DNR Ebola: Is there a professional obligation to provide treatment?

By Avigile Baehr

Overhead pages are a staple of a busy ER. They give doctors and nurses a couple extra minutes to prepare for the quick action needed to save patients’ lives after strokes, heart attacks, or trauma. Now, imagine a case today:

Attention, ER staff. A 32 year old female at high risk for Ebola is coming in via ambulance with fever, vomiting, and unstable vital signs. If you are willing to accept the personal risk inherent in providing medical care to this patient, please report to room 3. Otherwise, please disregard this announcement.

A conditional appeal, not an imperative. A qualification that seems to run counter to the oaths that medical professionals take. And yet, a stipulation that hospitals and healthcare providers have considered as they decide how and whether to engage with this deadly infection. Ebola poses a very real threat to providers: two nurses contracted the virus while caring for a patient in Dallas, and California nurses have gone on strike in response to lack of preparedness for safely dealing with the infection. Given the disease’s documented transmission to healthcare providers, its high fatality rate, and the lack of an FDA-approved treatment or vaccine, what are our professional obligations in caring for these patients?

The classic principles of medical ethics are autonomy, beneficence, justice, and nonmaleficence. For the purposes of the ‘obligation to treat’ dilemma, I will assume that Ebola patients want to receive treatment, and I will not consider the ethics of experimental treatments as they might relate to the ‘do no harm’ principle. The principles of beneficence and justice, however, are particularly salient to this question. Healthcare providers are not merely obligated to do no harm, but we must also do good by our patients. Despite the uncertainty regarding some experimental treatments for Ebola, timely supportive care is unquestionably beneficial for these patients. Intravenous fluids help prevent shock and organ failure. Breathing tubes can keep patients alive until the virus runs its course. In certain cases, CPR can restart a heart and give someone a chance to survive. Fair and equitable treatment of Ebola patients requires that they be treated by the same clinical standards that apply to any other critically ill patient. By these core principles, the ethical imperative to provide medical treatment to Ebola patients is clear.

What argument can be made, then, for refusing to provide comprehensive medical treatment to a patient with Ebola?

Perhaps providers are only obligated by these principles once they accept someone as a patient. Can a doctor or nurse then ethically refuse to engage in a provider-patient relationship with someone suffering from Ebola, thus freeing him or her of any obligation to treat?

In routine medical care, maybe or maybe not. Most states have specific clauses that allow providers to refuse to provide certain treatment, such as abortion care, on the basis of moral objections. But, both the law and medical professional societies uniquely distinguish emergency situations as obligating medical treatment without qualification. The Emergency Medical Treatment and Active Labor Act requires that all hospitals who offer emergency care services and who receive any Medicare funding (read: the vast majority of US hospitals) evaluate and stabilize any patient who seeks medical care. This law was designed to prevent hospitals from refusing to treat uninsured or underinsured patients, but it also serves to promote fairness and ameliorate other treatment disparities. Similarly, the American Medical Association Principles of Medical Ethics dictates that physicians should be free to choose the terms in which they agree to provide medical care, except in emergencies. By virtue of their agreement to serve as medical professionals, providers implicitly engage in a patient-provider relationship with anyone who seeks urgent care at their facility.

But, perhaps there should be an exception for personal risk. A similar dilemma with concern for provider safety arose in the early days of the HIV/AIDS epidemic, but both the American Medical Association and the American Dental Association explicitly reaffirmed the duty to treat. Both professional societies appealed to fairness, stating that a patient should not be subjected to discrimination based on any characteristic, including disease status. There is a utilitarian argument to be made in support of this personal risk exception: if a provider treats and subsequently contracts Ebola from one patient, then that provider’s other patients might suffer. However, in the United States, healthcare associated transmission of Ebola remains an incredibly rare event, and a utilitarian analysis does not fall in favor of refusing to treat Ebola patients. Two of the 170+ people who had direct or possible contact with the three Ebola patients from Dallas contracted the virus, and no healthcare provider has died from Ebola transmission in the United States. To put this number in context, an estimated one in ten healthcare workers experiences a needle stick each year, placing them at risk for blood borne pathogens such as HIV and Hepatitis C. Providing care for sick patients inherently carries a certain degree of risk, but so long as providers are able to mitigate that risk through personal protective equipment and standard precautions, this does not excuse them from their professional responsibilities.

