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JME Online First, published on September 9, 2014 as 10.1136/medethics-2014-102434 Current controversy
The Ebola outbreak in Western Africa: ethical obligations for care Aminu Yakubu,1 Morenike Oluwatoyin Folayan,2 Nasir Sani-Gwarzo,3 Patrick Nguku,4 Kristin Peterson,5 Brandon Brown6 1
National Health Research Ethics Committee, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria 2 Institute of Public Health and Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria 3 Port Health Services Division, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria 4 Nigeria Field Epidemiology & Laboratory Training Program (NFELTP), Haile Selassie St, Asokoro, Abuja, Nigeria 5 Department of Anthropology, University of California, Irvine, California, USA 6 Program in Public Health, Department of Population Health & Disease Prevention, University of California, Irvine, California, USA Correspondence to Aminu Yakubu, National Health Research Ethics Committee, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria; [email protected] Received 18 August 2014 Accepted 20 August 2014
ABSTRACT The recent wave of the Ebola Virus Disease (EVD) in Western Africa and efforts to control the disease where the health system requires strengthening raises a number of ethical challenges for healthcare workers practicing in these countries. We discuss the implications of weak health systems for controlling EVD and limitations of the ethical obligation to provide care for patients with EVD using Nigeria as a case study. We highlight the right of healthcare workers to protection that should be obligatorily provided by the government. Where the national government cannot meet this obligation, healthcare workers only have a moral and not a professional obligation to provide care to patients with EVD. The national government also has an obligation to adequately compensate healthcare workers that become infected in the course of duty. Institutionalisation of policies that protect healthcare workers are required for effective control of the spread of highly contagious diseases like EVD in a timely manner. The recent wave of the Ebola in Guinea, Liberia, Sierra Leone and Nigeria in Western Africa is considered the worst outbreak since the recognition of the virus in 1976. By 15 August 2014, 2127 cases had been reported of which 1145 had died.1 The control of Ebola virus disease (EVD) in the region raises a number of ethical challenges for healthcare workers practicing in countries where health systems and infrastructures are weak, healthcare financing is poor and health insurance coverage is limited.2 3 We discuss the implications of weak health systems for controlling EVD and limitations of the ethical obligation to provide care for patients with EVD using Nigeria as a case study.
EBOLA AND REQUIREMENTS OF THE HEALTHCARE SYSTEM The management of suspected cases of EVD requires isolation in a single patient room (containing a private bathroom) with a sealed door and use of appropriate personal protection equipment (PPE) by healthcare providers entering the room. Visitors are prohibited. Diligent environmental sanitation and safe handling of potentially contaminated materials are important.4
To cite: Yakubu A, Folayan MO, Sani-Gwarzo N, et al. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/medethics2014-102434
STATUS OF THE HEALTHCARE SYSTEM IN NIGERIA TO CONTAIN EVD Few healthcare providers have the required supplies and infrastructure for managing EVD. Many clinics do not have running water, climate control, medical and PPE supplies, laboratory facilities, and capacity to ensure good environmental sanitation.
The ability of healthcare workers to prepare for potential exposures is also limited. This affects the response to EVD in ways that has implications for both the patient and healthcare workers. Indeed, healthcare workers more than other individuals are the most affected by EVD: the current death toll is four of which two are healthcare workers, one the index case and the fourth a protocol officer.5
ETHICAL OBLIGATIONS FOR HEALTHCARE WORKERS TO PROVIDE CARE FOR PATIENTS WITH EVD: THE NIGERIAN EXPERIENCE In July 2014, the first case of EVD was confirmed in Nigeria. By 15 August 2014, 198 primary and secondary contacts of the index case and 12 confirmed cases had been reported,4 of which seven are healthcare providers. Nigeria was ill prepared for the outbreak. After the case report, healthcare workers were rapidly trained on diagnosis and management of EVD and the use of PPE. Despite these measures, the risk of healthcare workers to become sick with EVD is affected by the potential risks of failure of the PPE due to accidents or substandard quality, violent patients and improper decontamination arrangements. As such, willingness of medical staff to provide care for patients with EVD is currently limited despite public calls and compensation of $185 per day.6 The Code of Medical Ethics7 provides few guidelines on the obligation of physicians to provide care for patients seeking emergency care. Healthcare workers are not penalised for failure to provide care and may ostracise patients with symptoms of EVD. In the absence of clear guidance, healthcare workers face a moral dilemma. Their conscience urges them to treat all patients, but a convergence of failed health system factors, the danger to life, emotional considerations like danger posed to family and friends, and the absence of commensurate compensation for engaging in such high risk service can make following one’s conscience costly. Where the healthcare worker is extremely concerned about the risk associated with performing care, quality of care provided may be compromised.8 The obligation to provide care in the face of these realities makes the philosophy of ‘duty to provide care’ inadequate as a moral guide in times of such complex challenges. At a time like this, the adaptation of the ethical philosophy of Hall and Berenson9 of encouraging healthcare workers to do the best they can for patients may be more appropriate. Such moral obligations should have limited sanctions for non-compliance so as not to infringe on the healthcare workers’ human rights.10
A, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102434 Copyright Article author Yakubu (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from jme.bmj.com on September 11, 2014 - Published by group.bmj.com
Current controversy In the case of EVD where healthcare workers are unable to provide protection for themselves due to limitations posed by the weak health system, it can be argued that obligation of the healthcare worker to provide care is subject to government’s fulfilment of its own prima facie obligation to provide safe work environment. Requiring healthcare workers to provide care to patients with EVD puts undue burden on them. Since the principle of justice requires fair distribution of benefits and risks, it is only fair that affected countries make arrangements to adequately compensate healthcare workers who become infected in the course of duty.
