Right of patients to confidentiality

One of the core principles of medical ethics is confidentiality. The Hippocratic Oath and the various codes of medical ethics derived from it including that of the Nigerian Medical and Dental Council, emphasise that the patient has the right to confidentiality and privacy even after they have died.9 ,10 The principle that a patient's medical information including his/her identity remains undisclosed is usually balanced with situations in which a discretionary breach of confidentiality is necessary in order to protect the community from imminent danger.11

During the EVD outbreak in Nigeria, perhaps because of early confusion, panic and a desire to demonstrate that the situation was being addressed, the name of the index case together with his status and the fact that he had dual nationality was freely provided to the media. The hospital where he was being treated was also identified. One could argue that the public deserves to know, but what about the effects on the patient, his relatives and the hospital? Furthermore, the names of cases and their contacts in Lagos and Port Harcourt as well as the names and locations of health facilities and even churches visited by these people were also freely released to the media. This breach in confidentiality created challenges for the contact tracing and social mobilisation units of the response teams. This public disclosure of names is unethical, not in anyone's best interest and often detrimental to containment efforts.12 This is because people are unlikely to seek care or cooperate with surveillance teams if they believe that their personal details will soon become public knowledge. The experience of the epidemiology and surveillance teams during the outbreak was that some contacts who had been so ‘exposed’ became hostile to the contact tracing teams supervising their 21-day quarantine. In addition, new contacts were reluctant to cooperate with the surveillance teams and it took a lot of effort by the contact tracing and social mobilisation teams to convince them otherwise.

The doctor who treated the Port Harcourt index case was reported to have secretly cared for the patient in a hotel room. This doctor was publicly identified and vilified by government authorities and the broadcast media. His actions were interpreted as being malicious and deliberately intended to spread infection. In retrospect, would it have been possible to inform the public of the incident without necessarily identifying the doctor by name? Consideration should have been given to his family including his 3-month-old son who may in later life be stigmatised for the apparently unethical behaviour of his father. The custodian of medical ethics, the Nigerian Medical and Dental Council, in its outrage was reported to have openly compared this doctor to traditional healers who are often deemed unprofessional and unethical.13 This statement accused the doctor without hearing his side of the story, as dead men do not talk, and also disparaged our traditional medical practitioners.

As response progressed, lessons were learnt about the management of personal information such that personal details were no longer mentioned during the daily debriefing meetings at the response centre or during press briefings. In addition, media personnel were continuously reminded to report EVD issues ethically. Those identified as cases and contacts were also reassured of confidentiality.

Stigma

This outbreak and the response to it raised a lot of stigma-related issues. Stigma raises stress levels in an already very stressful situation, and may also increase exposure to risk and reduce access to protective interventions.14 Some staff at the mortuary where the doctor was taken when he died, experienced this first-hand. Some were evicted from their homes and ostracised by their community leaders, while their wives faced rejection in markets and public places. After their 21 days of quarantine, some of them publicly celebrated by carrying placards stating that they had survived Ebola, apparently in an effort to fight stigma. Some contacts of confirmed EVD patients were so stigmatised that local vendors refused to sell them food.

Psychosocial and social mobilisation teams working with the emergency response units held community meetings and face-to-face discussions to resolve stigma issues. A team of three to five personnel met leaders and members of the community. This allowed correct information about EVD transmission, signs and symptoms, incubation periods, quarantine, surveillance, prevention and the dangers of stigma to be shared and easily understood. The concerns and fears of community leaders were listened to and resolved, and their commitment to stop discrimination against EVD cases and contacts was secured. Gaining the trust of some communities proved challenging. However, the presence of members of the social mobilisation team who knew the language and culture of the local people helped to overcome this problem. Face-to-face discussion was another strategy used with individuals living in the same areas as cases and contacts. This involved the identification of relevant households, and the training and deployment of personnel to instruct all household members on EVD.

Non-maleficence

The principle of non-maleficence made popular by Beauchamp and Childress15 ,16 includes the doctrine of ‘primum non nocere’ (first do no harm). During the initial panic and confusion in the early phase of the EVD outbreak, the possibility of using experimental drugs was raised. The probable success of the experimental drug ZMapp, used to treat two Americans who had contracted EVD in a West African country, made headline news. However, since this and similar drugs were not yet licensed or available for public use, the WHO convened a meeting of experts in ethics who discussed and then sanctioned the use of experimental drugs to treat EVD.17 ,18

Soon after these WHO recommendations, the Nigerian government announced that they had obtained access to an experimental drug donated by a Nigerian doctor living abroad.19 This was probably intended to show that the government was in control of the situation and to calm widespread fear and panic. However, it was soon revealed that the experimental drug, Nano Silver, was in violation of the USA Federal Food, Drug, and Cosmetic Act,20 with some groups claiming that it was actually a pesticide.21 The government quickly retracted its earlier statements and distanced itself from the drug.22 If not for the diligence of some groups, a potentially dangerous drug might have been used to treat Ebola patients in Nigeria with possibly disastrous consequences. This highlights the importance of the involvement of government regulatory agencies such as Nigeria's National Agency for Food and Drug Administration and Control (NAFDAC) in decisions on controversial drug treatments.

Dignity of persons

It is a well-established ethical principle that the dignity of patients be maintained at all times. Again, in the initial confusion and panic, healthcare workers were infected before facilities were brought up to standard. However, a new isolation unit was soon established where patients were now managed. Also, in the initial stages very few doctors in Lagos were willing to treat patients.6 However, within a few weeks, volunteer healthcare workers had been provided with personal protective equipment (PPE) and trained in the care of patients. This training was facilitated by members of Médecins Sans Frontières (MSF) and WHO teams, and covered infection prevention practices in treatment centres, the use of PPE, and EVD patient care. PPE and other resources were also procured for all staff working in case management. This led to improved care and contributed to the successful containment of EVD in Nigeria.

Obligation of healthcare workers to provide care

This ethical issue was addressed by Yakubu and Folayan.8 While the health worker has an obligation to provide care, he or she must also be trained and properly equipped to provide this care. Indeed, the doctrine of ‘first do no harm’ applies to both the patient and the health worker.

Healthcare providers must be supplied with suitable equipment and trained to deal with hazards encountered in the line of duty. In the early stages of the outbreak, the fear of many health practitioners was obvious. There were reports of private and public health facilities refusing to attend to patients with fever and or admit any patients at all.23 To address this problem, the response team improved training in infection prevention and control (IPAC) for private and public health practitioners and opened triage centres specifically for EVD referrals. IPAC training consisted of 1 day of instruction to provide healthcare practitioners with the knowledge and skills to identify, isolate and notify cases of EVD while staying protected. Simple measures like maintaining a 1 m distance from patients, history taking focused on EVD, having a holding area within the facility, knowing how to disinfect with hypochlorite solution, and the use of gloves and other general PPE, was emphasised. Two triage centres were equipped and opened in tertiary health facilities. These functioned as reference centres to which health practitioners could transfer patients suspected of having EVD for further assessment by the Ebola response team; patients were then either put under surveillance or transferred to the treatment facility. These measures greatly helped to allay the fears of health workers and ensure continued health service delivery at public and private health facilities.