# National Ethics Teleconference

***Health Care Ethics Issues Raised by SARS***

##### June 24, 2003

# 

# INTRODUCTION

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health
Care and a physician at the VA NY Harbor Healthcare System. I am very
pleased to welcome you all to today\'s National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of important VHA ethics
issues. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# ANNOUNCEMENTS

Remember that CME credits are available for listeners of this call. To
get yours go to <http://vaww.ees.aac.va.gov/ethics>.

Before we proceed with today\'s discussion on Health Care Ethics Issues
Raised by SARS, I need to briefly review the overall ground rules for
the National Ethics Teleconferences:

-   We ask that when you talk, you please begin by telling us your name,
    location and title so that we continue to get to know each other
    better. During the call, please minimize background noise and PLEASE
    do not put the call on hold.

-   Due to the interactive nature of these calls, and the fact that at
    times we deal with sensitive issues, we think it is important to
    make two final points:

    -   First, it is not the specific role of the National Center for
        Ethics in Health Care to report policy violations. However,
        please remember that there are many participants on the line.
        You are speaking in an open forum and ultimately you are
        responsible for your own words, and

    -   Lastly, please remember that these Ethics Teleconference calls
        are not an appropriate place to discuss specific cases or
        confidential information. If during the discussions we hear
        people providing such information we may interrupt and ask them
        to make their comments more general.

Today's presentation will begin by highlighting the history,
epidemiology, and VHA policies on SARS. Following this introduction we
will consider infectious epidemics from several ethics-related
perspectives including: the duties of VHA clinicians and administrators
to provide care, issues related to patient confidentiality, public
health imperatives, and workforce related issues. Since policy in this
area is not yet fully developed, we wanted to foster an open discussion
of the issues, examine current field practices and seek input from the
field on these controversial topics.

Joining me on the call today are Meaghann Weniger and Ciara Gould, the
Ethics Center's interns in the Washington DC office. Meaghann has a
background in theological studies, and will begin an MD/MPH program at
the University of Nebraska Medical Center this fall. Ciara has a
background in biomedical ethics, and is currently in her last year of
studies in the University of North Carolina MSPH program.

Thank you all for joining me. I would like to first turn things over to
Ciara to give us a brief history of the SARS outbreak, how SARS has
affected the VA, and how the VA is responding to this crisis?

# PRESENTATION 

Ms. Gould:

The present outbreak of Severe Acute Respiratory Syndrome or SARS began
when a doctor from Guangdong, China traveled and checked into a Hong
Kong hotel. Five days later, other hotel guests and a flight attendant
now geographically dispersed fell ill with fever and respiratory
distress, and admitted to local hospitals Hanoi, Singapore, and Toronto.
By March 7^th^, health care workers in all four of these locations began
falling ill with similar symptoms of fever and respiratory infections.
WHO investigators traced more than 100 SARS cases back to the flight
attendant from the Hong Kong hotel.

SARS is a new, transmissible, serious illness characterized by fever and
respiratory symptoms of cough, shortness of breath, difficulty
breathing, hypoxia, and radiographic findings of pneumonia. In some
patients, the illness progresses to respiratory failure requiring
intensive support. SARS has a case fatality rate of greater than 5
percent. The etiology is thought to be a *coronavirus* (SARS-CoV). SARS
is transmitted person-to-person, by respiratory droplets or contact with
environmental surfaces contaminated by droplets. SARS has spread
globally and has been suspected or has occurred in thousands of persons
around the world. SARS is treated symptomatically; there are no known
effective antiviral medications to date. Transmission to health care
workers is remarkable with approximately 30% of the cases occurring in
this segment of the population.

The VA has taken several steps to address and prepare for SARS in its
facilities. The SARS website, updated daily by the office of Public
Health and Environmental Hazards, contains links to a multitude of
resources for clinicians and administrators in the field. The address to
that website is
[www.publichealth.va.gov/SARS](http://www.publichealth.va.gov/SARS).
Additionally, the VA created Directive 2003-023 to set forth a clear and
uniform communication protocol for the reporting of SARS cases in VA
facilities.

