On the Ethics of Treating Ebola (or refusing to)

The Wall Street Journal reported yesterday that “far more Liberian doctors are in the U.S. and other countries than in the country of their birth, and their absence is complicating efforts to curb what has become a global health crisis.”

ebola heroes 2

The article further documents the difficulty in getting doctors to treat patients with Ebola. This is not the first time I have read about something in this line – there were also reports of staff of the Madrid Carlos III Hospital staying away due to fear of Ebola.

The topic has come up among our students too. We train at one of the nine South African hospitals that are to be the first port of call for suspected Ebola cases. What would we do if we actually had a confirmed case? Would we, as students, treat them? Mostly we think we would not (right now… read on).

In principle, I do not think it is wrong to defer treating a patient because of lack of training. For example, I have not yet been trained to do a C-section (only to assist) and so it would actually be negligent of me to attempt one on my own. But if we want to be really accurate, you cannot compare the two… because who has truly been trained to deal with something like Ebola? Very, very few people.

I do not think that med students should under any circumstances treat Ebola patients. Why? Simple. We are students. We are not employed. If we fall ill, it will not be covered as an injury on duty by the government (because we are not an employee). We do not have any insurance to cover any of the sequelae, because again, we are not officially working.

But in a few short months, we WILL be qualified, employed doctors. And what then? Then we are bound by Oath to treat. Then we cannot refuse. But again, what if I have not even been trained how to don the HazMat suit? What if I do it wrong?! I still nearly-strangle myself while gowning for surgery every once in a while (thank you to all the scrub nurses that have un-entangled me time and time again). LOOK at these photos of doctors suited up for treating Ebola. It is INTENSE.

Image via Wall Street Journal, Glenna Gordon. Please click image for original article and more photos.

So the question is, really: is it acceptable for a healthcare professional to refuse to treat a patient out of fear? I know that in the early years of HIV, many HCWs refused to treat patients with HIV out of fear. But now we know how it is transmitted and we can prevent it, so even though we are careful, nobody that I know of refuses to see such a patient.

Ebola, on the other hand: we know how it is transmitted, but preventing transmission in a healthcare setup is not quite as easy as preventing HIV. There are still cases where protocols were ostensibly followed, yet the HCWs fell ill. How? And of course, the course of illness if one contracts Ebola is so much quicker and more violent than HIV. So much less manageable.

https://twitter.com/LibyaLiberty/status/523407178355339265

I don’t think it is acceptable to force a physician to leave where he is working and go into a highly infectious zone. If he volunteers, sure. But coercing physicians from a different country to deal with something they may not feel equipped for can surely not be “right”?

And if a patient arrives in your casualty and you are the first point of contact? The way we have been taught is that we cannot ever deny life-saving treatment. So if the patient is exsanguinating right there, you are responsible. If the patient is relatively stable, you may organise that another physician takes over his management.

On a side-note: I am not sure that it is entirely accurate that a shortage of doctors is curbing the containment of the disease. Doctors certainly are not the only ones instrumental in the endeavour. What of lab technicians? What of the researchers? What of the pharmaceutical companies? What of the politicians? What of the infrastructure that is so severely lacking?

I know that HCWs are very reluctant to voice their concerns and just hope that they won’t ever be exposed to a situation where Ebola is real in their wards. We know that we are meant to be the passionate ones. The people who chose our careers because we wanted to help. To save lives.

But our lives are not one-dimensional. We too have families. Dreams. Lives outside of medicine. We too would like to live a few more years. We too think that we are worth more alive than dead.

I think it is a scary prospect and denying discussion on the matter by making HCWs feel ashamed of their fears, is not the way to deal with it.

As someone said to me yesterday,

“You will give your life to Medicine. But Medicine will not come to your funeral.”

I think it is pretty clear that I have more questions than answers. I would love to hear your opinion/debates/rants/ethics on the matter.

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13 thoughts on “On the Ethics of Treating Ebola (or refusing to)”

  1. My cousin was the treating physician of the first case in the country. It was unsuspected and he was not protected. And so he had to isolate himself and his assistants until thier blood works up clear them of contracting the virus. It was a nightmare, especially to his pregnant unemployed young wife.

    Physicians are neither slaves nor monks. They have the right to choose. And this come from a person who think war is a childish thing and trialling a solider to refuse to participate is nonsense( it is not the same as abandoning your team after you signed up).
    A human being should use his mind and conscious and do what he thinks is right.

    1. That is insanely scary. Treating a patient while wearing the right gear is one thing, but treating the case unprotected… I think I would get major PTSD. Hope he and his wife have recovered from the shock by now!

