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INFECTIOUS diseases experts and ethicists are calling for the development of a transparent, ethically rigorous process for providing the best possible care for patients with emerging, highly infectious diseases, while protecting the safety of health care workers.
The authors of an “Ethics and law” article in the MJA this week said that in the wake of the recent, large-scale Ebola virus disease (EVD) outbreak it was “imperative” to develop a “predetermined, institutionally endorsed” process to assess difficult clinical scenarios. (1)
The EVD outbreak caused more than 10 000 deaths worldwide, including 495 among health care workers. While the disease was mostly confined to West African nations, 24 patients with EVD were admitted to hospitals in high-income countries, including nurses caring for a patient in a US hospital.
The authors said the key concern regarding the care of patients with EVD in Australia was “ensuring that no patient was denied therapy that should be provided, while preventing unnecessary risk” to health care workers.
Professor Sharon Lewin, director of the Peter Doherty Institute for Infection and Immunity (a joint venture of the University of Melbourne and Royal Melbourne Hospital), told MJA InSight that now was an ideal time to explore the complex issues that arose in managing new infectious diseases.
“In the thick of an epidemic, you don’t have the time for an institutionally endorsed process, so having discussions in advance and anticipating issues will be very helpful exercises for institutions”, Professor Lewin said.
A transparent, institutionally endorsed process would be an appropriate way to address the complexities and uncertainties inherent in managing new diseases.
“My view is that as clinicians, our top priority is always duty of care to our patients using the best available scientific evidence to guide policy and, of course, respecting the rights of the health care worker to not do anything that they feel puts them at risk”, Professor Lewin said.
“It is the institution’s responsibility to always make sure that there is a safe environment for their health care workers, however this is coloured by the complexity that in the situation of a new infectious disease, we don’t always have all of the answers.”
Professor Cheryl Jones, president of the Australasian Society for Infectious Diseases, told MJA InSight that, overall, clinical ethics expertise was very strong in Australia.
“However, there are significant knowledge and policy gaps [in helping] government, institutions, health care workers and the community formulate responses to the ethical challenges that arise from the provision of care in response to emerging infectious diseases”, said Professor Jones, who also leads a research program through the Marie Bashir Institute for Infectious Diseases and Biosecurity.
She welcomed the MJA authors’ proposal for a clear, ethical framework and policy that would address the issue of emerging infectious diseases like EVD and severe acute respiratory syndrome (SARS).
“This will assist [health care workers], institutions and the community formulate approaches promptly and transparently in times of pandemics. This framework needs to be informed by qualitative research that consults all stakeholders”, she said.
Professor Jones said such an approach was used for EVD, but it took some time to develop.
“International clinical practice algorithms for Ebola infection were adapted in Australia by state-based health jurisdictions, widely disseminated to [health care workers] and the public. These aided institutions and [health care workers] to have a consistent, transparent and rigorous approach to the assessment of individuals who arrived in Australia with suspected Ebola”, she said.
Professor Lewin said in the recent EVD outbreak, to the best of her knowledge, Australian institutions educated their staff about the risks and used science to guide their policies. “I am unaware of any situation where there were staff who felt unsafe.”
Dr David Hunter, associate professor of medical ethics at Flinders University, said there was a well recognised trade-off between providing the most appropriate treatment for patients with infectious diseases and protecting health care workers, and this challenge was heightened with high-risk diseases.
“The treatment of infectious diseases like Ebola makes that issue considerably more difficult, because the risks are considerably higher, and there are also the social side effects as well as perceptual risks.”
Dr Hunter said the perception of risk could be skewed by extensive media coverage of potential cases, which could increase the risk of social isolation for health care workers treating these patients.
“It would be sensible for hospitals to have policies on what information is released … because you could see health care workers being ostracised in various ways if it was known that they were treating a patient with Ebola, for example”, he said.
(Photo: Jodi Jacobson / iStock)
Heaven spare us if Ebola or anything like it should break-out of West Africa into the rest of the world. Although conditions will be different elsewhere, we should learn all we can about the disease and its control from the recent tragic epidemic and continue with the search for a cure.