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PUBLIC HEALTH ETHICS VOLUME 3 •NUMBER 1 •2010 •23–34 23
Non-Professional Healthcare Workers and
Ethical Obligations to Work during
Pandemic Influenza
Heather Draper∗, Tom Sorell, Jonathan Ives, Sarah Damery,
Sheila Greenfield, Jayne Parry, Judith Petts and
Sue Wilson, University of Birmingham, UK
∗Corresponding author: Centre for Biomedical Ethics, Primary Care Clinical Sciences, University of Birmingham, Birmingham B15 2TT,UK . Tel.: +44(0)121
4146941; Email: h.draper@bham.ac.uk.
Most academic papers on ethics in pandemics concentrate on the duties of healthcare professionals.Thispaper
will consider non-professional healthcare workers: do they have a moral obligation to work during an influenza
pandemic? If so, is this an obligation that outweighs others they might have, e.g., as parents, and should such an
obligation be backed up by the coercive power of law? This paper considers whether non-professional healthcare
workers—porters, domestic service workers, catering staff, clerks, IT support workers, etc.—have an obligation
to work during an influenza pandemic. It uses data collected as part of a study looking at the attitudes of healthcare
workers to working during a pandemic to suggest the philosophical arguments explored. These include: being in
a position to do good, the ethics of work, competing obligations to family members and in particular to children
and the obligations of citizens in a state of national emergency. We also look at whether compulsory measures
are justified to support a national health service during a health emergency. We conclude that even if they are,
compulsion should not be restricted to non-professionals who happen to be working in the health service at the
time. Rather, compulsion involving a larger pool of people with the relevant skills and abilities is more equitable.
Introduction
The potential seriousness of an influenza pandemic, in-
cluding the strain it will place on health services world-
wide,iswelldocumented(Meltzeret al., 1999; World
Health Organization, 2005; The Public Health Agency
of Canada, 2006; Cabinet Office and Department of
Health, 2007; Commonwealth of Australia, 2008). Front-
line healthcare professionals may be at greater risk of in-
fection than the rest of the community, and they may
choose not to work because they perceive the risk to
themselves and their families of working to outweigh
their normal obligations to protect the interests of their
patients. Some jurisdictions have enacted policies that
will compel healthcare professionals (Coleman, 2008)
and other workers (Martin, 2009) to work during a
pandemic.
The World Health Organization (WHO) counsels that
compulsion may have human rights implications, and
that any such policies must take account of the risk of
working, be fairly implemented and have a clear appeals
process (World Health Organization, 2007). Ruderman
et al. (2006) argue for public debate leading to clear guid-
ance to healthcare professionals, but such guidance may
leave individuals to decide for themselves whether to
work or not according to their personal circumstances
and perception of the risks, as events unfold. For in-
stance, the UK General Medical Council (2008) say:
...in an emergency, wherever it arises, you must
offer assistance, taking account of your own safety,
your competence, and the availability of other op-
tions for care. In a pandemic this means that you
may work outside your normal field of practice,
either in providing care to patients with influenza,
or patients with other conditions. (Our emphasis)
What about non-professionals? AsReid (2005: 354) notes,
they
...face a common risk and burden of psycholog-
ical distress, and face them with relevant moral
dilemmas. Indeed some of them face these dilem-
mas with less luxury of choice, less economic
and social reward, less information and hence less
safety derived from information than the doctors
doi: 10.1093/phe/php021
Advance Access publication on 1 October 2009
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24 •DRAPER et al.
Figure 1. Interventions that ancillary and clerical respondents indicated may increase their likelihood of working during a
pandemic.
whose moral obligations bioethicists have tradi-
tionally sought to define.
In the UK National Health Service (NHS), non-
professional healthcare workers account for nearly half of
the workforce ( NationalHealth Ser vice, 2006). They pro-
vide clinical and clerical support; administration; hotel
and domestic services; buildings and maintenance ser-
vices, etc. Many have roles that will be as vital as those
of doctors, nurses and other professional groups in a
prolonged healthcare crisis like pandemic influenza. The
arguments used to support a professional obligation to
work during an emergency—the very choice of profes-
sion and the social contract that legitimises a profes-
sion and is grounds for self-regulation (Ruderman et al.,
2006)—seem inapplicable to non-professional health-
care workers.
