Personal Protective Equipment for front-line health workers: an ethical imperative

By Elizabeth Fenton

Covid-19 poses risks to health care workers that exceed those posed to members of the public. Repeated exposure to infected patients increases their risk of infection, and might also make their symptoms more severe if they become infected. Although reported numbers vary, in Italy approximately 9% of COVID-19 cases are health workers, and at least 37 doctors have died from the disease. In China, an estimated 3000 health workers have become infected and at least 13 have died, though that number might be higher. Leaving health care workers, and the many others required to make hospitals function, vulnerable to infection is bad for everybody – without functioning hospitals many more people will suffer and die, and not just from COVID-19. Even in a time of pandemic, other health problems arise or are ongoing – people have heart attacks, break bones, get appendicitis, have cancer. We expect our health services to be available, and to be appropriately staffed.

But under what conditions can we continue to expect this?

Reciprocity is a critical ethical value during a public health emergency. It is the value that underpins our individual responsibilities to help one another, and to fulfill professional responsibilities we have to our society. But reciprocity also means providing the support necessary to ensure that those with professional responsibilities can fulfill them safely, without taking on undue risks. The expectation that health care workers will turn up to work during a pandemic depends on hospitals and the institutions that govern them meeting their reciprocal obligation to minimize the risks to which those workers are exposed.

COVID-19 is highly infectious in hospital settings, and some settings are much more dangerous than others. Operating theatres, for example, are particularly problematic because the virus can be widely distributed through the intubation process and also through the spread of the patient’s bodily fluids around the room. Aerosol spread means the virus will remain on surfaces in the room, including the walls and ceiling. It is not surprising that surgeons are concerned about the implications for risk exposure in theatre. One surgeon from the UK notes that “very soon all our operating theatres will be covered in COVID-19.” This concern is exacerbated by evidence that patients who are infected but are not symptomatic can be efficient in spreading the virus: an infected patient undergoing surgery in China infected 14 people before the onset of fever.

Personal protective equipment (PPE) in the context of COVID-19 includes gloves, medical masks, goggles or face shields, gowns, and in higher-risk settings respirators and aprons. When used correctly, it reduces the risk of infection for those equipped with it, and the risk of an individual with the disease from infecting others. Front line health care workers are questioning whether sufficient PPE will be available to them in the coming weeks and months, and whether the forms of PPE they are given will provide sufficient protection against COVID-19.

This is not merely a logistical question, but an ethical one: are our health care institutions fulfilling their reciprocal obligations to protect their most vulnerable staff? Many staff are being advised to wear PPE only when caring for patients with confirmed or suspected cases of COVID-19. But if infected patients who are not symptomatic (and who therefore may not have been tested, so are neither suspected nor confirmed) can spread the virus, this advice suggests a potentially dangerous underuse of PPE.

It might be argued that there is uncertainty about the types of PPE needed to protect different health workers in different contexts, and that over-consumption may result in critical shortages. However, countries yet to face the surge of cases that are crippling hospitals in Europe and the US have time to absorb lessons from the experience of workers in those hospitals, as well as guidance from China’s experience on the level of PPE needed to protect health workers. This guidance suggests using aggressive measures to protect health care workers, measures that would typically be adopted for the treatment of patients with cholera or plague. We also ignore at our peril lessons from other public health emergencies of the not-so-distant past. During the 2014-2016 Ebola epidemic in west Africa health care workers were up to 32 times more likely to become infected than the general population, and many died. The disastrous impact of these deaths on staggeringly under-resourced health systems underscored the importance of adequate and timely protective equipment.

If health care workers do not feel protected by the type or quantity of PPE provided, we can no longer expect them to come to work. Our health care institutions must give their staff the best chance of protecting themselves from the most severe forms of COVID-19. Anything less is a failure of our obligations to them, and of our obligations to provide a functioning health system to all those who will need it.


Author: Elizabeth Fenton

Affiliations: Bioethics Centre, University of Otago

Competing interests: None

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