Are doctors obligated to treat during a pandemic?

In this paper, we explore the moral obligation for healthcare professionals to care for those affected by SARSCoV-2.

The rapid spread of virus SARS-CoV-2 (severe acute respiratory syndrome corona virus 2) has resulted in a global pandemic. Hospitals and intensivists around the world have faced ethical challenges with many countries facing limited access to ICU making in times of crisis relies on these foundations of medicine, which are essential to arrive at

beds, mechanical ventilators and protective personal equipment. These unprecedented times have revealed the vulnerabilities within healthcare systems, creating confusion and disarray among health care workers as protocols and indications to test evolve daily, roles and responsibilities remain uncertain, and guidelines for treatment continue to change. These challenges include the moral obligation for healthcare professionals to care for those affected by SARS-CoV-2. Ethical dilemmas arise as treatment standards can be compromised, resulting in professional and personal hardship. There is a need for clear guidelines guided by a strong ethical framework for both medical practitioners and the public. It is necessary to approach this issue holistically to examine the effects of compromised healthcare on medical practitioners during a time limited resources. Rather than a moral obligation bound by social contract, there is an opportunity to promote altruism for others. This requires guidelines framed by ethical decision making, full transparency and clear communication. NEED FOR GUIDELINES

As the world finds itself caught in the midst of a pandemic, complexities around the ethics of health care delivery have come to the forefront alongside the need for a vaccine and efficacious treatment. It is necessary to examine health ethics in a global pandemic as they determine the expectations of our healthcare workers and how to distribute scarce resources in a fair and equitable way. Doctor’s face the ethical dilemma behind the “moral obligation” of healthcare professions to provide care for those with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). The moral obligation to treat is guided by the four pillars of medical ethics; autonomy, beneficence, non-maleficence and justice. Decision compromise during times of limited resources. Whilst healthcare workers are morally bound to treat, it is essential to recognise the potentially damaging consequences that may result for both doctors and future medical practice.

The SARS-CoV-2 pandemic has resulted in a shift in priority from the individual to a utilitarian view, which aims to maximise the overall good for the greatest number of people.[1] This has resulted in a number of ethical dilemmas, firstly that of restricted autonomy for health care practitioners/professionals (HCPs), as they have an ethical duty to provide treatment to patients despite the risk to their own health and the health of their family and friends. There has been significant difficulty in maximising benefit and minimising harm as SARS-CoV-2 is a new manifestation of disease, without efficacious treatment or cure. This creates uncertainty regarding prognosis, leading to restrictive criteria to treat in resource poor settings. Equitable distribution of resources is challenged in the context of limited supplies and guidelines regarding the allocation of supplies during a pandemic.

INTRODUCTION

The SARS-CoV-2 pandemic has demonstrated the need for guidelines founded in an ethical framework to establish guidelines for best practise decision making. Guidelines dispel uncertainty regarding professional rights and responsibilities, and increase the awareness and comfort levels of both the public and healthcare workers.[1] In addition, clear communication with the public will foster trust and solidarity in doctors and the healthcare system. Guidelines based on an ethical framework allows HCPs to safeguard the standard of patient centred care and moral equality afforded outside of a pandemic. It further helps to alleviate psychological distress experienced by clinicians who are forced

Recommendations

Quantifying the expected risk that HCPs are required to take

The moral duty to care for both the sick as well as themselves in order to continue providing care

Expectations to do no harm to others by reducing transmission of the disease

Exceptions for HCPs not required to assist (i.e. immunocompromised/pregnant)

Clear guidelines for indications to treat, criteria for treatment and triage

Regularly reviewed guidelines by a monitoring committee to ensure equitable distribution of limited resources without prejudice

Treatment and triage criteria to be regularly reviewed as knowledge regarding the disease evolves

Separate clinicians providing care to patients with those making triage decisions

Decisions should be made by a triage officer and a team of expert respiratory physicians and infectious disease consultants

Communication to the patient and family regarding treatment should be a team-based approach

Table 2: Recommendations for guidelines and quality control to facilitate health care professional safety.

to make difficult decisions regarding patient care by guiding them with current evidence-based protocols. RESTRICTED AUTONOMY

The absence of guidelines can lead to loss of trust in healthcare professionals and reduced presentations to hospital.[2] Healthcare workers have faced insecure housing and prejudice as a result of their occupation.[3] Risk of exposure to SARS-CoV-2 has also lead to reduced health care access for medical and emergent conditions.[4] The United Kingdom observed that presentations for suspected heart attacks halved since March 2020. Uncertainty about HCP roles and availability of intensive care resources such as mechanical ventilators has lead to public uncertainty which has the potential to prevent compliance with legislation and may instil a reluctance to practice reciprocity and put the needs of others above the individual. Thus, a fair decision making process with equitable distribution of scarce human resources is imperative to generate public trust and ensure the best standard of care is provided to all patients duty to face the danger and to continue their lajeopardy of their own lives.”[1]

during these times.[2]