We conducted a study in the UK looking at healthcare
workers’ attitudes to working during pandemic influenza
(Draper et al., 2008). The study had two phases. We ran
focus groups and interviews with a range of different
healthcare workers organised according to their vari-
ous employment categories. The themes that emerged
from these (Ives et al., 2009) were then used to in-
form a survey (Damery et al., 2009). Two of the fo-
cus groups consisted of non-professional—ancillary and
clerical (A&C)—staff: administrators, cleaners, kitchen
workers, lab workers, mortuary attendants, porters, etc.
In this paper, the findings from the A&C focus groups
and survey responses inform our discussion of whether
non-professional healthcare workers have a duty to work
during an influenza pandemic.
Taking into account the views of the A&C workers
allows us to consider the possible success of interven-
tions that stop short of compulsion, and that may incline
them to work. For instance, A&C participants expressed
concerns about how they would get to work if there was
disruption to public transport or fuel shortages; or, if
they had children, how they could work if schools were
closed. Planners might reasonably surmise that if these
problems could be solved, obstacles to working would
be removed. For example, if planners provided trans-
port to and from work; made arrangements for employ-
ees to work at an alternative healthcare facility nearer
their home; or, encouraged flexible working so that par-
ents could juggle childcare between themselves, or enable
other family members or friends to help. However, our
survey results indicate that these solutions may not in
fact increase the likelihood that A&C workers will report
for work (see Figure 1). Perhaps these kinds of obstacles
to working cannot be understood solely as practical is-
sues that can be resolved with pragmatic solutions. If the
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NON-PROFESSIONAL HEALTHCARE WORKERS ’ DUTIES •25
problems are motivated beneath the surface by fairly deep
moral concerns, which cannot be addressed by practical
measures, finding a solution to these concerns requires a
form of practical moral dialogue (Ives and Draper, 2009)
between the employer and the employee, in which ethical
demands are considered in the context of the pre-existing
values and circumstances of those whom we wish to per-
suade to work.
We suspect that concerns about working were rooted
in the perception that working would require parents to
give less priority to the needs of their own sick children, or
to settle for unsatisfactory childcare in a time of height-
ened health risks. These perceptions are not addressed
by traditional codes of conduct for healthcare workers,
which are concerned with disregarding risk to self for the
sake of patients. For example:
When pestilence prevails, it is [physicians’] duty
to face the danger, and to continue their labors for
the alleviation of suffering, even at the jeopardy
of their own lives (American Medical Association,
1847).
The writers of this eighteenth-century code probably
only envisaged male physicians, and were not much
preoccupied with childcare. Nonetheless, there would
likely be little support today—inside or outside health-
care institutions—for a campaign that urged staff to care
less for their children. This does not mean that there is no
duty to care for the sick, but that there is no duty to put
the care of the sick ahead of serious concerns for one’s
children.
Skills that are Scarce and Widely
Needed Create Special Obligations
for those who Possess them
The special skills that enable healthcare professionals to
aid the sick are often thought to justify a strong obli-
gation to provide care in a time of emergency (Clarke,
2005). Healthcare professionals have abilities others lack,
abilities that are particularly likely to do good, and so
healthcare professionals have strong obligations to ex-
ercise these skills when they are needed. But the ability
of these professionals to exercise their skills effectively
depends partly on the support of those working in non-
clinical and/or non-professional roles. This was recog-
nised by our A&C focus group participants:
A1P1: if ...he [another participant] decides not to
come in because he’s frightened...that’s the pro-
curement line stopped, so we are not getting the
drugs or the linen packs. If the ancillary staff, the
domestic staff and the porters don’t come in, then
there is no rubbish being moved, there’s no linen
packs being moved around the hospital, there’s no
cleanliness ...we still have to run the day-to-day
operations of the hospital, and we still have to be
a financially viable institution after a pandemic,
so 4’s [another participant] role is important for
that.