CONCLUSIONS Traditional public health ethics has paid little attention to the protection of the rights of healthcare workers. Healthcare workers have rights to protection as do the general public to care during an infectious disease outbreak like EVD where the risk of death is high. The lack of appropriate protections challenges the ethical imperative of healthcare workers to provide care, forcing them to depend on their conscience to choose whether or not to provide care despite the implications of this choice for the survival of patients. Governments need to institutionalise policies that protect healthcare workers if they are to effectively curtail the spread of highly contagious and deadly diseases like EVD in a timely manner. Contributors All authors contributed to the final version of this manuscript. Competing interests None.
2
Provenance and peer review Commissioned; internally peer reviewed.
REFERENCES 1
2
3
4
5
6
7 8 9 10
World Health Organization. Global Alert and Response (GAR): Ebola virus disease update – west Africa. 15 Aug 2014. http://www.who.int/csr/don/2014_08_15_ ebola/en/ (accessed 16 Aug 2014). Strengthening of Health Systems for Equity and Development in Africa. Third Session of the African Union Conference of Ministers of Health, Johannesburg, South Africa, 9–13 April 2007. http://www.carmma.org/download/file/fid/154 (16 Aug 2014). Sambo LG. Health systems and primary health care in the African Region. African Health Monitor 2011;14:2–3. http://www.aho.afro.who.int/sites/default/files/ publications/67/Ahm-issue-14.pdf Centre for Disease Control and Prevention. Safe management of patients with Ebola Virus Disease (EVD) in US hospitals. http://www.cdc.gov/vhf/ebola/hcp/ patient-management-us-hospitals.html (accessed 16 Aug 2014). Obi P, Adekoya B. Nigeria may have halted the Ebola’s advance as doctor is discharged. This Day Live, 17 Aug 2014. http://www.thisdaylive.com/articles/ nigeria-may-have-halted-ebolas-advance-as-doctor-is-discharged/186560/ (accessed 18 Aug 2014). Grady D. With Ebola cases still few, populous Nigeria has chance to halt its outbreak. The New York Times, 15 Aug 2014. http://www.nytimes.com/2014/08/ 16/science/with-ebola-cases-still-few-populous-nigeria-has-chance-to-halt-itsoutbreak.html?_r=0 Medical and Dental Council of Nigeria. Rules of professional conduct for Medical and Dental practitioners in Nigeria. Jan 1995. McKoy JM. Obligation to provide services: a physician-public defender comparison. Virtual Mentor 2006;6(5):332–4. Hall MA, Berenson RA. Ethical practice in managed care: a dose of realism. Ann Intern Med 1998;128:395–402. World Health Organisation. Ethical considerations in developing a public health response to pandemic influenza. WHO/CDS/EPR/GIP/2007.2, 2007.
