Ethical Issues in Healthcare Epidemiology and Infection Prevention

Emily Landon

Cassandra Oehler

Medical ethics are the governing principles that guide a practitioner’s interactions with his or her patients and assist the practitioner in coming to the best decisions for an individual patient while respecting the impact of that patient’s care on the practitioner and on the healthcare system as a whole. Medical ethics calls on physicians to synthesize their clinical reasoning with their moral judgment and often, although not always, to balance competing concerns and values (such as a patient’s family’s reluctance to withdraw intensive care unit [ICU] support and a physician’s clinical judgment that the patient cannot derive medical benefit from such support) in order to produce an appropriate decision. These concerns are very real and often nuanced, and decisions cannot be formulaic or readily prescribed based on a one-size-fits-all approach. Unfortunately, most healthcare practitioners, including infection preventionists and hospital epidemiologists, are either not trained in ethics or undertrained for their specific needs, and it can be difficult to identify ethical issues, much less articulate them clearly if one has not had training in this area. This balancing of ethical concerns takes on a different scope for an infection prevention practitioner, but the basic principles of medical ethics remain both relevant and useful in beginning to understand ethics in this field.

BASIC ETHICS FOR INFECTION PREVENTION

Medical ethics considerations are traditionally divided into four general guiding principles: autonomy, nonmaleficence, beneficence, and justice.¹ The need for the application of these principles for the ICU physician considering a patient’s end-of-life wishes or an obstetrician’s management of a nonviable pregnancy may be more immediately apparent. Although it is less often recognized, infection preventionists and hospital epidemiologists no less frequently balance these same principles in the execution of their daily decision-making.

In general, autonomy refers to the sovereignty accorded to the competent patient’s independent will and decisionmaking. Paternalism is widely considered to be in tension with the principle of autonomy and can aid in understanding it. Any medical decision that is made by a provider for a patient (as opposed to being made by a patient or the patient’s surrogate) could be considered paternalistic or failing to respect patient autonomy.¹ While autonomy is highly valued by patients and the medical system, there are limits, both at the extremes of medical care and in the more quotidian minutiae of care. The decision not to offer surgical resection of metastatic lesions to a patient with widely metastatic cancer would technically be paternalistic but is considered appropriate and reasonable and even honoring the surgeon’s autonomy to use his or her judgment. The decision to not consent a patient for each individual lab to be tested on their blood could also be thought of as a limitation of autonomy but is also considered reasonable if it is consistent with the patient preferences that have already been agreed upon.

Nonmaleficence requires that the practitioner not intervene in any way that will harm the patient and can be thought of as being summed up as “do no harm.” Beneficence is often considered to be the other side of the nonmaleficence coin and refers to the practitioners’ need to provide a benefit to patients and to do what is, in their judgment, best for the patient. Finally, justice refers to considering the fairness of a decision in a broader context—the healthcare system and society. Nowhere in medical practice are these principles practically given equal weight, and in any given medical decision, they may be in tension with one another to varying degrees.

In medical practice, autonomy and beneficence are often given the most weight. However, in the practice of healthcare epidemiology, the concept of “doing no harm” or “nonmaleficence” is central. Harm prevention is central to the work that these specialists do and the arguments they make in favor of interventions to prevent healthcare-associated infections (HAIs) in their patients. Hidden in the questions that must be answered about whether or not a particular patient needs to be isolated or how to disinfect some piece of equipment are questions about autonomy, beneficence, nonmaleficence, and justice. Often these questions are answered based almost entirely on the goal of “doing no harm” or, in the vernacular of healthcare epidemiology, reducing the risk of infection transmission as much as possible. However, in deciding whether a child with a carbapenem-resistant Enterobacteriaceae (CRE)
infection is able to use the playroom or when administrative leaders are deciding whether it is too expensive to add a supplemental water disinfection system, these raise conflicts of competing ethical principles (autonomy and justice in these cases, respectively).²^,³

To unpack these concepts, one needs to understand the different priorities of clinical medical ethics and public health ethics. (See Table 7-1.) As shown in the table, medical ethics is focused first on individuals: it is about treating a specific disease and respecting autonomy and privacy. Patients are expected to retain control over their care and make decisions for themselves, and when they cannot, surrogate decision makers are used to make decisions based on what they suspect the patient likely would have chosen when he or she was able to do so.⁴ Conversely, in public health ethics, decisions are made based on the health of a population and preventing illness and often prioritize justice over individual autonomy and individual patient decision-making.⁵^,⁶

In public health ethics, the decision maker is generally the infection preventionist over and above the patient. Less concern is given to the preferences of the individuals for whom the decision is being made—a framework that would be too paternalistic for modern clinical medical ethics. Infection preventionists make decisions about medical choices that affect large groups, and they prioritize the health outcomes of the group under their care over the self-determination of any individual patient. A patient can choose to forego treatment for colon cancer without increasing the likelihood of others getting sick, but the same patient refusing treatment for tuberculosis would have a very different outcome. For this reason, what is unacceptable in medical ethics is often preferable in public health ethics.