Providing this support to clinical colleagues is something
in which the A&C workers are trained and are arguably
best placed to do, especially in times of crisis. This spe-
cialised ability is something they have in common with
healthcare professionals. They understand the way their
healthcare facility works, e.g., its IT systems. They know
the clinical staff, and they know what is required in each
of the clinical areas that their various roles support. It
is true, important and a point to which we will return,
that this specialised skill and ability is not as hard for
others to acquire as some other professional skills are.
In that sense, there is potentially a wider ready pool of
people to fill these roles than the professional ones. But
non-professionals in post when a pandemic breaks out
nonetheless possess skills that are in heavy demand. Ac-
cordingly, at least in the short term, they are arguably
under a special obligation to exercise those skills. A ver-
sion of a ‘can implies ought’ principle applies. As our
participants put it:
A1P2: I kind of feel about it that same way as if
I saw someone get knocked down by a car, I’d go
and help if I could.
A1P9: I am agency staff but I don’t feel any differ-
ent. If I’m of use then there’s no point me sitting
around redundant ...
However, the duty of beneficence is what Kant (1991: 197)
called a ‘duty of wide obligation’: there are many ways in
which a person can meet it, and some discretion for the
agent in choosing the means by which it is met. Perhaps
an agent will choose to help family before strangers if he
cannot help both; or perhaps he will give to a charity for
the extremely poor as opposed to a charity for orphans.
There is no saying that in making one choice rather than
the other, he fails in his duty of wide obligation, or does
something wrong. In these cases the ‘can implies ought’
principle does not give determinate guidance; and in
the case of pandemics it may not necessarily oblige non-
professionals to work. Moreover, acting beneficently may
be regarded as supererogatory where the costs of doing
so are great. If this is right, then it may be supererogatory
for healthcare workers to risk their lives (or those of their
family members) in carrying out their jobs.
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26 •DRAPER et al.
Risks to Self
Not all those who work in non-clinical roles will be at a
particular risk, as some jobs do not require contact with
patients, and some roles are compatible with working
from home. Some A&C staff work in such clinical areas
that will not be expected to deal with influenza-affected
patients. This is not to say that there will be no risk
of catching the virus, but rather that it would not be
any greater than being anywhere else in the community
during the pandemic. This was recognised by some, but
not all, of our participants:
A1P1: ...for me there’s as much chance of catch-
ing it from Mr G’s—the local corner shop—or the
gangway of a day life shopping in the supermarket
as ... because I am as close proximity to people
walking down the streets in [place name removed]
or whatever as I would be in hospital.
For these kinds of workers, then, there seems little per-
sonal cost in applying the duty to help because one can.
For those working in close proximity of infectious
patients—and this applies only to certain kinds of non-
professional healthcare workers, e.g., ancillary nursing
staff, phlebotomists, ward clerks—the risks of infection
would be greater. It is not yet clear how great this risk will
be, and not just because we will not know until a pan-
demic begins what strain of virus we are dealing with.
The actual risk also depends upon the availability and ef-
ficacy of vaccination, prophylaxis and personal protective
equipment (PPE) (as well as training in its correct use,
and compliance with training). If, for example, effective
PPE is widely available and used correctly, the risks may
be reduced to a level that does not justify a refusal to help.
Finally, there are workers for whom the possibility of
infection poses a greater than normal risk to health.
A2P5:AndI’manasthmaticaswell,sothat’ssome-
thing else I’ve got to think about. If I was in that
situation, if I did come down with flu I would be
more likely to contract complications. So I would
be very worried about coming to work.
For individuals like these, other things are not equal. The
effects of catching the virus are worse for them than for
others, even though their risk of infection is the same as
everyone else’s. During a pandemic, health services are
likely to be so stretched that some kind of treatment ra-
tioning will be inevitable. This means that some people
who in normal times would be treated and survive will
die because the treatment they need will not be available
to them. This is an important consideration for those
who are at a particular risk of complications arising from
a respiratory infection such as influenza. For such indi-
viduals, there will be a cumulative cost of offering aid.
Risks to Family Members
Risks to family can be mitigated. The use of PPE reduces
the risk of ‘taking the virus home’. Likewise, changing
clothes and showering before leaving work, and even vol-
untary quarantine at work, will reduce the risk to families
of healthcare workers engaged in this work. These mea-
sures are only a partial solution, however, and will not
fully guard against A&C workers becoming ill and trans-
mitting the virus to their families. Further, while these
measures may be perceivedto be effective in normal times
(to mitigate ‘usual’ risks), they may not be perceived as
being effective against pandemic influenza, given that an
influenza pandemic is likely to be accompanied by media
hyperbole about its dangers.
