pandemic planning

Pandemic Planning – Considering Professional ObligationsPandemic Planning – Considering Professional Obligations

July 11, 2007July 11, 2007

Copyright 2007 Trinity Health – Novi, Michigan INTERNAL2

Pandemic

So the plague defied all medicines; the very physicians were seized with it…men went about prescribing to others and telling them what to do…and they dropped down dead, destroyed by that very enemy they directed others to oppose. This was the case of several of the most skillful surgeons.

Dafoe, Plague Diaries


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Communicable diseases have always posed risks to those providing care for the afflicted.


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A number of surveys indicate that close to 50% of healthcare workers will not show up for work in a pandemic.

A 2005 Johns Hopkins study indicated that 42% of survey responders would not respond in the event of a flu pandemic, 40% felt that they would be asked to show up and 33% thought they were knowledgeable about the health impact of pandemic flu. Willingness was lowest among technical and support staff.


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“Duty to/of Care” (Daniel Sokol)– At best, too vague– At worst, ethically dangerous


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Healthcare professionals have obligations to a specific group of persons (patients) that non-medical personnel have no obligation to help.

• The nature and scope of the duty needs to be determined

• Conflicting duties need to be recognized and acknowledged


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The phrase, “duty to/of care” doesn’t spell out the precise nature of the duty, nor of its limits.

The phrase has rhetorical appeal but its meaning is not clear. It is ethically dangerous in giving the illusion of legitimate moral justification.

Modify the phrase in favor of more specific descriptions of the obligation of healthcare workers


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For example: • Are healthcare professionals obliged to do

everything in their power to benefit their patients?• Do some healthcare professionals have a greater

obligation than others to put themselves at risk in caring for patients?

• Are there limits to the “duty to/of care”?• What distinguished normal duty from acting

beyond the call of duty?


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• “Duty to/ of care” is neither fixed nor absolute but heavily dependent on context.

• The appearance of a highly virulent disease challenges healthcare professionals to question their interpretation of the duty to/of care, especially its limits (e.g., HIV/AIDS in 1980s, SARS in 2003)


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Influences that may limit the “duty of care” include:• normal risk level of the working environment• the healthcare worker’s specialty• the likely harm and benefits of treatment• the competing obligations deriving from the

worker’s multiple roles


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Case:

A physician visiting Kikwit during the 1995 Ebola virus outbreak, came across 30 dying patients in an abandoned hospital. Was the last doctor justified in leaving the patients, or should s/he have been obliged to single-handedly treat the highly and dangerously infectious Ebola patients? Does the visiting physician have any obligation to these dying patients?


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The answer depends, at least in part, on the actual risk to the doctor and the potential benefits to the patients.

If the actual risks for serious illness or death for the healthcare professional is low and the benefits of treatment substantial, then there may be an obligation to treat. However, if the risks are high and the benefits are low, the healthcare professional may be justified in not providing care/ treatment.


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For over 100 years the following provision was found in the AMA code of ethics:

“…when pestilence prevails, it is their (physicians’) duty to face the danger, and to continue their labors for the alleviation of suffering, even a the jeopardy of their own lives”.

This provision was removed from the AMA code in the 1950s.


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However, the AMA policy document “Physician Obligation in Disaster Preparedness and Response” adopted in June 2004 says:

“National, regional and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians…individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life…physicians should balance immediate benefits to individual patients with ability to care for patients in the future.”


Pandemic – Toronto Pandemic Influenza Plan

Core Ethical Values Toronto’s Approach

Duty to Provide Care – Health care workers have an ethical duty to provide care and respond to suffering. During a pandemic, demands for care may overwhelm health care workers and their institutions, and create challenges related to resources, practice, liability and workplace safety. Health care providers care against competing obligations (I.e., to their own health, family and friends). When providers cannot provide appropriate care because of constraints caused by the pandemic, they may be faced with moral dilemmas.

To support providers in their efforts to discharge their duty to provide care, Ontario and/or Toronto will:

•Work collaboratively with stakeholders, regulatory colleges and labour associations to establish practice guidelines

•Work collaboratively with stakeholders, including labour associations, to establish fair dispute resolution processes

•Strive to ensure the appropriate supports are in place (e.g., resources, supplies, equipment)

•Develop a mechanism for provider complaints and claims for work exemptions


Pandemic – Toronto Pandemic Influenza Plan

Core Ethical Values Toronto’s Approach

Reciprocity – Society has an ethical responsibility to support those who face a disproportionate burden in protecting the public good. During a pandemic, the greatest burden will fall on public health practitioners, other health care workers, patients, and their families. Health care workers will be asked to take on expanded duties.

They may be exposed to greater risk in the workplace, suffer physical and emotional stress, and be isolated from peers and family. Individuals who are isolated may experience significant social, economic, and emotional burdens.


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Clark (2005) argued that the duty to care for those with infectious diseases is a primary ethical obligation for healthcare workers for a number of reasons:

1. The ability of healthcare professionals to provide care is greater than that of the public, thus increasing their obligation to provide care

2. By freely choosing a profession devoted to care for the ill, they assume risks

3. The profession has a social contract that calls on members to be available in times of emergency


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A moral obligation to treat exists if all four of the following criteria are present:

1. A need exists because of significant risk of harm to the patient if the clinician does not assist.

2. The clinician’s intervention or care is directly related to preventing harm to the patient.

3. The clinician’s expert knowledge and ability has the potential to prevent harm/or provide benefit.

4. The potential prevention of harm or providing of benefit outweighs any harm the clinician might incur.


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Benefit-risk ratio

What would constitute an appropriate determination that caring for a patient would be too risky for an individual?

Is the determination of personal harm a person-by-person subjective judgment or a team/group objective judgment?


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How does the obligation to facilitate patient care extend to all other associates not providing direct patient care, e.g., billing, environmental services, communications?

Do all trained medical professionals (who have also enjoyed the benefits of that training) have an obligation to serve in a pandemic?

Do those whose specialty is most relevant to an influenza pandemic have a greater obligation to serve?


PandemicRecommendations• Organization proactively consider position and

provide education• Consider using a Values-Based Decision Making

Process to look at the issue• Inform prospective staff members of expectations• Fully engage the organization in expressing fears,

needs, questions, and concerns in anticipating a pandemic…and work to address them.

• Process for Healthcare Professionals to identify potential barriers to availability and suggesting actions to mitigate them

pandemic planning – considering professional obligations july 11, 2007

Documents

trinity health novi

michigan internal

duty of care

pandemic case

flu pandemic

pandemic influences

health impact of pandemic