Dr. Berkowitz:

Such protocols recognize how important it is for VHA to carefully track
the incidence of suspect and probable cases of SARS in order to
understand the epidemiology among enrolled veterans, and to define
resource usage and allocation. Since SARS is an emerging public health
threat, keeping active surveillance of suspect and probable cases will
allow VHA programs and policies to be maximally responsive to public
health, medical care, and disease control recommendations. VHA tracking
will also support consistent VA-wide participation in the important
activity of reporting cases to public health authorities. In addition,
tracking suspect and probable cases in VHA will allow rapid and accurate
responses should additional patient care resources be needed for
diagnosis, clinical or long-term care for veterans with SARS.

As Ciara alluded to a moment ago, the outbreak of SARS is a complicated
international health care issue, with ramifications for the entire
health care delivery system. Aside from patients, the two groups most
directly affected by the SARS outbreak in the health care system are
clinicians involved in direct patient care, and health care
administrators who have to make decisions about allocating funds and
resources for the prevention and treatment of this disease. They also
have to manage workplace issues that arise from exposure to SARS**.**
Both of these groups face complex ethical issues about how patients with
SARS should be treated, how resources should be directed toward
treatment, how to contain the disease, and how workforce related SARS
issues should be handled.

Let us look first at the duties clinicians have towards patients during
outbreaks of highly communicable diseases. Meaghann, this is obviously
not the first time in medical history that practitioners have been
challenged by an epidemic of this sort. How have practitioners reacted
to epidemics in the past, and what lessons can that teach us now?

**Ms. Weniger**:

Historically, outbreaks of highly contagious infectious diseases have
tested the limits of a physician's duty to treat sick and dying
patients. Reports from the fourteenth and seventeenth century outbreaks
of bubonic plague tell of London physicians fleeing the city or locking
themselves within the protection of their homes.[^1] When the yellow
fever and cholera epidemics swept through the United States in the
nineteenth century, the widening gap between the number of infected
persons and the number of city physicians willing to treat the diseases
obliged civic authorities to employ "mercenary plague doctors" from
outside communities.Error: Reference source not found While these
examples are admittedly dated, more recent decades have shown that this
moral obligation to provide care gets revisited when a new disease
threatens medical professionals. For instance, the emergence of HIV/AIDS
provoked an intense debate over the ethical issue of clinicians'
obligations to treat infected patients. Despite the persistence of
ethical and legal pronouncements related to clinicians' obligations to
treat HIV positive patients, in the early 1990s, there remained a
persistent claim among some who believed that physicians were not
ethically required to take such risks in treating patients. In fact, a
1992 survey of physicians and medical students published in JAMA found
that 23% of physicians indicated that they would not care for persons
with AIDS if they had the choice.[^2] One of the main reasons was the
fear of becoming infected themselves. Considering the communicable
nature of the modern SARS outbreak, the duty to treat SARS patients has
been a conversation of contention.

Dr. Berkowitz:

Fortunately, we are not aware of reported cases in the VA or even in the
US of a practitioner refusing to treat a SARS patient. Even so, it is
important to take a moment to lay out the ethical arguments for the duty
of health care practitioners to treat the sick.

**Ms. Weniger**:

There are two arguments that can be used to establish a physician's duty
to treat: the social contract argument and virtue argument. The social
contract argument is rooted in the concept of a profession. In the June
4, 2003, *JAMA* article by Masur, he states generally that, "physicians
and nurses have an obligation to treat sick and potentially infectious
patients because they are members of a profession whose primary goal is
an ethical calling: caring for the sick."[^3] This voluntarily chosen
profession binds the health care professional to ethical obligations
above those of the general public in caring for the sick, even if doing
so is potentially or actually dangerous for the provider.

Another argument that can be put forward is that of a "virtue-based"
medical ethic, which describes the highest good as an act in keeping
with the goals and ends of an individual or community. An application of
this ethic ascribes two components to medicine: commitment to an end,
i.e., healing, and commitment to the functions or duties necessary to
attain that end, i.e., caring for the sick.Error: Reference source not
found Thus, accepting the duty to care for the sick obligates physicians
to treat sick persons who present themselves for medical care except
under the rare circumstances of extreme personal risk.

Dr. Berkowitz:

Those points are well taken. Another issue in the treatment of SARS is
the lack of known effective curative treatment. What are the ethical
implications of this uncertainty?