Some of our non-professional participants suggested
voluntary quarantine as a solution to the problem of
bringing the virus home.
A1P6: You’d have to [stay at the hospital], you
couldn’t take it home ...I mean I’ve got two small
children, I wouldn’t go home if I knew I’d been in
contact with it cause it would be ... what would
make me ill would probably, you know, be termi-
nal for them.
A1P1: I mean I per ...I mean I’m in a relationship
with my girlfriend but we don’t have children so
for me its probably not as big a worry, although
we do mix with extended family who have young
children, and if it got to the point where its like
one in five are dying then I’m there doing my
best, I mean like [names another participant] said
earlier, I’d wanna be isolated ... I’d want to have
somewhere to stay around the hospital site where
I wasn’t gonna impact on my family.
A1P2: To be honest I’d prefer to stay here [the
hospital] because my other half is a police officer
and if I was to pass it to him and then it goes
around ...
These sentiments were not, however, confirmed by the
survey results. Being provided with accommodation
had little impact on respondents’ reported likelihood of
working (Figure 1). Was this a reasonable response?
There are considerations on both sides. Voluntary
quarantine undoubtedly adds considerably to the cost
of helping (both to the individual and his/her family).
The pandemic is likely to strike in waves of around 15
weeks. This is a long time to be deprived of a family life,
and a long time for some families to have a significant
member away. Besides, voluntary quarantine will cause
greater hardship for some families than others. Lone
parents, for instance, or families with children where
both parents work in the health service will be particu-
larly badly affected. On the other hand, long absence is
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NON-PROFESSIONAL HEALTHCARE WORKERS ’ DUTIES •27
sometimes a cost of meeting an emergency. Perhaps be-
ing tied to hospital housing is comparable to absence
through conscription in wartime. Conscription was not
considered an unreasonable cost to families or conscripts
during World War Two, for instance. We will return to the
question of whether pandemic calls for measures similar
to war measures.
Not being able to Care for Sick Family Members
Different costs for non-professionals arise when family
members or their own children fall ill. Would the obli-
gation to work override the obligation to care for a sick
family member? Here, the obligations of care might not
be met simply by a guarantee of someone to look after
the family member. Instead, the obligation may be felt as
one of providing this care oneself, particularly in the case
of parents and children. In these cases, it is not clear that
obligations to family members can be either discharged
or mitigated by the facilitation of voluntary quarantine.
Given that non-professional workers can be thought to
have no overriding professional duties to care for pa-
tients, as is sometimes argued in the case of professional
clinical practitioners, further justification would be re-
quired for any measures that required them to put the
obligation to help others above their (morally serious1)
obligations to family members. One general justification
may be drawn from the special obligations citizens may
have in emergencies.
Duties in a National State of
Emergency
An emergency is a situation in which there is an immi-
nent threat to people’s lives or, short of this, a signif-
icant threat to people’s well-being—and a need to act
swiftly and decisively to remove the threat or minimise
its effects. Public emergencies are threats to whole pop-
ulations. Governments have special responsibilities to
confront emergencies, and doing so calls for at least two
things—a general division of labour corresponding to the
distinct kinds of dangers that an emergency poses, and
the development of routines that make responding to the
dangers second nature to those involved in that division
of labour (Sorell, 2003). In normal times, several emer-
gency services operate to confront emergencies that usu-
ally pose localised threats to limited numbers of people.
In general emergencies—all-out war is an example—the
emergency services may have to be supplemented by the
effort of ordinary members of the public, or, in the in-
termediate case, by trained groups of reserve personnel.
It is against this background that the widely recognised
special responsibilities of professional healthcare work-
ers (as opposed to non-professionals) can be understood.
Not only do these people have skills that are useful in an
emergency, but also they are typically identified in nor-
mal times as having a role to play in emergencies, and
they go through explicit drills and engage in planning
so as to be able to play their role effectively in an actual
emergency.
