Duty to treat and perceived risk of contagion during the COVID-19 pandemic: Norwegian physicians' perspectives and experiences-a questionnaire survey.

BACKGROUND: The COVID-19 pandemic actualised the dilemma of how to balance physicians´ obligation to treat patients and their own perceived risk of being infected. To discuss this in a constructive way we need empirical studies of physicians´ views of this obligation. METHODS: A postal questionnaire survey was sent to a representative sample of Norwegian physicians in December 2020. We measured their perceived obligation to expose themselves to infection, when necessary, in order to provide care, concerns about being infected themselves, for spreading the virus to patients or to their families. We used descriptive statistics, chi-square tests and logistic regression analyses. RESULTS: The response rate was 1639/2316 (70.9%), 54% women. Of doctors < 70, 60,2% (95% CI 57.7-62.7) acknowledged to some or a large degree an obligation to expose themselves to risk of infection, and 42.0% (39.5-44.5) held this view despite a scarcity of personal protective equipment (PPE). Concern about being infected oneself to some or to a large extent was reported by 42.8% (40.3-45.3), 47.8% (45.3-50.3) reported concern about spreading the virus to patients, and 63.9% (61.5-66.3) indicated worry about spreading it to their families. Being older increased the odds of feeling obligated (ExpB = 1.02 p < 0.001), while experiencing scarcity of PPE decreased the odds (ExpB = 0.74, p = 0.01). The odds of concern about spreading virus to one´s family decreased with higher age (Exp B = 0.97, p < 0.001), increased with being female (Exp B = 1.44, p = 0.004), and perceived lack of PPE (Exp B = 2.25, p < 0.001). Although more physicians working in COVID-exposed specialties experienced scarcity of PPE and reported perceived increased risks for health personnel, the odds of concern about being infected themselves or spreading the virus to their families were not higher than for other doctors. CONCLUSION: These empirical findings lead to the question if fewer physicians in the future will consider the duty to treat their top priority. This underscores the need to revisit and revitalise existing ethical codes to handle the dilemma between physicians´ duty to treat versus the duty to protect physicians and their families. This is important for the ability to provide good care for the patient and the provider in a future pandemic situation.

Nurses' duty to care during the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: Despite the increased demand for nurses worldwide, discussion of nurses' duty to care is lacking. This study aimed to examine nurses' duty to care during the coronavirus disease 2019 (COVID-19) pandemic and to identify the influencing factors. METHODS: This was a cross-sectional descriptive research study that used a structured online questionnaire. Registered Korean nurses answered a demographic questionnaire and the Nash Duty to Care Scale. RESULTS: Age and employment at tertiary hospitals increased nurses' duty to care. Male sex, a highly educated status, and employment at tertiary hospitals increased the perceived risk. Male sex and employment at tertiary or general hospitals increased confidence in the employer, while a high level of education and a longer total clinical career decreased the same. Age and a higher monthly wage increased perceived obligation. Age, lack of religious beliefs, and clinical experience of 3-7 years increased professional preparedness. CONCLUSION: Without enough nursing manpower, the disaster response system could prove to be inefficient. Considering that adequate nurse staffing is essential in disaster management, it is crucial to ensure that nurses have a will to provide care in the case of disaster. In the future, a more active discussion on nurses' duty to care and additional research on factors that may hinder and facilitate the same are needed.

Nursing violent patients: Vulnerability and the limits of the duty to provide care.

The duty to provide care is foundational to the nursing profession and the work of nurses. Unfortunately, violence against nurses at the hands of recipients of care is increasingly common. While employers, labor unions, and professional associations decry the phenomenon, the decision to withdraw care, even from someone who is violent or abusive, is never easy. The scant guidance that exists suggests that the duty to care continues until the risk of harm to the nurse is unreasonable, however, "reasonableness" remains undefined in the literature. In this paper, I suggest that reasonable risk, and the resulting strength of the duty to provide care in situations where violence is present, hinge on the vulnerability of both nurse and recipient of care. For the recipient, vulnerability increases with the level of dependency and incapacity. For the nurse, vulnerability is related to the risk and implications of injury. The complex interplay of contextual vulnerabilities determines whether the risk a nurse faces at the hands of a violent patient is reasonable or unreasonable. This examination will enhance our understanding of professional responsibilities and can help to clarify the strengths and limitations of the nurse's duty to care.

