Ethical Obligations of Health Care Workers During a Pandemic

Health and Healthcare CategoryThe article I posted a few weeks ago in regards to the H5N1 vaccine caused me to consider a potential pandemic and the health care workers’ obligation to work should the event come to pass.

The World Health Organization estimates that

today a pandemic is likely to result in 2 to 7.4 million deaths globally. In high income countries alone, accounting for 15% of the world’s population, models project a demand for 134-233 million outpatient visits and 1.5-5.2 million hospital admissions.

Prepare For DisasterThe romantic notion of selfless sacrifice in medicine may be the exception rather than the norm in the face of a global pandemic, which would stretch our already over-stretched resources to the breaking point. Although history has given us many noble figures in medicine, how noble will we be if we are faced with a highly virulent strain of flu to which none of us are immune, and to which a vaccine to prevent the illness might not be available until after the outbreak of the disease has already begun?

There is a precedence for this,

during the early years of the Human Immunodeficiency Virus (HIV) epidemic doctors debated whether it was acceptable to refuse to treat those with HIV; and during the Severe Acute Respiratory Syndrome (SARS) outbreak some HCW’s were not willing to treat SARS patients.

Fear is a powerful motivator. Although health care workers generally are a selfless lot, many health care workers may refuse to work during a pandemic due to fear for their own safety and that of their families. Is it ethically wrong to refuse to work if a spouse or a child becomes ill? To what extent are health care workers expected to put the welfare of others above their own, or their children’s, needs?

In the US Armed Forces, soldiers who go AWOL (absent without leave) can be severely punished, including a jail term. Can (or should) health care workers be held to the same standard, which boils down to duty to country first and personal concerns last?

I don’t have any answers to these questions. This issue will have to be addressed personally by all health care workers who are involved in direct patient care. When the time comes, we will all be faced with hard decisions.

The only thing I am sure of is that this issue should be planned for and thought about before the time comes that the notion of self-sacrifice must be put to the test.


Draper, H., Wilson, S., Ives, J., Gratus, C., Greenfield, S., Parry, J., Petts, J., Sorell, T. (2008). Healthcare workers’ attitudes towards working during pandemic influenza: A multi method study. BMC Public Health, 8(1), 192. DOI: 10.1186/1471-2458-8-192

  • Kobie

    Thanks for the article. Dept of Health and human services is having a webcast on Tuesday July 8th. at 2 pm.
    Official site:
    Avian Flu diary:

    HCW (Doctors – Nurse – EMT – Radiologists) can not always leave the germs at work. H5N! kills kids more than adults Source World Health Organizatin :

    Post early, post often and Happy 4th of July !!


  • Thanks, Kobie.
    I appreciate the heads-up regarding the upcoming event. I will definitely check it out.
    Happy 4th!

  • starlight

    The WHO’s numbers are not accurate.

    There are approximately 6.5 Billion people worldwide. The attack rate is generally predicted to be at least 30%. That would be 1,950,000,000 people infected with pandemic flu.

    If there were 1.9 billion infected and only 7.4 million fatalities, it would be a .38% case fatality rate. This is well within the limits of seasonal flu.

    The 1918 pandemic flu fatality rate was 2%. That would be the equivalent of 39 million fatalities – not 2 to 7.4 million.

    Right now the H5N1 virus has a fatality rate worldwide of over 60% – 30 times higher than the 1918 pandemic, and it could obtain the ability to transmit from person to person without losing that virulence.

  • Toby Nelson

    Bless you starlight for your realistic math. The WHO numbers don’t relate to reality.

  • Kobie


    On the HHS webcast with teh OSHA folks they did admit that 68% CFR *could* continue. This is so far beyond 1918 relm that many hesitate to mention it.

    It suprises me that people and business are not doing more. If you belive you can do something about global warming then know you can do something about the Pandemic or most any other disaster. Yes you can.

