Committing to endangerment: medical teams in the age of corona in Jewish ethics.

Doctors have been treating infectious diseases for hundreds of years, but the risk they and other medical professionals are exposed to in an epidemic has always been high. At the front line of the present war against COVID-19, medical teams are endangering their lives as they continue to treat patients suffering from the disease. What is the degree of danger that a medical team must accept in the face of a pandemic? What are the theoretical justifications for these risks? This article offers answers to these questions by citing opinions based on Jewish ethical thought that has been formulated down through the ages. According to Jewish ethics, the obligation to assist and care for patients is based on many commandments found in the Bible and on rulings in the Responsa literature. The ethical challenge is created when treating the sick represents a real existential danger to the caregivers and their families. This consideration is relevant for all dangerous infectious diseases and particularly for the coronavirus that has struck around the world and for which there is as yet no cure. Many rabbis over the years have offered the religious justifications for healing in a general sense and especially in cases of infectious diseases as they have a bearing on professional and communal obligations. They have compared the ethical expectations of doctors to those of soldiers but have not sanctioned taking risks where there is insufficient protection or where there is a danger to the families of the medical professionals.

Must I Respond if My Health is at Risk?

BACKGROUND: Widespread epidemics, pandemics, and other risk-prone disasters occur with disturbing regularity. When such events occur, how should, and will, clinicians respond? The moral backbone of medical professionals-a duty to put the needs of patients first-may be sorely tested. DISCUSSION: It is incumbent on health care professionals to ask what we must do and what we should do if a dangerous health care situation threatens both ourselves and our community. Despite numerous medical ethical codes, nothing-either morally or legally-requires a response to risk-prone situations from civilian clinicians; it remains a personal decision. The most important questions are: What will encourage us to respond to these situations? And will we respond? These questions are necessary, not only for physicians and other direct health care providers, but also for vital health care system support personnel. Those who provide care in the face of perceived risk demonstrate heroic bravery, but the choice to do so has varied throughout history. To improve individual response rates, disaster planners and managers must communicate the risks clearly to all members of the health care system and help mitigate their risks by providing them with as much support and security as possible. CONCLUSIONS: The decision to remain in or to leave a risky health care situation will ultimately depend on the provider's own risk assessment and value system. If history is any guide, we can rest assured that most clinicians will choose to stay, following the heroic example established through the centuries and continuing today.

Ethical challenges experienced by UK military medical personnel deployed to Sierra Leone (operation GRITROCK) during the 2014-2015 Ebola outbreak: a qualitative study.

BACKGROUND: As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom (UK) government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. METHOD: Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between October 2014 and April 2015 in one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. RESULTS: Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and 'empty beds' presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants' ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values (that might not be shared with non-military workers). CONCLUSION: We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers' experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers.

Where Caring Is Sharing: Evolving Ethical Considerations in Tuberculosis Prevention Among Healthcare Workers.

In many settings, the dedication of healthcare workers (HCWs) to the treatment of tuberculosis exposes them to serious risks. Current ethical considerations related to tuberculosis prevention in HCWs involve the threat posed by comorbidities, issues of power and space, the implications of intersectoral collaborations, (de)professionalization, just remuneration, the duty to care, and involvement in research. Emerging ethical considerations include mandatory vaccination and the use of geolocalization services and information technologies. The following exploration of these various ethical considerations demonstrates that the language of ethics can fruitfully be deployed to shed new light on policies that have repercussions on the lives of HCWs in underresourced settings. The language of ethics can help responsible parties get a clearer sense of what they owe HCWs, particularly when these individuals are poorly compensated, and it shows that it is essential that HCWs' contribution be acknowledged through a shared commitment to alleviate ethically problematic aspects of the environments within which they provide care. For this reason, there is a strong case for the community of bioethicists to continue to take greater interest both in the micro-level (eg, patient-provider interactions) and macro-level (eg, injustices that occur as a result of the world order) issues that put HCWs working in areas with high tuberculosis prevalence in ethically untenable positions. Ultimately, appropriate responses to the various ethical considerations explored here must vary based on the setting, but, as this article shows, they require thoughtful reflection and courageous action on the part of governments, policy makers, and managers responsible for national responses to the tuberculosis epidemic.