COVID-19-related anxieties: Impact on duty to care among nurses.

BACKGROUND: Duty to care is integral to nursing practice. Personal obligations that normally conflict with professional obligations are likely amplified during a public health emergency such as COVID-19. Organizations can facilitate a nurse's ability to fulfill the duty to care without compromising on personal obligations. RESEARCH AIM: The study aimed to explore the relationships among duty to care, perception of supportive environment, perceived stress, and COVID-19-specific anxieties in nurses working directly with COVID-19 patients. RESEARCH DESIGN: The study design was a cross-sectional descriptive study using an online survey. It was conducted at an ANCC Magnet® designated 385-bed acute care teaching hospital located in a suburban area. PARTICIPANTS AND RESEARCH CONTEXT: Included in this study were 339 medical surgical nurses working directly with COVID-19 patients during the early phase of the pandemic. ETHICAL CONSIDERATIONS: The study was reviewed by the institution's clinical research committee and determined to be exempt. A survey invitation letter with a voluntary implied consent agreement was sent to participants with a description of the research study attached to the anonymous survey. RESULTS: Nurses with specific COVID-19-related anxieties were more likely to agree that it was ethical to abandon the workplace during a pandemic. CONCLUSIONS: Organizations can and ought to mitigate the negative effects of COVID-19 on duty to care in future pandemics and healthcare emergencies by incorporating several recommendations derived from this study.

The duty to care and nurses' well-being during a pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic is impacting the delivery of healthcare worldwide, creating dilemmas related to the duty to care. Although understanding the ethical dilemmas about the duty to care among nurses is necessary to allow effective preparation, few studies have explored these concerns. AIM: This study aimed to identify the ethical dilemmas among clinical nurses in Spain and Chile. It primarily aimed to (1) identify nurses' agreement with the duty to care despite high risks for themselves and/or their families, (2) describe nurses' well-being and (3) describe the associations between well-being and the duty to care. RESEARCH DESIGN: Cross-sectional self-reported anonymous data were collected between May and June 2020 via electronic survey distribution (snowball sampling). ETHICAL CONSIDERATIONS: The Institutional Ethical Review Committees in both countries approved the study (CHUC_2020_33 and 27/2020). FINDINGS: In total, 345 clinical nurses answered the primary question about the duty to care for the sick. Although in the total sample 77.4% agreed they have a duty to care for the sick, significant differences were found between the Spanish and Chilean samples. Overall, 53.6% of the nurses reported low levels of well-being; however, among those reporting low well-being, statistically significant differences were found between Spanish and Chilean nurses as 19.4% and 37.8%, respectively, disagreed with the statement regarding the duty to care. DISCUSSION: Participants in both countries reported several ethical dilemmas, safety fears, consequent stress and low well-being. These results suggest that prompt actions are required to address nurses' ethical concerns, as they might affect their willingness to work and psychological well-being. CONCLUSION: Our findings shed light on the ethical dilemmas nurses are facing related to the duty to care. Not only has the coronavirus disease 2019 pandemic given rise to ethical challenges, but it has also affected nurses' well-being and willingness to work during a pandemic.

Caring for Infectious Disease in the Prehospital Setting: A Qualitative Analysis of EMS Providers Experiences and Suggestions for Improvement.

