Major emergencies are always challenging for the health care workers in terms of increased demand and risk of shortage of available resources. When the emergency is caused by a viral outbreak, these challenges are intensified for the health professionals. During the H1N1, several studies highlighted the paradoxical situation between the physicians’ and nurses’ duty to care for patients and the personal duty to care for themselves and their families (11). The COVID-19 pandemic is no exception to this dilemma.
To our knowledge, our study is the first one to assess the factors that inﬂuence the medical practice during COVID-19 pandemic in Lebanon and the ethical considerations when treating patients.
This cross-sectional survey enrolled 318 Lebanese physicians, including men and women of different ages and specialties, practicing in many regions and having multiple socio-economic and cultural backgrounds.According to the literature, medical doctors, like the general population, may have an exaggerated perception of their personal risk during a pandemic (4). However, during this COVID-19 pandemic, a high proportion of healthcare workers became infected with the virus, with numbers reaching 20% in Italy, making this increased risk an alarming reality rather than a perception (11).
In this perspective, when asked about the risk of contracting COVID-19, the majority of family doctors or medical specialists considered themselves at higher risk of infection. Due to the diversity of symptoms and manifestations related to this viral infection, patients may seek consultation with any type of medical specialty: family medicine, internal medicine, infectious disease, pulmonology, emergency medicine…. At the same time, anesthesiologists considered themselves to be the most at risk during work compared to other specialties, which could be related to airway exposure during intubation in the operating, or intensive care unit. This is due to the fact that the COVID-19 wasn’t mandatory before the hospitalization and any patient might be asymptomatic carrier of the virus and thus, transmit the disease to the anesthesiologist. Surgeons, however, considered themselves at a lower risk of contracting the virus relatively to other specialties, since elective surgery are postponed and they are often face covered with surgical mask when interacting with patients in the operating room. and this.
In general, the risk of infectious disease is an inevitable consequence of caring for patients who may be asymptomatic carriers (20%) or who do have mild disease. Over the years and during pandemics, many types of airborne infections have been transmitted to health care workers and many lives have been lost among the medical staff. For instance, the world still remembers Carlo Urbani, the World Health Organization physician who investigated and alarmed the world over the SARS epidemic before the virus killed him in 2003 (12). With that in mind, doctors have major concerns with airborne or air droplets epidemics, but as our study shows, the vast majority of them fear spreading the virus to their families first, then to their patients, and finally to themselves. Only 3.8% of physicians were not afraid when dealing with infected patients.
Therefore, faced with these real concerns, do healthcare workers have a choice and avoid treating infected patients in the perspective of limiting their personal risk and that of their families? In this survey, more than 90% of physicians considered that treating patients with COVID-19 was not an option it was an obligation. For them, this was widely seen as a duty, then a medical mission, then an obligation. In fact, these terms are often used interchangeably, but they do not mean the same (13). The duty to treat would mean at least that during ordinary days, the physician cannot refuse to treat any patient. Under this point of view of the duty, the risk to the physician would not be a limit to take care of patients. The dilemma appears when this duty expands from everyday work to pandemic situations. In this case, the community creates a more affirmative definition of the duty and enlarges it to imply obligation and responsibility to help others that are in need. For instance, obligation is considered to be, according to the society, a moral contract to treat patients without regard to the risk to doctors’ own health. However, the definition of a mission comes from the physicians’ point of view because altruism is the central of any physician-patient relationship and doctors cannot but help others who are in need of their knowledge and expertise. The duty to treat is considered to be the natural consequence of a social contract between doctors and the public. This contract empowers the medical professionals because they are in charge of the medical treatments (4). So, if we accept the duty to treat, could there be limitations to this duty (14)? During past pandemics such as the Spanish flu, doctors were considered to have a “mission”. They were the “heroes” whose mission was to take care of patients and save the world. No single reason should have compromised their principle of altruism (4,14). Does this mean that it is an obligation, just as the military are most at risk in wartime? Don’t doctors have the right to choose which patients to treat? After lengthy debate, the American Medical Association (AMA) implemented in 2004 new wording for “Physician’s Obligation in Disaster Preparedness and Response” that gives physicians the “obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future” (15). However, since no personal or professional duties are ever absolute, exceptions may apply. Specific examples were listed and divided into four themes: physical health, mental health, competing personal obligations and unacceptable levels of personal risk (14) . These exceptions can be somehow used as pretexts by doctors who refuse to treat patients during pandemics. According to Dr. Orentlicher "allowing physicians to take into account the risk to their own health would open the door to pretextual denials of care to unpopular patients" (4).
Nonetheless, as is widely seen, and in line with the beneficence ethical principle, physicians and health care professionals rarely refuse to provide care during a pandemic. In our survey, the vast majority of doctors declared that they were even willing to help if they were requisitioned in the event of a lack of specialists in the main specialties dealing with the disease, such as intensive care, emergencies and infectious diseases. In addition, the majority of doctors said they were ready to adopt an “on call” system during the crisis period. However, this “on call” system should be organized to limit the spread of the disease to all health care workers, but should not let the burden fall on a small number of physicians, nor encourage some of them to opt out from their duties (4).