Ethical considerations in the management of Ebola virus disease.

Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD? How should treatment decisions be made regarding limitation of therapy for patients with EVD? There are two main ethical questions regarding the critical care of patients with EVD in an Australian setting: Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD? How should treatment decisions be made regarding limitation of therapy for patients with EVD? The key concern is ensuring that no patient is denied therapy that should be provided, while preventing unnecessary risk to HCWs. It is imperative to develop an approach that facilitates rigorous, evidence-based and ethically justifiable decision making, which should include a predetermined, institutionally endorsed process for assessing difficult clinical scenarios as they arise.

Hepatitis C virus infection in health-care settings: medical and ethical implications.

Hepatitis C is a major public health issue. It infects about 200 million people worldwide and is a major cause of chronic liver disease. Its transmission in medical facilities is a topic of increased concern, as outbreaks of the disease had raised the attention of media and medical authorities. To date, evidence suggests that infection from in which a health-care worker is involved is mostly result of bad injecting practices as well as the result of shared medical devices. Furthermore, the infection caused by physicians is rare and very few well documented cases exist on the literature. Among countries, different definitions and legislation exist, in that mode that the responsibility of this issue almost is an obligation of individual institutions. Nonetheless, Hepatitis C virus transmission in medical facilities is an important source of new cases, and as treatments options are very limited, it's recommendable that institutions as well as governments implement policies to avoid Hepatitis C spread in a almost fully preventable setting.

Cardiac Surgery in HIV Patients: State of the Art.

The clinical status of HIV infection has changed dramatically with the introduction of combined antiretroviral therapy. Patients with HIV are now living long enough to be susceptible to chronic illnesses, such as coronary disease and nonischemic cardiomyopathy, which can be consequences of the combined antiretroviral therapy treatment itself. Cardiovascular diseases are a major source of morbidity and mortality in HIV-positive patients. Increasingly, such patients might be candidates for the full range of cardiac surgical interventions, including coronary bypass, valve surgery, and heart transplantation. There has been a shift from offering palliative procedures such as pericardial window and balloon valvuloplasty, to more conventional and durable surgical therapies in HIV-positive patients. We herein provide an overview of the contemporary outcomes of cardiac surgery in this complex and unique patient population. We review some of the ethical issues around the selection and surgical care of HIV-positive patients. We also discuss strategies to best protect the surgical treatment team from the risks of HIV transmission. Finally, we highlight the need for involvement of dedicated infectious disease professionals in a multidisciplinary heart team approach, aiming at the comprehensive care of these unique and complex patients.

Can "presumed consent" justify the duty to treat infectious diseases? An analysis.

BACKGROUND: AIDS, SARS, and the recent epidemics of the avian-flu have all served to remind us the debate over the limits of the moral duty to care. It is important to first consider the question of whether or not the "duty to treat" might be subject to contextual constraints. The purpose of this study was to investigate the opinions and beliefs held by both physicians and dentists regarding the occupational risks of infectious diseases, and to analyze the argument that the notion of "presumed consent" on the part of professionals may be grounds for supporting the duty to treat. METHODS: For this cross-sectional survey, the study population was selected from among physicians and dentists in Ankara. All of the 373 participants were given a self-administered questionnaire. RESULTS: In total, 79.6% of the participants said that they either had some degree of knowledge about the risks when they chose their profession or that they learned of the risks later during their education and training. Of the participants, 5.2% said that they would not have chosen this profession if they had been informed of the risks. It was found that 57% of the participants believed that there is a standard level of risk, and 52% of the participants stated that certain diseases would exceed the level of acceptable risk unless specific protective measures were implemented. CONCLUSION: If we use the presumed consent argument to establish the duty of the HCW to provide care, we are confronted with problems ranging over the difficulty of choosing a profession autonomously, the constant level of uncertainty present in the medical profession, the near-impossibility of being able to evaluate retrospectively whether every individual was informed, and the seemingly inescapable problem that this practice would legitimize, and perhaps even foster, discrimination against patients with certain diseases. Our findings suggest that another problem can be added to the list: one-fifth of the participants in this study either lacked adequate knowledge of the occupational risks when they chose the medical profession or were not sufficiently informed of these risks during their faculty education and training. Furthermore, in terms of the moral duty to provide care, it seems that most HCWs are more concerned about the availability of protective measures than about whether they had been informed of a particular risk beforehand. For all these reasons, the presumed consent argument is not persuasive enough, and cannot be used to justify the duty to provide care. It is therefore more useful to emphasize justifications other than presumed consent when defining the duty of HCWs to provide care, such as the social contract between society and the medical profession and the fact that HCWs have a greater ability to provide medical aid.

