Specific Topic(s): risk management in a high threat environment

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ – Health-care personnel, as well as health-care facilities and medical transports, whether military or civilian, must be respected by all. They are protected while performing their duties and the safest possible working environment shall be provided to them.

Geneva Conventions: not applicable

Ethical principles: World Medical Association declaration of Geneva (1) at: https://www.wma.net/wp-content/uploads/2018/07/Decl-of-Geneva-v2006-1.pdf and World Medical Association International Code of Medical Ethics (2) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

Discussion:

Review of the question: this question examines the balance between the individual needs of patients to receive medical care against the risks to healthcare workers of being exposed to a highly infectious disease (and the consequence of infection)? This has been a significant issue in many health systems during the coronavirus crisis – see further reading.

Interpretation of the principles/policy from the references: the provision of a safe working environment is an important issue in armed conflict, humanitarian emergencies and other crises. It is widely accepted that healthcare workers have a duty to their patients (WMA (1) THE HEALTH OF MY PATIENT will be my first consideration) and that this is even greater in an emergency (WMA (2) A PHYSICIAN SHALL give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care). However, this obligation is balanced against the potential risk to the healthcare worker from rendering this assistance. Finally, there is a duty upon employer to minimise this risk as far as reasonably practicable; by providing safe systems of work, including personal protective equipment. These issues were specifically considered as part of the UK military response to the Ebola crisis in 2014.

Framework for answering the scenario/question:

• What is the risk? – what is the likelihood of exposure, transmission and what is the severity of impact of the disease?

• What are appropriate control measures? – this includes identification of infected patients, separation of patients from anyone else, cleaning regimes, disposal of contaminated material etc etc… as well as PPE.

• What resources are available? – how much PPE and other protective equipment is available, what actually needs to be ‘rationed’?

• Who needs the most protection? – are there particular healthcare workers and procedures that require a higher level of protection than others – e.g. aerosol generating procedures, workers in intensive care or infectious disease wards?

• Who should be excluded from exposure? – are there any healthcare workers who are at greater risk from contracting the disease and who should be excluded from exposure e.g. pregnant, pre-existing disease?

• How will individuals be allowed to make their own personal choices? – in the end, exposure to a higher level of personal risk than normal practice should be a personal choice, how might individual’s exercise this choice?

Further issues for consideration:

• The same issue applies to the choice to expose oneself to danger to save lives in other emergency situations like entering a burning building, whilst under enemy fire, or when exposed to the threat of chemical weapons. What is the balance between an individual’s choice to accept the risk to save life versus an employer’s duty to minimise the risk to employees?

• Military personnel (including healthcare workers) have already agreed to be exposed to harm by serving in the Armed Forces. When is it legitimate to give a direct order to a uniformed person to expose themselves to risk or death?

• Could a military person refuse to expose themselves to risk if they were not provided with protective equipment, e.g. body armour?

• Could military personnel be ordered to be exposed to greater level of risk in a health emergency than their civilian colleagues?

Bricknell M, Hodgetts T, Beaton K, et al. Operation GRITROCK: the Defence Medical Services’ story and emerging lessons from supporting the UK response to the Ebola crisis. BMJ Military Health 2016;162:169-175. http://dx.doi.org/10.1136/jramc-2015-000512 (full access requires a subscription)

Bakewell F, Pauls MA, Migneault D. Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic [published online ahead of print, 2020 Apr 24]. CJEM. 2020;1‐4. doi:10.1017/cem.2020.376

Binkley CE, Kemp DS. Ethical Rationing of Personal Protective Equipment to Minimize Moral Residue During the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1111‐1113. doi:10.1016/j.jamcollsurg.2020.03.031

Thomas JP, Srinivasan A, Wickramarachchi CS, Dhesi PK, Hung YM, Kamath AV. Evaluating the national PPE guidance for NHS healthcare workers during the COVID-19 pandemic [published online ahead of print, 2020 May 1]. Clin Med (Lond). 2020; clinmed.2020-0143.

Reidy, Pelagia & Fletcher, Tom & Shieber, Clare & Shallcross, Jane & Towler, Helen & Ping, Michelle & Kenworthy, Leigh & Silman, Nigel & Aarons, Emma. (2017). Personal Protective Equipment Solution for UK Military Medical Personnel working in an Ebola Virus Disease Treatment Unit in Sierra Leone. Journal of Hospital Infection. 96. 10.1016/j.jhin.2017.03.018.