DURHAM, N.C. – The unique circumstances arising from the COVID-19 pandemic altered a long-held convention that doctors provide care regardless of personal risk.

In a study assessing doctors’ tolerance for refusing care to COVID-19 patients, Duke Health researchers identified a growing acceptance to withhold care because of safety concerns. 

“All the papers throughout history have shown that physicians broadly believed they should treat infectious disease patients,” said the study’s lead author, Braylee Grisel, a fourth-year student at Duke University School of Medicine. 

“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,” Grisel said. 

Publishing April 24, in the journal Clinical Infectious Diseases, the researchers analyzed 187 published studies culled from thousands of sources, including academic papers, opinion pieces, policy statements, legal briefings and news stories. Those selected for review met criteria for addressing the ethical dilemma posed by treating a novel infectious disease outbreak over the past 40 years.

Most articles -- about 75% -- advocated for the obligation to treat. But COVID-19 had the highest number of papers suggesting it was ethically acceptable to refuse care, at 60%, while HIV had the least number endorsing refusal of care at 13.3%.

The trendline stayed relatively stable across outbreaks occurring from the 1980s until the COVID-19 pandemic hit – with just 9% to 16% of articles arguing that refusing care was acceptable.

What changed with COVID? The authors found that labor rights and workers' protections were the chief reasons cited in 40% of articles during COVID, compared with only about 17%-19% for other diseases. Labor rights were cited the least often for HIV care, at 6.2%.

Another significant issue cited during the COVID pandemic was the risk of infection posed to doctors and their families, with nearly 27% of papers discussing this risk, compared to 8.3% with influenza and 6.3% for SARS. 

“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,” said senior author Krista Haines, D.O., assistant professor in the departments of Surgery and Population Health Sciences at Duke University School of Medicine. 

The authors noted that the COVID pandemic had several unique characteristics that collectively altered the social contract between doctors and patients, potentially driving changes in treatment expectations. Such factors included:

•    Shortages of resources available to care teams, including personal protective gear, hospital rooms, respirators, treatments and vaccines;
•    Polarizing misinformation about vaccines, effective treatments and how the virus spread;
•    Increased rates of reported mistreatment against staff from patients and their family members.

The authors note the ongoing debate over whether vaccination status should be considered in the decision to treat a patient.

“There was a great deal of discussion among frontline providers and ethicists on how best to allocate scarce resources,” the authors wrote. “Patients who refused vaccination were at a higher risk of complications while also putting other patients and providers at risk. 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.”

Grisel said the study’s finding provides insight regarding how care should be provided in future pandemics. What had been a fairly solid expectation that physicians were obligated to provide care despite the risks to themselves now appears to have softened. It is unclear how these results may change in the future when the pandemic is less of an active threat.  

“This study really shows how outside pressures in the sociopolitical sphere influence and affect doctors and care providers,” 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. Health care systems can learn how to mitigate these influences to ensure that hospitals are adequately staffed to meet patient needs.”

In addition to Grisel and Haines, study authors include Kavneet Kaur, Sonal Swain, Laura Gorenshtein, Chinecherem Chime, Ellen O’Callaghan, Avani Vasireddy, Lauren Moore, Christina Shin, Michelle Won, Santita Ebangwese, Todd Tripoli, Stephanie Lumpkin, Zachary Ginsberg, Sarah Cantrell, Jennifer Freeman and Suresh Agarwal.

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