    Preparation ranges from three weeks of food at home to automatic time keeping systems so HCW do get paid. NOTE: three weeks of food has saved me money for then I buy in bulk which is cheaper and make fewer trips. The problem is rotating stock and finding dried / powdered milk and dried eggs.

    Thought of the day “Those who are prepared suffer far less than those who are not” – Kobie, me as far as I know.


  • Anonymous

    Thanks Toby, Yes, the numbers are frightening.

    So it would be 39 million dead if the pandemic virus has a 2% case fatality rate. If the case fatality rate were around 60% (which is what it has averaged worldwide) the numbers of dead worldwide would be
    1.1 billion.

    And the U.S. has approximately
    300,000,000 population
    90,000,000 infected

    1,800,000 dead @ 2% fatality rate
    54,000,000 dead @ 60% fatality rate

    I find it easier to think about the numbers in my state.

    12,000,000 population
    3,600,000 infected

    72,000 dead @ 2% fatality rate
    2,160,000 dead @ 60% fatality ate

    Unfortunately, virtually all government plans are using the 1918 pandemic fatality rate of 2% for their worst-case scenario.

    Our state could never do everything that we would want to do for each patient – even if the fatality rate were 2%. But it would certainly make a massive difference in the plans that we would make to try to care for the seriously ill and to deal with the dead.

  • starlight

    Sorry – that last post was mine.

    We have better medical care than they did in 1918, but most pandemic flu patients won’t have hospital care because there won’t be room in the hospitals. There will be a shortage of health care personnel because they will probably be infected in numbers greater than the population as a whole. Even getting adequate medical supplies will be a problem.

    Kobie is right there is a lot that we can do – as families and individuals.

    We are actually in an official “pandemic alert period” right now although that hasn’t really been made clear to the public. The alert period is supposed to be a time when people prepare for a pandemic that may come.

    One of the things that the government will try to do is called community mitigation measures – to try to reduce the number of people who become infected.

    Schools will close – government plans call for closures up to twelve weeks depending upon the severity of a pandemic.

    People who are sick will be asked to stay home and they may ask his or her family members to stay home also.

    It’s important to have a stockpile of food because it would be impossible to get to a grocery store if a family is in quarantine or isolation.

    Also it’s possible that our grocery stores won’t have food on the shelves because our transportation system may break down. People who work in that industry will be sick and it may be impossible to move gas to gas stations, and we may not get the supplies that we normally get from overseas – which is a great deal of what we consume.

    We should have nonperishable food, water, baby food, pet food, over-the-counter medication, cleaning supplies, paper products.

  • cyberbian

    You have made the argument as if this were a simple personal choice. It is not.
    Any doctor is living a privledged life. You have made a choice, and are rewarded richly for it, usually well in advance of the day you need to make good on your debt.

    You cannot simply choose to stay home, when you are needed. I surely hope that anyone who makes that choice, understands that those who remain alive do not require your further services. Your licenses should be immediately and permanently revoked. Please consider the possability before you make the selfish choice. The pool of patients will be greatly reduced once you come out of hiding. Consider all of your patients as deceased, and learn to bag groceries.

  • Kobie


    Hi. You are right – It is a choice. Some plastic surgens live the great, not just good life. However your post seems to say that medical persons have no choice regardless of the conditions.

    However – soldiers, fire fighters, dentists are not required to a life threatning situation un-protected and potentialy bring back a deadly virus that can kill the family.

    No mincing words, no suger coating. Without PPE and protection HCW could infect themselves with an air borne disese. AIDS is not airborne. Drug resistant TB is. Now imagine not one but thousands of people showing up in the ER designed to handle tens of people.

    Without planning and preparation I can not imagine how bad it will be. With planning it will still be bad but there will be guidelines, expectations, coping skills and leagel protection for HCW.

    Cyberbian you may find it interesting that HCW are required to show up but electrictians, IT staff, food workers and custodians are not. Ditto for delivery. Might be hard to work without lights, patient records, pay, food or supplies. My big concern – sewage. Water, lights, power can all be cut off but people still go #1, #2, etc. Medical waste is not to be triffled with. Those are bad working conditons for any HCW.