Objective: The purpose of this study was to examine the attitudes and behaviors of emergency medical technicians (EMTs) and Paramedics when faced with the decision to care for patients with suspected Ebola Virus Disease (EVD) and to illicit suggestions for improvement of infectious disease (ID) preparedness. Methods: A convenience sample of 22 EMT/Paramedics were recruited from an emergency department at one of the designated Ebola centers. Each provider participated in one of three on-site focus groups. Participants answered questions about how they gained their knowledge, felt about caring for EVD patients, made decisions about caring for EVD patients, and suggestions for improvement of ID preparedness. Focus groups were recorded, transcribed, and coded using inductive content analysis. Results: Analysis revealed five prominent themes: reactions to scare, education/training, danger, decision making, and suggestions for future responses. Overall, first responders were excited to be a part of the response to EVD. They were more comfortable caring for EVD patients if they received adequate education and transparency from the administration. This resulted in a decreased perceived danger of the disease and decreased hesitancy when caring for EVD patients. However, those that expressed the most hesitancy also expressed the most emotional distress. Suggestions for improvement of ID preparedness included continuing education, tiered training models, peer training models, collaboration between emergency medical services (EMS) systems, better communication between departments, and the development of an infectious disease response team. Conclusions: Although first responders were excited to be a part of the response to EVD, this did not come without hesitation and emotional distress. Some of these concerns may be mitigated by first providing a clear definition of "duty to care," followed by interventions such as the development of clear and consistent ID preparedness training and interventions that address the emotional distress experienced by these providers.

Characterization of nurses' duty to care and willingness to report.

BACKGROUND: Nurses must balance their perceived duty to care against their perceived risk of harm to determine their willingness to report during disaster events, potentially creating an ethical dilemma and impacting patient care. RESEARCH AIM: The purpose of this study was to investigate nurses' perceived duty to care and whether there were differences in willingness to respond during disaster events based on perceived levels of duty to care. RESEARCH DESIGN: A cross-sectional survey research design was used in this study. PARTICIPANTS AND RESEARCH CONTEXT: Using a convenience sample with a snowball technique, data were collected from 289 nurses throughout the United States in 2017. Participants were recruited through host university websites, Facebook, and an American Nurses Association discussion board. ETHICAL CONSIDERATIONS: Institutional review board approval was obtained from the University of Texas at Tyler and the University of Arkansas. FINDINGS: Analysis of willingness to report to work based on levels of perceived duty to care resulted in the emergence of two groups: "lower level of perceived duty to care group" and "higher level of perceived duty to care group." The most discriminating characteristics differentiating the groups included fear of abandonment by co-workers, reporting because it is morally the right thing to, and because of imperatives within the Nursing Code of Ethics. DISCUSSION: The number of nurses in the lower level of perceived duty to care group causes concern. It is important for nursing management to develop strategies to advance nurses' safety, minimize nurses' risk, and promote nurses' knowledge to confidently work during disaster situations. CONCLUSION: Level of perceived duty to care affects nurses' willingness to report to work during disasters. Primary indicators of low perceived duty to care are amenable to actionable strategies, potentially increasing nurses' perceived duty to provide care and willingness to report to work during disasters.

Duty to provide care to Ebola patients: the perspectives of Guinean lay people and healthcare providers.

AIM: To examine the views of Guinean lay people and healthcare providers (HCPs) regarding the acceptability of HCPs' refusal to provide care to Ebola patients. METHOD: From October to December 2015, lay people (n=252) and HCPs (n=220) in Conakry, Guinea, were presented with 54 sample case scenarios depicting a HCP who refuses to provide care to Ebola patients and were instructed to rate the extent to which this HCP's decision is morally acceptable. The scenarios were composed by systematically varying the levels of four factors: (1) the risk of getting infected, (2) the HCP's working conditions, (3) the HCP's family responsibilities and (4) the HCP's professional status. RESULTS: Five clusters were identified: (1) 18% of the participants expressed the view that HCPs have an unlimited obligation to provide care to Ebola patients; (2) 38% held that HCPs' duty to care is a function of HCPs' working conditions; (3) 9% based their judgments on a combination of risk level, family responsibilities and working conditions; (4) 23% considered that HCPs do not have an obligation to provide care and (5) 12% did not take a position. CONCLUSION: Only a small minority of Guinean lay people and HCPs consider that HCPs' refusal to provide care to Ebola patients is always unacceptable. The most commonly endorsed position is that HCPs' duty to provide care to Ebola patients is linked to society's reciprocal duty to provide them with the working conditions needed to fulfil their professional duty.

