Part of the Cure or Spreader of the Disease?

For want of a nail the shoe was lost,

for want of a shoe the horse was lost;

and for want of a horse the rider was lost;

being overtaken and slain by the enemy,

all for want of care about a horse-shoe nail.

— Benjamin Franklin, The Way to Wealth (1758)¹

The World Health Organization has designated coronavirus disease 2019 (COVID-19) as a pandemic.² As the death toll rises each day we are inundated with new information on the transmissibility, mortality, and aerosol stability of the infective virus, severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2).^{3 , 4} One fact is very clear: While providing optimal treatment for patients, careful execution of infection control measures is necessary among healthcare providers to prevent nosocomial transmission.

Personal protective equipment (PPE) recommendations have been made explicit^{2 , 3} and include fluid-resistant gowns, gloves, eye protection, face shield, hair covers, and fit-tested N95 respirators or powered air-purifying respirators. However, given the unexpected and unanticipated pandemic and consequent limitation of resources in most healthcare settings, PPE is being increasingly rationed, forcing many healthcare workers to reuse or forego the use of PPE entirely.³ The US Centers for Disease Control and Prevention has even recently resorted to recommending the use of scarfs or bandanas instead of necessary masks and N95 respirators.^{3 , 5} In turn many hospitals are relying on community donations, including self-made masks and makeshift face shields, all of which puts healthcare workers at major risk of infection.

These circumstances present physicians with an ethical dilemma. According to the American Medical Association Code of Medical Ethics, physicians have a professional obligation to act in the best interests of patients and to do no harm, even in the face of greater than usual risks to their own safety, health, or life.⁶ This leads to a difficult question: Should we provide care without adequate protection? During the Black Plague of the Middle Ages, many of the already few healthcare professionals at the time left their practices and moved with their families to rural retreats—along with many others—to avoid becoming infected in crowded cities while treating patients.⁷ SARS-1 (2002-2004) did not reach the global scale of SARS-CoV-2, but nevertheless stimulated consideration of important ethical issues in the provision of care. At that time shortages of PPE and a lack of sufficient dedicated infectious disease specialty care led to a disproportionate surge of healthcare worker infections early on during the SARS outbreak in East Asia.⁸ In 2015 Ebola’s high case-fatality rate put West African low-income countries with fragile health systems and limited healthcare supplies at extremely high risk, costing the lives of hundreds of healthcare workers.⁹

When PPE is not available, refusal to provide medical treatment deprives patients of needed care, resulting in harm to individuals and communities. The consequences of providing care without adequate PPE, however, are also grave—healthcare workers potentially become ill; infect their colleagues, patients, and families; and are removed from the workforce. This not only decreases the human resources available to care for a population in crisis, it also transforms healthcare workers into vectors for the disease they are working to eradicate. Without PPE providers cannot perform their ethically required duties toward their patients. Those who seek to avoid doing harm by caring for patients under these circumstances are at risk of perpetuating an arguably greater harm. Moreover a substantial loss of workforce as a result of a lack of PPE, especially those more vulnerable to a complicated COVID-19 disease progression, leads to a loss of skilled workers, experienced teachers, and specialists after the pandemic ends. Reports from China and Italy illustrate the loss of many healthcare workers across all disciplines and the cross-training of, for example, surgical specialists to cover emergency departments and intensive care units.^{10 , 11}

What Comes Next?

Going forward, all reasonable efforts should be made to organize patients into COVID-19–dedicated units and, when necessary, to transfer patients to facilities with adequate resources. The existing supply of PPE should be conserved as much as possible, which implies canceling elective surgeries, limiting participation of non-essential medical personnel in direct patient care, reusing PPE, and allocating PPE only for higher risk exposures. To help ensure adequate supplies of PPE for those on the front lines community donations, existing manufacturers, newly converted factories, and in-house innovations can be engaged.