**Ms. Weniger**:

This measure of uncertainty emphasizes the duty to provide supportive
and palliative care even if no curative treatment is available. The need
for physicians to address patient fears and to discuss relevant
information is not diminished by uncertainty. Along with focusing on the
control of symptoms and the relief of distress, clinicians have an
obligation to communicate with patients as they establish shared goals
for care. Palliative care should be regarded as co-existing with
disease-oriented therapy throughout patient care.

Medical uncertainty is nothing new, but this degree of uncertainty
really challenges the notion of informed consent. How can a patient be
adequately informed about the risks and benefits of a proposed treatment
when those risks and benefits have to be learned during the course of
treatment? Along with a discussion of medical options, informed consent
discloses risks involved in treatment, the probability of success,
whether adverse outcomes will be reversible or irreversible, and the
understood cause of the ailment. When so much uncertainty exists, such a
discussion and decision-making process is nearly impossible and relies
heavily on the disclosure of such uncertainty and developing trust that
the team is acting in the patient's best interest.

# 

# Dr. Berkowitz:

# 

# Informed consent and communicating uncertainty are some of the ethical practices that practitioners struggle to maintain during a public health crisis. Other ethical principles that can be challenged during an epidemic are those related to privacy and confidentiality. How does a practitioner balance the duty to protect the patient's confidentiality with the duty to protect the public good? For many practitioners, this is a difficult question.

**Ms. Weniger**:

Public health laws are the most obvious threat to confidentiality, since
they require practitioners to report suspect and probable cases of SARS.
Confidentiality has been established as one of the most important facets
of the patient-practitioner relationship. This ethical concept, however,
is not absolute and there remains the possibility of breaching
confidentiality if it is necessary to serve the public interest. This
notion was upheld by the Supreme Court in a 1905 landmark case, Jacobson
v. Massachusetts, where the Court stated: "There are manifold restraints
to which every person is necessarily subject for the common good... Upon
the principle of self-defense, of paramount necessity, a community has
the right to protect itself against an epidemic of disease which
threatens the safety of its members."[^4] The emergence of the SARS
epidemic forces the medical community to recognize the tension that
often occurs between individual confidentiality and the protection of
wider public health. Considering the relationship between SARS and
public health, conflicts may arise between respect for persons (and
their privacy) and autonomy or beneficence (the promotion of human
welfare).

As the crisis surrounding SARS makes clear, patient privacy is not an
absolute right, and can, at times, for example, be outweighed by the
public interest if there is a clear and imminent danger. However, health
professionals report suspected SARS data to public health authorities
with the understanding that public health authorities will maintain
confidentiality of those reports. When public health concerns intrude on
a SARS patient's assumed right to confidentiality, the greatest care
must be taken to ensure only necessary disclosure.

Dr. Berkowitz:

Thank you, Meaghann. Again, I refer everyone to VHA Directive 2003-023
that lays out procedures for reporting suspect and probable cases of
SARS properly.

Let us now look at how SARS related issues are challenging health care
administrators. I would like to turn now to Ciara Gould and ask what
duties do health care administrators have during an epidemic like SARS.

**Ms. Gould**:

The American College of Healthcare Executives Code of Ethics describes
the duties health care administrators have to four specific groups:
hospital patients, the organization, its employees, and the surrounding
community. These obligations must be constantly balanced and evaluated,
and at times may conflict with one another, causing ethical dilemmas. To
ethically balance these concerns requires a carefully planned just
process for decision-making.

# Dr. Berkowitz:

# 

# Perhaps you could further explain the ethical obligations of hospital administrators and how these obligations may conflict with one another. For example, additional training and infection control measures are not free and can strain health care budgets. How should health care administrators make these tough resource allocation decisions?

**Ms. Gould**:

It is up to administrators to determine the appropriate level and source
of funding for infection control to minimize the adverse impact to
others (for example, consumers of a community outreach program or
patients seen in the emergency department) while maximizing gain by the
greatest number possible. In allocation decisions, some factors to
consider are the communicability of the disease, risk of contracting,
cost, associated pain and suffering, and the impact on quality and
length of life[^5]. Of course, a hospital could achieve nearly perfect
infection control by funneling all of its resources into staff training,
state of the art equipment, and facility renovation. However, this
extreme would not be reasonable since other services would greatly
suffer and a large number of people would be harmed without access to
cardiology, physical therapy, and other such services. Conversely, the
hospital administrator who underestimates the need is equally at fault
in not meeting his or her ethical obligations to patients, staff or
community.

