Physicians have a time-honoured sense of duty and responsibility to help those in need, even if their own lives may be at risk.
The SARS epidemic and H1N1 pandemic brought risks that had not been seen in decades. Now, COVID19 has shone a new, dramatic and sweeping light on the impact of infectious illness on the healthcare system, not only in terms of the “cases of illness” in hospitals but on the delivery of care in the community.
What is the “duty of care” for family physicians during a pandemic? In 2011, after SARS and the H1N1 pandemic, I wrote the following as part of Master’s thesis project:
“The risk of another pandemic lies in our future. Having enough HCWs (healthcare workers) to provide care is an important consideration in pandemic planning. Frontline HCWs in Ontario such as community family physicians are a vital component of the healthcare system. The duty of care of physicians and other HCWs has come to light in the recent SARS and H1N1 pandemic. A number of reasons affecting hesitation, motivation and ability have been found including fear, personal safety, inadequate protective equipment, fear of disability or illness, stress and risk to families, unknown expectations and feeling unprepared in responding to a public health emergency.”
Clearly, as we move through the current COVID 19 pandemic, family physicians continue to face similar issues today as we try to manage our offices, provide care for our patients in the clinic and in their homes and ensure that we ourselves stay healthy.
The tension between our own personal safety and our duty of care as family physicians has not been fully addressed despite the SARS pandemic in 2003. The Canadian Medical Association’s (CMA) 2018 revised code of ethics does not include any clear outline of the duty of care during a pandemic. The code “informs ethical decision-making” but falls short of policies during public health emergencies. For example, it does not update its earlier conflicting statements: “Provide whatever appropriate assistance you can to any person with an urgent need for medical care” yet “Promote and maintain your own health and wellbeing.” It does not address how to manage this conflict when the safety of the healthcare provider is at risk.
This year, the CMA released the Framework for Ethical Decision Making During the Coronavirus Pandemic that recognizes the unique situation during a pandemic, recommends separation of clinical decision-making and the allocation of resources and recognizes the medical-legal risks in times of uncertainty. However, the document does not specifically address the full scope of tensions experienced by physicians surrounding duty of care.
In the past, both the CMA in their 1922 code of ethics and the American Medical Association (AMA) in their code of ethics from 1846 to 1950 have had specifically worded statements regarding the roles, responsibilities and expectation of physicians during infectious disease outbreaks. As Yale University’s Chalmers Clark wrote in In Harm’s Way: AMA Physicians and the Duty to Treat, the removal of these statements was in part due to the belief after the 1950s that significant infectious diseases were unlikely.
The CMA in 2008 published a document, Caring in a Crisis: The Ethical Obligations of Physicians and Society During a Pandemic, that identifies some of the concerns of practicing physicians in Canada. However, it did not go so far as to revise its existing code of ethics. The AMA, instead, updated several ethical policies with respect to the roles and responsibilities of physicians during a public health emergency after the 2001 terrorist attack.
For family physicians in particular, limited access to infection prevention and control (IPAC) expertise, inconsistent access to personal protective equipment (PPE) and lack of office-based preparation for pandemic illness has meant that many offices have been closed. Some have struggled to re-open as Ontario “flattens the curve” and the need for care in the community grows. For those who are providing face-to-face care, the logistical constraints of physical distancing and increased cleaning requirements risk slowing appointment-based, in-person care at a time when we need the capacity of family physicians to be optimized.
Most patients first turn to their trusted family doctor for advice and care. The healthcare system also turns to family physicians to support community-based needs and the long-term care sector, ensure care for patients at home and, as we have seen in the current pandemic, ensure that assessment centres are staffed and the emergency room is not overwhelmed.
While virtual care has evolved rapidly, it will remain a tool of care for only a portion of patients in primary care and only for some of the time. Many patients need face-to-face assessment for a variety of issues including acute episodic illness, prenatal care, well-baby care and management of chronic illnesses. Face-to-face care clearly is required for procedural care (ie., skin biopsies, IUD insertions, wound care) and, of course, for delivery of immunizations to prevent other infectious illnesses. We must continue to ensure that we have equipped family physicians to continue to provide this necessary care.
Though pandemic preparedness planning had been at the forefront in the hospital sector since SARS and H1N1, no organized approach to ensuring community preparedness was undertaken between 2009 and 2020 and family physicians and other frontline healthcare workers continue to face significant personal risk both to themselves and their families.
An acknowledgement of these risks is vital to ensuring physicians continue to provide care for their patients in Ontario. Self-employed physicians in community practice have a responsibility for the safety of their employees, however they do not benefit from the legislative rights of other workers.