MORAL OBLIGATION TO TREAT

ent moral obligation for HCPs. As stated by Upshur R et al. the medical knowledge and skill of physicians and health care practitioners is superior to those of the general public, it is an assumed risk taken by freely choosing a profession devoted to caring for the ill and there is a binding social contract that requires HCPs to be available and assist during times of emergency.[5] The dilemma of a moral obligation to treat arises from the tension between a HCP’s autonomy versus their duty to “do no harm.” The SARS-CoV-2 has challenged practitioners to maintain standards of care and remain true to the ethical foundations that would normally frame treatment.

It is through restriction of individual autonomy during a pandemic that public health is preserved and protected. In addition to this, HCPs have a moral and social obligation to treat, which in itself can limit autonomy by requiring that practitioners set aside conflicting liberties. HCPs must balance the demands of their role which necessitates treating patients during a pandemic, with the risks of compromising their own health and the wellbeing of their families.[1] Although it is easy to say that HCPs are required to treat, the dilemma arises in establishing the extent to which this obligation binds them. This includes the degree to which HCPs must risk their health to care for sick patients. The CMA Code of Ethics states that HCPs have an obligation to treat.

“when pestilence prevails, it is their (physician’s) bours for the alleviation of suffering, even at the The practitioners “duty of care” to the sick is an inher

Conversely, Upshur et al. questions whether HCPs should have “minimal self-regard” and “pursue their duties at the cost of their own lives.” [5] Dr James Mahoney, a 62 year-old Pulmonologist from New York, delayed his retirement to assist in the ICU at University Hospital Brooklyn. [6] Due to the severe lack of medical equipment, and limited supplies of PPE, Dr Mahoney contracted SARS-CoV-2 and passed away. It is clear that in a resource poor setting, assumptions of a moral duty of care can imply that the life of a healthcare worker is less valued than that of

a member of the general public. On May 23 rd 2020, the death toll of healthcare workers in England and Wales alone had surpassed 300 deaths, three times more than the number of deaths in Australia.[7] With such high risk posed HCPs, it is essential to clarify roles and responsibilities, increasing the likelihood that HCPs will altruistically contribute to the crisis.

RESOURCE ALLOCATION DURING TIMES OF SCARCITY

Whilst HCPs strive to deliver the same standard of care to all patients, during a pandemic resource limitations can result in inequities in health care delivery. HCPs are further limited in their ability to exercise their clinical judgement as they are bound by treatment criteria. Patient centred care and the “responsibility of acting for the benefit of the patient is… a sacred duty that all physicians owe to their patients.”[8] To choose who receives treatment thus videeply held moral beliefs.

“Fifty years ago, US doctors could be charged with crime for rationing health care. It was considered murder or manslaughter. Treating everyone equally was a matter of both law and ethics. Even when survival chances were uncertain, ethical and legal mandate was to continue treatment.”[9] Australia has had the benefit of geographical isolation, reduced community transmission and time to prepare for an influx of SARS-CoV-2 patients. Northern Italy, however, was one of the first countries to experience the crisis. Hospitals lowered the age cut off for treatment from 80 to 75, and doctors were forced to decide who received potentially life-saving treatment.[10] In response, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive care issued recommendations for critically ill patients in the ICU, urging “clinical reasonableness” and a “soft utilitarian approach in the face of resource scarcity.”[9] Thompson et

olates the obligation to do no harm and transgresses al. argues that not only do we need to consider the ethics when establishing practise guidelines, but also to reflect on the “moral obligation to demonstrate transparency, accountability, fairness and trustworthiness in allocation of scarce resources.”[2] These guidelines should aim to fairly allocate resources and be directed by a utilitarian framework to maximise the best possible outcome for the most people.