Yakubu A, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102434
Downloaded from jme.bmj.com on September 11, 2014 - Published by group.bmj.com
The Ebola outbreak in Western Africa: ethical obligations for care Aminu Yakubu, Morenike Oluwatoyin Folayan, Nasir Sani-Gwarzo, et al. J Med Ethics published online September 9, 2014
doi: 10.1136/medethics-2014-102434
Updated information and services can be found at: http://jme.bmj.com/content/early/2014/09/09/medethics-2014-102434.full.html
These include:
References
This article cites 3 articles http://jme.bmj.com/content/early/2014/09/09/medethics-2014-102434.full.html#ref-list-1
P
JME Online First, published on September 9, 2014 as 10.1136/medethics-2014-102434 Current controversy
The Ebola outbreak in Western Africa: ethical obligations for care Aminu Yakubu,1 Morenike Oluwatoyin Folayan,2 Nasir Sani-Gwarzo,3 Patrick Nguku,4 Kristin Peterson,5 Brandon Brown6 1
National Health Research Ethics Committee, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria 2 Institute of Public Health and Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria 3 Port Health Services Division, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria 4 Nigeria Field Epidemiology & Laboratory Training Program (NFELTP), Haile Selassie St, Asokoro, Abuja, Nigeria 5 Department of Anthropology, University of California, Irvine, California, USA 6 Program in Public Health, Department of Population Health & Disease Prevention, University of California, Irvine, California, USA Correspondence to Aminu Yakubu, National Health Research Ethics Committee, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria; [email protected] Received 18 August 2014 Accepted 20 August 2014
ABSTRACT The recent wave of the Ebola Virus Disease (EVD) in Western Africa and efforts to control the disease where the health system requires strengthening raises a number of ethical challenges for healthcare workers practicing in these countries. We discuss the implications of weak health systems for controlling EVD and limitations of the ethical obligation to provide care for patients with EVD using Nigeria as a case study. We highlight the right of healthcare workers to protection that should be obligatorily provided by the government. Where the national government cannot meet this obligation, healthcare workers only have a moral and not a professional obligation to provide care to patients with EVD. The national government also has an obligation to adequately compensate healthcare workers that become infected in the course of duty. Institutionalisation of policies that protect healthcare workers are required for effective control of the spread of highly contagious diseases like EVD in a timely manner. The recent wave of the Ebola in Guinea, Liberia, Sierra Leone and Nigeria in Western Africa is considered the worst outbreak since the recognition of the virus in 1976. By 15 August 2014, 2127 cases had been reported of which 1145 had died.1 The control of Ebola virus disease (EVD) in the region raises a number of ethical challenges for healthcare workers practicing in countries where health systems and infrastructures are weak, healthcare financing is poor and health insurance coverage is limited.2 3 We discuss the implications of weak health systems for controlling EVD and limitations of the ethical obligation to provide care for patients with EVD using Nigeria as a case study.
EBOLA AND REQUIREMENTS OF THE HEALTHCARE SYSTEM The management of suspected cases of EVD requires isolation in a single patient room (containing a private bathroom) with a sealed door and use of appropriate personal protection equipment (PPE) by healthcare providers entering the room. Visitors are prohibited. Diligent environmental sanitation and safe handling of potentially contaminated materials are important.4
To cite: Yakubu A, Folayan MO, Sani-Gwarzo N, et al. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/medethics2014-102434
STATUS OF THE HEALTHCARE SYSTEM IN NIGERIA TO CONTAIN EVD Few healthcare providers have the required supplies and infrastructure for managing EVD. Many clinics do not have running water, climate control, medical and PPE supplies, laboratory facilities, and capacity to ensure good environmental sanitation.
The ability of healthcare workers to prepare for potential exposures is also limited. This affects the response to EVD in ways that has implications for both the patient and healthcare workers. Indeed, healthcare workers more than other individuals are the most affected by EVD: the current death toll is four of which two are healthcare workers, one the index case and the fourth a protocol officer.5
ETHICAL OBLIGATIONS FOR HEALTHCARE WORKERS TO PROVIDE CARE FOR PATIENTS WITH EVD: THE NIGERIAN EXPERIENCE In July 2014, the first case of EVD was confirmed in Nigeria. By 15 August 2014, 198 primary and secondary contacts of the index case and 12 confirmed cases had been reported,4 of which seven are healthcare providers. Nigeria was ill prepared for the outbreak. After the case report, healthcare workers were rapidly trained on diagnosis and management of EVD and the use of PPE. Despite these measures, the risk of healthcare workers to become sick with EVD is affected by the potential risks of failure of the PPE due to accidents or substandard quality, violent patients and improper decontamination arrangements. As such, willingness of medical staff to provide care for patients with EVD is currently limited despite public calls and compensation of $185 per day.6 The Code of Medical Ethics7 provides few guidelines on the obligation of physicians to provide care for patients seeking emergency care. Healthcare workers are not penalised for failure to provide care and may ostracise patients with symptoms of EVD. In the absence of clear guidance, healthcare workers face a moral dilemma. Their conscience urges them to treat all patients, but a convergence of failed health system factors, the danger to life, emotional considerations like danger posed to family and friends, and the absence of commensurate compensation for engaging in such high risk service can make following one’s conscience costly. Where the healthcare worker is extremely concerned about the risk associated with performing care, quality of care provided may be compromised.8 The obligation to provide care in the face of these realities makes the philosophy of ‘duty to provide care’ inadequate as a moral guide in times of such complex challenges. At a time like this, the adaptation of the ethical philosophy of Hall and Berenson9 of encouraging healthcare workers to do the best they can for patients may be more appropriate. Such moral obligations should have limited sanctions for non-compliance so as not to infringe on the healthcare workers’ human rights.10
A, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102434 Copyright Article author Yakubu (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from jme.bmj.com on September 11, 2014 - Published by group.bmj.com
Current controversy In the case of EVD where healthcare workers are unable to provide protection for themselves due to limitations posed by the weak health system, it can be argued that obligation of the healthcare worker to provide care is subject to government’s fulfilment of its own prima facie obligation to provide safe work environment. Requiring healthcare workers to provide care to patients with EVD puts undue burden on them. Since the principle of justice requires fair distribution of benefits and risks, it is only fair that affected countries make arrangements to adequately compensate healthcare workers who become infected in the course of duty.
