Differentiating risk imposition and precaution

In the case of the ward caring for the elderly (above) the institution can choose not to take preventive action and in so doing to allow harm (from otherwise avoidable infection) but does not directly impose risks of harm. Healthcare institutions do directly impose risks on patients and/or staff. In these cases we can differentiate risk imposition and precaution (Hayenhjelm 2012). Institutional obligations apply to decisions to tolerate or impose risks and to the degree of precaution that is taken. The use of antibiotics imposes a heightened risk of untreatable infection on others. In these cases there is an intended benefit for an individual and some small increase in risk to others. The imposition of risks associated with the use of antibiotics will be considered in subsequent chapters. In other cases risks of substantial harm are imposed on individuals in order to protect others from harm. It is these kinds of risk that are considered in this section.

Patients with infectious diseases may be placed in a discrete (cohort) area of a hospital with other patients with suspected or proven infection. For example it has become accepted practice in some hospitals in the UK to cohort patients with Clostridium difficile disease (in the same ward or area of the ward). This practice reduces the exposure of others and of the general hospital environment to C.difficile. These patients have diarrhoea and may carry microbes that have the potential to cause hospital infections (such as MRSA). The acquisition of ‘new’ hospital infections in these types of facility is well recognised. Another example comes from studies, which show that when patients are placed in single rooms (often to control the risk of infection of others), there is an increased risk that they will acquire a ‘new’ infection that was carried by the previous room occupant. In effect precautions taken to

protect the majority lead to the exposure of patients with infections to an increased risk of acquiring other infections. Patients may also suffer other types of (non-infection related) harm such as psychological or physical harm consequent upon the imposition of isolation measures (Stelfox et al. 2003; Morgan et al. 2009; Day et al. 2011).

In these examples the cohort area or single room may be designed and operated in different ways. Scanlon states that - “the cost of avoiding all behaviour that involves risk of harm would be unacceptable. Our idea of “reasonable precautions” defines the level of care that we think can be demanded: a principle that demanded more than this would be too confining, and could reasonably be rejected on that ground” (Scanlon 1998, p209). Comparability and the relevance of harms are important (Scanlon 1998, p239). The particulars of the care of patients may prevent adverse consequences to a greater or lesser extent. If the preventive

(precautionary) measures are sufficient then in actuality there may be no risk imposition attributable to the decision to cohort the patients or place patients in single rooms. In these kinds of ‘risk imposition’ cases institutional obligations to take effective precautions to prevent adverse consequences (including infection) would seem to be particularly important because the institution has imposed these risks. We all benefit through actions taken to control the spread of infection in healthcare institutions. Even so those who suffer irretrievable harm as a consequence of actions taken to control risks to others could reasonably reject a principle supporting exposure to those risk(s) if there were feasible alternative arrangements that would not impose a comparable burden on others.

the exposure of staff and others to a potentially fatal infection such as SARS. A number of healthcare staff died of SARS in several countries including Canada (predominantly following accidental exposure) (Tomlinson 2008). Staff harmed as a result of the risk imposition could reasonably reject a policy of admitting patients with transmissible and potentially fatal infections to intensive care units, but so could anyone who might need healthcare who would be placed at risk as well. Otherwise this would be an example of redistribution of burdens - in this case from the patient to healthcare workers, and potentially to other patients as a consequence of effects on healthcare staff. Many healthcare workers could potentially be harmed, and many actual and potential patients. It is hard to see how we could reject a principle requiring a hospital to ensure that healthcare workers are protected as far as possible in this kind of scenario. If staff cannot be protected from the additional risk of acquisition of a life-threatening infection in an intensive care unit then the admission of patients with transmissible and potentially fatal infection could be reasonably rejected. Reasonable rejection would come from the perspective of those immediately burdened (healthcare staff) but also from those deprived of healthcare resources consequent upon the spread of SARS amongst hospital staff and patients.

4.5 Conclusion

At the end of Chapter One I asked how we should decide the distribution of resources and the priority given to the control of antibiotic resistant microbes when resources are constrained. ‘Primum non nocere’ – first, do no harm is an adage widely taught and familiar to medical students but probably incorrectly assigned to Hippocrates (see Schwarz 2004). There is general agreement that Hippocrates did say that the physician must “have two special objects

in view with regard to disease, namely, to do good or to do no harm” (Schwartz 2004). Sometimes we cannot do ‘good’ without also risking harm and it is that tension that is the subject of the foregoing discussion. I have argued that the mitigation of risks of irretrievable avoidable harm should be given at least the same level of priority that might be given to an equivalent benefit derived from investment in diagnosis or treatment enhancement, and a higher priority than is given to conditions associated with retrievable or more trivial burdens. There are reasons derived from the relationship between the hospital and patients, which add additional weight to the economic arguments for investment in preventions of ‘avoidable infection’. A ‘reasonably avoidable’ harm is a harm for which the institution has a causal role and for which there was a feasible alternative course of action, which would have ameliorated the risk of harm. I am proposing that protecting individuals from risks of serious, avoidable and irretrievable harm to which those individuals have not consented or could not (rationally) consent is an important moral objective for healthcare institutions, and should be given at least the same priority as equivalent benefits in health improvement. An institution should intervene to prevent foreseeable harm if the intervention will save more than it costs

(releasing resources for other things), or if there is a feasible reconfiguration of services that reduce that risk without a transfer of a proportionate or greater harm to others. We could also argue that it is reasonable to try to prevent potential disasters, although the extent of this requirement needs to be further specified otherwise it could become paralysing.

We can conclude that a hospital may provide more or less benefit, but we can reasonably reject any principle that allows hospitalisation to add additional, foreseeable and avoidable harms to patients when there are alternative and feasible arrangements, which would prevent

CHAPTER 5