The Dalhousie Dentistry Story: A Case for Proportionality, Professionalism, and the Promotion of Moral Character

La tribune de l'éditeur / Editor's Soapbo

On pandemics and the duty to care: whose duty? who cares?

BACKGROUND: As a number of commentators have noted, SARS exposed the vulnerabilities of our health care systems and governance structures. Health care professionals (HCPs) and hospital systems that bore the brunt of the SARS outbreak continue to struggle with the aftermath of the crisis. Indeed, HCPs – both in clinical care and in public health – were severely tested by SARS. Unprecedented demands were placed on their skills and expertise, and their personal commitment to their profession was severely tried. Many were exposed to serious risk of morbidity and mortality, as evidenced by the World Health Organization figures showing that approximately 30% of reported cases were among HCPs, some of whom died from the infection. Despite this challenge, professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk. DISCUSSION: In the aftermath of SARS and with the spectre of a pandemic avian influenza, it is imperative that we (re)consider the obligations of HCPs for patients with severe infectious diseases, particularly diseases that pose risks to those providing care. It is of pressing importance that organizations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. In this paper, we address the issue of special obligations of HCPs during an infectious disease outbreak. We argue that there is a pressing need to clarify the rights and responsibilities of HCPs in the current context of pandemic flu preparedness, and that these rights and responsibilities ought to be codified in professional codes of ethics. Finally, we present a brief historical accounting of the treatment of the duty to care in professional health care codes of ethics. SUMMARY: An honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue

Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public's perspectives

<p>Abstract</p> <p>Background</p> <p>Pandemic influenza may exacerbate existing scarcity of life-saving medical resources. As a result, decision-makers may be faced with making tough choices about who will receive care and who will have to wait or go without. Although previous studies have explored ethical issues in priority setting from the perspective of clinicians and policymakers, there has been little investigation into how the public views priority setting during a pandemic influenza, in particular related to intensive care resources.</p> <p>Methods</p> <p>To bridge this gap, we conducted three public town hall meetings across Canada to explore Canadian's perspectives on this ethical challenge. Town hall discussions group discussions were digitally recorded, transcribed, and analyzed using thematic analysis.</p> <p>Results</p> <p>Six interrelated themes emerged from the town hall discussions related to: ethical and empirical starting points for deliberation; criteria for setting priorities; pre-crisis planning; in-crisis decision-making; the need for public deliberation and input; and participants' deliberative struggle with the ethical issues.</p> <p>Conclusions</p> <p>Our findings underscore the importance of public consultation in pandemic planning for sustaining public trust in a public health emergency. Participants appreciated the empirical and ethical uncertainty of decision-making in an influenza pandemic and demonstrated nuanced ethical reasoning about priority setting of intensive care resources in an influenza pandemic. Policymakers may benefit from a better understanding the public's empirical and ethical 'starting points' in developing effective pandemic plans.</p

Communicable Disease Control in the New Millenium: A Qualitative Inquiry on the Legitimate Use of Restrictive Measures in an Era of Rights Consciousness

Background: When Canadian public health officials issued thousands of quarantine orders during the SARS outbreak in 2003, it raised difficult questions about the legitimacy and acceptability of restrictive measures to achieve public health goals. While public health interventions have traditionally been justified on utilitarian grounds, this project aims to establish an empirical basis to justify public health action. The objectives are: 1) Descriptive: To describe the views of members of society on the justifiability of using restrictive measures to achieve public health goals; 2) Analytic: To analyze the use of restrictive measures at the intersection of public health policy, human rights norms, and ethics; and 3) Normative: To situate public health ethics within a Habermasian model of communicative ethics that can serve as the basis of justification for the legitimate use of restrictive measures based on the intersubjective recognition of public health and human rights. Methods: Individual interviews were conducted with 62 participants, including 23 health care providers, 16 members of the public, 13 community and/or spiritual leaders from the Greater Toronto Area, as well as six public health officials and four health care regulators at the local, provincial, and federal levels of jurisdiction. Findings: Participant views were analyzed and organized into themes that revolve around the following concepts: 1) common good; 2) types of quarantine; 3) compliance; 4) reciprocity; 5) uncertainty; and 6) communication. Conclusions: Combining empirical research with conceptual scholarship, it is argued that the recognition of and commitment to the common good by participants, which emerged as an overarching theme, provide justificatory power for the use of quarantine during communicable disease outbreaks. But to respect rights, while being committed to the common good, it is argued that we must move beyond the see-sawing between ostensibly competing requirements toward a conception that gives equal weight to public health and human rights; that is, both imperatives – the community and the individual – refer to one another without dissolving into one another. Following a Habermasian account of opening processes of decision-making to a moral-practical discourse, it is argued that public health ethics offers an important site for integrating his model of discourse ethics within public health deliberations to expand the scope of moral argumentation on--and ultimately to ground the justification of--the use of restrictive measures.Ph

Evidence and Effectiveness in Decisionmaking for Quarantine

When public health decisionmakers turned to quarantine during the recent severe acute respiratory syndrome (SARS) epidemic, difficult questions were raised about the legitimacy and acceptability of restrictive measures to attain public health goals. SARS also brought to light how scientific uncertainty can permeate public health decisionmaking, leading us to think about the relationship between the adequacy of evidence of the effectiveness of an intervention and its role in the justification of public health action. In this article, we critically examine the role of evidence and effectiveness in decision-making for quarantine. It is our contention that the effectiveness of a public health intervention should not be defined exclusively in (absolute and objective) scientific terms but rather conceptualized relationally and normatively in public health decisionmaking

Your liberty or your life: reciprocity in the use of restrictive measures in contexts of contagion

In this paper, we explore the role of reciprocity in the employment of restrictive measures in contexts of contagion. Reciprocity should be understood as a substantive value that governs the use, level and extent of restrictive measures. We also argue that independent of the role reciprocity plays in the legitimisation the use of restrictive measures, reciprocity can also motivate support and compliance with legitimate restrictive measures. The importance of reciprocity has implications for how restrictive measures should be undertaken when preparing and evaluating public health responses to contagion

A qualitative study of the duty to care in communicable disease outbreaks

Health care providers' (HCPs') duty to care during communicable disease outbreaks has resurfaced as an important and contentious topic. This renewed interest follows the re-emergence of communicable diseases, largely thought to have disappeared and therefore irrelevant to modern day practitioners. The 2003 SARS outbreak particularly presented propitious circumstances for reconsidering this issue. This study seeks to characterize the views of individuals on the nature and limits of this duty. The authors employed qualitative methods to gather lay and expert perspectives. Individual interviews were conducted with 67 participants consisting of HCPs, spiritual leaders, regulators, and members of the public from the greater Toronto area. Participants' views were analyzed and organized according to three main themes, constituting a framework that combines micro-, meso-, and macro-level structures and processes: the scope of obligations of HCPs, the roles of health care institutions, and the broader social context, respectively. Our data suggest that the duty to care must be placed in a wider context to include considerations that transcend individual provider obligations. It thus follows, based on our data, that the duty to care cannot be left to personal choice or an appeal to morality based on an ethic derived entirely from individual obligations. The micro-meso-macro analytical framework that we have developed can guide the articulation of accepted norms of duty to care during epidemics and the development of policy for public health crises. It can also enhance the focus of our current expectations of HCPs' duty during epidemics. This can be achieved by informing regulatory bodies, collaborating with policy makers and engaging the public.Duty to care Health care providers Epidemics Communicable diseases Empirical Qualitative Canada