Dr. Berkowitz:

Can you give us an example of how hospital administrators must balance
their ethical obligations, for example, in order to make the hospital
safe for its employees.

Ms. Gould:

Well, let us take a look at one ethical duty hospital administrators
have: to ensure that their facility is a safe workplace for all
employees. All hospital employees have ethical obligations of varying
degrees and priorities. Clinicians have an ethical (though perhaps not
legal) obligation to provide care to patients suspected of or actually
having SARS. Health care administrators have an ethical obligation to
ensure those clinicians are kept as safe as possible and provided with
all reasonable measures to avoid infection. Since SARS has
disproportionately infected health care workers, provision of a safe
work environment takes on new dimensions in the face of this threat.
There are additional needs for infection control supplies and for
employee education on precautions and policies.

The CDC estimates that most of the SARS infections in health care
workers can be attributed to lack of infection control procedures,
improper implementation or disregard for these procedures. Therefore,
administrators have an obligation to ensure that all hospital employees
are not only aware of the VHA SARS triage procedures, but are also able
to implement these procedures should the need arise.

# Dr. Berkowitz:

# 

# This raises another question: if hospital administrators have a duty to minimize the risk of infection, should staff be required to disclose if they have recently traveled to a SARS hot spot, like Toronto or Hong Kong. Can staff have an expectation of privacy that what they do away from the hospital or clinic is a personal matter? Do they have a "private life" that is off-limits for disclosure to administrators or patients such as where they spent their vacation? What ethical issues are at stake here?

Ms. Gould:

That is a very difficult question, because it touches on a number of
ethical issues in containing communicable diseases. There are persuasive
arguments that can be made on both sides of the question. For instance,
according to the CDC's *Interim Domestic Guidance on Persons Who May
Have Been Exposed to Patients with Suspected Severe Acute Respiratory
Syndrome (SARS)*, most reported cases of SARS in the US are from travel
to countries with community transmission of SARS, with secondary
transmission due to close contact and health care workers. This being
the case, knowing if someone has recently returned from a trip to an
area with SARS is the single most important indicator of that person's
risk for developing the disease. The CDC recommends in the *Interim
Guidelines about Severe Acute Respiratory Syndrome (SARS) for Persons in
the General Workplace Environment* that workers returning from an area
with SARS need to be vigilant for the development of fever or
respiratory symptoms, and to not report to work, school, or other public
areas if symptoms develop. The health care environment, however, should
be treated more stringently than a general work environment because of
the increased risk of transmission of disease in a hospital. That risk
is not negligible. The Ontario Ministry of Health and Long-Term Care
reported in the June 13 Morbidity and Mortality Weekly Report that in 74
probable and suspected cases of SARS between April 15 and June 9, 90%
resulted directly from exposure in hospital, and 38% as a result of
exposure during hospitalization.

Recognizing the transmission that occurs in hospitals, the CDC issued
*Interim Domestic Guidance for Management of Exposures to Severe Acute
Respiratory Syndrome (SARS) for Health-Care Settings*. This guidance
does not specifically address what to do with clinicians returning from
areas with SARS, but it does include some specifics that could apply.
So, for instance, the guidance states that health care facilities that
care for SARS patients should implement surveillance of health care
workers who have any contact with these patients. Health care workers
who have had unprotected exposures to SARS patients should be monitored
regularly for 10 days following exposures, and be interviewed before
reporting to work each day regarding respiratory symptoms.

It also states that health care workers who have had unprotected
high-risk exposure to SARS should be excluded from duty.

The final of reasoning argues that clinicians should be required to
disclose travel from an area with SARS and that, at a minimum, those
clinicians need to be monitored for early signs of the disease.
Additionally, administrators should consider in their deliberations the
possibility of isolating infected employees, including healthcare
professionals.