Bioethics meets Ebola: exploring the moral landscape.

INTRODUCTION: The Ebola Virus Disease (EVD) outbreak in West Africa raised ethical issues about structural disadvantage; the duty to care of healthcare workers; the use and study of unregistered agents; the use of restrictive measures like mass quarantine and the importance of public trust. SOURCES OF DATA: WHO reports, literature on EVD and ethics. AREAS OF AGREEMENT: The use of restrictive measures and the testing of unregistered agents is ethical if support for individuals or communities is provided. AREAS OF CONTROVERSY: Controversy exists over ethical trial design for the study of unregistered agents and over the limits of the duty to care. GROWING POINTS: The role of the WHO in outbreak control and research oversight needs rethinking and further support. Solidarity in global health needs fostering. AREAS TIMELY FOR DEVELOPING RESEARCH: Research is needed on how to restore and enhance health systems and public trust in EVD-affected countries.

Physicians' obligations to patients infected with Ebola: echoes of acquired immune deficiency syndrome.

Physicians across the United States are engaged in training in the identification, isolation, and initial care of patients with Ebola. Some will be asked to do more. The issue this viewpoint will address is the moral obligation of physicians to participate in these activities. In order to do so the implicit contract between society and its physicians will be considered, as will many of the arguments that are redolent of those that were litigated 30 years ago when acquired immune deficiency syndrome (AIDS) was raising public fears to similar levels, and some physicians were publically proclaiming their unwillingness to render care to those individuals. We will build the case that if steps are taken to reduce risks-optimal personal protective equipment and training-to what is essentially the lowest possible level then rendering care should be seen as obligatory. If not, as in the AIDS era there will be an unfair distribution of risk, with those who take their obligations seriously having to go beyond their fair measure of exposure. It would also potentially undermine patients' faith in the altruism of physicians and thereby degrade the esteem in which our profession is held and the trust that underpins the therapeutic relationship. Finally there is an implicit contract with society. Society gives tremendously to us; we encumber a debt from all society does and offers, a debt for which recompense is rarely sought. The mosaic of moral, historical, and professional imperatives to render care to the infected all echoes the words of medicine's moral leaders in the AIDS epidemic. Arnold Relman perhaps put it most succinctly, "the risk of contracting the patient's disease is one of the risks that is inherent in the profession of medicine. Physicians who are not willing to accept that risk…ought not be in the practice of medicine."

Medical students' professionalism attributes, knowledge, practices, and attitudes toward COVID-19 and attitudes toward care provision during pandemic amidst the COVID-19 outbreak according to their demographics and mental health.