Pandemic influenza: are we prepared to face our obligations?

After decades of low personal risk for contracting lethal diseases, physicians are suddenly facing the possibility of a substantial increase in occupational risk during an influenza pandemic. If they are not confronted before the onset of an influenza pandemic, feelings of unease and fear or ignorance about physicians' professional obligations could profoundly hinder individual physicians in fulfilling their professional duties. Such feelings could therefore undermine institutional and societal preparations. In their review published in Critical Care, Anantham and coworkers outline the ethical framework that forms the basis of the professional obligations of physicians who respond to health care emergencies, such as an influenza pandemic.

Reciprocal obligations for prevention of occupationally acquired tuberculosis among healthcare workers.

As I began my work on occupationally acquired tuberculosis (TB), I was perturbed by a series of media reports on TB among healthcare workers (HCWs) in India. This included a report on the death of a resident doctor who was suffering from multidrug-resistant (MDR) TB. The risk of occupationally acquired TB is well documented. A few studies have reported an increased risk of TB among HCWs in developing countries, including India.

Balancing the Duty to Treat Patients with Ebola Virus Disease with the Risks to Dialysis Personnel.

In 2014, the author was invited to present at the American Society for Nephrology's annual conference in Philadelphia on the ethics of treating patients with Ebola virus disease. The argument was made that the status of health care workers, including nephrologists, was the dominant ethical standard that generated both the duty to treat and the conflicts between this commitment and other ethical commitments that arise in public health emergencies. Conflicts between duty to treat and personal safety, duty to community, and duty to colleagues were illustrated, and suggestions for designing ethics into medical practice were given. This article is a summary of that presentation.

Health care provider obligations in caring for patients with tuberculosis.

It is well acknowledged that physicians and other health care providers have an obligation to provide clinical care to their patients even under occasionally difficult circumstances. However, the exact degree and extent of that obligation, and the various scenarios under which it might be lessened or even cease to exist, have recently become the focus of much discussion and debate. The reason for this emerging debate is twofold: the recent occurrence of pandemic viruses such as severe acute respiratory syndrome and H1N1, and the emergence of highly resistant strains of infectious pathogens such as multi and extensively drug-resistant tuberculosis (TB). Health care providers have been asked to place themselves at risk to an extent many did not foresee when they chose to enter their profession, and many have done so under difficult conditions, often without adequate supplies and support. The present article explores the ethical obligations as well as the reciprocal rights of health care providers who are caring for patients with TB, with a particular focus on drug-resistant strains of the bacterium. It is a condensed version of a World Health Organization (WHO) Working Paper prepared for the WHO Working Group on Ethics and Tuberculosis.

[Does patient safety justify mandatory vaccinations?]. / Rechtfertigt der Patientenschutz verpflichtende Impfungen?

BACKGROUND AND OBJECTIVES: Medical and dental students belong to a group of health care workers (HCWs) who are frequently exposed to patients with occupationally transmissible infectious diseases. Vaccinations are the most effective interventions to protect HCWs and patients from vaccine-preventable infectious diseases. Despite decades of effort to encourage HCWs to be immunized, vaccination levels (e. g. influenza) remain insufficient. METHODS: To assess the attitudes of German medical and dental students towards mandatory immunizations, an anonymous questionnaire was offered to medical and dental students of the University of Frankfurt/Main, Germany. Overall, 56.9 % (1823/3200) of all medical and dental students attended to the study. RESULTS: This study - so far the largest study done on this issue - showed that almost 88.5 % of the responding medical and dental students would accept mandatory vaccinations for HCWs. CONCLUSION: Contrary to the widespread concern that a vaccination requirement would cause resistance, our data support that mandatory vaccinations (at least for HCWs who care for immunocompromised patients) might be widely accepted.