  2. I don’t think I have a whole lot to contribute, mainly because I just finished a big hike and my body/brain is tired. But I loved reading what you have to say, and you bring up some excellent points. Also, I wholeheartedly agree with this:

    “But our lives are not one-dimensional. We too have families. Dreams. Lives outside of medicine. We too would like to live a few more years. We too think that we are worth more alive than dead.”

  3. I work in the labs of one of the designated South African hospitals. Over the years we have processed samples from several suspected VHF cases which have all turned out to be negative, as well as the Ebola positive samples of 1996. Ironically, techs are not bound by the Oath but they are being sent into the VHF lab to process these samples, whilst some of the younger medics (pathologists and registrars) are distancing themselves and refusing to handle any of the suspected samples. With certain professions there are risks involved and you know this when you sign up for it. Remember the Concordia incident where the ship’s captain was later arrested because he abandoned ship before the passengers were evacuated? I think ethically it is wrong for doctors to refuse treating these patients. People may have the right to choose, but what would happen if we all refused to treat these patients or handle their samples?

    “We know that we are meant to be the passionate ones. The people who chose our careers because we wanted to help. To save lives.”

    Sadly I know too many doctors who are neither compassionate or care about helping and saving lives. They became doctors because of the potential to have a lucrative career. For them it’s just a job. This country needs more doctors like you.

    1. Thank you, Izzy! It must be quite daunting handling those samples. I assume you have access to the protective gear and special labs and all of that though, right? If we all refused I think we would have a real problem. I often wonder if docs and nurses wouldn’t benefit from some training at the labs, though. I get the feeling that you guys are a lot more proficient at occupational safety.

  4. I don’t know if there is a right answer? We all went into this profession because we want to “help people.” So what do we do when helping people puts us at our own risk? How would we feel if we actively chose to not get involved and the problem gets worse? It’s a personal decision for everyone, but I don’t think it is ever easy

    1. Exactly. It’s easy to postulate from a distance, but what if somebody dies because we did not get involved? It’s especially hard with things like Ebola because the mortality is so high that you won’t even know for sure if your presence could have helped. If I’m honest, I’m not the person who is going to pack my bags and volunteer in one of those countries… I kind of wish I were that brave and selfless. But at the same time, I don’t think I could walk away if it reached my hospital. I don’t know. One hopes that if the decision ever needs to be taken, help and advice will be available somehow!

  5. I think you are right Mariechen, just now Ebola presents a tremendously scary and huge ethical dilemma for all HCWs. It is also part of the territory for all HCWs. You mention HIV/AIDS, I can also think of SARS, Legionnaire’s disease, TB, pandemic influenza, on and on. All very scary and dangerous, especially for HCWs at their start. There will be quiet times, but one can also expect something new to crop up every now and then and need attending to. And until we are able to understand and deal effectively with the new threats that come along, there will be those of us who will fall off the edge. It can be terrifying and can prevent people from entering the health care arena and prompt some already there to back away.

    Thank you for being so thoughtful (as I know you always are!) about this one Mariechen, and stay safe!!!!

    1. Thank you, Nancy! I think that if everyone took cognizance of the things you mentioned, then HCWs would also feel safer and understood by the surrounding communities. Sometimes it just helps knowing that people recognize the risks we all face, and that we will be supported if we encounter trouble. I really wish there was a fail-safe way of addressing these risks, but I’m not ready for robot-doctors and nurses just yet 😉

  6. On one of my first days studying to be a paramedic our lecturer said to us “A dead hero can’t save lives”.

    If a healthcare practitioner dies or is disabled while trying to treat a patient, then they are not only unable to treat that patient, but also many more patients in the future. But the patient also needs to be treated – a bit of a catch-22 situation. I think this is a point where medical ethics come into play, you need to be able to do the greatest amount of good for the greatest number of patients. But ethically you have to treat the patient as well, access to healthcare is one of the basic human rights.

    With Ebola I think it is a case of early identification and stratification of at risk patients, and education of all levels of healthcare workers (including students and even auxillary workers) on how to do this. In a more general sense, safety measures and training are often neglected, while they should be of paramount importance.

    1. Thank you, what a fantastic comment. A dead hero can’t save lives, indeed.
      I agree. Providing a hazmat suit and saying “there you go” is not enough. People need training in donning and doffing such protective suits otherwise they may as well not wear them at all.
      Same with TB masks: so many hospitals just provide a standard size, while if you’re not fitted for your proper size, you might as well not be wearing a mask at all.

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