Ethical obligations of society to health care providers during a major threat to population health

1. Ethical obligations of society to health care providers during a major threat to population health September 9, 2006 Dr. Jeff Blackmer Executive Director, Office of Ethics, CMA

4. Objectives • At the end of the discussion, participants will: • Understand the relationship between physician obligations and the reciprocal obligations of society to physicians and their families in times of pandemic • Begin to consider the possible roles of regulatory bodies in this situation

5. Outline • Background • Cases • Ethical obligations of physicians • Obligations owed by society to physicians and their families: • Before a pandemic • During a pandemic • After a pandemic • What can regulatory bodies do?

6. Disclaimer • Many of these same obligations could be said to exist towards other health care workers and support staff • Physicians will be highlighted because • This is primarily a meeting of physicians • There are some unique features when it comes to discussing physicians • Codes of Ethics/professional obligations • first point of contact • lack of employer insurance/financial backup/salary • expectations to work outside of area of specialty/potential broad scope of practice • liability issues

7. Concept of Reciprocity • U of T Joint Centre for Bioethics report, November 2005 (Stand on Guard for Thee): • “People are more likely to accept (difficult ethical) decisions if the decision-making processes are reasonable, open and transparent, inclusive, responsive and accountable, and if reciprocal obligations are respected.” • This acceptance of decisions applies equally to members of the public as well as physicians and other health care professionals

8. Article published in CMAJ on ethics and pandemics • Five email responses: • 4/5 recognized the professional obligations of physicians in a crisis, even when their own health may be at risk • 5/5 emphasized that they are not willing to assume those risks unless ensured that the government, hospitals and others will fulfill their reciprocal obligations • Suggests that physicians may be more aware of, and critical of, the support system than during the SARS epidemic • They have been sensitized to the obligations of others by their experience of the “system failings” during SARS

9. There may be less willingness for physicians to unquestioningly place themselves in harm’s way without assurances that they will be protected to some extent • They may expect these assurances prior to the onset of the pandemic, not while it is occurring

10. There is a growing awareness that just as health care workers have certain duties and obligations, they have certain rights and expectations as well • “(The substantive value of) reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families.” • U of T Report

11. Our task is to discuss how society can meet its reciprocal obligations to support those facing this disproportionate burden, particularly physicians and their families

12. Physician A • Dr. A is a 63 year old orthopedic surgeon who has had a specialized practice in Melfort for the last 30 years • At a hospital medical staff meeting, it was made clear that all hospital physicians would be expected to provide frontline care for patients in the case of a pandemic influenza outbreak

13. Dr. A would like to help out, but is concerned that he does not have the skills to care for patients who are acutely sick with a respiratory illness, and is worried that he may harm some patients instead of helping them • He is also concerned about possible liability issues should a patient be harmed while under his care for a condition he has not treated to any significant extent since his residency

14. Physician B • Dr. B is a 40 year old family physician with a private practice in Saskatoon • She is married with 2 young children • She is used to providing care for people with respiratory illnesses and influenza, seeing many of them each winter during cold and flu season

15. Dr. B. feels strongly that she has an ethical obligation to provide care in the case of a pandemic, and is willing to assume the risk to herself; she considers it a part of her duties as a physician • However, she is very concerned about the possibility of bringing home an illness to her family, and also what would become of them financially and emotionally should she become ill or die while caring for patients during a pandemic

16. Ethical obligations of physicians • Traditionally, physicians have respected the principle of altruism, whereby, throughout history, they have traditionally set aside concern for their own health and well-being in order to serve their patients • While this has often manifested itself primarily as long hours away from home and family, and a benign neglect of personal health issues, at times more drastic sacrifices have been required

17. During previous pandemics, physicians have served selflessly in the public interest, often at great risk to their own well-being (although there are also isolated historical exceptions of physicians who have fled from such situations) • The SARS epidemic has served to reopen the debate with respect to the ethical obligations of physicians during a pandemic

18. What exactly is the obligation of health care providers during a pandemic? Is it to provide care to all those in need regardless of the level of personal risk? • Or do physicians have a right to refuse to provide care when their own health (or that of their family) is at risk? • Is the provision of services during a pandemic based on the obligation of governments and others to provide reciprocal services to physicians; if this reciprocity is not honored, are physicians then absolved of their obligations?