The potential for conflict between the ethical and moral responsibilities outlined in the CMA code of ethics for physicians versus a legal right to refuse to work due to an unsafe work environment need to be better addressed. For example, firefighters cannot refuse to enter a burning building as it is an implied risk of their job; however, they are also not expected to take those risks without the provision of proper safety gear and equipment.
Each province and territory has legislation protecting workers from illness or injury at work, setting guidelines to reduce the risk to workers. The question then arises of what risk level is it ethical to not provide a duty of care. Asked Daniel Sokol, a lecturer in medical ethics and law, St. George’s, University of London: “Should a doctor come to work with a 10 per cent risk of death – or even a 1 per cent risk? What corresponding benefit to patients is required to justify that 1 per cent risk of death.”
Physicians who feel unsafe are more likely to not provide care during a pandemic. Governments as well as evolving primary care groups in Ontario Health Teams can ensure that the necessary support, education and training are available. Other reciprocal obligations should also be considered, including ensuring disability or life insurance for those who become ill with pandemic-related illnesses. Grants or subsidies for physicians to alter, change or re-design offices to align with best practices for preventing the spread of infectious disease would allay physician and patient fears and will be of significant future benefit for the entire population.
It seems unimaginable that community-based physicians are ill-prepared to respond to a pandemic and might compound the issue of poor access to care by becoming ill themselves. It is this type of social contract, properly designed, that will allow physicians to focus on the importance of the medical aspects of pandemic health rather than the business aspects of medicine.
It is not clear how our current pandemic will evolve. What is clear is that we need every available healthcare provider, especially family physicians, to remain fully engaged in healthcare delivery. This must be met by a recognition of the need to support them with the infection prevention and control tools, including PPE, that will enable them to care for patients safely now and in the future.
I would like to thank and acknowledge Dr. Sarah Newberry for her guidance and unwavering support of this commentary.
There are no conflicts of interest to declare.
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So just when patients need doctors the most they can wimp out and abandon the needs of their patients at their own discretion? I`ve had my double dose of the vaccine and my doctor still won`t see me.
Your thoughtful article brings out serious issues. To what extent are Family Physicians, community based specialists and other community health care workers a part of the larger system? Are they totally independent private practitioners and therefore responsible only for themselves, or are they part of a public health care system with mutual obligations to and from that system? In Canada, family physicians are paid at a low level compared to hospital-based physicians, and are not allowed to charge more when their economic model is totally disrupted by an epidemic. They are thus susceptible to financial ruin as well as personal danger. Yet provincial hospital systems need the work of community physicians to continue their part of the system in order to continue running the hospitals efficiently. Thus there should be an obligation on provincial systems to either provide supports such as PPE, and sick leave for those unable to work due to quarantine requirements or reimburse those extra costs. Provincial ministries of health cannot on the one hand depend on the work of community physicians and other health workers, while limiting their earnings and imposing conditions on their practice, yet on the other hand throw them to the wolves in times of trouble.
In 2009, when the H1N1 pandemic threatened, and we did not know how severe it would be, many community physicians in Alberta were uncertain about remaining at their posts if it became severe, though others planned to stick it out. (https://apfmj.biomedcentral.com/articles/10.1186/1447-056X-12-3) The same issues are occurring now, but community physicians are still taken for granted.
Appreciate you taking the time to comment and very much agree with your statements as they were the same reason I choose to write this piece. The idea of ‘duty’ and the very real issues of community based private primary care practice and the significance of not only it’s vital importance, but it’s integration within the public system gets often overlooked when focus on hospital based planning. As you read in the article, the second paragraph quote was my personal feeling from 2011 and when I looked at again a few months ago, I struck me that not much had changed for community practice in all this time and we have work to do in the present, but also the future. Appreciate the comments.
Wonderful Insight into an issue that needs to be addressed
Appreciate your comments Bryan.
This article is very Ontario based. Did you consider the situation in Alberta where the Minister of Health, Tyler Shandro, has launched open warfare with family physicians in a pandemic!
Hi Kathleen. Well not sure exactly what you mean by Ontario based. But yes, I am a Ontario based practising Physician for 21 years. I have heard about the Alberta issues only through the news, but ‘open warfare’ against physicans during pandemic, in my opinion is probably not the best allocation of energy, but not quite sure how that impacts the article except to prove the point, as I hear moral is low and physicans may not feel safe and valued.
Thanks Dr. Banwatt for this very thoughtful commentary. Excellent points and considered discussion.
Thanks Sharon. Much appreciated
Interesting article. As a pharmacist working in a community pharmacy, I would say that similar issues are a concern. I would suggest that the primary care workforce needs to be protected- not just family docs.
Hi Barry P. I am a family doc, so I can only speak to my primary care experiences as a Self Employed physician in the community. Correct me if I’m wrong, but 80-85%of pharmacist are employed and have the larger corporation for support. But, I agree there are still many other issues out there.