The Dual Responsibility of Physicians During a Disease Outbreak Dominique Brown



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Running head: The Dual Responsibility of Physicians During a Disease Outbreak

The Dual Responsibility of Physicians During a Disease Outbreak

Dominique Brown

Concordia University

Paper Due: Week 7

Abstract


During the occurrence of a communicable disease outbreak, physicians are faced with the dual responsibility of upholding their commitment to respective patients while simultaneously managing their dual responsibility to protect the public. This paper explores the ethical considerations physicians encounter in the face of appropriating the design, development, and subsequent implementation of control measures to protect the public during a communicable disease outbreak.

The Dual Responsibility of Physicians


A disease outbreak is described as the incident of disease events that occurs in excess of what would be considered commonplace in a defined community, geographical area or season (WHO, 2014). According to the World Health Organization(WHO), even a single case of a communicable disease that has been long absent from a population, or caused by an unrecognizable agent to a particular community warrants the description of an outbreak. An outbreak should be both reported and investigated. Consequently, the reemergence of old infectious diseases and emergence of new infectious diseases typically provokes a renewed focus on communicable disease surveillance and control. The challenge for surveillance though, usually lies within the dual responsibility of healthcare professionals, specifically physicians, to uphold their obligation to patients while preserving their duty to the community during times of distress and crisis.

In response to an outbreak, several control measures are usually undertaken by health authorities. In order to prevent further disease transmission, enhanced control measures are typically implemented. To understand the importance of controlling disease transmission during an outbreak, it is imperative to be conscious of the harms associated with communicable disease transmission. Communicable diseases are described as "infectious diseases that are transmissible by direct contact with an affected individual, individual's discharges, or by indirect means" (Merriam-Webster, 2014). The spread can happen by means of airborne viruses, bacteria, blood or other bodily fluids. Indiscriminately, communicable diseases spreads across socioeconomic, ethnic, racial, and cultural barriers with no regard to community ties. Due to their rapid spread and their devastating consequences to the human race, communicable diseases are also a major cause of mortality and morbidity. Therefore, it goes without question that public health's role to protect the population at large requires the control of a communicable disease outbreak. But, in autonomous cities and regions, there are many complications associated with regulatory measures in public health's attempt to control disease transmission.

Autonomy is described as the right of self-government. According to Tom Beauchamp and James Childress, who developed the standard approach to biomedical ethics, autonomy is defined as the occurrence of individuals making choices with substantial understanding and without the influence or pressure of controlling forces. In healthcare, personal autonomy is widely valued by healthcare professionals. It is a key concern in biomedical ethics and typically is associated with allowing or enabling patients to make their own decisions regarding the health care interventions they will or will not receive (Entwistle, Carter, Cribb & McCaffery, 2010). Respect for autonomy is especially considered and analyzed in situations that demand the need for health care and public health intervention measures- as in the case with communicable disease outbreaks. Autonomy as it relates to such measures challenges confidentiality, fidelity, and privacy. Resultantly, striking the balance between control efficacy and invasiveness of public health measures remains controversial.

As it relates to physicians, health care professionals who must also strive to achieve a balance between the protection of individual autonomy and the protection of the population during disease outbreaks, special consideration to the obligation to both is imperative to examine. Beauchamp and Childress developed an approach that attempted to resolve ethical issues by way of four ethical principles: autonomy, beneficence, non-maleficence, and justice. Each principle would need to be carefully analyzed and weighed to determine the optimal course of action in an ethically complicated situation. Principlism, as it is also referred to as , considers the rights of patients, and the obligations of doctors to their patients. This approach carefully analyzes the physician/patient relationship as the central construct of bioethics. While the principles of both non-maleficence and justice are established around the physician's obligation not to cause harm to the patient (Cheyette, 2011). This approach provides an ethical framework for bioethics as it pertains to health care policies. Moral obligations are also scrutinized as the social significance of many contagious diseases are examined. The ethical implications associated with society's coexisting obligation to the population and support for individual rights in relation to social interactions during outbreaks- are also closely linked to the dual responsibility in addressing communicable diseases that physicians face during an outbreak.

Ideally, medical professionals and public health authorities attempt to use intervention methods that would achieve desired outcomes with minimal infringements on individual liberties, however, this cannot always be accomplished. When a particular contagious disease outbreak requires immediate attention and management, often there is the potential individual liberties can be befittingly but controversially compromised. Even when, by public health standards, justification exists that necessitates that certain individuals in the community participate in quarantine and isolation measures, this undoubtedly still challenges the physicians role to uphold individual patient rights.

Quarantine and isolation are public health measures used to restrict or limit disease transmission (CDC, 2013).Though, it is important to note these two terms are not interchangeable and in fact are two separate public health measures. Isolation is used to separate or divide persons who are ill with a communicable disease from those who are healthy. While, quarantine is used to separate and regulate the movement of individuals who may have been exposed to a communicable disease to examine if they resultantly become ill. Both measures are arguably intense impediments to individual liberty and autonomy. They both also emphasize the complications so closely associated to the physicians role during the time of a communicable disease outbreak. Consider then, how physicians must manage their dual responsibilities when implementing such measures. Consider then how certain measures must be done even when in direct conflict with the interest of individual patients to ensure the protection of the population's health.

In fact, there have been many accounts in medical history that have challenged the autonomous decision making, liberty, and privacy of individuals for the sake of the public's health. These instances have been the result of measures taken immediately in the face of rapid infectious disease transmissions. The ethical considerations provoked by such measures highlight the liberty- limiting controversies that exist in modern day public health approaches in autonomous regions. As historical references prove, the controversy over the extent to which public health's regulations can outweigh individual autonomy and physicians responsibility to uphold patient privacy and confidentiality, as it relates to a disease outbreak, is not a new argument. In point of fact, critically examining and analyzing a couple of past examples of disease epidemics does well to highlight the ethical complications associated with prevention approaches during infectious disease outbreaks.

Ebola hemorrhagic fever is one of numerous viral hemorrhagic fevers. It is described as a severe disease that is often fatal (CDC,2014). Symptoms usually include that of high fever, severe headache for a day, and then subsequent sore throat, diarrhea, coughing, and vomiting (Ibrahim, 2013). Within 3 days the patient can become extremely ill where hallucination and bleeding is also possible. When an outbreak occurred in Uganda, government outbreak response elicited certain control measures to prevent the further transmission of this fatal disease. Control measures included "isolation, restriction from free movement, assembly and liberty" (Ibrahim, 2013). Aside from the psychological damage these response activities can emanate, such as anxiety, helplessness, and often consequent depression, these measures also raise ethical concerns. Such liberty-limiting outbreak response measures have been argued to conflict with the constitutionally protected rights of individuals. Additionally, stress related suffering as a result of the negative social impact during and after outbreak response was pessimistic. Individuals felt not only isolated, but neglected and abandoned as they suffered in solitude through this devastating disease. The social detachment in itself raised ethical concerns.

Although, medical and relief personnel were trained on the proper use of protective clothing, basic principles of patient isolation and management of quarantine, consideration to ethics and how it related to these particular measures were not examined. Consequences of following strict criterion to halt the spread of Ebola led to a host of other issues, namely ethical complications that evoked controversy within the community between the physicians, the government, and the affected locality. This was indeed not the only case in medical history where controversies were presented that pegged ethics against public health outbreak measures. In fact, efforts to control two other infectious disease outbreaks emerged many ethical concerns and controversies. The public health measures taken during the recent outbreaks of Severe Acute Respiratory Syndrome (SARS) challenged ethics in a way that questioned the extent to which liberty and autonomy were protected and upheld by physicians, public health leaders, and government officials alike. Multiple ethical principles were not only highlighted but challenged during response efforts to these outbreaks and pinned many human rights advocates against the efforts of public health.

In 2003, the SARS outbreak had finally been contained after spreading to more than two dozen countries in North America, South America, Europe, and Asia. SARS is described as a serious form of pneumonia, caused by a virus affecting one's ability to breathe. Therefore, prior to its containment, this disease was indeed a major threat to society. Due to its severity, it forced medical and government officials to make difficult choices, often with limited information and short deadlines (Singer et al.,2003). Immediate choices concerning quarantine enforcement, public identification of individuals known to have contracted SARS, and the extent to which health care professionals, namely physicians, were expected to provide proper care had to be decided. Yet, critical ethical and legal questions became a challenge during this period. Three values, in specific, were heavily challenged for both public health leaders and physicians alike: the duty to protect the public in the interest of common good, individual rights of privacy and liberty (Gostin, Bayer, Fairchild, 2003).

