CASE:

Marcus is a third-year internal medicine resident on the last shift of his emergency medicine
rotation at a small hospital in the northeastern United States. The shift is unusually busy. A few
hours into his shift, a critically ill woman is brought in to the emergency department with fever,
cough, and hemoptysis. Her family reports that she was previously healthy but became sick
rapidly about 2 days after she attended a large conference at a local hotel. One hour later,
another ER patient describes similar symptoms. His wife reports that he became ill after
attending the same business conference 4 days ago.

Marcus has not seen the patients but attends a staff meeting in which the attending physician
discusses the possibility that the patients have pneumonic plague. The attending physician, Dr.
Gattler, is suspicious of the possibility that Yersinia pestis may have been released at the hotel
in which the conference took place.

"It's unlikely," he says, "but we can't rule it out. Until we can, we need to take the appropriate
precautions. The terrorism response plan will be put into place, and I will notify the public health
authorities immediately after we finish here."

Dr. Gattler asks Marcus, who has been trained in the terrorism response plan, to help with triage
and identifying other potential patients.

"The patient in room 3 has fever and a cough," a nurse says, "no hemoptysis, but he's a young
guy, and he looks really sick."

"Marcus," Dr. Gattler says, "go see that patient. I'll be there once I get a few more calls made.
You know what you're doing, right?"

Marcus nods. He remembers everything from disaster preparedness training. It was only 2
months ago. At that time, though, he didn't imagine then he would actually be faced with a
situation like this. Marcus knows this patient is ill, but he also knows that if this is pneumonic
plague, he is putting himself at risk, and he may be quarantined after seeing the patient. It
seems like a sufficient number of doctors and nurses are around to help anyway, and many
more will be there in a few minutes. The patient in room 3 needs a doctor, but Marcus's wife and
daughter also need him at home. "It seems like I shouldn't really have to do this as a resident
anyway," Marcus thinks. "How can I be expected to put myself and my family at risk?"
Key Points:

1. Dr. Marcus is a third-year internal medicine resident on the last shift of his emergency
medicine rotation
2. Patients with fever, cough, and hemoptysis who attended a conference. Possibility of
pneumonic plague (Yersinia pestis) unlikely but cannot be ruled out.
3. Terrorism Response Plan was initiated
4. Dr. Marcus has been trained for disaster preparedness

Ethical Dilemma: Patient Care Versus Personal Safety

Questions:

1. Does Dr. Marcus have a legal obligation to treat patients with the infectious disease?
2. Does Dr. Marcus have a legal right to refuse her obligation?
3. Does Dr. Marcus have an ethical obligation to treat patients with the infectious disease?

Ethical Principles Involved: Negligence, Beneficence

Question 1:

The duty to care is one component of the law of negligence. To establish a physician's liability in
negligence, four requirements must be met:

(1) the physician must owe the defendant a duty of care

(2) the physician must fail to meet the standard of care established by law

(3) the patient must suffer an injury or loss

(4) the physician's conduct must have been the actual and legal cause of the patient's injury.

When a physician-patient relationship exists, the physician has a legal and ethical duty to care
for and not abandon that patient. A limit to this duty exists where the patient is given a
reasonable opportunity to arrange for alternative health care services.

A physician does not owe a duty to care for, and thus has not been legally required to treat,
someone who is not already his or her patient. However, there are exceptions to this rule, this is
the duty to provide treatment in emergency departments despite the absence of a prior doctor-
patient relationship. A duty to care has been found based on the fact that the public relies on the
care of physicians in hospitals that hold themselves out as providing emergency care.
Question 2:

Workers with the responsibility to protect public safety (i.e., firefighters, police officers and those
involved in the operation of a hospital) cannot refuse work if the danger is a normal part of their
job or if refusal will endanger the life, health or safety of another person.

The question is whether circumstances such as the one outlined in the case above would
constitute a danger that is a normal part of a physician's job. In today's physicians there is a
widespread awareness of the threat and management of pneumonic plague, physicians are
aware of the risk of exposure to serious infectious diseases associated with their particular
specialty. By entering into this profession, physicians are implicitly consenting to the risks and
responsibilities associated with that job.

It is also arguable that taking on significant risks to personal health is an extraordinary act that
goes beyond the professional duty to care. In a context where there is no established physician-
patient relationship, no emergency scenario, no legitimate reliance on the fact that care would
be provided, as well as reasonable alternatives for care, one could argue that there would be no
duty on a physician to provide care in the face of risks to personal health that are over and
above the risks associated with that physician's day-to-day provision of care.

Question 3:

The professional obligation of physicians to treat patients is grounded in the ethical principle of
beneficence. Beneficence captures the moral obligation on the part of physicians to further the
welfare of patients.

The physician-patient relationship is generally characterized ethically and legally as a

fiduciary(trusting) relationship. This characterization recognizes a special vulnerability of
patients entrusting their care to physicians. In this fiduciary relationship, physicians are bound to
act with good faith and loyalty, not allowing their personal interests to conflict with their
professional duties.

According to Patients’ Bill of Right:

1. Right to Appropriate Medical Care and Humane Treatment. - Every person has a
right to health and medical care corresponding to his state of health, without any
discrimination and within the limits of the resources, manpower and competence
available for health and medical care at the relevant time.

and According to Code of Ethics of the Philippine Medical Association:

Article II,

Section 1. A physician should be dedicated to provide competent medical care with full
professional skill in accordance with the current standards of care, compassion, independence
and respect for human dignity.

Section 2. A physician should be free to choose patients.

Section 3. In an emergency, provided there is no risk to his or her safety, a physician should
administer at least first aid treatment and then refer the patient to the primary physician and/or
to a more competent health provider and appropriate facility if necessary.

In this case Dr. Marcus has been trained for disaster preparedness. He should be competent
enough to handle bioterrorism attacks and reduce the risk to himself by initiating Standard and
Transmission Based Precautions. Thus, he has the legal responsibility to take care of the
patients in the emergency department.

Pneumonic Plague:

Standard Precautions: Hand washing before and after all patient contacts and contact with
patient care equipment.

Contact Precautions: Use of gloves, gown and eye protection.

Airborne Precautions: In addition to standard precautions, a mask with respiratory protection

(i.e. N-95, N-100 particulate respirator) or Powered Air Purifying Respirator (PAPR) should be
worn by providers and a surgical mask placed on the patient when not in their hospital room. If
equipment is visibly soiled or significant contact has been made with the patient, remove the
protective clothing BEFORE entering areas that are not contaminated to prevent transmission of
material. Maintain patients in negative pressure isolation rooms. Victims presenting immediately
after aerosolized exposure require decontamination