19. Reciprocal Obligations:Before a pandemic occurs • Planning and decision making • Access to equipment and training • Clear plan for resource utilization • Clarification of plans for “conscription”

20. Planning and decision making • Traditionally much of the planning for an epidemic has been done at the policy-making and political levels (e.g. federal and provincial governments, WHO, etc…) • This occurs with variable degrees of input from physicians and health care workers • If physicians are going to be the first line responders, they need to be more involved in planning and decision making at the local, national and international levels

21. In Canada, this can occur at the provincial medical association and CMA levels, as well as input from other medical bodies as appropriate • Canada, and Canadian physicians, are in a unique position because of our extensive experience during the SARS epidemic • The CMA has been very involved at the international level in lending its expertise to other bodies preparing for the next epidemic (e.g. CMA and WHO)

22. WMA Statement on Avian and Influenza Pandemics drafted by the CMA, AMA, GMA and BMA • This document outlines: • The role of governments • The role of the National Medical Association • The role of individual physicians • Among its recommendations: • That physicians participate in local pandemic planning efforts and be involved in communicating vital information to the public. • That NMAs be actively involved in the national pandemic planning process.

23. Access to equipment and training • Physicians should have access to proper equipment which might reasonably be required during a pandemic • During the SARS epidemic very few family physicians (and others) had access to proper masks, gloves, gowns, etc… • Although not every physician will require a respirator, at minimum an effort must be made to ensure they have a fitted mask proven to be effective against the spread of droplet and air-borne pathogens

24. Several planning documents have outlined the equipment which physicians and hospitals should have on hand during a pandemic (e.g. Ontario Health Plan for an Influenza Pandemic June 2005) • Physicians should be provided with this equipment, and training for its use, without charge

25. Training • Few physicians are trained specifically in infectious diseases or public health • While many will have expertise or experience in treating patients with typical viral respiratory illnesses, this may not translate to the pandemic environment • Whenever possible, physicians who request extra training in these areas should be provided with such, particularly those most likely to be treating patients on the front line during a pandemic (e.g. GP’s in large cities, non-internists in tertiary care hospitals)

26. Clear plan for resource utilization • Physicians should be made aware of • Backup/relief arrangements • Clearly defined roles and expectations • Vaccination plans

27. Backup/relief arrangements • During SARS it became clear that a disproportionate burden was placed on a relatively small number of physicians • Particularly true for those in Toronto with a specialty in the area • Physicians from outside the area arrived to assist, but on an ad-hoc and voluntary basis, leaving behind gaps at their own institutions • Better planning might be able to relieve some of this burden

28. A maximum number of hours per week or maximum number of infected patients per physician might be established • Backup rosters could be created • A list of local, provincial and national physicians with appropriate expertise could be developed

29. Licensing standards and requirements can be simplified to allow for cross-border movement and relief, particularly in those provinces with less resources and expertise • Compensation programs can be developed to make sure those physicians working longer hours are fairly remunerated (should also address physicians who have volunteered in another province where they are not likely to have a billing number) • Transportation and housing costs for traveling physicians should be covered

30. Clearly defined roles and expectations • At a recent joint session between the CMA’s Committee on Ethics and Council on Health Care and Promotion, it became clear that the main concern of participants was not whether they had an obligation to treat patients, but what exactly this obligation might entail • “I do lab medicine. How can I look after a patient on a ventilator?”

31. In general, it would be considered unethical for a physician to practice medicine outside of their area of expertise • However, this does not apply if • The care need is urgent • A more skilled person is not available • Not providing the care will lead to worse consequences than providing it

32. If the roles and clinical obligations of various physicians were better defined prior to a pandemic, it would alleviate much of the concern and anxiety • E.g. creation of a list of specialties with various suggested roles (there may be several) for each, including direct and indirect patient care, administration, information gathering, etc… • Each physician in Canada cannot be expected to play an identical role and assume the same duties in a pandemic situation, but each should be aware of their role in advance

33. Vaccination plans • There has been much debate in the media and literature about how best to distribute what is likely to be a limited supply of vaccine (with a questionable effectiveness) • There appears to be a general consensus emerging that physicians and other frontline health care workers would be amongst the first to be vaccinated (plans in Canada, the UK and Australia all list health care workers as having the top priority for vaccinations)