In conclusion, the basic principles of medical ethics unequivocally support treatment of Ebola patients. Ebola patients can present in critical condition and require timely medical care, thus placing them in the category of a medical emergency and further obligating providers and hospitals to accept these patients for treatment. Personal risk might be an important consideration, but the risk of transmission can be appropriately mitigated through proper protective equipment in the United States. Ebola patient in room 3? That announcement will never sound routine, but we must treat even these patients fairly and by the highest standards of medical care. 

Avi is currently an MD/MBE candidate at the University of Pennsylvania. She graduated from Vanderbuilt University in 2011 with a degree in biology and philosophy. This post was chosen as a finalist for the 2014-2015 Daniel Callahan Young Writer’s Prize. 

Deadline Approaching

The deadline to submit for the Daniel Callahan Young Writer's Prize is this Saturday, November 15th. Below is a summary of the contest and the guidelines for submission. Don't forget to submit!

Prize Summary 
This post is pleased to announce a new award, The Daniel Callahan Young Writer's Prize, sponsored by Daniel Callahan. Submissions will take the form of essays on a bioethics topic that are written as blog posts, designed for this blog, Bioethx Under 25. From all submissions, a group of finalists will be chosen and then an expert panel of bioethicists, including Daniel Callahan, will read the finalists' essays and award one prize amounting to $500. 

All submissions will be considered for publication on the blog and eligibility to be a finalist or receive the prize is dependent on willingness to edit and revise the essay for publication. Submissions will be judged anonymously. Please see guidelines below for further information. 

Prize Submission Guidelines

- Essays must be 500-1000 words and original submissions to Bioethx Under 25 i.e. never posted before on the blog. 

- Essays must conform to all other submission guidelines for the Bioethx Under 25 blog and thus, be clearly related to bioethics and be written in an accessible manner. Please refer to the blog's About Page for more information. 

- Essays will be accepted from September 10th, 2014 to November 15th, 2014. 

- Any writer who is also a student in high school, college, or a graduate program is eligible to submit. Any writer who is not a student is eligible so long as he/she has not completed a PhD and/or worked more than 5 years in the bioethics field with a terminal degree (e.g. JD or MD). So long as the other guidelines have been met there is no age limitation or requirement for submission. 

- Writers are not eligible if they currently or have previously worked full time for The Hastings Center or Daniel Callahan. Anyone affiliated with Bioethx Under 25 in an editing capacity is also ineligible. 

- To submit, please email bioethicsunder25@gmail.com with your essay attached in word format. In the body of the email please indicate that you are submitting for The Daniel Callahan Young Writers Prize and include your name, phone number, email address, current occupation and place of occupation (if a student, then your school, potential degree, and expected graduation year), and your highest degree attained with the school and year. 

- For any questions please email bioethicsunder25@gmail.com or comment below. 

Breaking the Barrier Between Us and Others

By Chelsea A. Jack

Disability scholars aim to socially deconstruct naturalized, or seemingly inevitable and fundamental, understandings of what it means to be able-bodied or disabled.  As is the case with much postmodern writing, disability scholars forward their ideas with a general suspicion toward claims of knowledge fortified by dichotomous relationships, e.g. male/female, nature/culture, disabled/abled. However, this is not to say that actual differences do not exist among different groups of people. It is only to say that the barriers between “us” and “them” are never quite as solid as they appear, and that questioning those barriers allows for reimagined relations among community members.