VA administrators should also be aware that employees who self-report
SARS exposure or symptoms may be at an elevated risk for privacy
violations due to the collegial nature of health care facilities and the
public's concern over safety in these facilities. These factors heighten
the responsibility of administrators to protect the privacy of their
employees.

# Dr. Berkowitz:

In fact Ciara, we have been in contact with staff from VHA's Public
Health Strategic Health Care Group and VHA's Occupational Health Care
Program. Policy regarding employee practices is in development. These
groups have been receptive to open dialogue regarding the possibility of
planned employee surveillance, reporting and leave requirements. One of
the purposes of this call is to air controversial issues and provide a
forum for dialogue on developing topics. During the discussion portion
later in the call, it will be interesting to hear how people in the
field think we should handle questions such as: reporting requirement
for returning employee travelers, employee surveillance for symptom
development and leave requirements/policy for quarantined employees.

But before we move to the discussions, I wanted to point out a number of
resources available to practitioners and administrators as they confront
the ethical issues raised by SARS.

1.  The VA Office of Public Health and Environmental Hazards maintains a
    SARS website that is updated daily with links and pertinent
    information. That address is:
    [www.publichealth.va.gov/SARS](http://www.publichealth.va.gov/SARS)

2\. The local ethics committee is a valuable resource for addressing
ethics-related issues raised by SARS. The Ethics Center's consultation
service is always available for ethics committees and administrators for
guidance at a national level. To reach us, e-mail VHA Ethics on the
Outlook System.

**MODERATED DISCUSSION**

Dr. Berkowitz:

I believe that we have representatives on the call from the VHA
Occupational Health Programs, and Public Health Strategic Health Care
Group. At this time, I would like to invite comment from these offices
on the ethical issues raised by SARS or policy development in those
areas. Drs. Deyton, Hodgson, or members of their staff, do you have any
reactions or additions to the presentation so far?

Lawrence "Bopper" Deyton, MD:

The presentation was good and comprehensive. I have no other comments
now.

Dr. Berkowitz:

At this point in the call, I would like to open the call for discussion
of health care ethics issues raised by SARS by asking our listeners in
the field to share their thoughts and experiences on this topic. We ask
that when you talk, you please begin by telling us your name, location
and title so that we continue to get to know each other better.

-   Has any facility considered a policy that would require clinicians
    to report possible exposure to SARS, such as travel to a country
    listed by the CDC as a SARS hot spot?

Infection Control Practitioner, Salem, Virginia:

We put a policy like that into effect as soon as SARS started. We sent
notes out to all of our physicians and nursing personnel about travel
from affected regions. We have not had any patients in this part of
Virginia with SARS or even suspected SARS until very recently.

Dr. Berkowitz:

What type of reaction did that evoke amongst the employees?

Infection Control Practitioner, Salem, VA:

For the most part, absolutely none. They just all accepted it, and said,
"OK."

Dr. Berkowitz:

Good. Have people reported?

Infection Control Practitioner, Salem, VA:

We have had no one travel to the affected areas.

Dr. Berkowitz:

Has anyone else had any experience with that?

William Nelson, PhD, Chief of Education, National Center for Ethics in
Health Care:

I was a little curious, you indicated that you sent out notices or you
informed clinicians. It sounded like you were limiting it to physicians
and nurses. I was wondering was that sent out a broader way, lets say to
social workers or other types of occupational or physical therapists or
any other employees? Or was it more a limited type of outreach?

Infection Control Practitioner, Salem, VA:

A notice went out to all staff. And what it said was that if you have
traveled by air or ship and developed respiratory symptoms within 10
days of return, notify occupational health before returning to work.

Stuart Selikowitz, MD, White River Junction, VT:

I am a surgical researcher and I am interested in infectious diseases. I
happened to be at a gas station the other day, during the SARS epidemic,
and I noticed somebody coming through with Toronto plates. I asked them
whether anyone had asked where they came from, and he said "No" he went
right through the Immigration Authority.

What kind of connections does the VA have with other sources of travel,
such as the immigration agencies and the police? What other ways are
infectious agents being brought in, and how does one be alerted to this?

Dr. Berkowitz:

I am not sure if Dr. Deyton or Dr. Hodgson want to respond to that
question about VA's connections with other agencies. I think that the
various regulatory agencies have been in flux about the different state
of travel, and what would and would not be permissible.

