It is back-to-school time – and back-to-school heralds the beginning of the flu season and triggers worries about the return of the H1N1 virus. Most of the health care organizations I work with in Ontario have been engaged for some time in a process of pandemic planning, a “what-if” planning exercise that seeks to prepare organizations for at least some of the eventualities that will unfurl in the event of a debilitating pandemic.
There are many ethical issues that require discussion as one plans for a pandemic, I want to mention one and go a little further into another. First, the mention:
Modes of health care – from patient centred care to public health
One of the great lessons from SARS in Ontario was the way in which the form of delivery and the modes of thinking changed during SARS. Before SARS the slogan in many facilities was “patient (client) centred (focussed) care. This is a development of the standard model of health care delivery. In this model, the primary relationship is between the patient, who presents with his or her symptoms and the care-giver (archetypically the physician) who diagnoses and prescribes. The model is individualistic and rights-based, with the patient or client at the heart of the enterprise and with a great deal of scope and authority for the individual physician to practise. But, of course, as SARS unfolded that model of health care and those ways of thinking were abandoned. Instead the model of health care switched to something far more like public health. Instead of the individual patient standing at the centre of the health care relationship, the dominant relationship became that between the community, and an enemy – in this case the bug. And, health care workers became the front line troops in that battle. That shift of emphasis necessitated a whole series of changes in behaviour. The rights of individual patients (to have visitors for instance) were abandoned, and physicians and others lost a great deal of their authority to practise as they saw appropriate. (You have to wear a mask…) I’m not sure that we have fully recognised the impact of that shift nor articulated its effects. That shift will occur again in the next pandemic. It will have to. In a community emergency the rights of each individual will be held to be of less account than the needs of the many. That is as it should be – however, we will need to exercise the greatest vigilance to understand what we are doing and why – to minimize the loss of rights and to reinstate those rights at the earliest opportunity.
If that is just a mention, let’s move on to look at the “duty to provide care.”
The duty to provide care.
Normally when this issue gets discussed it is in the context of a duty on health care workers to provide care to others even under conditions of personal risk. Again, one of the lessons from SARS was that even though that disease was primarily a disease of health care workers, care providers continued to work even under conditions of personal risk. Is there a “duty” to provide care and to whom does that duty apply. That tends to be where we start, but I am not sure that is the most interesting question to ask on this topic. It seems pretty clear that there is some sort of duty on health care workers to provide care. Health care is a “special” enterprise which is proudly unlike other more commercially oriented activities. Health care workers will often speak of a “calling” or an “avocation” and of being motivated by a desire to help others and serve the community. In that respect it is not unlike the police and emergency services – or indeed the armed forces. We would look quite askance at the police officer or member of the military who refused to serve because it was risky. So, if there is a duty – what are its limits?
In a number of hospitals with which I work we have had a series of conversations about pandemic planning, and the question of the ”duty to provide care” surfaces in a different form. Let me put it like this. Imagine you are a nurse, and as a nurse you recognize that you have a duty to provide care. It is your job – and you are obliged to go in to work. But let us also imagine that you are a Mum. Your duty as a Mum is to care for your children, what happens when those two duties collide?
It is worth saying at the outset that this moral dilemma is not one that can be solved by looking to professional ethics. The duty of the nurse – as a nurse, is to provide care, but the personal obligation – if you like the duty of the Mother, is to take care of her children. They are both moral (or ethical) obligations that arise from two roles the person has. Nor has the person done anything wrong to create this situation. She just has more than one role (as many, or indeed all of us do.) But let us imagine she can’t do both. What will she do? Is there a “should” here? We haven’t detailed the situation, and it is easy to imagine cases that fall along the entire spectrum. At either end of the spectrum there will be situations where it is clear that anyone should do one thing rather than another – the negative impact on the children is very minor and the benefits you bring to your community by going to work are very great – and vice versa. But what happens in the great grey mass of cases in the middle. How does that individual person decide what she (or he) will do? (I don’t think this conversation necessarily presupposes one gender or another, I’m more interested in looking at the roles people play and the obligations that arise through those roles.)
It is at this point that the discussion inevitably takes a more interesting and more practical turn. The organizations doing the pandemic planning, and the communities they serve, have an interest in getting their care providers to come to work – so how do they help them do that? How do organizations support their workers so that those workers can take care of their family and other responsibilities and still, wherever possible, be able to come to work? The turn, then, is from what looks like a question of professional ethics, its impact on the individual, and a puzzle about how to motivate people to do their duty; to a genuine moral dilemma which pits two extremely important ethical values or principles against each other. So that brings us to the practical questions. What steps are individuals taking in their personal lives to attempt to ensure that their personal obligations are taken care of in a pandemic, and secondly what steps are the organization taking to try to create the conditions that make it as likely as possible that people will be able to come to work?