Should a hospital be allowed to force professional staff to work with SARS patients? Lucy Smith says no. St. Michael's Hospital says yes.
Smith, a nurse with 17 years' experience who works in the Toronto hospital's dialysis unit, rebelled when she was “drafted” into St. Mike's special SARS team. She refused, claiming measures to protect her, and by extension her 3 children and immunocompromised mother, who is recovering after a kidney transplant, were inadequate.
“Maybe I could pass something to her,” says Smith. “If it was just myself, I would [join the team]. But can the hospital guarantee that I [won't] get sick, or my kids and mother?”
She says the offer of increased pay — $67 an hour for a nurse with her experience — supports her argument. “If this is within the scope of my practice, why are they offering double time?”
About 100 staff volunteered to be part of the hospital's SARS team, but another 65 were needed. Smith was selected, and says her director implied that her refusal to join the team might lead to dismissal; her union advised her to obey the order. While attending the June 9 orientation meeting, however, Smith announced that she would not join the team. The head nurse told her not to come in for her regular shift the next day.
Although the case involved only 1 nurse, it holds implications for a system under siege by SARS. Under Ontario's Occupational Health and Safety Act, Smith can refuse to work when the “physical condition of the workplace…is likely to endanger.” The Ontario Nurses Association (ONA) says members have a “right to refuse to work only where unsafe conditions exist and they cannot be adequately protected through infection control procedures.”
“Many nurses in Toronto could theoretically refuse to work because they haven't got masks that fit,” said ONA president Barb Wahl. This would qualify as a health and safety concern. Smith says new safety protocols that have been introduced are not enough. “We're making this up as we go along.”
If an assignment is refused, Wahl acknowledges that “nurses are at risk of being disciplined by employers.”
Did Smith have an ethical duty to accept the assignment? “The hospital and public seemed to be saying, ‘I’m a nurse, so ethically I have to,' ” says Smith. “But what about my responsibility to my kids and mother?”
Dr. Peter Singer, director of the University of Toronto Joint Centre for Bioethics, says there is a “threshold beyond which health care workers aren't obliged to take personal risks. We don't expect firefighters to jump into a burning pit, or police officers to throw themselves in front of a bullet.”
How health care workers define this threshold “is an intensely personal decision … but obviously, it has serious implications for our collective response to a problem like SARS.”
Dr. John Williams, the CMA's director of ethics, says physicians have traditionally put the well-being of patients ahead of their own. “However, not all physicians are required to be heroes, especially if they could do more good for patients by staying away from dangerous front-line situations. Hopefully, there will always be enough volunteers to do the front-line work.” — Barbara Sibbald, CMAJ