Dr. Selikowitz:

But, again, what connections does the VA have with these other
authorities to put together a comprehensive picture of what is happening
to the incoming sources of infections?

Dr. Deyton:

The only response I make to that is the Center for Disease Control
issues guidance to all federal agencies as well as state and local
government for those kinds of issues. If the CDC ever made
recommendations about immigration boarder control, we would follow their
lead.

Dr. Hodgson:

We have no formal connection with any other agency, and, in fact, we do
not plan to go there. We do assume health care workers are professional,
we assume they will do the right thing and we fundamentally think that
people will do what they are told when it is good for the patients.
Unless there is a very good reason to change that, I do not think we are
going to develop formal connections with the other agencies.

Dr. Berkowitz:

I think from a professional perspective the obligation is clearly to
comply and to report as deemed fit by people who have made coherent and
fair procedures for such reporting. I think that should cover us as long
as everyone does the right thing.

Let us go back to my question about health care workers obligation to
treat people even if they are in a contagious state. Any comments on
that or feelings?

San Antonio, TX:

Thus far, we have not had any experience with that yet. When we were
asking for volunteers for the smallpox vaccine, many people actually
refused. Not because they were contraindicated but because they did not
want to be called to care for smallpox patients . If that ever occur
there would be many medical issues about that. I had MICU nurses who
basically said, I am not going to be vaccinated because I am not going
to be around if we have a case. I would like to open it up to that
particular scenario. We had 30 employees from the South Texas HCS
vaccinated from two different VA's facilities. Not nearly enough staff
to provide treatment for smallpox patients. The question was, will they
still be required to care for patients?

Lorraine Martin, RN, New Jersey HCS, NJ:

When I was a field nurse in 1980, we had patients developing atypical
symptoms; young men with PCP, kaposi's sarcoma and babies with failure
to thrive due to CMV.

Out of 60 nurses, only six of us agreed to care for these patients. You
know the rest of the story, our understanding of the disease evolved and
we became more aware of how it was transmitted. But in 1980, no one knew
how it was transmitted.

So this is interesting because this could become a real ethical dilemma.
If we do get a patient who is admitted, after travel, and everyone says
"not me," I think it should be discussed now and made very clear.
Everyone knows standard precautions and you must take care of these
patients. If I had not lived it in the 80's, I would not believe it
could happen, but it can.

Dr. Berkowitz:

I think Lorraine two differences I can think of between then and now is
one, we know more about SARS, and two, we know how it is transmitted and
I think that that degree of panic would not be justified.

Ms. Martin:

And the human condition has not changed people might\--I think that it
is good that we are discussing it now, that is my whole point.

Dr. Berkowitz:

It is a good point, we need to think in advance about our obligations.
We need to understand the facts and spread the truth about a disease as
opposed to making reactionary statements and spreading rumors. I think
that really helps a lot. The second thing that is different now than in
the early 80's, is our ability to disseminate information. It is so much
greater. Again I refer back to that SARS website
(www.publichealth.va.gov/SARS), which is really a resource that should
be available to everybody and should go along way towards allaying fears
and towards arming people with the facts, which I think it is essential
for intelligent reactions and intelligent decision making.

Ms. Martin:

I applaud your reaction.

Battle Creek, MI, VAMC:

Everybody in the health care field has an obligation. It is the
obligation for the administration to provide the necessary equipment.
The health care providers, physicians and nurses should do their part.
There should be no reason why somebody should refuse to do his or her
part.

Linda Titus, Connecticut HCS, CT:

I think this would be an excellent topic for a publication from the
Center, which you have done so well in the past. And this really is a
provocative topic that the more information and ways of approaching it
in terms of education in staff, etc, would be helpful to us in the field
at least, I can speak for myself

Dr. Berkowitz:

Linda, can I ask you to be a little specific, I assume you are referring
to a National Ethics Committee report. Are you suggesting a National
Ethics Committee report on the obligation of health care workers to
treat?

Ms. Titus:

Yes, the entire subject. What is our ethical obligation in this era
either potential or real, of serious communicable diseases? That can be
helpful in terms of a dialog in education and kind of building consensus
around what our obligations are. Ahead of time, I totally agree.

