(319) The Duty to Treat During Pestilence and Plague: A Systematic Review

Introduction: Historically, healthcare providers have grappled with balancing obligations to self, family, and patients during deadly pandemics. While HIV/AIDS seemed to settle this issue, COVID-19 has rekindled debates about the ethics of treatment refusal. Our systematic review of ethics literature explores the duty to treat during pandemics and its evolution over time.

Methods: We conducted a mixed quantitative and qualitative systematic literature review to explore the reasons for the duty to treat during a pandemic in the United States. We searched MEDLINE, Embase, CINAHL, and Web of Science, using terms such as obligation to treat, refusal to treat, HIV/AIDS, COVID-19, and pandemics. Conducted on 10/25/2022, our search yielded 1539 articles. After duplicate removal and dual, independent screening, 187 studies met our inclusion criteria. After excluding informational articles, we reviewed and analyzed 155 articles for argument quality, ethical position, reasons given, and concepts.

Results: The top five pandemics represented in our sample were HIV/AIDS (72.2%), SARS (10.2%), COVID-19 (10.2%), Ebola (7.0%), and Influenza (7.0%). Most articles (81.9%) indicated an obligation to treat. However, this obligation varied significantly by pandemic. COVID-19 had the highest number of papers indicating permissibility of treatment refusal (60%, p=0.0001), while HIV had the least (13.3%, p=0.026). Ebola, SARS, and Influenza had a similar level of refusal, ranging from 16.7-25%. During the 2020 decade, 56.3% of papers concluded that refusal was acceptable, compared to 9.1% in the 2010s. We identified twelve ethical reason domains. Several reasons were significantly different during COVID vs other pandemics, including unreasonable risks to self/family (26.7%, p=0.0001) and labor rights (40%, p=0.0001).

Conclusions: During the COVID-19 pandemic, ethical arguments surrounding care provision have evolved significantly. A surge in ethics literature has advocated for the ethical permissibility of treatment refusal, mostly due to labor rights and risk to self/family. A systematic review helps to understand the evolution of clinical ethics over time. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic.