Ebola has been a hot topic at the ER nurse’s station lately. In the wee morning hours when the department slows down, we speculate as to our actions should a patient with Ebola arrive in our waiting room. Who would care for the patient? Some have declared they will walk off the job and never look back. Others are embracing Ebola preparation by practicing donning and doffing hazmat suits. Most staff support a system where providers without children or families ‘go in’ first. What would you do?
We can all speculate as to our actions should our hospital or clinic receive a suspected Ebola patient. But, what are your legal rights concerning care of highly infectious disease? If you decide to walk off the job based on risk of disease transmission, are you placing yourself in legal jeopardy? There are a few laws and areas of precedent to consider.
For those of us working in the emergency department, refusal of care immediately triggers thinking about EMTALA. The Emergency Medical Treatment and Labor Act is a federal law requiring that any patient presenting to the emergency department be stabilized and treated in a non-discriminatory manner. Patients must be screened and, if necessary, treated regardless of ability to pay, national origin, race, creed or color.
Ebola qualifies as an emergency medical condition, so patients with the disease would fall under EMTALA law. Upon arrival at the emergency department, even if Ebola is suspected, EMTALA would require the patient be medically screened and treated until the emergency condition is resolved or stabilized. Hospitals lacking the ability to provide care to such patients may transfer to another facility under strict transfer guidelines.
Both individual providers and hospitals have a legal obligation to comply with EMTALA. If found in violation of the act, hospitals and healthcare providers may lose their Medicare provider agreement and be fined up to $50,000 per violation as well as be subject to any lawsuits that may arise.
Ethical Principles of Providing Medical Care
Healthcare providers operate on a foundation of ethical principles, namely beneficence (doing good), non maleficence (do no harm), and justice (just distribution of finite resources). Beneficence is the most prominent principle that comes into play in considering treatment of patients with Ebola. It refers to a provider’s duty to help patients, so long as the patient’s initial complaint falls within the provider’s scope of practice.
Beneficince looks different depending on the provider’s scope of practice, moral beliefs, and abilities. The risk of disease transmission, the grounds on which providers are most likely to refuse to treat Ebola patients, does not preclude providers from the principle of beneficence. Under this ethical medical principle, providers are obligated to treat patients with highly infectious disease.
While Ebola is new to our country, the idea of refusing to treat those with infectious disease is not. The tension between risk of infection and duty to treat the ill has been around since the bubonic plague in the 14th century when doctors fled cities stricken with the disease in order to protect themselves. These actions led to laws and societal expectations obligating physicians to treat patients, even at risk of disease transmission.
The issue again came to the forefront in the 1980’s with the AIDS epidemic. Fierce debate over healthcare provider’s right to choose which patients to treat ensued. The conflict was never clearly resolved but resulted in the release of opinion statements from many reputable health organizations. The American Medical Association issued documents stating “A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is seropositive for HIV. Persons who are seropositive should not be subjected to discrimination based on fear or prejudice”. The American Dental Association echoed this sentiment. Situations like these set a precedent for treating patients regrdless of infectious risks.
U.S. Laws Outlining Medical Treatment
Aside from EMTALA which governs treatment of patients in emergent situations within emergency facilities (EMTALA does not apply to outpatient clinics), U.S. law overall allows healthcare providers to accept or decline patients at will. There are two exceptions to this rule. The first is if a provider-patient relationship has been established. Breaking this relationship without transferring care to another provider constitutes “abandonment”. The American with Disabilities Act of 1991 also prohibits providers from refusing care to patients on the basis of disability.
States may have their own laws outlining when providers can and cannot refuse to treat certain patients. The Rhode Island Department of Health, for example, recently released a statement saying “In Rhode Island, licensed healthcare professionals in active practice are obligated to treat and/or care for Ebola patients, while minimizing the risk of Ebola transmission to self and others”. The statement notes that failure to comply is a potential breech of the state’s healthcare licensing laws and could result in sanctions.
Decisions About What Kind of Care to Provide
As we saw in the case of Thomas Duncan, the first patient diagnosed with Ebola in the United States, life-saving measures such as dialysis and intubation increase healthcare worker’s exposure to disease-transmitting body fluids. Some hospitals are weighing withholding such measures to protect hospital staff. Deciding the course of treatment of Ebola patients based on these considerations presents a host of other moral and legal issues.
We have little if any data regarding the efficacy of these treatment measures in patients with Ebola and can expect this debate to evolve as we see hospitals make decisions and develop protocols regarding their stance on invasive treatments in patients with Ebola virus.
In many cases, an argument could be made either way when it comes to healthcare provider’s obligation to treat or refuse to treat a patient with Ebola. For example, nurse practitioners could argue that treatment of Ebola is outside of their scope of practice. A counterargument could be made that any NP with experience in the ICU or ER should have the capability to apply their skills to an acutely ill Ebola patient. In the emergency department, EMTALA laws give clarity to the legality of the situation. Patients with medical emergencies must be treated. Hospitals and individual providers can be held liable for withholding treatment of such patients.
Furthermore, societal and moral code frowns on refusing to treat patients, even in the face of infectious disease. Hospitals are, however obligated to give providers the necessary resources to care for patients safely and effectively mitigating the risks of providing care. Societal and moral code may not be written explicitly into federal and state law, but a case for upholding these principles could likely be made in court.
In most cases, healthcare organizations and state authorities recommend a volunteer system when it comes to situations like caring for Ebola patients. Some providers will be excited by the challenge of stepping up to be on the forefront of a developing medical situation allowing others with hesitation or other competing obligations to avoid the risk without legal consequences.
Would you refuse to treat a patient with Ebola virus?
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