Dr. Berkowitz:

We will certainly pass that along. Maybe I will ask our folks in
Washington who have done a lot of research for this call if they could
forward to you, Linda some of the references for the literature that
they have all ready found in preparation for this call.

Dr. Selikowitz:

Not dealing with SARS so much, but dealing with the interchange of
information from both patient and health care worker. I remember when I
was active in the clinical division, that people with HIV infection did
not have to tell the physicians or the health care workers, that they
were infected or that they were positive and therefore exposed the
health care worker to whatever they had. But, they were not obligated to
say anything. The same thing could pertain as far as infectious disease
such as SARS.

I remember reading in the paper whether it was right or wrong, of
patients in China having been infected and then going back into their
family situation because they didn't want to stay in the hospital, and
then infecting their villages. I think we have to think about the
obligations not only of the health care worker, but also the obligations
of the patients. It is not a one-way street. I would like some comments
on that.

Dr. Berkowitz:

I think that in the China example, that behavior was recognized in
China, and it was codified in law and it was made a crime if you did not
report or knowingly transmitted SARS. I think there are legal
ramifications in the United States, also of knowingly infecting someone
with HIV. But I think when you talk about obligation; I think there are
different levels of obligation. If you did an ethics analysis and broke
it down, I think that there would probably be a clear tipping of the
scale towards an ethical obligation to report relevant information about
your health condition if by not doing so would put another person in
harms way. Since SARS is spread by much more casual contact then HIV, I
think that obligation to report would be a much stronger than in a
bloodborne illness where universal precaution should avoid that type of
spread anyway. So I think that they are slightly different scenarios and
the balance on the other side has to consider privacy rights, right to
determination about your own information and stigma that could result
from undesired release of such information. There is a balance, but I
think that in something as easily transmissible as SARS that that
balance from a moral standpoint, clearly to me anyway, would tip towards
the obligation to report. I think it would be wrong to withhold that
information. I am not aware of that being codified in law or policy.

One other thing to think about is, do patients have obligations to their
providers? This has come up when staff are inadvertently stuck with a
needle or exposed to a patient's blood, and the patient has to give
consent to have testing for HIV or is asked to do that. The patient can
refuse the test, and there are very good arguments for that. But I am
not sure that the patient enters into a social contract with the
provider or what responsibility the patient has to protect those who are
putting themselves in harms way to try to get them better.

One other area of SARS that is striking to me is looking at areas where
there have been outbreaks. Several hospitals have been closed to further
access by patients because the hospitals themselves became health
hazards as a result of SARS. I think if were to happen in the VA, it
would pose tremendous challenges for a closed system, such as VA, where
patients have entitlements and rights to care. We did not really discuss
that in the discussion or the presentation part of today's call. I am
not sure if anyone has thought about that or if there are plans for
alternate care, or if that is something that anyone wishes to think
about or comment about. Dr. Deyton, has anyone in the Public Health
Strategic Health Care Group considered the eventuality of having to
close hospitals and how that would affect the system?

Dr. Deyton:

That is an important issue. What we are trying to do is get good
educational materials out there to our front line provider so that
recognition of the clinical scenario and the case definition would
prompt immediate actions that would keep emergency rooms, clinics, and
hospitals able to accept patients and care for patients. Given the
review of what the current CDC recommendations are for employee
self-quarantine after unprotected exposure, we are all worried what may
happen with being able to staff hospitals in the autumn. If SARS begins
to come back during cold and flu season when respiratory syndromes all
look pretty similar until there is adequate diagnostics and time to
determine what the illness is. Is it a cold? Is it pneumonia? Is it
SARS? We are having ongoing discussions with occupational health,
infection control, and infectious disease to try to put in place the
right educational materials, the right screening programs, and the right
protocols to help in that kind of situation. We do not have answers at
this point; it is all happening right now.

Dr. Berkowitz:

One thing we have not discussed yet is the issue related to abrogation
of rights in times of quarantine. We discussed this a while back when we
had a prior teleconference entitled the "Ethics of Medicine and
Disasters." Triage changes during disasters or serious public health
times and quarantine poses specific ethical challenges. It will pose
challenges for our health care system, for our workers, for our
patients, for other people we have not really mentioned such as perhaps
our hospital Federal police, who may be called in to do things that have
not been doing. We all hope it does not come to that, but there are
potential and further loss of freedoms for the public good if things do
get worse.