PHYSICAL AND PSYCHOLOGICAL IMPACTS

Not only do physicians face the trauma of violating ethical standards by withholding or withdrawing treatment, but it is compounded by patients dying alone and away from family and loved ones. Neil Shortland, Professor of criminology and justice studies likened the moral anguish caused by such a decision to the psychological trauma occurring in soldiers who are forced to witness or engage in acts that “transgress their own morals and beliefs.”(8) To base

Physical impacts

Overwhelming amount of critical cases leads to physical and mental exhaustion and impaired decision. This causes HCPs to be more prone to making errors, thus creating more guilt. Eventually, this becomes a vicious cycle affecting the doctor’s ability to function, let alone to treat. Physical exhaustion and the neglect of self needs as doctors place the needs of patients above their own, prevent HCPs from providing treatment in the long term as the crisis continues (burn out)

Psychological impacts

Decreased self-esteem as doctors, emphasising feelings of imposter syndrome Creating doubt regarding their current knowledge, thus affecting treatment of other patients regardless of disease Causing a profound sense of helplessness as they must “let patients die.” This helplessness is worsened by the fact that the disease currently has no known treatment or prevention Anxiety and depression as a result of helplessness increasing suicidal ideation and suicide attempts Post Traumatic Stress Disorder (PTSD) Mental exhaustion also affects HCP’s relationships with families and co-workers. Conflict decreases morale and can also lead to decreased trust and solidarity

decisions on making the “least-worse” decision creates a psychological trauma known as “moral injury.” This psychological harm is so great that it can damage one’s sense of right and wrong and cause severe traumatic grief and long-term trauma. The consequences of these decisions can physically and psychologically impact physicians.

CONCLUSION

HCPs face a multitude of challenges regarding their moral obligation to treat and providing optimal care during a pandemic in a resource finite setting. Establishing practice guidelines fosters solidarity and trust in the hospital system, creating sustainable and equitable environments with a patient centred focus. These guidelines must be transparent and inclusive to foster public trust and cooperation and define HCPs scope of practice.[5] It is through guidelines and codes developed within an ethical framework that we are able to create this environment, and the burden faced by HCPs can be significantly lessened.

Monique Lam is a final year medical student from Bond University, Gold Coast. She is incredibly passionate about global health particularly around refugee and maternal health as well as international aid. Throughout her medical degree, she has been actively involved in organising and attending events run by the Bond University Making a Difference Global Health group. Quality is her middle name.

Acknowledgements

Nil

Conflicts of Interest

Nil

Correspondence

monique.lam@student.bond.edu.au

References

1. Ruderman C, Shawn T, Benismon C, Bernstein M, Hawryluck L, Zlotnik Shaul R et al. On pandemics and the duty to care: whose duty? who cares?. BMC Med Eth. 2006;7(5):1-6 2. Thompson A, Faith K, Gibson J, Upshur R. Pandemic Influenza preparedness, an ethical framework to guide decision making. BMC Med Eth. 2006,7(12):1- 11 3. Uibu K. Doctor evicted over coronavirus fears after she refused to stop ‘essential’ hospital work [Internet]. ABC News [cited 2020 June 03]. Available from: https://www.abc.net.au/news/2020-04-22/coronavirus-fears-doctor-evicted-during-crisis/12162880 4. Wood J. COVID-19 is causing people with other serious illnesses to avoid hospital [Internet]. World Economic Forum [cited 2020 May 27]. Available from: https://www.weforum.org/agenda/2020/04/ covid-19-hospitals-empty-cardiac-emergencies-pandemic/ 5. Upshur R, Faith K, Gibson J, et al. Stand On Guard For Thee Ethical considerations in preparedness planning for pandemic influenza. Toronto; University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group; 2005 6. Coleman J. Doctor who delayed retirement to fight pandemic at low-income hospital dies of COVID-19. The Hill [cited 2020 May 21]. Available from: https://thehill.com/blogs/blog-briefingroom/news/498354-doctor-who-delayed-retirement-to-fight-pandemic-at-low-income?fbclid=IwAR3kyPdfDh-kn7kvJiKwTk1uA3NzvHK6K-h56DrvjXnpCyn3zhxCHGm_p5Y 7. Reference Worldometer. Coronavirus cases. Worldometer Web site [cited 2020 May 23]. Available from: https://www.worldometers.info/ coronavirus/coronavirus-cases/ 8. Shortland N. Doctors are making life-anddeath choices over coronavirus patients – it could have long-term consequences for them. The Conversation [cited 2020 May 18]. Available from: https://theconversation.com/doctors-aremaking-life-and-death-choices-over-coronavirus-patients-it-could-have-long-term-consequences-for-them-134728 9. Shurkin J. COVID-19: The ethical anguish of rationing medical care. Discover Magazine [cited 2020 May 18]. Available from: https://www.discovermagazine.com/health/covid-19-the-ethical-anguish-of-rationing-medical-care 10. Rosenbaum L. Facing Covid-19 in Italy – ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020;382(1):1873- 1875 11. Coronavirus lockdown protest: What’s behind the US demonstrations? BBC News [cited 2020 May 17]. Available from: https://www.bbc. com/news/world-us-canada-52359100