Emergencies can typically also be associated with the
curtailment of at least some civil liberties, justifying con-
scription (but not the right to conscientious objection)
to the armed forces, restrictions on the freedom of move-
ment (quarantine, curfew, travel across certain borders,
etc.), triage and other forms of rationing, censorship and
so forth. Both the emergency itself and the response to
it are likely to disrupt normal life in many ways. Emer-
gencies may also entail more exacting moral demands, so
that acts that would normally be supererogatory become
obligatory. Citizensmay be expected to behave differently
and may expect more of themselves as a result. Emergen-
cies may, therefore, change the way in which the costs to
individuals of helping where they can are calculated.
Pandemic influenza currently tops the UK Govern-
ment’s National Risk Register. This means that it is re-
garded as the gravest probable threat to national security
at the present time (Cabinet Office, 2008). An outbreak
is therefore likely to constitute a national emergency.
In our focus groups, participants talked about every-
one pulling together at a time of crisis:
A2P6: I think when you work in the NHS you feel
as though you’ve got an obligation ...
A2P4: Yeah
A2M: Yeah
A2P6: ... for the public anyway because ...
service ...
A2M: Yeah
A2F: Yeah
A2P6: you’re actually in the health
A2P3: Of course you have
A2P7: So if you’re getting people out of the com-
munity who are becoming ill, they’re coming to
you, whichever department you’re in, if everyone’s
together
A2P6: Yeah, it’s our job
A2M: Yeah That’s our job
A2P7: It’s our job to look after people and provide
aservice
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28 •DRAPER et al.
A2P6: If the health service breaks down ...
A2P4: That’s it, isn’t it
A2M: That’s it
A2P6: We’re finished
A2P7: Forget it, you know ...If we all stay at home
then that’s it, the country will just collapse
A2P4: Yeah.
Pulling together may also mean working in different
roles:
A1P1: It’s ... its ... if a third of the domestic
cleaning staff went off and they needed someone to
help clean the wards keep them clean and someone
could show me what I was meant to be doing I’d
go in and do it cause I’m ...
A1P5: It’s all hands to the pump in it really?
A1P1: ...employed by the Trust to provide a ser-
vice that’s in my contract, I’m employed by the
Department of Health and that doesn’t mean I’m
gonna turn around and say ‘No that’s not my job’
cause I’m here for the patients. So if they want me
pushing trolleys around as a porter or making cof-
fee in the canteen I’d do that, I don’t know about
everyone else.
The idea that there is a duty to pull together at a time
of crisis was supported by the vast majority of our A&C
survey respondents (92.7 per cent; n=166) though there
was less support for changing workplace or extended
roles to enable this duty to be discharged (see Figure 1).
In a pandemic, emergency coercive measures may be
justified. Given the concerns of the present paper, two
kinds of coercive measures are particularly relevant: on
the one hand, quarantining or social distancing measures
and, on the other, measures requiring certain groups to
work. Voluntary measures may not only be ineffective
against some of the infection risks; they may also leave
vital services short of staff. Again, the choice of some
people not to report to work will mean that the risks
of working are not equitably distributed, with a greater
burden falling on those who do work.
There is a tension between voluntary cooperation and
the demands of protecting national security and ensur-
ing a fair distribution of risk among those working in
essential services during a pandemic. Services that count
as essential during a pandemic (internet provision and
broadcasting, for instance) may not count as essential
in normal times, and the relevant workers may or may
not know their role when an outbreak comes, or feel
a particular duty to the public as part of their usual
role. One way of encouraging a more equitable distri-
bution of risk and encouraging A&C workers to work
is to promote the message that everyone (i.e., regardless
of their employment) should keep working as normally
as possible. This means discouraging individuals from
quarantining themselves unless and until they are show-
ing signs of illness. But this does not ensure equity of
risk exposure, as a greater dangers of infection will be
present in some workplaces will than others. In particu-
lar, the workplaces of some healthcare non-professionals
will present greater dangers. Making it compulsory for
non-professional healthcare workers to work, then, may
result in unequal risks, and, with that, significant scope
for injustice.
