By Adaeze Aniodoh
“The public’s and the health workers’ concerns are not mutually exclusive; the goal is safety and fairness for all. Patients have a right to be protected. Health workers also have rights, and when infected they become patients.”
Recently the world has come to shock as the World Health Organisation declared COVID-19 ‘a public health emergency of international concern’ on January 30, 2020. The declaration of COVID-19 a pandemic has reverberated all over the world with attendant consequences: nations have closed their borders, airlines have ceased to fly, businesses have shut down and the healthcare system have become increasingly overburdened with a disease that has been described as a mystery and an invisible enemy. It is anticipated that the aftereffects of the global pandemic would be a recession worse than the Global Depression of the 1930’s. In the face of this severe and highly infectious disease is a reoccurring question in moments of health crisis: do healthcare workers have a duty to care for patients when doing so exposes them to considerable risks and even death?
Duty to Treat
During pandemics healthcare workers will inevitably be in close proximity and greater risks than those in unrelated or nonacute specialties. Notwithstanding this, all healthcare workers have a moral obligation to help their patients and the society without any form of discrimination. Healthcare workers operate on the basis of ethical principles, namely beneficence (doing good), non-maleficence (do no harm), and justice (just distribution of limited resources). Beneficence trumps all other principles and comes into play in considering treatment of patients in times of public health emergency. The principle requires that a healthcare provider has both professional and ethical duty to address a patient’s needs as long as the patient’s initial complaint falls within the provider’s scope of practice. With the duty of beneficence to patients: there is an implicit contract with the society to provide medical help in times of crisis.
The Hippocratic Oath which is enshrined in the Declaration of Geneva prescribes medical ethics in a doctor-patient relationship. It is also replete in most countries’ domestic legislation. The UK General Medical Council advises in Good Medical Practice that: ‘Doctors must not refuse to treat patients because their medical condition put the doctor at risk’. The American Medical Association adds a more sustainable perspective: Its code of conduct provides that “physicians should balance immediate benefits to individual patients with ability to care for patients in future” The discretion to treat or not to treat is left to the individual, but the justification not to treat is not on the physician’s obligation to self or loved ones but strictly on beneficence to future patients. In Nigeria, all freshly inducted medical personnel are required to publicly declare their readiness to obey the Code of Medical Ethics and other laws that control the medical profession. These rules affirm the solemnity of medical career and acknowledge public trust in healthcare workers. The oath taking practice is also an ubiquitous practice amongst Africans.
How absolute is the duty to treat?
One may wonder if the duty of healthcare workers to treat patients is absolute where willingness to work will put significant risk to one’s self or family. In developing countries with difficult and unattractive working conditions the duty to treat then becomes objectionable. African countries have signed the Quagadougou Declaration to improve healthcare delivery in the region, yet there is little or nothing to show for it. The African region is in short supply of health workers; a crisis exacerbated by inequalities in workforce distribution and brain drain. Corruption and bad leadership have also contributed to a situation where there is lack of medical equipment and essential medicines. There is also a lack of transparency by patients who fail to disclose their medical history for fear of stigmatisation and being turned away from assessing medical facilities. This has exacerbated the problems faced by healthcare professionals.
COVID-19 pandemic presents a conundrum on the absoluteness of healthcare workers duty to treat. An estimate of the proportion of infected people requiring hospitalisation when combined with likely infection attack rates (which is around 50-80%) show that even those with much developed healthcare systems are likely to be overwhelmed. A preliminary reproduction number of the virus is currently estimated to be between 1.4 to 2.5; this means that each infected individual could infect between 1.4 and 2.5 people. This simply tells how infectious the disease is and the challenges with managing the pandemic.
Healthcare workers in developing countries face infectious disease with fewer resources and at greater risks to themselves than their developed counterparts. In the case of Ebola outbreak, many medical staff fled health centres leaving dying patients behind. In December 2007, in Bundibugyo, Uganda- a city bereft of basic modern amenities, many healthcare workers are known to have died from Ebola due to the highly infectious nature of the disease. Even in well situated economies, pandemics still present the same challenge. In Toronto, Canada, during the Severe Acute Respiratory Syndrome episode, some healthcare staff abandoned patients and failed to turn up to work out of concern for their own welfare while those who did were stigmatised by their community for fear of contracting the disease. It is expected that this behaviour will be experienced with the COVID-19.
The Hippocratic Oath which is applicable in both developed and developing countries is silent on the issue of doctors treating people during pandemics. No personal or professional duties are absolute. For example, the duty to keep patient confidential information has exceptions for reporting child abuse and public safety. With regard to the duty of healthcare providers, it is impracticable to treat patients who cannot be saved but would readily transmit their deadly infectious disease to the care providers. The American Nursing Association in its ethics code states that “accepting personal risk exceeding the limits of duty is not morally obligatory, it is a mere option “.
Thus, a healthcare worker may not always be able to abide by the code of ethics of his profession. A healthcare worker may legitimately refuse to treat a patient without incurring any liability if he has prior excessive commitment and lack of relevant expertise. In this case, the refusal to treat is induced by a patient’s interest and not that of the worker’s interest, which would have led to the profession’s integrity being undermined. Despite professional codes and official proclamations, it seems that the obligation to treat a patient has remained an ideal rather than a practice. Caring for patients in crises moments has been considered praiseworthy and virtuous rather than obligatory. In perilous times, healthcare workers should be encouraged to provide care for those in need.
Way Forward
Universal participation of health workers minimises the magnitude of the risk per worker and the community at large. Instead of focusing on the lacunas in the law that limit the duty to treat, it would be more reasonable to identify factors that pose high risks to healthcare workers so as to encourage them to treat patients during pandemics. For example, personal protective equipment should be provided to every healthcare worker, while isolation centres should be furnished to match up to the dictates of the pandemic. Good financial and welfare benefits should be available to healthcare workers and their families in the case of death or permanent disability while patients who wilfully fail to disclose information likely to put health workers at risk should be prosecuted, so as to serve as a deterrence to others.
Author: Adaeze Aniodoh
Affiliation: Doctoral Candidate, School of Law, University of Manchester.
Competing interests: None