Recognizing “duty to self” to save health worker lives

A case for updating the current Pharmacy Code of Ethics in the United States

One of the unfortunate hallmarks of the pandemic, and if I may add preventable, has been the loss of lives. We have lost individuals that were vulnerable – the elderly, those with preexisting conditions, and those unable to quarantine. In this third category were frontline workers including health workers. Last September, the World Health Organization (WHO) reported that around 14% of COVID-19 cases, and in some countries as high as 35%, are among health workers who only represent less than 3% of the population, and in low- and middle-income countries even less than 2%. It is alarming to see the disproportionate impact on health workers. And it is even more alarming to realize that most of them lacked control over their personal safety.

I have highlighted in my blog last year the harrowing and often times inhumane conditions health workers were forced to work under while not being properly protected from virus transmission. In addition, they were forced to operate below the normal standards of patient care due lack of resources and oftentimes faced disciplinary action for standing up for their rights. In that vein, I had raised the question “Does being a health worker mean that one has to give up one’s instinct of self-preservation?” In essence, what is the right of health workers to remove themselves from situations which they believe present a risk to their own life/health or the life/health of their family members and how does one fulfil these competing duties of care to themselves while also upholding the duty to care for their current as well as their future patients.

As I contemplated these questions, I was invited to speak at the Geneva Health Forum on the event of “The Year of the Nurse and the Midwife 2020 – a Catalyst for Change” with the Chief Nursing Officer of the World Health Organization, Elizabeth Iro, and International Council of Nurses (ICN) CEO Howard Catton and ICN board member, Roswitha Koch. It was an honor as nurses have been one of the most vocal members of the health care team. While preparing for the talk, I came upon the American Nurses Association's Code of Ethics for Nurses. The Interpretive Statements which were added in 2015 set a very needed perspective on how nurses had to view taking care of themselves while also providing patient care in life-threatening situations. Both obligations are set on an equal footing[1]. The nurse’s duty to self has the same priority as his/her duty to patients.

Naturally, as I have spent a majority of my pharmacy career as a community pharmacist in the United States (US), I thought of how the Pharmacist Code of Ethics (CoE) in the US was laid out. The CoE was last updated by the American Pharmacist Association House of Delegates in 1994. Its eight statements which are couched as principles only seem to lay out responsibilities and hence describe duties imposed upon the pharmacists in their interactions with others. And, even though in one statement it states that “[a] pharmacist serves individual, community, and societal needs”, it never includes the needs or the rights of the individual pharmacist. Once again, the health worker is only seen as a deliverer of service without his/her own existence, safety or health given credence.

As pharmacists we know that this truly does not encompass our everyday practice. My communications with pharmacists and news reporting during the pandemic highlighted the realities pharmacists faced. Some of the elements that jeopardized the health and safety of pharmacy staff during the height of the pandemic were lack of personal protective equipment; lack of disinfectants and sanitizers; lack of clear risk communication from leadership; non-utilization of available alternatives for reducing spread and contact with possibly infected individuals; abuse and violence; no clear protocols on sick leaves and quarantines; working while awaiting results or tested positive; and unclear accommodations for older pharmacy staff with pre-existing conditions. It was also reported that minimal proactive measures were taken to reduce spread of COVID-19 especially in chain pharmacies compared to independent pharmacies such that stores were closed after pharmacy staff was infected but proactive safeguards were not taken to prevent the spread. At times, the pharmacy was not cleaned when a store employee was sick even when that employee had worked in the pharmacy.

Needless to say, a lot of pharmacists feared for their life though they continued to provide care. Unfortunately, this pandemic is not a one-off situation. Moreover, even pre-pandemic pharmacists faced numerous situations that put their health and safety at risk. Therefore, it is high time that the rights of pharmacists were formally recognized, and pharmacists educated on how better to protect themselves.

Therefore, to give necessary attention and emphasis to that goal, we need to revisit the purpose of the CoE and make it relevant for today’s practice. It is clear that our CoE must include the duty to self. Or else, it will remain an archaic document and we would have failed not only those tirelessly serving the community today but our up-and-coming pharmacist in leaving them a sustainable workplace ingrained in decent and safe workplace practices. In fact, one wonders, if the “duty to self” had already been in the code and given an even footing to duty to patients would we have saved health workers lives.

[1] Provision 2 of the Code states that the nurse’s primary commitment is to the patient.
 Provision 5 of the Code states that the nurse owes the same duty to self as to others.