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Pandemic flu: Ethics and patient responsibility
Source: http://www.independent.com.mt/news.asp?newsitemid=91782
Pandemic flu: Ethics and patient responsibility
by Prof. Pierre Mallia
First it was the avian flu and now it is the swine flu. What we often ignore is the fact that these are normal influenza. What makes them different from the seasonal influenza are two main facts.
First, viruses tend to be mild or strong according to certain strains. For example, we thought that this swine flu would be much stronger than it actually is. It is therefore the experience of the first patients and the first hospitals which start determining outcomes. The same virus can however mutate and change its characteristics. Therefore we are never so sure, even if we develop vaccines.
Secondly, what makes the seasonal influenza less fearful is the symbiotic relationship medicine has with the pharmaceutical industry. It gives us time to develop vaccines, and these, through the good work of health promotion, are popular with many people. There is thus what is called a ?herd? immunity. This means that even if you are not protected with a vaccine, chances are that you are protected a little against getting it because the vaccine keeps the numbers in check. Of course we promote more strongly the vaccination programme in people who are more at risk ? the elderly, children, and those suffering from certain chronic diseases.
What makes a pandemic special is this fact, among other technicalities. People are not vaccinated because there is no time to develop a vaccine. Therefore the number of people getting a virus can simply jump from a handful to hundreds and thousands within a day. There is no herd immunity and the more virulent the virus, the worse. Of course the influenza as such takes its normal course. Some are milder than others. But the problem with a pandemic, as we are continuously told on the media by our dedicated doctors and director at the department of health, is the fact that once you have a larger than usual chunk of the population who are ill, the virus spreads even more quickly. Suddenly many people are on sick leave, and this includes health workers. So there will not only not be enough health workers, but indeed the hospitals and clinics are overloaded more than usual, with fewer staff. Moreover medication can become scarce; many went through the experience of buying medication ? even at a higher than usual price, just for storing it.
Panic can easily strike with people hoarding food, and even not going to work so as not to come into contact with the virus. People often tend to be more afraid because of fear induced by the media. This fear is good to the extent that it makes us think and act beforehand. This is where the ethics of public resource allocation and indeed doctor and patient responsibility come in.
It goes without saying that developing vaccines costs money and these vaccines may be more costly than the usual ones because they are out of the blue and involve greater risks in developing due to the possibility of mutations of the virus ? if it mutates, chances are the vaccine will then not work. But if it proves useful public health authorities cannot waste this resource and the government will feel obliged, ethically, to give it to those most at risk ? who include two main categories. First those patients, mentioned above, who are more at risk, and secondly health care workers. Of course we need health care workers, be they doctors, nurses, and indeed everyone who makes, in his or her own small way, the health system function smoothly every day. A chain is as strong as its weakest link. So if we protect them by giving them free and immediate vaccines, then the chances are good that the hospital will suffer less from people out on sick leave. Indeed it may be unethical for a health worker to refuse vaccination and decisions have to be taken with regard to these individuals. They cannot, under these circumstances, be treated as normal citizens, because they are the soldiers fighting the war. Perhaps there will be herd immunity within the hospital community, but in reality anyone who gets the virus can easily transmit it in this highly vulnerable zone. We have to remember that the hospital will have its normal complement of ill people who are all more vulnerable to obtain an infection.
It goes without saying that health care professions are bound by ethical duties. Hospital transmission is not a new concept. We all remember the MRSA bacterium ? a bacterium resistant to penicillins and which is found mostly in hospitals. The cause of this virus was not merely overuse of antibiotics, the spread involved health workers not washing their hands between one patient and another. Alcoholic liquids which can be rubbed onto the hands and that evaporate quickly are now in common use. The importance of precautions has been demonstrated in Canada, as explained by our visiting professor in the department of family medicine. When there was the SARS virus, places like Ontario, where even family doctors were not taking precautions such as using gowns, face masks etc, suffered considerably more from the transmission of the virus than places where these precautions were taken. Sick people come to the clinic. It is not only they who can, by their coughs and sneezing, transmit the virus in waiting rooms, but the doctors and nurses who come into direct contact with them ? their hands carry the virus from one person to another, and they can easily swallow the air where a patient has just coughed.