PURPOSE: This study examines various aspects related to medical professionalism in medical students during coronavirus disease 2019 (COVID-19) pandemic, focusing on their medical professionalism attributes, KPA (knowledge, practices, and attitudes) toward COVID-19 and attitudes toward provision of care in pandemic. We assessed whether these aspects related to medical professionalism were varied by their demographics and mental health level. METHODS: Six questionnaires related to medical professionalism were distributed online to medical students in six grades at a single medical school. A one-way analysis of variance was used to examine differences in scores related to medical professionalism based on their demographics, for examples, gender, grade, residence, religion, as well as their mental health levels. Pearson correlation analysis was used to examine correlations between each variable. RESULTS: Female students scored higher on medical professionalism attributes and attitudes toward duty-to-care than male students. Medical professionalism attribute scores were higher with higher relationship satisfaction and resilience levels but lower with higher anxiety levels. Furthermore, these scores were significantly associated with attitudes toward COVID-19 preparedness. However, COVID-19 knowledge and practice scores were negatively associated with attitudes toward COVID-19 preparedness and careers after graduation. Meanwhile, students who took the leave of absence related to 2020 doctors' strike had significantly lower scores on attitudes toward COVID-19 preparedness and duty to care than those who did not. CONCLUSION: Our findings suggest that mental health of medical students is strongly related to their various aspects related to medical professionalism, especially their attitudes toward COVID-19 preparedness. Good mental health was positively linked to medical professionalism attributes and attitudes toward COVID-19 preparedness. However, knowledge and practice of COVID-19 were negatively associated with willingness to participate in the pandemic response. Additionally, the experience of the 2020 leave of absence impacted the attitudes of medical students toward COVID-19 preparedness (p=0.015) and their duty to care (p=0.012) negatively.

The Duty to Care is Not Dead Yet.

The COVID-19 pandemic exposed social shortcomings and ethical failures, but it also revealed strengths and successes. In this perspective article, we examine and discuss one strength: the duty to care. We understand this duty in a broad sense, as more than a duty to treat individual patients who could infect health care workers. We understand it as a prima facie duty to work to provide care and promote health in the face of risks, obstacles, and inconveniences. Although at least one survey suggested that health care workers would not respond to a SARS-like outbreak according to a duty to care, we give reasons to show that the response was better than expected. The reasons we discuss lead us to consider normative accounts of the duty to care based on the adoption of social roles. Then, we consider one view of the relationship between empirical claims and normative claims about the duty to care in the COVID-19 pandemic. Here, we draw insight from Mengzi, with an emendation from Dewey. Our perspective leaves many question to research, but one point seems clear: there will be future pandemics and the need for health care workers who respond.

COVID-19 Pandemic- Ethical Challenges for Healthcare Workers Practicing in Resource-Limited Settings.

In this review, the ethical issues peculiar to the COVID-19 pandemics and the role of healthcare workers, especially those in resource-limited settings are x-rayed. We contend that there is a pressing ethical issue that needs urgent clarification on the rights and responsibilities of healthcare workers, especially in the current context of COVID-19 pandemic preparedness and responsiveness. We searched MEDLINE, Web of Science, EMBASE, Google Scholar, PUBMED related articles, newspaper articles, and online news sources for relevant information. The various professional codes of conduct (World Medical Association, Medical and Dental Council of Nigeria) were also consulted. The ethical principles of equitable distribution of healthcare resources, confidentiality with associated stigmatization, issues relating to duty to care by the healthcare workers and those pertaining to conduct of clinical trials and access to approved therapies or vaccines were highlighted in this study. We agree with the submission that healthcare workers only have a moral duty to treat patients with COVID-19 if the necessary protective equipment and adequate compensation are not provided. We argue that the duty of physicians and other healthcare workers to care for patients during pandemics such as COVID-19 is obligatory in the absence of required protective equipment and other forms of compensation. There is a need for the government and other stakeholders to put in place a National Pandemic /Epidemic Ethical Framework to address these identified ethical challenges.

Ethical issues in the access to emergency care for undocumented immigrants.

Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when providing care for these patients. This article examines those ethical issues and recommends best practices in emergency care for UIs. After a brief introduction and description of the UI population, the article proposes central principles of emergency medical ethics as a framework for emergency physician decisions and actions. It then considers the role of law and public policy in health care for UIs, including the Emergency Medical Treatment and Labor Act, the Patient Protection and Affordable Care Act, and current practices of the US Immigration and Customs Enforcement agency. The article concludes with discussion of the scope of emergency physician practice and with recommendations regarding best practices in ED care for UIs.

The Hang Up.