Based on the summary report from the Chinese Center for Disease Control and Prevention, 4% of all COVID-19 infections were healthcare personnel, of which 15% had severe or critical illnesses.¹² Examining the integrated surveillance data from Italy and Spain earlier in the country’s outbreak, 20% of infections were seen in healthcare workers. During the mass shortage of PPE, studies comparing non–medical-grade masks with medical-grade masks demonstrated significantly higher rates of infection among healthcare workers using non–medical-grade masks because of poor filtration and moisture retention.¹³ Furthermore in a study comparing medical-grade surgical masks with N95 respirators, the use of medical-grade surgical masks was associated with significantly higher rates of COVID-19 infection.¹⁴ Thus, although some protection is better than none, the shortage of PPE and the risks to healthcare workers spread as quickly as SARS-CoV-2 itself. We can learn from the experiences of our colleagues across the planet. The pandemic is global, and its lessons on the importance of protecting the healthcare workforce are global as well.

Proposals and Implications

On the basis of the preceding discussion we propose 4 options for physicians who are caring for patients when PPE is unavailable:

• •Option 1: Physicians can abstain from participating in direct patient care until PPE becomes available. From an ethical viewpoint this may seem contrary to our obligations; however, in certain instances individual physician choice and unique circumstances (eg, medical conditions, family situations) should be taken into account. The possibility of contracting and further spreading the infection when PPE is insufficient may be a compelling reason to refuse to participate in direct patient contact. Exposing oneself and one’s family, colleagues, and patients to harm and thereby exacerbating the scope of the pandemic can be a substantial risk. Moreover the physician may face a higher risk of contracting or succumbing to the virus because of advanced age, comorbidities, or immunosuppressed status. Caring for others requires caring for oneself first.
• •Option 2: Given limited resources physicians can continue to care for patients as best they can, whether in-person or remotely by way of tele-rounds, while observing personal hygiene (eg, frequent hand washing, 6-foot separation from others, and coughing and sneezing into one’s elbow), accurate use of whatever PPE is available, and postexposure decontamination (change of scrubs, showering, and disinfecting all personal and exposed medical devices and equipment). Physicians who exhibit symptoms and test positive for COVID-19 should follow official and institutional policies.
• •Option 3: The same as option 2, but minimizing the possibility of transmitting the virus to one’s family or friends by self-imposing strict social isolation and living at the hospital or elsewhere rather than at home, at least until the pandemic has begun to recede and testing for SARS-CoV-2 is negative.
• •Option 4: The same as option 3, but continuing to work despite showing symptoms or testing positive for SARS-CoV-2, given that most of the healthcare workforce is expected to become infected without PPE. This scenario recognizes direct patient care as our paramount obligation, even with the direct risk to self and propagation of the infection to other patients and their families—in other words potentially causing direct harm to self and others for the benefit of infected patients.

Regardless of which of the above options is chosen, the consequences of physicians as potential helpers or as vectors of the virus must be considered. Conserving the healthcare workforce by limiting their exposure to the infective agent, as presented in Options 2 and 3, can help keep our healthcare providers reasonably safe to allow for continued patient care. The first option—absenting oneself from providing care—is not preferred; it is reminiscent of 14th century physicians absconding to safety outside plague-infested cities. The fourth option—providing care while sick—is far from ideal yet is anecdotally seen in hospitals across North America. Options 2 and 3 seem to be most acceptable when some PPE are simply not available.

Conclusion

The safety of our patients, healthcare providers, and communities should be our highest priority. Unprotected physicians could be the next patients, along with their families, colleagues, and the patients they care for. As individual physicians and collectively as a profession, we must be role models and fierce advocates for breaking the chain of SARS-CoV-2 transmission and protecting the healthcare workforce in order to help preserve the entire healthcare enterprise.

The practice of medicine has often been described in terms of military metaphor, using phrases such as ”fighting disease,” “silver bullets,” “the therapeutic armamentarium,” and “the body’s defenses.” That tradition can be applied to our current situation to good effect. The world is at war with COVID-19, and the frontline army is composed primarily of healthcare workers. We need weapons and armor appropriate to the battle to be effective in curing infected patients and limiting the spread of COVID-19: We need to be properly equipped if we hope to win this war with as few casualties as possible.