December 2014 | ISSUE 15
Laying your life on the line: a doctor’s duty?

Earlier this year, Dr Stella Adadevoh, a Nigerian doctor sacrificed her life to stop the spread of Ebola in Nigeria. Her acute clinical judgment and steadfastness meant that the Ebola outbreak in Nigeria infected only 20 people, killing eight. Nigeria was declared free of the virus in October 2014, two months after her death.

LKCMedicine Vice-Dean for Clinical Affairs Associate Professor Pang Weng Sun said, “Dr Adadevoh’s dedication to the science and art of medicine is indeed exemplary.”

He added, “But are doctors and other health professionals obliged to risk their lives to save and heal others? Does the patient’s best interest override the clinician’s interest beyond the point of self-preservation? The line is grey and clinicians invariably take calculated risks in difficult situations like this.”

Dr Adadevoh joins a long line of doctors who have given their lives to save others. Before the age of modern medicine, being a doctor was a risky business. Illnesses, such as tuberculosis, decimated populations. And healthcare workers were often among the first casualties.

“We’ve been spoilt by the relative safety in which we’re working,” said LKCMedicine Lead for Infectious Diseases Associate Professor Lim Poh Lian, who also heads the Department for Infectious Diseases at Tan Tock Seng Hospital (TTSH).

“But if you’re scared of the heat, don’t enter the kitchen. When we take the Hippocratic Oath, we accept a responsibility to do our duty and that is to care for the sick,” she added.

LKCMedicine Professor of Infectious Diseases Annelies Wilder-Smith agrees. Facing an outbreak, such as the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, is a testing time. “But you just get on with the job. Of course you’re scared, especially during the initial days when you don’t know what you’re dealing with. But once you get through that and your infection control measures are in place, you get a sense of control,” she said.

During the SARS outbreak, doctors at TTSH faced heavy responsibilities. Once the hospital had been designated as the national SARS centre, any individual with a suspected SARS infection was admitted. During the initial months of the outbreak, doctors had to make clinical decisions without the confirmation of a diagnostic test about whether to admit a patient to the SARS group ward.

“So you had to make a lot of clinical judgment calls. It was a huge responsibility,” said Assoc Prof Lim, who was a consultant at TTSH at the time.

Throughout the early weeks of the outbreak, clinicians had to rapidly piece together information to make sure that how they defined the illness, who was deemed at risk and how they treat patients took into account all the latest developments.

“Right at the outset, one school of thinking advocated giving ribavirin, a toxic antiviral that is used for Respiratory Synctitial Virus (RSV) and Lassa fever, because SARS seemed similar. But very quickly, in vitro evidence emerged to show this wasn’t the case. So it was important to keep the science at the heart of our actions, and not rush in blindly,” said Assoc Prof Lim.

But Dr Adadevoh wouldn’t have succeeded without the unwavering support of the healthcare system as a whole. “It is not only the frontliners, but the entire health system that has to come together to deliver care in the safest way while taking into consideration both society and healthcare workers. Kudos to the healthcare system that stood by her,” said Assoc Prof Pang.

Healthcare systems and authorities also have a duty to protect healthcare workers. “The healthcare system has to learn to eliminate unnecessary risk and deaths by providing the right structure, equipment and protocols, so that healthcare professionals can get on with their job,” said Prof Wilder-Smith.
What made this instance stand out is that Dr Adadevoh’s decision did not just affect the wellbeing of one patient. The highly contagious nature of the disease meant that her decision would affect the whole community. By keeping that one patient in hospital, even if it was against his wishes, she prevented the disease from spreading uncontrollably.

During times of crisis, doctors’ privileged position in society heightens their responsibility and the potential implications of their decisions. They have to weigh up an individual’s needs and rights, such as patient confidentiality, against the needs and rights of society as a whole.

One of the many changes that followed the SARS outbreak in Singapore is that taxi receipts now include the license number of the taxi. This was introduced after a SARS patient took a taxi from the airport to the hospital. With no further information about the driver, the medical team was stumped as to how to find him. They even considered publishing a photo of the patient in national newspapers to help locate the driver.

For Assoc Prof Lim, being a good doctor during outbreaks comes down to fulfilling your duty to patients by thinking clearly and doing the best you can; to your colleagues by turning yourself in if you have become infected; and to society by providing clear information about what’s happening to give people confidence.