To prevent patient harm, and thus respect the non-maleficence ethical principle, decisions need to be based on evidence, principles, and values. Regarding treatments, contrary to what is observed in other known diseases for which drugs have been approved after thorough clinical studies and requiring the FDA and/or EMA approval for prescription, the actual pandemic and crisis state shed light on the global need for immediate treatment which prompted doctors to prescribe drugs with a possible benefit, albeit small, for treating affected patients. In the era of evidence-based medicine, decisions for treating patients infected with COVID-19 are not always supported by evidence and recommendations but by expert opinion that demonstrate an efficacy of drugs that are proven safe in the treatment of another disease or that have well known adverse events. Doctors in this investigation were in favor of such an approach. However, in the absence of randomized control trials and clear-cut evidence, these drugs are usually used as a “last resort” or in the context of clinical trials. Therefore, beneficence and non-maleficence are two overlapping principles that can be argued from different angles (7,16).
Justice is also a debatable ethical principle during pandemics. Should we treat the patients by priority? Which means, should any patients be treated before others, or to a higher extent, instead of others? In which case, who would be the priority? The people most likely to recover, the patients suffering the most or the most commendable people (17)? In fact, although no doctor wants to see a patient not receiving the best medical care, in times of pandemic, contagion means additional pressure on limited medical resources which can become saturated, and physicians may find themselves obliged to choose which patient to treat. When asked in the survey, 60% of doctors stated that patients should be treated by priority, considering pregnant women as a first priority, then immunocompromised patients followed by young patients and the elderly. Still, 40% of them declared that no patient should be prioritized over another. To objectivize this decision, clinical scoring systems are widely used to prioritize scarce medical resources during a pandemic crisis. Most systems prioritize those patients most likely to benefit from treatment. Any system employed should by analyzed for prognostic accuracy as well as for ethical acceptability and fairness. These systems help physicians to evaluate and improve prognostic judgments as to which patients are likely to benefit through survival to discharge. Prachand et al. developed a scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid-19 pandemic. This score takes into consideration resource limitations, COVID-19 transmission risk to providers and patients’ characteristics using a 5-point scale for each item in every category, with a maximum of 105 points. There is no cut off values but the lower the score, the better the prognosis is and the safer the procedure can be. This score describes these operations as medically necessary, time-sensitive (MeNTS) procedures (18). On another note, in this questionnaire, physicians revealed a neutral position concerning the withdrawal of mechanical ventilation from a patient with a poor prognosis if the latter is needed to treat a higher “priority” patient. Again, the occurrences of the latter term are difficult to interpret and are based on personal values, but this largely shows the impact of societal, moral, and ethical issues that doctors face and that are hardly resolved by a simple answer or in a same manner by different physicians. In the context of this debate of withholding or withdrawing of the ventilation, many clinical guidelines have been published to help doctors in their decisions. All these documents try to differentiate between futility and benefit according to different perspectives. Orlowski et al, consider that “if a treatment is clearly futile in the sense that it will not achieve its physiological objective and so offers no benefit to the patient, there is no obligation to provide the treatment” (19). However, Snyder and Swartz doesn’t limit futility to the psychological aspects and enlarge its spectrum to include the physiological aspect without giving more precision (20). Winter and Cohen11 define the physiological futility as the dysfunction of three or more organs (21). The assessment of benefit is more controversial because it is fundamentally subjective, in fact, a small physiological amelioration might seem sufficiently beneficial to the patient, but not to the physician (22). That’s why it is important to understand what is considered to be benefit and from whose perspective. Amidst this vagueness and in order to take their decision, doctors can be guided by the family or the family demand, the medical recommendation, and the ethical committee of the hospital (20,23).
Autonomy is another primordial issue always addressed, especially during pandemics. The patient-physician relationship is based on full trust and the physician has access to patient's privacy, only because of his professional status. Breaking medical privacy by disclosing the identity of sick patients is known to be discordant with the ethical principles of medical practice; however, concerns about patient autonomy are a key factor that prevents disease reporting. Few ethical guidelines allow us to marginalize the privacy of patients for the greater good of the population, whereas the other majority has a complete opposite opinion. On the one hand, Canadian laws permit disclosing personal health information for public health purposes without patient approval considering that during a pandemic, public good should supersede an individual's right to privacy (24). On the other hand, the AMA and US law limits this broad exception and précises that patient privacy may be violated only where imminent harm to an identifiable victim is known (25). In the latter case, during a pandemic, infected patients' identities can be reported to public health officials only, and contact tracing enabled, at minimal cost to patient privacy. In Lebanon, laws include incoherence and are subject to abuse (26). , In our study, the majority of physicians were in favor of revealing the identity of patients to public health officials who do contact tracing in order to protect their families and communities.
Perhaps the most concerning issue raised by this paper is the willingness of physicians to reveal "the identity of patients who refuse to adhere to strict recommendations in order to protect their families and communities" (page 13, line 14). The authors claim "this is indeed in accordance with the ethical guidelines and laws that allow and require us to marginalize the privacy of patients for the greater good of the population" (p 13 line 15). This in no way represents the ethical opinion of physicians in the United States or the UK. AMA Opinion 5.05 and the US case of Tarasoff v Regents of UC, 551 P.2d 334 (1976) agree that patient privacy may be violated only where imminent harm to an identifiable victim is known. This section of the paper needs to be rewritten to indicate either (1) it is in accordance with Lebanese and perhaps other nations' customs to severely limit the privacy rights of individuals; or (2) acknowledge that this approach to patient privacy protections is discordant with those of the AMA and US law and ethics.
Finally, concerning the management of the crisis in Lebanon, physicians seem to adopt a neutral position with regard to the country’s capacity to manage such a pandemic, probably because of the uncertainty of the evolution of the disease, which remains a worldwide problem. The medical staff remains ethically responsible for putting the interests and well-being of the patient first.