34. This is based primarily on the premise that physicians cannot care for their patients if they are ill themselves (and also that if they are ill they can transmit the virus to patients) • This premise might be expanded to vaccinating the families of physicians • Physicians will be less likely to contract the virus at home, and less likely to feel the need to stay at home and care for sick family members • Physicians will be less worried about their loved ones and better able to focus on their work

35. Regardless of the decision, it should be made well in advance with a clear communication strategy and rationale so that physicians and their families know exactly what to expect • Any stockpiling of vaccines or medications by health care workers or others should be discouraged

36. Clarification of plans for conscription • Recently there has been discussion about the possibility of legislation in this regard in at least two provinces • Depending on its wording, this legislation might require physicians (and others) to report for duty during a pandemic (or other crisis) regardless of the risk to themselves or their families • It might also require physicians who are retired to return to active service to ensure there are sufficient physician resources to respond to the outbreak

37. Pros • Would help ensure sufficient resources • Would clarify health care workers’ obligations • Would reassure the public that they will be cared for during a pandemic • Cons • There is no proof this relatively extreme approach is required • Using legislation instead of negotiation might make many health care workers upset and defensive • The possible sanctions for non-compliance could be problematic

38. Any discussions along these lines should involve physicians and other health care workers • Legislation should only be considered if there is clear and compelling evidence that human resources are likely to be insufficient, and that there are no non-legislative means of ensuring they are made adequate • Lacking this evidence, it would be hard to ethically justify a policy of conscription

39. Obligations during a pandemic • Access to information • Backup resources • Compensation • Insurance • Liability coverage • Licensing programs • Counseling and support • Room and board

40. Access to information • This was, in many ways, the biggest failure during the SARS outbreak • Physicians should have access to up-to-date, real time information needed to track the spread of the virus and to provide best care for their patients • They should be kept informed of developments locally, nationally and globally as they occur • This would ideally occur through several methods of communications, including faxes, emails and online access to information

41. Expenses are likely to be high and should be borne primarily by government agencies responsible for public health • Governments should coordinate with provincial and national medical associations, and liaise closely with relevant international bodies (WHO, GOARN) • Reporting and tracking should be facilitated and simplified so that physicians are aware of the spread of disease, its methods of transmission and common signs and symptoms before they present in the office

42. Provincial and national medical associations should receive infrastructure support to enable them to communicate with members in a timely, meaningful way • While the information to be disseminated is likely to come from public and government sources, the dissemination itself is likely to occur through medical organizations

43. Backup resources • Physician rosters and rotation schedules should be established and respected • Provisions need to be made for “burn out” and for physicians who become ill themselves during the outbreak

44. Compensation • Unlike public servants and most employees, the majority of physicians are not automatically eligible for compensation for time away from work due to illness • This also applies to those physicians who have to close their offices due to a quarantine • Funds should be provided to make up for lost earnings in both these situations, as well as to compensate office staff and meet overhead and other expenses

45. Insurance • Most physicians do not have disability insurance unless they have purchased it themselves • In the case of physicians without such insurance, it should be provided for them, and for those with insufficient insurance, it should be increased • At a minimum, this should cover lost earnings, medical care not covered by provincial public plans, medications, hospital accommodation and rehabilitative therapy

46. Many physicians may not have sufficient (or any) life insurance • Life insurance should be provided for all those who die as a result of providing care during a pandemic • Benefits could be based on average yearly earnings

47. The family of the one physician who died during the SARS outbreak did not receive any compensation as he was not considered an employee • The families of the nurses who died received substantial settlements

48. Liability coverage • This may be of particular concern to those practicing outside their area of expertise or their usual scope of practice • Expanded liability insurance could be provided to physicians who find themselves in this situation and are providing the best care they are able to, even when it would not meet the standards of an expert in the field

49. Licensing programs • Provincial regulatory authorities should simplify the process for obtaining licenses for physicians wishing to provide support and relief work outside of their home provinces • This would also help ensure that experts could move quickly from place to place when needed without excessive liability concerns based on licensure

50. Counseling and support • Psychological and emotional counseling and support services should be provided for physicians, their staff and their families • Counselors specializing in burn out and grief/trauma counseling should be made available at no expense • SARS demonstrated the real need for this type of support service in a timely fashion