A systematic review posted in Clinical Infectious Diseases reveals that, amid the COVID-19 pandemic, many physicians felt less ethically obligated to provide care to infectious-disease patients if they fear contracting the disease.
A Duke University–led team reviewed 155 published studies exploring treatment obligation and refusal, HIV/AIDS, COVID-19, and pandemics up to October 25, 2022.
"During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients," the study authors wrote. "While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal."
82% still endorsed an obligation to treat
The included studies examined ethical treatment obligations for patients with HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS; 10.2%), COVID-19 (10.2%), Ebola (7.0%), and flu (7.0%).
Most articles (81.9%) argued for an obligation to treat these patients, while most papers (60.0%) that endorsed withholding treatment were on COVID-19, and HIV had the fewest papers advocating for treatment refusal (13.3%).
The most common reasons given for an obligation to treat were professionalism (55.5%), the social contract (45.3%), and the law (20.3%). The most common reason for advocating for withholding COVID-19 treatment was labor rights and worker protection (40%); labor rights were cited in only 17% to 19% for other infections.
For HIV care, labor rights was the least cited reason for treatment refusal (6.2%). A total of 26.7% of articles published during COVID-19 cited the risk of infection to physicians and their families, compared with 8.3% for flu and 6.3% for SARS.
"All the papers throughout history have shown that physicians broadly believed they should treat infectious disease patients," lead author Braylee Grisel, a fourth-year student at Duke University School of Medicine, said in a Duke press release. "We figured our study would show the same thing, so we were really surprised when we found that COVID-19 was so different than all these other outbreaks."
Consideration of vaccination status
The researchers said the COVID-19 pandemic may have altered the perceived social contract between physicians and patients, because it had several unique characteristics, including a shortage of resources (eg, personal protective equipment, hospital rooms, respirators, vaccines, treatments), broadly disseminated misinformation about the disease (eg, how the virus spreads, effective treatments, vaccine efficacy and safety), its highly contagious nature, and escalating abuse of staff by patients and their families.
Arguments were made based on reciprocity, medical triage, and personal responsibility to exclude patients who refused vaccines from consideration when ventilators and other resources were limited.
Senior author Krista Haines, DO, of Duke University, said, "Some of these results may be because we had the unique opportunity to evaluate changing ethics while the pandemic was actively ongoing, as COVID-19 was the first modern outbreak to put a significant number of frontline providers at personal risk in the United States due to its respiratory transmission."
Some papers discussed the consideration of COVID-19 vaccination status in treatment decisions. "Patients who refused vaccination were at a higher risk of complications while also putting other patients and providers at risk," the researchers wrote. "Arguments were made based on reciprocity, medical triage, and personal responsibility to exclude patients who refused vaccines from consideration when ventilators and other resources were limited."
The findings show how physicians are not immune from sociopolitical influences, Grisel said. "In future pandemics, we may need to become more aware of how the risks and outside pressures of an active pandemic influence willingness to provide care," she said. "Health care systems can learn how to mitigate these influences to ensure that hospitals are adequately staffed to meet patient needs."
The authors noted that the obligation to provide care was supported throughout the 20th and early 21st centuries. "Striking a balance between providing care, limiting patient discrimination, respecting provider autonomy, and protecting the healthcare workforce is crucial to adequately meet public needs during a global health crisis," they concluded.
