The Ebola virus disease (EVD) crisis affects emergency physicians working both domestically and abroad, particularly those returning to U.S. soil after serving in an endemic area.  Emergency physicians who have been exposed to Ebola patients may find themselves in the crosshairs of the debate over individual health care worker (HCW) rights versus HCW responsibilities. What follows is a discussion of some of the issues on each side of the debate.

Pro: Individual HCW/EP Rights Come First

Most EPs would hope that their individual liberties would be upheld before, during, and after caring for patients with EVD or other infectious diseases. Before caring for such patients, it is a reasonable expectation that processes and procedures (including access to training) that protect professional EP interests would be in place locally and nationally. Similarly, proactive policies must be in place to protect the interests of trainees and students who are, in some cases, paying for the privilege of a professional education. Junior doctors, in particular, should not be put in the line of fire when senior faculty and attending EPs have more experience in caring for high-risk patients. Proactive policies should restrict residents from working with highly contagious diseases (in either a research or clinical capacity) without advanced training and immediate faculty backup. Local policies that protect vulnerable providers from specific infectious agents (eg, pregnant physicians from TORCH [toxoplasma, other viruses, rubella, cytomegalovirus, herpesvirus]) should be considered when an ED has multiphysician coverage or a backup plan that does not put patients at imminent risk.

During an encounter with a highly contagious patient or a patient deemed to be at substantial risk, EPs have a right to safety. The workplace should provide adequate security, materials, and equipment (eg, personal protection equipment [PPE]) as well as adequate space (isolation rooms, etc.) to care for the contagion. While ED boarding and overcrowding can seem antithetical to these goals of isolation and provider safety, EPs and other HCWs have legitimate rights to be safe from hospital-based or prehospital harms.

After caring for patients at high risk, EPs should continue to have their interests protected. Those taking exposure risks on the frontlines should not suffer discrimination nor should they risk loss of employment or income. Unlike what happened in the widely publicized case of a New York City EP who returned from working with EVD in Guinea, EP privacy and confidentiality should be protected. The fear-mongering media have rights also, but freedom of the press should be subordinate to the privacy interests of providers and patients alike. Furthermore, physicians working on the frontlines of outbreaks of Ebola or related diseases should not be incarcerated or subject to baseless quarantine policies, especially when such policies are motivated more by political interests than by science.

Con: Individual Rights Are Subordinate to Public Health

While individual rights to life, liberty, and the pursuit of happiness are fundamental freedoms for all American citizens, these freedoms aren’t entirely free. Indeed, every right carries with it parallel obligations, duties, and responsibilities.

The aforementioned rights to a safe workplace imply that individuals will contribute to that safety through proper hygiene, hand washing, use of universal precautions, engaging in training, and adherence to biosafety guidelines (including the proper use of PPE, isolation facilities, and barrier protection when indicated).

While individual EPs certainly have a right to do what they wish on their own time (within the limits of the law), they cannot refuse to come to work when scheduled. To do so would undermine any vestige of professionalism and potentially place patients, colleagues, and the public health at risk. Opt-out policies for trainees do not extend to fully credentialed EP attending staff.

If people voluntarily choose to help in West Africa, they must understand that the assumption of individual risk does not give them license to burden others or put others at risk. EVD disproportionately affects HCWs; half the physicians in all of Liberia are now dead, and 38% of EVD cases in Guinea are HCWs. The current Zaire strain of Ebola, responsible for the current epidemic, is especially lethal, carrying an 89% case fatality rate. Given that there is no effective treatment, this risk is not trivial. For this reason, EVD was declared to be a public health emergency of international concern by the World Health Organization on Aug. 8, 2014.

We can and should support the many brave EP colleagues who are generously volunteering in the global war on EVD. However, we should enlist and support those soldiers who understand that courage is the Aristotelian mean between foolhardy, cowboy, or carelessness on the one hand and self-concerned, cringing, or cowardice on the other. Courage is a classic virtue of antiquity and remains so in the fight against poverty and tropical disease to this day.

As educated professionals, EPs should be allowed to assess their own risk, but EPs must understand they may become liable if their risk assessment is reckless or inaccurate. EPs must take their guardianship of the public trust seriously. Often missing from the current discussions is the medical fact that EVD patients are typically infectious in the hours prior to developing fever. Furthermore, they remain infectious for weeks, even after symptoms subside (eg, EV has been isolated in semen 80 days after infection). Hence, an exposed EP cannot know for certain if they are infectious until adequate incubation time has passed after exposure.

While self-monitoring for three weeks is recommended after potential exposure, there is no evidence to support a 21-day quarantine. Hence, evidence-based EPs may readily dispute the need to follow laws in Connecticut, New York, and New Jersey that mandate such quarantines. However, we have no countervailing evidence to suggest what is the safe length of time to be in quarantine, self-imposed or otherwise.

The EP duty to promote the public health is part of the ACEP Code of Ethics. The 10th Principle of Ethics for Emergency Physicians states that EPs shall “support societal efforts to improve public health and safety.” This would include macro-level EP duties to the overall community as well as a duty as citizens to submit to public health authorities and the extant laws of the land. In some cases, this includes the duty to accept quarantine and to help quarantine others at risk.

Similarly, EPs are not above public health reporting laws. Certain communicable diseases (like hemorrhagic fevers) must be reported to public health authorities under the law. While discrimination must be eschewed, responsible reporting must be encouraged.

EPs also have micro-level duties to individual patients. As with the early days of the HIV epidemic, ACEP policy underlines that EPs care for all patients; this is not a selective duty. The second Principle of Ethics for Emergency Physicians states: “EPs shall respond promptly and expertly, without prejudice or partiality.” The first and most important principle in the ACEP Code of Ethics enjoins EPs to “embrace patient welfare as their primary professional responsibility.” Opt-out polices or calling in “sick” on the basis of contagion would be unethical as we owe a duty to every patient, including those with EVD.

Indeed, EPs who live out these principles and respond with courage to Ebola and similar public health crises must ultimately be honored as heroes, not vilified as vectors.

Dr. Larkin is Lion Foundation professor and chair of emergency medicine at the University of Auckland in New Zealand. Dr. Bookman is associate professor of emergency medicine, medical director, and the director of the electronic medical record for the department of emergency medicine at the University of Colorado School of Medicine in Aurora.