OpinionOpinion
In every country, the burden of fighting the pandemic lies on
the shoulders of healthcare professionals. However, the actual
course of this battle is conditioned by the epidemic management
strategies introduced by the authorities and state institutions.
Today we can see clearly how the differences in the organization
of public healthcare in various countries may influence the arising
bioethical problems and the attempts at solving them. One of the
problems is the acceptance of the new risk, potential infection
with SARS-CoV-2 at work, by healthcare professionals. This issue
had been earlier discussed in the countries affected by SARS virus,
which was a new danger for the medical staff. Writing about the
lesson from the epidemic of SARS in 2003, Emanuel reaches to the
core of medical ethics, that is the ethical obligation to act for the
patient’s benefit, and emphasizes the need to make every healthcare
professional aware of that obligation. He juxtaposes this bioethical
challenge with the duties of the state institutions, the task of which
is to organize healthcare in a way ensuring maximum protection
of physicians and nurses at the frontline, and indicated the need to
start a global debate on the topic with a view to possible epidemics
in the future [1].
The risk related to epidemic-prone diseases and the duty to
treat patients were discussed in a 2008 article by Dwyer and Tsai
written after the SARS epidemic in Taiwan. The paper indicates
that every healthcare professional should fulfil their professional
duties in accordance with the law and the regulations of biomedical
ethics, but, simultaneously, these duties should be organized “in a
way that is both fair and efficacious” [2]. In various countries, there
are similar ethical regulations based on the same universal rules
collected in codes of conduct for medical professionals, revolving
around the core idea of providing help to patients. In Poland,
the currently binding Code of Physician’s Ethics from 1991 (last
amended in 2003) contains the same universal rules of medical
ethics and does not provide specific regulations referring to
extraordinary situations, such as an epidemic or pandemic [3]. We
have not been affected by the epidemic of SARS so there was no
debate on new ethical challenges related to an infectious disease
that is potentially lethal also for the medical staff. However, in the
Polish law there is an Act of 5 December 2008 on preventing and
combating infections and infectious diseases among people [4].
Pursuant to Article 47 of this act, the state authorities may
direct the employees of healthcare entities to fight the epidemic.
The practical consequences of this legal regulation have already
become an experience of many Polish physicians and nurses who,
regardless of their experience and specialisation, were directed to
work in the indicated places, with the orders brought by the police,
often at night. The act does not oblige the employer to provide
the employees directed to work this way with adequate personal
protection equipment and reduce the exposure risk to minimum.
This leads to a new question: should healthcare professionals accept any risk, even the risk that can be avoided by proper
administrative decisions, to act for the benefit of the patients? Can
healthcare professionals be forced (not only by referring to the
general rules of biomedical ethics, but also by imposing penalties
for refusal to exert their professional duties in the entities indicated
by the state authorities) to risk their lives and lives of their family
members in the situation when people and institutions responsible
for work organization fail to fulfil their obligations and do not
bear any consequences? It seems that such a force-based solution
is difficult to accept both for physicians with many years of work
experience and to those at the beginning of their professional
career. Moreover, coercion, which naturally leads to resistance,
has nothing in common with medical ethics. In our opinion, in the
future, when the pandemics has ended, this situation may leave a
negative mark on the perception of the physician’s job, both by the
society and the physicians themselves.
Another problem lying on the border of ethics and organization
is deciding about the use of ICU treatment based not only on purely
medical criteria, but also additional regulations. During the first
stage of the pandemic, in many countries there was a debate about
the need to formulate bioethical recommendations for making
decisions about ICU treatment during the pandemic. In Spain, the
discussion ended with a consensus; the recommendations were
published and accepted by the society [5]. In Poland, for many years
we have been witnessing a discussion about the lack of proper
funding and irregularities in the organization of public healthcare.
It provokes a question whether new extraordinary regulations
limiting the already limited options of specialized ICU treatment
may be suggested or recommended when the state institutions
have not fulfilled their obligation of organizing the availability
of such treatment in normal conditions, before the pandemic. In
other words, we find it disturbing to note that such extraordinary
regulations may serve as a permission for irregularities and
questionable if they should be discussed at all.
References
- Emanuel EJ (2003) The Lessons of SARS. Ann Intern Med 139: 589-591.
- Dwyer J, Tsai D FC (2008) Developing the duty to treat: HIV, SARS, and the next epidemic. J Med. Ethics 34: 7-10.
- Polish Code of Physician’s Ethics.
- (2008) Act of 5 December on preventing and combating infections and infectious diseases among people.
- Rubio o, Estella A, Cabre L, Saralegui-Reta I, Martin MC, et al. (2020) Ethical recommendations for a difficult decision-making in intensive care units due to the exceptional crisis due to the COVID-19 pandemic: rapid review and consensus of experts. Med Intensiva 44(7): 439-445.