TABLE 7-1 Sample Systematic Framework for Outlining Ethical Issues

*Modified Kaldjian framework*		*Example*
1.	State the problem plainly.	Too many healthcare personnel (HCP) are declining the influenza vaccination, exposing patients to risk.
2.	Organize the available facts.	What benefit does influenza vaccine provide to HCP? Patients? Why is compliance low—lack of knowledge or fear of allergy or side effects? Is the vaccine being made readily available to the HCP?
3.	Ask—is more information or dialogue needed?	Are we confident about the vaccination rates? Do the HCP understand the expectations?
4.	Ask—is this an ethical problem?	What ethical principles are at stake if one makes influenza vaccine mandatory? Are they synergistic or in conflict?
5.	Use the available information about the issue, facts, and the context to formulate a plan. Clarify which ethical principles are at stake stating which will take priority and which will be compromised.	Influenza vaccine will be a condition of employment for all HCP. This policy is fair (justice); it preferences doing no harm to patients but subverts individual HCP autonomy.
6.	Support your decision by referencing similar situations and medical guidelines. Find ways to mitigate harms done by subverting other ethical principles if possible.	HCP often agree to sacrifice some small amount of personal autonomy in the workplace for the sake of nonmaleficence toward their patients. The influenza vaccine is another such instance. Guidelines and recommendations are in favor of every HCP receiving influenza vaccine unless contraindicated. Little can be done to preserve autonomy without harming justice but HCP with contraindications to the vaccine can be exempted.
Adapted from Kaldjian LC, Weir RF, Duffy TP. A clinician’s approach to clinical ethical reasoning. J Gen Intern Med. 2005;20:306-311.

This reasoning extends to another key piece of patient autonomy: privacy. In the United States, the Health Insurance Portability and Accountability Act (HIPAA) codified the regard for patient privacy in federal law.⁷ Yet, even this far-reaching law has a giant carve-out for reporting of infectious diseases (ID) both to public health authorities and within health systems.⁸ Practitioners collect identifiable patient information for surveillance and tracking and report deeply personal information about specific diagnoses—often ones with significant attached social stigma—to local public health authorities every day. Isolation signs are placed on the doors of patients with potentially transmissible pathogens that divulge specific information about their health, all of this without ever consulting the patients or obtaining their consent. Privacy can often be uniquely opposed to the goals of public health ethics.

In short, clinical medical ethics prioritizes autonomy of the individual patient and beneficence on the part of the provider. Public health ethics focuses on justice and expects its decision makers to prioritize nonmaleficence for the community. Optimally, these things would not be in conflict and one would always be able to both do good and avoid harm, but these priorities do not always harmonize, and the approach is different for individuals than it is for communities. Individual patients expect their providers to do more than just protect them from additional harm when they are sick. They come for medical care because they are hoping for good to be done, whether in terms of managing symptoms or curing disease. At the same time, communities collectively agree that an individual’s health concerns
or medical care should not harm others or put the community at risk. Hence, the focus on avoiding harm when considering populations and not specific individuals. For example, quarantine and isolation for certain infections is a common practice as it avoids harm to communities but may actually penalize an already sick individual. In medical ethics, on the other hand, individual good is the priority, and this could mean giving lower priority to the collective good. Even with evolving antimicrobial stewardship programs in hospitals, many patients receive broad-spectrum empiric antibiotics despite the low likelihood of them having drug-resistant infection because clinicians cannot justify failing to adequately treat a theoretical Pseudomonas infection even if their empiric antibiotic choice incrementally decreases by a tiny amount the likelihood that the same regimen will work for the next patient.

While the tension between public health ethics and medical ethics is omnipresent in infection prevention, understanding that tension and balancing those competing concerns can help to define approaches to long-debated issues like the ones described in this chapter. Melding the two different approaches together by defining the values at stake and recognizing whose values are in opposition can augment the more commonly employed risk assessment methods and lead to more satisfactory and thoughtful solutions to tricky problems.

Many approaches to ethical reasoning have been suggested and are appropriate.⁹^,¹⁰ We propose a modified version of the method described by Kaldjian and shown in Table 7-1.⁹ Kaldjian proposes a framework to organize potential ethical issues in a systematic way that mirrors the approach that clinicians take to clinical differential diagnosis and problem solving. This approach may also serve infection prevention experts well and be congruent with their daily problem solving.

Only gold members can continue reading. Log In or Register to continue