    BTW – preps may be harder as
    In its letter to Medline and its other U.S. customers, Hong Ray cited a long list of events and government actions that have led to its inability to fulfill its contracts. These include a fire at a major raw material manufacturer, dramatic changes in government policy impacting labor, taxes and credit and pollution-control measures associated with the Beijing Olympics.
    According to Amdur, Hong Ray’s situation is by no means unique.

    “All of our suppliers are facing enormous and unexpected obstacles in fulfilling their contract obligations,” said Amdur. “While Hong Ray is the first factory to formally declare ‘force majeure,’ other factories, including those that manufacture latex gloves, face similar circumstances. In Malaysia, for example, the government recently declared a change in pricing for natural gas, almost tripling the price overnight.”


    Cyberbian – HCW do not get an employee discount on the ICU ward which is where their family could be. Like the military, I do not want someone working on me who’s mind and heart are elsewhere. There is an ethical obligation to deliver quality service. No one can ask more than what a person can give.

    Parting quote: Henry Ford said “If you think you can or you think you can not – you will be right” If you think you can you can. If you think you can not you will stop yourself. For two years average citizens along with many governments, not just the US, have been working and testing and re-testing. All our information is on line. Feel free to get it, just please pass it along.

    The number of H5N1 cases contiues to grow. We did stop AIDS when it was but a few cases. Hope we can stopy H5N1.

    “Fear is beliving that what you can not see nor touch nor change will happen.
    “Faith is beliving that what you can not see nor touch nor change will happen.”

  • Kobie


    Good post. Yes 2% is not a cealing. Yes HHS and some other high ranking people have said it could be far worse.

    Sounds like you have a handle on the general scenario. CitiBank was suprised that they had plans for CIO, CFO, VP marketing and such but no plans to make sure ATMs where re-stocked or tellers showed up.

    BTW – Toilet paper takes up the most room to stockpile and draws the funniest looks from neighbors.

    Here is an ethical question – from the “Grasshopper and the ant” You three weeks or more food and supplies. Your brother-in-law and neighbors did not. The food is gone from grocery stores. Do you break quarentine?

    The most non-confrontational way I have found to get people talking is to print out the H5N1 chart and leave it in the break room or on a bullitin board for others to see.

    It is ethical to let people make an informed descision – feel free to quote the facts and do not hold back.

    “This little light of mine, I’m gonna let it shine” – a kids song.

  • Anonymous

    Interesting webcast. The legal triage that will speed up the courts as well as protection for health care workers was interesting.

    Yes it is HHS, not FEMA that declares a health emergency with is seperate from a normal emergency. Normal emergency? – pandemic will not be anything close to normal.

    New report issued yesterday (July 8th, 2008) : Home Health Care During an Influenza Pandemic: Issues and Resources
    HHS webiste for the original text:

    According to the webcast 7.6 million people received home health care.

    During the N.Y. Transit strike hospitals could not discharge people to home health care because home health care workers could not get to them. You guessed it – hospitals started to back up.

    During a pandemic Home health care for sick individuals is expected to rise dramaticaly to free up space.

    From the executive summary:
    “In the event of an influenza pandemic, because of anticipated shortages of health care professionals and widespread implementation of social distancing techniques, it is expected that the large majority of individuals infected with the influenza virus will be cared for in the home by family members, friends, and other members of the community ? not by trained health care professionals. Given these circumstances, home health care workers can expect to be called on to provide care for two main populations of patients:

    Those medical and surgical patients, not hospitalized because of the pandemic, who are well enough to be discharged early from hospitals to free up hospital beds for more severely ill patients.

    Patients who become or already are dependent on home health care services (predominantly elderly persons with chronic disease) and will continue to need in-home care during the influenza pandemic whether or not they become infected with the influenza virus.”




Jennifer Bunn, RN

Jennifer Bunn, RN, is a registered nurse who has been practicing for over 15 years.

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