It might be thought that the position of non-
professional healthcare workers in an emergency is no
worse than that of emergency service personnel in nor-
mal times. After all, police, firemen, doctors and nurses
are at the best of times more exposed to the risks of as-
sault, injury and infection than the public in general, and
that does not seem to be regarded as an injustice. This
is partly because the greater exposure to risk is accepted
as part of the relevant professions when people choose
to enter them. Non-professional healthcare workers can
also foresee some of the risks of working in a healthcare
setting in normal times, and accept those risks. The dif-
ference lies in the consequences of withdrawing labour
whentherisksareheightened.Theskillsofprofessional
healthcare workers are necessarily in short supply in a
health emergency. Non-professional healthcare workers,
on the other hand, may be regarded as non-professional
just because the skills required to do the job are either
generic, or ones that can be acquired easily, with little
training. This means that the people who actually have
the jobs may not be the only ones who are (in principle)
able to do them.
In view of this, there may be a moral argument for
having a larger pool of people with A&C responsibilities
in emergencies than in normal times. The argument is
that, with the bigger pool, heightened risks are shared
and shortages of workers are less likely to occur. Many in
the general population already have skills—for instance
clerking, catering, and IT support—that could be put to
good use in the health service during a pandemic. Other
people, as our participants implied by their own willing-
ness to change roles, could be deployed to do relatively
low-skilled work: ancillary nursing, portering, cleaning,
etc. To the extent that anyone can fulfil a role, actual or
current occupiers of that role do not uniquely have the
obligation to fulfil it, especially when doing so carries in-
creased personal costs. Accordingly, if the emergency jus-
tifies compulsion, non-professional healthcare workers
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NON-PROFESSIONAL HEALTHCARE WORKERS ’ DUTIES •29
can only be singled out for coercion if they have unique
or difficult-to-replace skills. If members of the public
in general have the required skills, their conscription or
compulsory redeployment may be more justifiable.
What is the basis of an obligation to ac-
cept compulsory redeployment? If redeployment is
legally compulsory—as with conscription into military
service—it may be a case of the obligation to obey the law.
But there may be, underneath that obligation, a deeper
obligation to co-operate with others, an obligation that
increases when lives are, or health is, at stake. Even in
normal times this obligation is engaged. For example,
drivers in the UK do not have to be forced to pull over to
let emergency vehicles pass speedily through heavy traf-
fic. They do so willingly. And although there are cases
where people stand back and do nothing even in cases
where people need life-saving help and calling assistance
is easy and safe—as in the notorious Kitty Genovese case
in New York (Manning et al., 2007)—there are many cases
of assistance and rescue by volunteers. These cases maybe
seen as the operation of a willingness to co-operate that
has moral content, and that can be effective even in the
absence of threats of punishment for non-cooperation.
Whether compulsory working or helping is necessary in a
pandemic depends partly on the risks involved and partly
on the strength of an ethic of co-operation. If the ethic is
strong, not compelling people to fall in with it may be a
sign of the state’s respect for its citizens.
A General Duty to Work: A Special
Duty that is Employment Specific
and Enforces a Duty to Work
There can be more than one basis for a duty to work in
emergencies. The general obligation to obey the law and
co-operate have already been mentioned. The duty to
continue working during pandemic influenza may also
flow from a general work ethic—a belief that it is good for
everyone to have paid employment and that one ought
to do the job one is paid to do. The work ethic is in part
an employee ethic. It is dishonest to take money for a job
that one knowingly has not done properly (unless one
forewarns the customer that this is all they can expect for
the price they are willing to pay). It is fraudulent to take
sick pay if one is well enough to work. One should also be
able to offer a credible justification for refusing to carry
out work one has agreed to do.
Risks to life or health might be one such justification.