FROM THE FIELD

**Dr. Berkowitz:**

Now I want to turn to our "From the Field" segment, where we take
comments from our listeners in the field on ethics topics not related to
today's call. Please remember, no specific consultation requests in this
open format, but I invite you now to make your comments on other
ethics-related topics, or to continue our discussion on health care
ethics issues raised by SARS.

**San Antonio, TX:**

Related to your statement on the abrogation of rights for quarantine,
the closest thing that I can think of related to that is tuberculosis,
and that goes back to the other statement about connections with other
agencies and that's law. If a patient has TB and does not comply with
airborne precautions or refuses to comply, we could get court order and
actually quarantine them in our infection disease facility here Texas.
So I think that would be a model for SARS and people at your level
should look at how we address that. In addition, here at San Antonio we
actually have an ethics team, related to non-compliant TB patients and
how we manage them within the facility before they get to an infectious
disease facility by court order.

**Dr. Berkowitz:**

I think clear policy in the area will certainly be important and there
is no doubt that if things---and again we hope and doubt that it will
get to this\--that there are possibilities of increased legal
requirements or martial law in an extreme disaster.

**Leland Saunders, MA, National Center for Ethics in Health Care,
VACO:**

Just today in the *New York* *Times*, there was an article related to
the Canadian experience with SARS. One of the things that was
specifically mentioned in the article was that some doctors in Toronto
have refused to care for patients with SARS, and some have actually
resigned so that they would not have to be near patients or colleagues
who have, or been exposed to SARS. Another related issue was that
physicians who had not treated SARS patients ostracized physicians who
had, and this set up a hierarchy, if you will, within the organization.
I just thought a very timely article about the ethics related issues
that Canada is encountering there now on several weeks.

# CONCLUSION

**Dr. Berkowitz:**

Well, as usual, we did not expect to conclude this discussion in the
time allotted, and unfortunately we are out of time for today\'s
discussion. We will post on our Web site a very detailed summary of each
National Ethics Teleconference. So please visit our Web site to review
today\'s discussion. And if you have any SARS related questions, visit
the SARS website at
[www.publichealth.va.gov/SARS](http://www.publichealth.va.gov/SARS).
Educating ourselves and arming ourselves with accurate and current
information is one of the best ways to prevent panic and assure the
decisions we make are fact-based---certainly a fundamental for ethical
decision-making at all levels.

I will be sending a follow-up email for this call that will include the
links to the appropriate web addresses for the call summary, the CME
credits, and the references.

**FINAL THOUGHTS**

I would like to thank everyone who has worked hard on the conception,
planning, and implementation of this call. It's never a trivial task and
I appreciate everyone\'s efforts, especially Meaghann Weniger, Ciara
Gould, Leland Saunders, and other members of the Ethics Center and EES
staff who support these calls.

***NEXT CALL***: Will be on **Wednesday July 30, 2003** from 1:00 to
2:00 Eastern Time. The tentative topic about the ethics of tissue
banking for use in genetic research. Please look to the Web site and to
your outlook e-mail for details and announcements.

-   I will be sending out a follow-up e-mail for this call with the
    e-mail addresses and links that you can use to access the Ethics
    Center, the summary of this call and the instructions for obtaining
    CME credits, and the references that I mentioned.

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-   Thank you and have a great day!

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    analysis of the individual physician's duty to treat. *Am. J. Law
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[^2]: Shapiro MT. Resident experiences in, and attitudes toward, the
    care of persons with AIDS in Canada, France, and the United States.
    *JAMA.* 1992;268(4):510-5.

[^3]: Masur H, Emanuel E, Lane HC. Severe acute respiratory syndrome:
    providing care in the face of uncertainty. *JAMA*. 2003; 289(21):
    2861-3.

[^4]: *Jacobson v. Massachusetts*, 1905.

[^5]: ^6^ Beauchamp, T. J Childress. [Principles of Biomedical
    Ethics]{.underline}. Fifth Edition