CONCLUSIONS Traditional public health ethics has paid little attention to the protection of the rights of healthcare workers. Healthcare workers have rights to protection as do the general public to care during an infectious disease outbreak like EVD where the risk of death is high. The lack of appropriate protections challenges the ethical imperative of healthcare workers to provide care, forcing them to depend on their conscience to choose whether or not to provide care despite the implications of this choice for the survival of patients. Governments need to institutionalise policies that protect healthcare workers if they are to effectively curtail the spread of highly contagious and deadly diseases like EVD in a timely manner. Contributors All authors contributed to the final version of this manuscript. Competing interests None.
2
Provenance and peer review Commissioned; internally peer reviewed.
REFERENCES 1
2
3
4
5
6
7 8 9 10
World Health Organization. Global Alert and Response (GAR): Ebola virus disease update – west Africa. 15 Aug 2014. http://www.who.int/csr/don/2014_08_15_ ebola/en/ (accessed 16 Aug 2014). Strengthening of Health Systems for Equity and Development in Africa. Third Session of the African Union Conference of Ministers of Health, Johannesburg, South Africa, 9–13 April 2007. http://www.carmma.org/download/file/fid/154 (16 Aug 2014). Sambo LG. Health systems and primary health care in the African Region. African Health Monitor 2011;14:2–3. http://www.aho.afro.who.int/sites/default/files/ publications/67/Ahm-issue-14.pdf Centre for Disease Control and Prevention. Safe management of patients with Ebola Virus Disease (EVD) in US hospitals. http://www.cdc.gov/vhf/ebola/hcp/ patient-management-us-hospitals.html (accessed 16 Aug 2014). Obi P, Adekoya B. Nigeria may have halted the Ebola’s advance as doctor is discharged. This Day Live, 17 Aug 2014. http://www.thisdaylive.com/articles/ nigeria-may-have-halted-ebolas-advance-as-doctor-is-discharged/186560/ (accessed 18 Aug 2014). Grady D. With Ebola cases still few, populous Nigeria has chance to halt its outbreak. The New York Times, 15 Aug 2014. http://www.nytimes.com/2014/08/ 16/science/with-ebola-cases-still-few-populous-nigeria-has-chance-to-halt-itsoutbreak.html?_r=0 Medical and Dental Council of Nigeria. Rules of professional conduct for Medical and Dental practitioners in Nigeria. Jan 1995. McKoy JM. Obligation to provide services: a physician-public defender comparison. Virtual Mentor 2006;6(5):332–4. Hall MA, Berenson RA. Ethical practice in managed care: a dose of realism. Ann Intern Med 1998;128:395–402. World Health Organisation. Ethical considerations in developing a public health response to pandemic influenza. WHO/CDS/EPR/GIP/2007.2, 2007.
Yakubu A, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102434
Downloaded from jme.bmj.com on September 11, 2014 - Published by group.bmj.com
The Ebola outbreak in Western Africa: ethical obligations for care Aminu Yakubu, Morenike Oluwatoyin Folayan, Nasir Sani-Gwarzo, et al. J Med Ethics published online September 9, 2014
doi: 10.1136/medethics-2014-102434
Updated information and services can be found at: http://jme.bmj.com/content/early/2014/09/09/medethics-2014-102434.full.html
These include:
References
This article cites 3 articles http://jme.bmj.com/content/early/2014/09/09/medethics-2014-102434.full.html#ref-list-1
P
