Most infectious diseases reinforce that appealing “them and us” schism that so often deludes health care professionals. They, our patients, have it, their contacts out in the world are at risk for getting it, and we, their caregivers, are safely removed from the whole thing. Not Ebola: We have met the patients, and they are us.
Many well-meaning commentators have tried to draw parallels between Ebola and the other infamous infections of the last few decades, but these analogies are not particularly valid. AIDS destroyed communities but proved minimally infective in health care settings, particularly once proper precautions were identified. Likewise tuberculosis: Doctors and nurses do contract it in the line of duty, but a vast majority of cases come from elsewhere.
Not true of Ebola, the health care virus extraordinaire. It appears minimally transmissible among humans save in settings when friends, relatives or licensed professionals care for the ill.
This pattern forces a completely new examination of health care workers’ rights and responsibilities to infected patients and to the community at large. The old generalities simply do not apply.
And in fact, those old generalities never helped much, anyway. Back in 1986, with the AIDS epidemic a mere five years old, I devoted most of an academic year to a study of the history and philosophy of doctors’ responsibilities to contagious patients. The project took so long mostly because, oddly, very little had been written about the subject, stretching back over centuries of medical practice.
Those were the days when AIDS patients were shunned in hospitals and offices by frightened doctors who just didn’t want to get involved. Those of us who did get involved were convinced that we were maintaining a proud, centuries-old professional tradition.
It turns out we were completely mistaken: There never was a coherent professional tradition of caring for contagious patients. From antiquity on, when plague descended, some doctors helped out and others quickly disappeared. “If you are asked to treat a patient with no chance of recovery,” wrote a 14th-century Italian surgeon to his students during the years of bubonic plague, “say that you will be leaving town shortly and cannot take the case.”
In the wake of AIDS, some professional organizations rewrote their behavior codes to specify that it is unethical to avoid possibly contagious patients. Nonetheless, the medical profession in its vast and varied splendor still contains those who run toward contagion and those who run away, and that is probably just the way it will always be.
But it should be understood that those who choose to run toward Ebola are running toward an entirely different set of obligations and constraints. Their choice is a laudable moral decision incorporating two mundane but inescapable facts: In the case of Ebola, caretaking is a job of the highest risk, and doctors and nurses are innately terrible at even the basics of infection control.
This second truth has been proved over and over in modern hospitals, where some infectious organisms are transmitted like wildfire from patient to patient by hospital staff members. The antibiotic-resistant staph called MRSA and the diarrhea-causing microbe C. difficile are among them.
It has taken us decades to understand the spread of these bacteria in hospitals, and to intervene with relentless policing of hand washing and use of protective clothing. For doctors and nurses, the press of other things always seems far more urgent and important than the scrubbing of the hands and orderly removal and disposal of contaminated clothing.
Still, our world has slowly evolved. No one dances through rounds in the intensive care unit anymore without a lot of hand sanitizing. We finally understand that when it comes to care-related infections, we are as much the problem as we are the solution, and all the washing and drying and dressing and undressing are simply a part of the job.
The same understanding is essential for Ebola care. Caretakers always have responsibilities to their own patients, but this infection loads them with significant responsibilities to the wider community.
The big one, obviously, is not to spread the infection. A close second is to do our best to tamp down the hysteria surrounding it.
How best to do that? Here we all appear to disagree. Ultimately, the ethicists and philosophers will have to parse out the theory, and politicians will have to sort out the specifics of quarantine. Scientists will weigh in with their careful risk assessments, always using those careful words “negligible,” “minimal” and “infinitesimal” that annoy patients so much.
But it seems to me that health care workers will do themselves a big favor by taking ownership of the situation and acknowledging that choosing to be part of the solution to this infection, sadly, turns us into part of the problem. Wouldn’t it be sensible and politic for us all gracefully to accept the fact that a terminal three weeks of limited liberty is necessarily a part of this particular job?