with
  symptoms that suggest infection with a contagious
  illness should present for evaluation and ensure
  that those who do can be treated without
  prejudice. whether or not they can demonstrate
  the ability to pay
• Funding must be provided to cover screening and
  treatment of patients with contagious illnesses.

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CONTAINMENT I

• While most people will cooperate with medical
  treatment and quarantines in the event of a
  bioterrorist attack, not all will, since not all
  trust the health care system, and illness and
  fear can hinder clear thinking.
• WG Physicians should know this and be prepared
  to intervene if necessary.
• Health care professionals have a general
  obligation to prevent patients from harming
  themselves or others and may use compulsion when
  necessary.

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CONTAINMENT II

• According to Wynia and Gostin, the job of
  declaring quarantine should be up to public
  health officials, not individuals physicians.
• This is for two reasons First, separation of
  these roles allows physicians to attend to
  individual patients interests.
• Second, it is ethically challenging for
  physicians to hold patients involuntarily
  because it entails overriding an individual
  patients wishes in deference to the communitys
  needs balancing respect for patient autonomy
  against public health benefit.

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CONTAINMENT III

• Although it presents a challenge for them,
  physicians have an obligation to mediate the
  tension between individual and community needs.
• This reflects the Platonic view that physicians
  must do what is best for the patients and for
  the state.
• Accordingly, physicians must maintain some
  independence from both the state and patient
  interests.

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CONTAINMENT IV

• Because physicians have a public duty to the
  state in addition to a private duty to individual
  patients, when time is limited, physicians
  should be empowered and willing to use short-term
  holds to prevent immediate spread of disease.
• This may seem paternalistic, and so to deny
  patient autonomy, but it recognizes the ethical
  obligation that physicians have to society in
  addition to the ethical obligation that they have
  to individual patients.
• To avoid abuse of patient rights, two physicians
  might be required to agree that a patient should
  be held against his or her will to protect the
  community.

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CONTAINMENT V

• WG Bioterror training should reinforce
  physicians ethical obligations regarding
  isolation of dangerously infectious patients, and
  there should be open debates on appropriate
  limits to this power, as well as to address
  practical considerations regarding quarantine,
  such as when public health authorities should
  enforce community quarantine and how to
  respectfully care for those under quarantine.

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TREATMENT

• Do physicians have a duty to treat in every case?
  Do they have a duty to treat when they are
  afraid of contracting, and possibly dying from,
  the very illness that they have the knowledge to
  treat?
• WG Some hospitals in New York have announced
  that they will not care for victims of bioterror
  attacks.
• Physician performance during epidemics, from the
  black plague to the HIV epidemic, has been
  notoriously spotty.
• And relatively few physicians have volunteered
  to receive smallpox vaccination, despite
  high-level government requests.

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THE DUTY TO TREAT I

• While Wynia and Gostin understand physician fear
  of treating illness that might expose them to
  risk, they think that several things suggest that
  doctors do have a duty to treat.
• First, they receive special training that
  increases the general obligation to render aid
  to others in need, because it increases the value
  of the aid and may reduce the risk associated
  with providing it.

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THE DUTY TO TREAT II

• Second, Physicians have long subscribed to
  explicit codes of ethics that demand the duty to
  treat, codes that the public assumes to be
  binding.
• Third, Physicians receive social standing and
  trust as part of a social contract, which
  includes an obligation to place the welfare of
  patients above self-interest.

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THE DUTY TO TREAT III

• Both the American College of Physicians and the
  Infectious Diseases Society of America subscribe
  to the view that health care professionals must
  provide high-quality nonjudgmental care to their
  patients, even at the risk of contracting a
  patients disease.
• And the American Medical Association says that
  physicians must treat the sick and injured with
  competence and compassion and without prejudice
  and apply our knowledge and skills when needed,
  although doing so may put us at risk.

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DUTY AND EPIDEMICS

• The obligation of doctors to care for the sick
  during epidemics should be made clear by
  professional medical associations.
• For Wynia and Gostin, the language of the AMAs
  Code of Medical Ethics is appropriate When an
  epidemic prevails, a physician must continue his
  or her labors for the alleviation of suffering
  people, without regard to the risk to his her
  own health or to financial return.

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TREATMENT AND EPIDEMICS

• Since health care professionals have an
  obligation to treat patients in an epidemic, they
  should receive all reasonable preventive and
  treatment measures in the event of an outbreak,
  such as vaccines, prophylactic therapies, those
  guarding from or preventing disease and safety
  training.
• This preferential treatment that health care
  professionals should receive is justified given
  the ethics of the personal risk involved, and
  because, as a practical matter, only healthy
  practitioners will be of value in responding to
  any ongoing threat.

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CONCLUSIONS I

• We must have a strong public health care system
  to defend against bioterrorism and naturally
  occurring epidemics.
• Such a system must be able to detect, contain,
  and treat infectious diseases.
• An effective health system must ensure universal
  rapid access to knowledgeable and compassionate
  health care professionals to evaluate and care
  for those exposed to infectious disease.

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CONCLUSIONS II

• There must be no ethical barriers in the health
  care system that would preclude or interfere with
  detection, containment, and treatment of
  infectious diseases.
• If barriers arise they must be confronted and
  resolved, because undiagnosed, unconfined, and
  untreated infections pose a risk to individuals
  and the community.