The SARS outbreak response was a little different dependent on the norms of the particular culture examined. In authoritarian regimes, where privacy has not always been valued as a priority, liberty-limiting, intrusive measures were used to aid in the halt of disease transmission. It questioned the extent to which the relationship remained rooted in privacy, trust, and confidentiality between the health care workers, specifically physicians, and their patients. The SARS outbreak mirrored many of the same ethical challenges as the Ebola outbreak in Uganda. In this regard, national efforts to enforce quarantine during infectious disease outbreak provokes many of the same concerns in different parts of the world.

Containment measures taken to control the rapid spread during disease outbreaks highlights many legal and ethical concerns. Often, disease management interventions that are seen as public health triumphs and effective achievements, have unfavorable consequences for civil liberties. The questionable implications such behavioral measures and interventions have on both ethical and human rights arguably elicits many social consequences.


But, because in times of crisis, governments must collect sensitive health information about patients and other vulnerable populations, surveillance continues to challenge individual privacy. Although, it is required that data is kept both confidential and anonymous during a crisis, it is not uncommon for certain personal information to be impulsively disclosed. For situations as such, disclosure can be warranted as a necessity to uphold the public's health, but even then, the identity of an individual should still be attempted to remain protected. The social consequences of the breach of the right to privacy can result in unemployment, loss of insurance, housing, and other social and psychological damages. In both scenarios, the challenge remained trying to uphold the rights to privacy and personal autonomy while attempting to achieve a substantial public health goal; the challenge additionally remained the attempt to uphold patient confidentiality in the health care setting while trying to accomplish a considerable public health intention.

Coercive public health powers such as quarantine and isolation are designed to protect the population's health, but due to the direct conflict of interests with individual patients, they must be balanced against their potential to jeopardize the liberties and autonomous decision making of individuals. In respect to physicians, when treating patients, physicians are very much obligated to maintain the individual patients interests as superior to those of the population, until communicable disease outbreak protocol warrants otherwise.

During a disease outbreak, physicians can be put in compromising positions in light of their unique patient knowledge. During the design of public health interventions such as that of quarantine and isolation, this exclusive knowledge is needed to assure proper measures are being taken to protect the general population. During this time, during service in this form, physicians become obligated to make population health and collective community interests superior to that of their individual patients' rights, as it pertains to patient/physician confidentiality and privacy. Physicians must respect the standards of medical professionalism and implement policies that balance benefits to risks with the public's best interest in mind (Bostick, Levine & Sade, 2008).

Alongside public health officials, physicians must assess the relative risks posed by the communicable disease in question. The relative risk is compared with that of the potential benefits and consequences of a public health intervention. If there are a plethora of severe negative consequences as the result of not intervening, intervention measures are often warranted. Achieving this though, requires that physicians and public health officials apply these efforts justly in a manner that achieves the least amount of infringements on personal liberties as possible. Interventions should also be implemented in a manner that is transparent in order to ensure that the general public understands the necessity of the particular public health measure. This allows physicians and other medical professionals to follow guidelines outlined by ethics, while simultaneously achieving public health goals and promoting the well-being of individuals.

As mentioned previously, physicians are in a unique position during communicable disease outbreaks in that decisions about quarantine and isolation measures are subject to their review. Public health physicians, in particular, are trained to analyze and evaluate the necessity of particular public health interventions during times of crisis. Their evaluation is largely dependent on the severity and communicability of the disease in question and how it relates to the general public's health. Should their evaluation lead them to determine that the presence of the infectious disease is serious enough to warrant isolation or quarantine to protect the well being of the general public, they are obligated to advocate for them as suitable control measures to halt the spread of further disease transmission. Unfortunately, this leaves many physicians the dilemma of having to reprioritize. When required to do so by law, physicians have to comply with requirements demanding that affected patients be reported to public health authorities. This, incontestably, raises concerns regarding breaches of confidentiality between physician and patient- which only goes to further highlight the unique burden carried by physicians during times of health crisis.