Here, with disability scholarship as my primary example, I draw on the writings of three feminist scholars across different academic disciplines to show how a self-reflexive style can show the vulnerable relationship between the self and other. Such stylistic choices in favor of self-reflexivity betray the academic mantle of omniscience, or objectivity, that characterize arguments removed from the first person. Further, these choices can encourage reimagined relations with those we might understand as other.

When philosopher Eva Kittay has written against ideal theory in bioethics, she has made a strategically feminist move in her criticism of such theory and its proponents, specifically philosophers Peter Singer and Jeff McMahan: she self-reveals. For example, when she criticized Singer’s and McMahan’s theories concerning necessary cognitive and psychological criteria for the status of moral personhood, Kittay reveals that her own daughter, Sesha, was diagnosed as severely to profoundly retarded. Kittay shares that her own daughter might be counted among those whom McMahan has stipulated as undeserving of justice or life. Kittay purposes the developmental experiences of her own daughter as counterpoints to Singer and McMahan’s arguments that deny severely disabled and congenitally severely mentally retarded (CSMR) persons the status of moral personhood.    

In her own reflections on feminist ethnography, anthropologist Ruth Behar has contemplated the implications of acknowledging the place of “I” in the representations of others. In The Vulnerable Observer, Behar suggests that it makes scholars nervous to “forsake the mantle of omniscience” in favor of revealing personal stories into what we have been taught to think of as the analysis of impersonal social facts (1996:12). Both Behar and Kittay approach their own feminist scholarship with an appreciation for humility. Humility, for Kittay, requires both resisting the impulse to impose your own values on others and acknowledging what you do not know (2009:229). As Kittay writes about her own daughter Sesha, she admits, “What cognitive capacities Sesha possesses I simply do not know, nor do others. And it is hubris to presume” (2009:229). By utilizing a narrative from her own life, Kittay not only values humility as a maxim of ethical theorizing but her argument here is feminist for its ability to respond to the theme of vulnerability and marginality underlying subject-object formation.

When Kittay revealed her own relationship to disability, she created a space for conversation about “the tenuous nature of selfhood,” to borrow phrasing from feminist scholar Karen O’Connell (2005:219). In O’Connell’s analysis of the Romany term for the Holocaust – a term that translates to “the devouring” – she argues that attempts to expel unwanted people (i.e. the disabled, women, Jews) are never successful, since total expulsion is a myth. The existence of the self requires attempts to expel unclean and improper elements (218). In this sense, the constitution of threats to the self represents an exigency for the latter. The self, then, is a very fragile thing. This realization then becomes critical in the analysis of violence toward otherness, whether manifested against disabled people, people of color, or women.

How might self-revealing break down entrenched notions of “we” versus “them”? In what way do hypothetical analogies in ideal theory – such as Singer’s between cognitively impaired people and chimpanzees – reinforce epistemic structures of hierarchy and domination, where moral knowledge rests on obscuring the situated-ness of the author herself – situation meaning the circumstances that formulate our identity, i.e. race, class, gender – and the disturbing absence of disabled people in this theorizing? I personally admire those, such as Behar and Kittay, who betray the academic mantle of omniscience in order to advocate humility and recognize the vulnerability of the self.

Works Cited

Behar, Ruth. 1996. The Vulnerable Observer: Anthropology That Breaks Your Heart. Boston: Beacon Press.

Kittay, Eva. 2009. “Ideal theory bioethics and the exclusion of people with severe cognitive disabilities.” In Naturalized Bioethics: Toward Responsible Knowing and Practice, edited by H. Lindemann, 218 – 37. Cambridge.

O’Connell, Karen. 2005. “The devouring: Genetics, abjection, and the limits of Law.” In Ethics of the Body: Postconventional Challenges, edited by Margrit Shildrick and Roxanne Mykitiuk, 217 – 34. MIT. 

Chelsea is a Research Assistant at The Hastings Center. She graduated with highest distinction from the University of Virginia, where she received a B.A. in political and social thought and anthropology with a minor in bioethics. Her research interests include medical and legal anthropology, political and social theory, bioethics, and contemporary feminist thought.