In certain circumstances, and for a variety of reasons, patients choose to refuse medical treatment. [1] These decisions, in the absence of cognitive impairment, are typically respected by clinicians. Similarly, situations arise when medical professionals decline to care for a patient. [2] Such refusal is fraught, with arguments made that this represents abdication of duty. However, in practice, it is generally accepted that a doctor cannot be forced to treat a patient and, indeed, doctors’ freedom of choice is protected in international law. [3] 

That said, refusal of treatment by patients or denial of care by medical professionals is challenging when public health is at risk, such as the covid-19 outbreak. In these circumstances, refusal represents an evident risk and poses legal or ethical questions. 

Specifically, occupational health and safety statutes govern healthcare facilities. During a pandemic or outbreak, healthcare workers may be faced with conditions they believe are unsafe. In that setting, refusal to work may be permissible if the environment represents an unacceptable hazard. “Unacceptable hazard” then becomes the object of discussion: does unacceptable risk exclude hazards that are inherent to the occupation of doctor (or any healthcare worker) and normal working conditions? Do covid-19 or other virulent infectious agents constitute “normal”? 

Relevant to the covid-19 outbreak, 28% of German healthcare professionals agreed (during a flu pandemic) that it would be “professionally acceptable for healthcare professionals to abandon their workplace” in order to protect themselves and their families. [4] In the UK, 37.9% of survey respondents agreed that during a flu epidemic “healthcare workers should be able to refuse to work with infected patients”. [5] 

It is reasonable to assume that in reality few clinicians would act in this manner despite some expressing such views. However, the UK Government’s suggestion that retired doctors may be called upon to supplement patient care in the context of escalating covid-19 cases places personal choice regarding refusal to care for patients at the core of such a contingency plan. In spite of potential individual willingness to make a contribution to colleagues, patients and public health, and by doing so risking exposure to the virus, retirement is typically associated with relatively advanced age and, therefore, elevated susceptibility to the illness. Indeed, it seems ethically unsound for otherwise willing retired doctors, or the Government, to consider such an approach given the risk associated with the strategy itself of increasing infection incidence. Due to this, retired doctors must not feel an “onus” on them to return to clinical practice and must be allowed, without any sense of coercion, self-determination regarding their ability to perform clinical duties competently. Such decisions will, clearly, be linked to the potential for de-skilling to have occurred and time since retirement from clinical work. 

Each of us is influenced by personal and professional drivers. In the event that incidence and virulence of covid-19 escalate, we should be prepared for, and not surprised by, the inevitable personal and very human choices of healthcare workers to decide for themselves whether to continue to care for patients, to return to the workforce from retirement, or to mitigate risk to themselves and their families.

Colum P. Dunne, Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland 

Suzanne S. Dunne, Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland 

Eimear Spain, Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland and School of Law, University of Limerick.

Competing interests: None declared.

References:

1. Derse AR,  “What part of “no” don’t you understand? Patient refusal of recommended treatment in the emergency department” 2005 72(4) Mt Sinai Journal of Medicine, 221. 
2. Stahl RY, and Emanuel EJ, “Physicians, Not conscripts – conscientious objection in health care” 2017 376(14) New England Journal of Medicine, 1380. 
3. Article 9. European Convention of Human Rights.European Court of Human Rights. Accessed 28th July 2019.  
4. Ehrenstein BP, Hanses F, and Salzberger B, “Influenza pandemic and professional duty: family or patients first? A survey of hospital employees.” 2006 6 BMC Public Health, 311.
5. Damery S, Draper H, and Wilson S, “Healthcare workers’ perceptions of the duty to work during an influenza pandemic” 2010 36 Journal of Medical Ethics, 12–18.