However, medical competence and unique insight is also essential in the development and designing of alternative interventions. One of the unfortunate but common consequences of isolation and quarantine measures being used as a control measure in populations is the social concerns it poses. If, in fact, physicians and others of the medical community feel that these consequences outweigh the actual implementation of these measures, alternative policies and interventions can be considered, so long as they will still achieve the public health goals sought. Physicians are obligated to ensure that at no time the measures taken to control an outbreak are implemented unjustly and that due-process of safeguards and legal review is considered for each individual case. Likewise, physicians are trained to ensure that the pursuit of achieving the public health goal never compromise that of the care patients receive as individuals during an outbreak. Physicians should still be explicitly committed to providing the best possible care for their individual patients even when they are dually concerned with protecting the health of an entire population.

The Code of Medical Ethics highlights that physicians have the responsibility to contribute to the improvement of the community and the betterment of public health by way of participating in certain activities (AMA, 2001). In the face of disease outbreaks and health crisis, physicians must shoulder the tasks of prevention, detection, containment and treatment (Bostick, Levine & Sade, 2008). Assuring that these duties are met leave physicians with a distinct leadership role that implores of them to maintain dual responsibility in proportion to the uniqueness of the situation.

Although transmission control measures are implemented to protect the population's health, it goes without question that it presents direct conflict with the rights and liberties of individuals. In this respect, providing optimal care during disease outbreak leaves physicians the dual responsibility to take into account both the best interests of the public and the individual patient to the extent that it is possible. Therefore, it is suggested after careful consideration, that so long as physicians follow certain ethical protocol, interventions rooted in science should seek to meet the appropriate balance of public needs and individual limits, should not target a specific population solely based on race or economic status, and should assure that the public is educated on the role they play to ensure the efficacy of such interventions.

These recommendations put emphasis on the imperativeness of halting disease transmission during an outbreak. However, they also require that ethical considerations are contemplated and the dual responsibilities of the physician are reasonably and justifiably fulfilled with attention, detail, concern and ethical scrutiny to provide optimal results for the general public. Consideration to these aspects in terms of a physicians commitment to public health and duple commitment to patient health during the unfortunate occurrence of a disease outbreak will likely ensure that physicians can achieve the interests of both patients and community without unjustifiably compromising either.







References


AMA. (2001, June). Principles of medical ethics. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page

Bostick, N., Levine, M., & Sade, R. (2008). Ethical obligations of physicians participating in public health quarantine and isolation measures. Public Health Reports, 123(1), 3-8. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2099320/

CDC. Centers for Disease Control and Prevention, (2014).Ebola hemorrhagic fever. Retrieved from website: http://www.cdc.gov/vhf/ebola/

CDC. Centers for Disease Control and Prevention, (2013).Quarantine and isolation. Retrieved from website: http://www.cdc.gov/quarantine/

Cheyette, C. (2011). Communitarianism and the ethics of communicable disease: Some preliminary thoughts. Journal of law, medicine & ethics, 39(4), 678-689. doi: 10.1111/j.1748-720X.2011.00635.x

Entwistle, V., Carter, S., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: The importance of clinician-patient relationships. Journal of General Internal Medicine25(7), 741-745. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881979/



Gostin, L., Bayer, R., & Faichild, A. (2003). Ethical and legal challenges posed by severe acute respiratory syndrome. JAMA, 290(24), 3229-3236. doi: 10.1001/jama.290.24.3229

Ibrahim, W. (2013). Ethical concerns regarding Ebola control measures in Uganda. Retrieved fromhttp://www.academia.edu/3401164/ETHICAL_CONCERNS_REGARDING_EBOLA_CONTROL_MEASURES_IN_UGANDA

Merriam-Webster. (2014). communicable disease. Retrieved from http://www.merriam-webster.com/medical/communicable disease

Singer, P., Benatar, S., Bernstein, M., Daar, A., Dickens, B., MacRae, S., Upshur, R., & Wright, L., Shaul, RZ. (2003). Ethics and SARS: lessons from Toronto. BMJ Clinical Research, 327(7427), 1342-4. Retrieved from http://www.bmj.com/content/327/7427/1342

WHO. (2014). Disease outbreaks. Retrieved from http://www.who.int/topics/disease_outbreaks/en/





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