On Pandemics and the Duty to Care: Whose Duty? Who Cares?

Published in BMC Medical Ethics (Vol 7, No 5), this 22-page paper urges focused reflection and open dialogue on the obligations of health care professionals (HCPs) to patients with severe infectious diseases, particularly diseases that pose risks to those providing care. This call for clarification of the rights and responsibilities of HCPs - and the articulation of a "pressing need" to articulate these standards in the form of professional codes of ethics - comes in the aftermath of severe acute respiratory syndrome (SARS) and in the current context of pandemic avian influenza preparedness.

According to these authors, it is of critical importance that organisations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. They stress that an honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations.

In the pages that follow, the authors proceed to open a social dialogue on the role of HCPs during health emergencies, in the hope of advancing public debate and stimulating action - particularly with the spectre of a bird flu outbreak on the horizon. To that end, they ask the following questions:

• Is there a problem? - The response by HCPs to SARS "was generally regarded as exemplary", with many caregivers going well above and beyond the call of duty to place themselves at personal risk of illness or death in order to help contain the virus. However, "the risk that was faced during SARS was not distributed equitably, and those HCPs who volunteered to provide care faced the greatest exposure."
• Do health care professionals have special obligations during infectious disease outbreaks? - At the centre of the duty to care is the principle of beneficience; the authors believe there are strong reasons to adhere to this principle even in the context of an infectious disease outbreak like avian flu. These reasons include:
  1. The ability of physicians and health care professionals to provide care is greater than that of the public
  2. By freely choosing a profession devoted to care of the ill, health care professionals have assumed risk
  3. Due to a "social contract" between HCPs and members of the public, it is reasonable and legitimate for the public to expect that HCPs will respond in an infectious disease emergency.
• What is the role of professional codes of ethics? - Though a code of ethics, articulated by a self-regulated profession such as health care, should not be understood as a concrete mandate ("law"), the authors stress that an informative, comprehensible, practical code is essential - and that it needs to be concordant with public expectations. Such a code could dispel confusion and uncertainty for HCPs regarding the duty to care. In addition, these codes "also serve as potent forms of symbolic communication to the public that is served by the professions" by reassuring them that the trust they place in HCPs is "justified and legitimate".
• What do current codes of ethics say regarding duty to care during epidemics? - Despite the fact that many HCPs were exposed to serious risk of morbidity and mortality during the SARS crisis, "professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk." This silence is not a new phenomenon.
• How strongly formulated should the duty to care be? - Though there is no consensus as to how explicitly and stringently the requirements for the duty
  to care should be communicated, "With the threat of a new epidemic, another round of full
  and open discourse is required as to whether the acceptable standard of professional engagement should occur at the level of 'supreme', 'good', or 'merely decent' Samaritan."

In the final sections, the authors examine concrete next steps forward in terms of creating clear, unambiguous codes of ethics for guidance during times of infectious disease outbreaks. They envision this two-step process to be centrally one of transparent, participatory dialogue - which involves not only HCPs but patients and members of the public, as well. Specifically:

1. Professional colleges would create a forum to engage their memberships and encourage exchange of views on the issue of duty to care during communicable disease outbreaks. This exchange would, in turn, inform the development of formal position statements and guidelines. These documents "ought to be made publicly available (e.g., prominently posted on the websites of professional health care colleges and associations) in order to encourage sustained dialogue..."
2. Strategies should be developed to foster public debate and dialogue on the positions taken by the various health care professions. To cite one example, a working group at the University of Toronto Joint Centre for Bioethics has produced a 15-point, value-based ethical guide for pandemic planning that includes discussion of the duty to care. This report has been made publicly available via the internet - click here for more information; in addition, webcasting and electronic town hall meetings are being planned. According to the authors, "It is of utmost importance to promote a public discourse on these issues and, most importantly, to give a voice to all those who would be directly affected by a communicable disease outbreak. Together, health care professionals and the general public should participate in discussions..."