Over the past year, our ethics service has had numerous consultations involving patients who use the emergency department for regular dialysis. Sometimes, they have access to outpatient hemodialysis that they forgo; other times, they've been "fired" from this kind of outpatient facility, and so the ED is their last option. In most of these cases, we're called because the patient is disruptive once admitted to the ICU and behavior plans haven't helped. But the call from a resident this March 2020 morning was different, the patient had end-stage renal disease and often missed hemodialysis, but he wasn't disruptive. "It's just that he comes in after using cocaine, and given scarcity with the coronavirus and ICU beds…." I have come to think that this is one of the more insidious effects of the pandemic: that there will be a resurgence of the view that some patients deserve health care by virtue of their compliant behavior and that those who are nonadherent don't.

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners.

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

Beyond Duty: Medical "Heroes" and the COVID-19 Pandemic.

When infectious disease outbreaks strike, health facilities acquire labels such as "war zones" and "battlefields" and healthcare professionals become "heroes" on the "front line." But unlike soldiers, healthcare professionals often take on these dangerous roles without any prior intention or explicit expectation that their work will place them in grave personal danger. This inevitably raises questions about their role-related obligations and whether they should be free to choose not to endanger themselves. In this article, I argue that it is helpful to view this situation not only through the lens of "professional duty" but also through the lens of "role-related conflicts." Doing so has the advantage of avoiding exceptionalism and allowing us to draw lessons not only from previous epidemics but also from a wide range of far more common role-related dilemmas in healthcare.

Medición funcional en el dominio de la ética empírica / Functional Measurement in the Field of Empirical Ethics / Medição funcional no domínio da ética empírica

El presente artículo propone un enfoque empírico de la ética derivado de la teoría psicológica del juicio humano propuesta por Norman Anderson. Muestra cómo la metodología de esta teoría ­denominada medición funcional­ puede utilizarse para caracterizar las diversas posiciones personales que existen en todas las sociedades respecto a los problemas de salud pública. Los principales resultados de tres estudios realizados en tres países diferentes (Guinea, Francia y Colombia) se presentan como ilustración de lo que puede aportar este enfoque. Dichos análisis se centraron en tres problemas deliberadamente muy diferentes: (a) el deber de atender a los pacientes infectados, en caso de una epidemia que ponga en peligro la vida de los cuidadores; (b) la aceptabilidad de la reproducción postmortem, en el caso de los soldados que mueren en combate, y (c) la aceptabilidad del suicidio asistido por un médico

This paper presents the proposal of an empirical ap-proach to ethics derived from a psychological theory of human judgment proposed by Norman Anderson. It shows how the methodology specific to this theory ­functional measurement­ makes it possible to char-acterize the various personal positions that exist in all societies regarding public health problems. The main results of three studies carried out in three different countries (Guinea, France, and Colombia) on various problems are presented as an illustration of what this approach can offer. These analyses focused on three deliberately very different problems: (a) the duty to care for infected patients in the event of a pandemic that puts at risk the lives of the health professionals, (b) the acceptability of postmortem reproduction in the specific context of fallen soldiers, and (c) the accept-ability of physicianassisted suicide

Este artigo propõe uma abordagem empírica da ética derivada da teoria psicológica do julgamento humano proposta por Norman Anderson. Mostra como a metodo-logia dessa teoria ­ denominada medição funcional­ pode ser utilizada para caracterizar as diversas posições pessoais que existem em todas as sociedades em relação aos problemas de saúde pública. Os principais resulta-dos de três estudos, realizados em três países diferentes (Guiné, França e Colômbia), são apresentados como uma ilustração do que esta abordagem pode contribuir. Esses estudos se concentraram em três problemas de-liberadamente muito diferentes: (a) o dever de cuidar de pacientes infectados no caso de uma epidemia que ponha em risco a vida dos cuidadores, (b) a aceitabilida-de da reprodução postmortem no caso de soldados que morrem em combate, e (c) a aceitabilidade do suicídio assistido por médicos