But the most important control is the population itself. Patient responsibility has come to be an important aspect of health care. Apart from the fact that we have to respect others and our own health, we have to follow the measures which are prescribed by the department of health. These lists may be long, but some common sense would take us far. Thus not going to work when one is ill is probably the most important issue. Working parents send their children to school when they already have running noses. Schools are a great source of infection. Children bring the bugs into our homes. What is worse ? schools start in the winter when people tend to remain indoors more and thus are more likely to catch a cold. Patient responsibility comes individually but also collectively. We have to work together. It is inexcusable that people with flu, who are advised not only to stay at home, but also to quarantine themselves in their rooms, if possible with only one family member being in contact with them, refuse to follow the procedure and think that the world without them will stop, so they go to work. This is not to be seen as commendable and heroic any longer. They are a threat.
Another dangerous practice is when people deliberately decide not to take the vaccine or to pretend that the government should always supply everyone. This is a scarce resource and we must accept that a possible pandemic is a special occasion. While people stockpile pills, some may be afraid of vaccines because once they took it and felt they got more ill. While it is true that the first time you take a vaccine, you can get mildly ill with the vaccine itself, when one takes vaccines regularly this stops occurring. Moreover many feel that they take a vaccine in vain because they still get common colds. A common cold is not the flu, and there are several going around each year. We need to educate the public more that a vaccine is against one particular virus which is the flu, which the WHO has considered important enough to develop due to the dangers it poses. We would get a pandemic every year if we did not have vaccines. We do not, on the other hand, need a vaccine for every common cold which lasts a couple of days.
There is also our collective responsibility. The Church authorities were very responsible when they accepted the suggestion that people not receive communion by hand. One patient of mine complained that while this practice was fine, he spent the whole Mass with someone coughing in the bench behind him. People who are coughing should not go to Mass, period. I am sure that the Church would agree; as one is always exempt from this sacrament when ill. Neither should we perhaps send people to give them this sacrament at home during this period. If the worse comes to the worst and a pandemic is imminent, it is probably prudent for the country to close down public places such as schools and churches for a while. We can use the media to our advantage for this and hearing Mass on television for a couple of weeks can save lives. But what about pubs, restaurants and the work place? If you stop everything you affect the economy which is what pandemics will cause anyway. You will probably be deceiving the end. People will suffer and you can get job losses. So prudence must keep us from over-reacting. We need to close down those places which can be closed without a great social impact.
While one does not wish to sound insensitive ? food for the soul is as important as food for the body; and if schools close down, many parents will not be able to go to work; we have to discuss these things in good time and use the scout motto: Be Prepared.
Pierre Mallia is Associate Professor in Family Medicine, Patients? Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.
Pandemic flu: Ethics and patient responsibility
by Prof. Pierre Mallia
First it was the avian flu and now it is the swine flu. What we often ignore is the fact that these are normal influenza. What makes them different from the seasonal influenza are two main facts.
First, viruses tend to be mild or strong according to certain strains. For example, we thought that this swine flu would be much stronger than it actually is. It is therefore the experience of the first patients and the first hospitals which start determining outcomes. The same virus can however mutate and change its characteristics. Therefore we are never so sure, even if we develop vaccines.
Secondly, what makes the seasonal influenza less fearful is the symbiotic relationship medicine has with the pharmaceutical industry. It gives us time to develop vaccines, and these, through the good work of health promotion, are popular with many people. There is thus what is called a ?herd? immunity. This means that even if you are not protected with a vaccine, chances are that you are protected a little against getting it because the vaccine keeps the numbers in check. Of course we promote more strongly the vaccination programme in people who are more at risk ? the elderly, children, and those suffering from certain chronic diseases.
What makes a pandemic special is this fact, among other technicalities. People are not vaccinated because there is no time to develop a vaccine. Therefore the number of people getting a virus can simply jump from a handful to hundreds and thousands within a day. There is no herd immunity and the more virulent the virus, the worse. Of course the influenza as such takes its normal course. Some are milder than others. But the problem with a pandemic, as we are continuously told on the media by our dedicated doctors and director at the department of health, is the fact that once you have a larger than usual chunk of the population who are ill, the virus spreads even more quickly. Suddenly many people are on sick leave, and this includes health workers. So there will not only not be enough health workers, but indeed the hospitals and clinics are overloaded more than usual, with fewer staff. Moreover medication can become scarce; many went through the experience of buying medication ? even at a higher than usual price, just for storing it.
Panic can easily strike with people hoarding food, and even not going to work so as not to come into contact with the virus. People often tend to be more afraid because of fear induced by the media. This fear is good to the extent that it makes us think and act beforehand. This is where the ethics of public resource allocation and indeed doctor and patient responsibility come in.
