One day during the peak of the severe acute respiratory syndrome (SARS) outbreak in Taiwan in 2003, a nurse walked from her hospital to a nearby bus stop. Dressed in uniform, she waited patiently for the bus. Then she saw one approaching. But when the driver noticed her, he picked up speed again and drove past. He did so to avoid any risk of infection for either himself or his passengers.
James Dwyer and Daniel Chang-Fu Tsai tell this story (J Med Ethics 2008; 34: 7–10) as an example of what can happen when a community is threatened by a serious, transmissible yet hitherto unknown disease. Together with other experiences from the SARS and AIDS epidemics, they use it to illustrate the need for societies to appraise in ordinary times the pressures that can affect health-care workers in extraordinary times. What exactly are the dimensions and limits of the “duty to treat”?
Dwyer works at the SUNY Upstate Medical University Centre for Bioethics and Humanities at Syracuse, NY, USA, while Tsai is at the National Taiwan University College of Medicine in Taipei, Taiwan. Although they do not propose definitive answers, they make a convincing case for all countries to evaluate democratically the measures that may be necessitated during a major epidemic.
Acceptance of potential danger as an inherent, even defining, element of medical practice came into sharp focus with the emergence of AIDS. As the numbers of HIV-positive patients became clear, however, alongside clarification of the dangers of needle-stick exposure and the rate of seroconversion, most health-care professionals concluded that the risks were acceptable. At the same time, at least in the USA, those hazards became very unevenly distributed. Cities varied considerably in their infection rates. And the risks fell disproportionately onto hospital staff, especially nurses and more junior doctors.
The dilemma emerged even more sharply with the advent of SARS, when early evidence indicated that about 30% of cases were health-care workers, and that around 10% of all patients died. Moreover, although greater sharing of infection dangers may have made sense for AIDS, the new situation was very different.
“It would be a public-health disaster to spread SARS patients evenly throughout practices, clinics, and hospitals”, Dwyer and Tsai write. “With diseases like SARS, it makes sense to cluster patients in designated units and hospitals. But this means that the associated risks will also be clustered.”
Perhaps with a nod towards bioethicists who write solely about the philosophical and ethical implications of a duty to treat, the authors point out that appeals to an abstract duty grounded in professional commitment do not address key practical issues. How are city health officials to decide which hospitals should receive people with suspicious symptoms? How are hospital administrators to arrange emergency screening and isolation? On what principles should health-care workers be reassigned from one area to another? What of the responsibilities of staff, treating highly infectious patients, towards their own children, parents, and spouses?
Even within the professional, dedicated hospital world, problems can arise. Dwyer and Tsai cite two such circumstances, which occurred during the SARS epidemic. First, a chief resident at one hospital with a bed shortage rang two other hospitals in the hope of transferring a patient who probably had the disease. Although told that no rooms were available, she had grounds to believe otherwise. Another resident was concerned about how an individual with SARS was treated after being moved to a different unit. The patient was not intubated in an appropriate, timely manner, and died shortly afterwards.
Dwyer and Tsai even question the Taiwanese government's decision to give special payments to doctors treating SARS patients. They argue that these looked more like incentives than recognition of an important social role and, because nurses received smaller sums, that they seemed unfair.
As microbiologists contemplate the abyss of a health service struggling to cope with an exceptionally virulent epidemic, there's clearly much more to consider than microbiology per se.