Your family or your job? Balancing the duty to treat with the duty to family in the context of the COVID-19 pandemic

By Doug McConnell

At an aged-care home in Australia, most of the social care workers abstained from work after a COVID-19 outbreak at the facility. They cited concern for their family members, some of whom were immunocompromised. Physicians and nurses in the UK have threatened to quit because a lack of adequate personal protective equipment (PPE) is putting them and their families at too much risk. In Spain, patients appear to have been abandoned in their aged-care facility, with some being found dead in their beds.

Are workers in any of these cases morally permitted to abstain from work to protect their families from infectious disease or have they failed in their duty to patients? One way to assess these cases is weigh the worker’s duty to treat against the combined risks and burdens of that work. If the duty to treat outweighs the combined costs of working then there is a moral obligation to work; if the combined costs of working outweighs the duty to treat then the worker is morally permitted to abstain from work.

Many healthcare workers (broadly conceived) will be asked to work longer shifts with fewer days off in a more stressful environment while wearing uncomfortable PPE much of the time. The fatality rate of healthcare workers who contract COVID-19 is ~1/500. Even with access to PPE, roughly 20% of ‘frontline’ workers are expected to become infected which means that ~1/2500 of the ‘frontline’ workforce would be expected to die of COVID-19.

For workers who live with others, there are further burdens that come with the obligation to avoid negligently harming others. This obligation is stronger if one is in close relationships with those others, as is typically the case with immediate family. The obligation is also stronger if the other is particularly vulnerable to COVID-19, as will be the case for elderly family members (~15% case fatality rate for those aged 80+ years). A ‘frontline’ nurse in Ireland has detailed some of the burden involved in meeting this obligation:

I’ll come home from work through my laundry room door that leads to the outside. I’ll strip naked including shoes and put everything straight into the washing machine on sanitize mode. I’ll use a Clorox wipe to clean anything I touched in the process. I’ll then take the towel that my husband has left for me and use it to walk to my master bedroom covered up. In there, a room that nobody else is allowed to enter after today… After my shower I’ll sanitize everything I touched again, then hand sanitize and get dressed. When I’m done with this process I’ll be able to sit in the family room 6 feet away from everyone I love.

These measures are likely to be required for weeks if not months and, even then, they might not prevent the worker infecting their family.

The main reason to think that workers would be morally obliged to take on these risks and burdens is because they have a duty to treat patients – this is what they are employed to do. The strength of the duty to treat depends on what the worker implicitly consented to in taking the role and how much the worker owes society for the benefits inherent in the role. Specialised physicians receive substantial benefits so have a very strong duty to treat. Towards the other end of the scale, social care workers receive substantially less from society than physicians and nurses, for example, so their duty to treat is much weaker.

If we assume that the measures taken by the Irish nurse above are required for any ‘frontline’ healthcare worker to meet their obligation to close family at home, does the duty to treat oblige workers to take on that burden (along with the other personal risks and burdens posed by COVID-19)? In my estimation, it does for physicians and nurses since these roles come with a strong duty to treat; however, uncertainty over the exact strength of this duty to treat leave this open to dispute.

I think it is less controversial to claim that social care workers are not obliged to take on such a burden to protect their families given their much weaker duty to treat. If that is correct, then the absentee Australian social care workers were morally permitted to abstain from work after the outbreak of COVID-19 in their workplace, especially those with immunocompromised family members. This line of argument does not, however, justify abandoning people in aged-care homes. Workers are still obliged to inform management so that alternative measures can be taken. Of course, the subsequent staffing shortage might still leave patients without treatment. One solution to this problem would be to offer workers temporary roles which have a stronger duty to treat underpinned by greater benefits such as higher pay and prioritised healthcare for workers and families.


Paper title: Balancing the duty to treat with the duty to family in the context of the COVID-19 pandemic    FREE

Author: Doug McConnell

Affiliations: The Uehiro Centre for Practical Ethics, University of Oxford

Competing interests: None

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