Download State of the Union Address

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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6.1 Time series of respiratory ambulatory visits to primary care providers, age and gender aggregated, 1992-2002
900,000
800,000
700,000
Number of visits
600,000
500,000
400,000
300,000
200,000
100,000
Jul-02
Jan-02
Jul-01
Jan-01
Jul-00
Jan-00
Jul-99
Jan-99
Jul-98
Jan-98
Jul-97
Jan-97
Jul-96
Jan-96
Jul-95
Jan-95
Jul-94
Jan-94
Jul-93
Jan-93
Jul-92
Jan-92
0
Month/Year
Note: "Respiratory ambulatory visits" include all ambulatory visits to a physician for COPD, asthma, pneumonia or repiratory infectious diseases.
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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.
2.
3.
4.
5.
The past and present context
Ethics and Infectious Diseases
The Challenges of the Duty to Provide Care
During Infectious Disease Emergencies
Preparing for the Pandemic
Conclusions
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Plague of Athens
Thucydides
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
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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 Diaries
Daniel Dafoe
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 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?
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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?
1.
2.
3.
4.
Infectious Diseases no
longer considered
relevant
Ethics concerned with
high technology
The other
Complexity
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Complexity
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Microbiology
Immunology
Clinical medicine
Epidemiology
Zoology
Geography
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Integration of Levels of Ethical
Reflection
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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
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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 GHQ12 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
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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
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Her heart it means good – for no
bounty she’ll take
She’d lay down her life for the
poor soldier’s sake,
She pray’d for the dying, gave
peace to the brave,
She felt that a soldier had a soul to
be saved;
The wounded they lov’d her, as it
has been seen,
She’s the soldier’s preserver they
call her their queen.
May God give her strength, & her
heart never fail,
One of heaven’s 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
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Codes of Ethics
Professional Standards
Virtue Ethics
Contract Law
Public Expectations
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Do We Expect Heroism?
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"...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
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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
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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
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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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Autonomy
Leslie Francis
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“ … 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
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Infectious diseases
challenge notions of
autonomy
Victim and vector
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Do public expectations matter?
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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?
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Supreme Samaritan
Good Samaritan
Minimally Decent Samaritan
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Duty to Care: Lessons Learned
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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
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institutions have a reciprocal duty to support and protect health
care workers, and to help them cope with very stressful
situations
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need for clear expectations of employees
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reward, not penalization for following safe practices
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recognition of heroism by the public & institutions
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Recommendations
1.
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.
2.
Governments and the health care sector should ensure that:
a.
b.
3.
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
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How useful are these recommendations at the
global level?
How to manage systems that cannot assure
protection to HCW’s?
Does the absence of this reciprocity absolve
HCW’s of their obligations to care?
What about sanctions?
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Conclusions
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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
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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
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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
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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/new
s_pandemic.htm
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Ontario Pandemic Plan
http://www.health.gov.on.ca/english/p
roviders/program/emu/pan_flu/pan_f
lu_plan.html
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