June is the fourth month of the Ebola Project; the UK armed forces that were initially deployed to Sierra Leone as part of Operation Gritrock have been returning to work from post-deployment leave since March. To date 15 personnel from tranches 1 and 2 have agreed to be interviewed in order to help us understand the nature of the ethical challenges that they faced in Sierra Leone as healthcare workers in the Armed Forces.
These invaluable firsthand accounts will allow us to develop training materials that can be used better to prepare healthcare workers who respond to future humanitarian crises involving deadly pandemics. Patients’ ‘in extremus’ suffering from Ebola and the highly infectious nature of the virus accentuate even the most common ethical dilemmas. On top of this, serving members of the armed forces had to contend with their dual obligation as healthcare professionals/military coupled with the context of Sierra Leone, with its extreme heat and already limited infrastructure damaged by the outbreak. The pressure and challenges upon individual healthcare workers were considerable.
We are now starting to work on generating ‘case studies’ that will form the basis of the future training materials. These case studies are informed by the experiences of the armed service healthcare personnel that have returned from Sierra Leone. None are based on just one individual’s experience. This is partly to protect the participants’ anonymity and partly to ensure a fair and balanced representation of the types of ethical dilemmas that are likely to be encountered when responding to a disaster. The aim of these case studies is to allow healthcare workers to be able to think about and discuss ethical problems prior to travelling to respond as healthcare workers to a mass emergency. By getting people to cognitively and psychologically respond to scenarios, ethical issues can be identified and solutions discussed without the immediate pressure of the live clinical environment. We will trial the cases and training materials in the forthcoming COST Disaster Bioethics Summer School (http://disasterbioethics.eu/ ) to be held here at the University of Birmingham on 7-11th September; funding is available for interested students and healthcare workers. (Please find further details on our main webpage: http://www2.warwick.ac.uk/fac/med/research/hscience/sssh/ethics/milmed/ebola/). This Summer School will be held in conjunction with the DMS (Defence Medical Services) annual Ethics Symposium on 8th September.
The case study below is a taster of that which will be included in the Summer School and the training materials being developed for DMS. This case study was generated by Heather Draper who developed questions and suggested answers in collaboration with colleagues at the COST (European Cooperation in Science and Technology) action conference in April, which was also focusing on humanitarian crises.
Senior Lecturer, MESH, University of Birmingham.
Example Case Study: Eligibility for humanitarian treatment
You are a military doctor working in a small Ebola treatment unit (ETU) during a major Ebola outbreak. The ETU was established to guarantee that only affected healthcare workers would get care. The reason behind these rules of eligibility for treatment is that it is believed that this measure will instil confidence in both the local and international communities, so that healthcare personnel continue to work or will come to the affected area to help care for the sick and contain the spread of the disease. The eight bed Unit is staffed by military healthcare workers, it has only recently opened and currently only has one Ebola-confirmed patient (about to be evacuated) and two suspected Ebola cases (which may or may not be confirmed).
You are contacted by a local Ebola treatment facility (ETF) and asked to admit a 16 year old woman with confirmed Ebola, even though she is not a professional healthcare worker. She is the sole surviving member of her family. She has nursed each family member, starting with her mother – a nurse who is believed to have contracted the virus while treating patients in the ETF – then her younger siblings and finally her father. The worker at the local unit believes the daughter of his deceased colleague will survive if she can be given intravenous fluids – not an option available at the local unit. You decide to take this patient. Your reasons are that your staff needs to begin to implement and ‘test’ their practices and policies. You also know the local worker has a great deal of experience and trust his judgement that this patient has a good chance of survival. Another member of staff disagrees arguing that in taking this patient the flood gates will be opened to taking other non-eligible patients and undermine the mission of having ring-fenced beds for healthcare workers.
What do you think the ethical issues are? Are there any competing obligations or interests? There are potentially eight ethical issues (although some of them are allied to each other).
If you would like to identify what you think the ethical issues are for yourself, please do so before viewing the examples below.
- Should you always help the suffering? Should you always help someone suffering regardless of the consequences to others or yourself?
- Is it justifiable to take a patient outside the rules of eligibility in order to determine whether the practices and policies of the new unit are sound?
- Should the patient be regarded as a healthcare worker given that she contracted the virus by caring for her family? What are the problems around defining a healthcare worker in this context? Can the concept be used to limit access to this resource? Should the daughter be treated on the grounds that her mother (who infected her) was a nurse who was infected because she continued to work with Ebola patients?
- Could the ethical issues in this case have been avoided by not offering a different standard of care to that available in the local hospital (i.e. beds guaranteed for health care workers but at the same level of care offered locally)?
- What effect might it have on the trust built up with the local community if this patient is refused admission?
- Consider the ways in which admitting this patient may preserve the mission and the ways in which it may threaten the mission. Is it acceptable to ignore the rules of eligibility when there is availability?
- Would it be right/wrong to refuse admission to this patient because you couldn’t offer the same care to other patients in her position?
- Given that this patient doesn’t meet the eligibility criteria, is it wrong to ask the staff to run the infection risks involved with treating this patient? What about the risks associated with insubordination?