It goes without saying that developing vaccines costs money and these vaccines may be more costly than the usual ones because they are out of the blue and involve greater risks in developing due to the possibility of mutations of the virus ? if it mutates, chances are the vaccine will then not work. But if it proves useful public health authorities cannot waste this resource and the government will feel obliged, ethically, to give it to those most at risk ? who include two main categories. First those patients, mentioned above, who are more at risk, and secondly health care workers. Of course we need health care workers, be they doctors, nurses, and indeed everyone who makes, in his or her own small way, the health system function smoothly every day. A chain is as strong as its weakest link. So if we protect them by giving them free and immediate vaccines, then the chances are good that the hospital will suffer less from people out on sick leave. Indeed it may be unethical for a health worker to refuse vaccination and decisions have to be taken with regard to these individuals. They cannot, under these circumstances, be treated as normal citizens, because they are the soldiers fighting the war. Perhaps there will be herd immunity within the hospital community, but in reality anyone who gets the virus can easily transmit it in this highly vulnerable zone. We have to remember that the hospital will have its normal complement of ill people who are all more vulnerable to obtain an infection.
It goes without saying that health care professions are bound by ethical duties. Hospital transmission is not a new concept. We all remember the MRSA bacterium ? a bacterium resistant to penicillins and which is found mostly in hospitals. The cause of this virus was not merely overuse of antibiotics, the spread involved health workers not washing their hands between one patient and another. Alcoholic liquids which can be rubbed onto the hands and that evaporate quickly are now in common use. The importance of precautions has been demonstrated in Canada, as explained by our visiting professor in the department of family medicine. When there was the SARS virus, places like Ontario, where even family doctors were not taking precautions such as using gowns, face masks etc, suffered considerably more from the transmission of the virus than places where these precautions were taken. Sick people come to the clinic. It is not only they who can, by their coughs and sneezing, transmit the virus in waiting rooms, but the doctors and nurses who come into direct contact with them ? their hands carry the virus from one person to another, and they can easily swallow the air where a patient has just coughed.
But the most important control is the population itself. Patient responsibility has come to be an important aspect of health care. Apart from the fact that we have to respect others and our own health, we have to follow the measures which are prescribed by the department of health. These lists may be long, but some common sense would take us far. Thus not going to work when one is ill is probably the most important issue. Working parents send their children to school when they already have running noses. Schools are a great source of infection. Children bring the bugs into our homes. What is worse ? schools start in the winter when people tend to remain indoors more and thus are more likely to catch a cold. Patient responsibility comes individually but also collectively. We have to work together. It is inexcusable that people with flu, who are advised not only to stay at home, but also to quarantine themselves in their rooms, if possible with only one family member being in contact with them, refuse to follow the procedure and think that the world without them will stop, so they go to work. This is not to be seen as commendable and heroic any longer. They are a threat.
Another dangerous practice is when people deliberately decide not to take the vaccine or to pretend that the government should always supply everyone. This is a scarce resource and we must accept that a possible pandemic is a special occasion. While people stockpile pills, some may be afraid of vaccines because once they took it and felt they got more ill. While it is true that the first time you take a vaccine, you can get mildly ill with the vaccine itself, when one takes vaccines regularly this stops occurring. Moreover many feel that they take a vaccine in vain because they still get common colds. A common cold is not the flu, and there are several going around each year. We need to educate the public more that a vaccine is against one particular virus which is the flu, which the WHO has considered important enough to develop due to the dangers it poses. We would get a pandemic every year if we did not have vaccines. We do not, on the other hand, need a vaccine for every common cold which lasts a couple of days.
There is also our collective responsibility. The Church authorities were very responsible when they accepted the suggestion that people not receive communion by hand. One patient of mine complained that while this practice was fine, he spent the whole Mass with someone coughing in the bench behind him. People who are coughing should not go to Mass, period. I am sure that the Church would agree; as one is always exempt from this sacrament when ill. Neither should we perhaps send people to give them this sacrament at home during this period. If the worse comes to the worst and a pandemic is imminent, it is probably prudent for the country to close down public places such as schools and churches for a while. We can use the media to our advantage for this and hearing Mass on television for a couple of weeks can save lives. But what about pubs, restaurants and the work place? If you stop everything you affect the economy which is what pandemics will cause anyway. You will probably be deceiving the end. People will suffer and you can get job losses. So prudence must keep us from over-reacting. We need to close down those places which can be closed without a great social impact.
While one does not wish to sound insensitive ? food for the soul is as important as food for the body; and if schools close down, many parents will not be able to go to work; we have to discuss these things in good time and use the scout motto: Be Prepared.
Pierre Mallia is Associate Professor in Family Medicine, Patients? Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.