But such risks, when they are part of the job that one
has agreed to do, are or should be reflected in the pay
awarded. A&C workers do a wide variety of jobs for
widely varying rates of pay, and on varying kinds of
contracts. The differential pay rates may largely reflectthe
perceived skills needed to do the job,r ather than differing
potential occupational hazards. So, for instance, skilled
information technology (IT) workers will receive more
money than ancillary nursing staff or cleaners, all of who
may be exposed to infectious or violent patients during
the course of their ordinary duties. These latter workers
also risk other occupational hazards (e.g., chronic back
pain) related to the kinds of jobs they do. Some workers,
then, are paid well but are not paid to expose themselves
to risk, and other workers are poorly paid, even though
exposure to some risk can be considered to be part of
the work they have agreed to do. Accordingly, it is not
obvious that working during a pandemic, with all the
attendant risks and burdens, can be considered part of
the normal employment of non-professional healthcare
workers. Indeed, an expectation that they ought to work
in circumstances of heightened risk may be considered
an indication of their systematic economic exploitation.
Nonetheless, participants in both A&C focus groups
singled out working in the public sector as a motivator
against absenteeism during a pandemic:
A1P2: ... it’s the good of human kind really, that
you wanna help if you can and put ... I think
that’s why we work in the public sector because if
I wanted to be a communications officer and not
have to get involved with serious stuff then I’d just
go and flog lawnmowers or something, you know
what I means [laugh] ... like that ...you know I
think.
A2P7: When I was in industry I hated it and if I
could have a day off I would have done. Nowadays
working in the NHS and I’ve had a bad day, I
come in the next day, bad day, I just keep coming
in because that’s what you’re paid ... you know,
and people that I knew ...they say ‘Yeah, I’ve got
a moral obligation as well’. But in industry you
think ‘I’m just making someone richer’. It’s the
way it’s done, you know.
A1P1: Personally I think if you’re working in any
local Government service be it police, the fire, the
council ...
A1P3: Well the whole public sector, isn’t it?
A1P1: ... et cetera and the healthcare, when you
take that job on you do get some nice cushy things
out of it, you get job security, you get better pro-
tection, you get a nice pension and I do think you
are obligated to come in and you don’t enter ...I
mean healthcare, fire service, even fire service ad-
min staff, I mean come a great blaze or something
they’re bound to be helping out.
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30 •DRAPER et al.
Here, our participants seem to be suggesting that it is
not just working in the public sector that supports an
obligation to help, but also the kind of job one does. If
this suggestion has some moral force, then A&C workers
might have a duty to work that is very similar to that of
professional workers. The vulnerability and helplessness
of patients and clients, and the fact that the relevant jobs
are for relieving vulnerability and helplessness, means
that there must be a higher threshold for not reporting
for duty than for other jobs. However, as we have already
noted, it is not clear why this duty to help the vulnerable
should fall especially on the shoulders of A&C workers
during a pandemic, rather than on us all.
Given that many A&C workershave signed an employ-
ment contract, unwillingness to work during a pandemic
could result in financial penalties. These penalties, whilst
not strictly coercive, might reasonably be thought to act
as a powerful motivator for working, especially amongst
low-income groups. The A&C response to our survey
suggested that rewards—as opposed to penalties—for
working during a pandemic might have some positive
impact (see Figure 1) though less than might be expected
given the general support for the principle of rewards for
working (74.9 per cent; n=134 of A&C workers believed
that people who worked through the crisis should be re-
warded in some way). Few responders, however, agreed
with the notion that there should be punishments for
not working (19.0 per cent; n=34) even though they
tended to agree both with the statement that everyone
should pull together during a pandemic, and also that
all healthcare workers (and not just doctors and nurses)
had a duty to work during a pandemic.
One of the arguments against coercive measures is
that individuals should not be compelled to take unrea-
sonable risks (Coleman and Reis, 2008). What counts as
unreasonable is unclear. Past performance is often used
as the benchmark for normal occupational risk. If work-
ers do not refuse to come into contact with patients with
HIV, Hepatitis B or C, SARS, Clostridium difficile and
so forth, then these risks become the benchmark against
which the duty to work in the face of a new risk is judged.
Reid (2005) warns against this approach, partly because
the obligation to work is more complex than setting the
limits of the obligation at a particular level of risk. It is
also about deciding whether
...knowing our own vulnerability to disease and
death, [we] prefer to live in a society that provides
healthcare to people with infectious disease, or in
a society that leaves epidemics to run their course
and devastate the population, or in a society that
practices a form of quarantining of the ill without
treatment, leaving them to die in isolation.
That is, people work not only in the light of the occupa-
tional risks to themselves, but also in the light of widely
shared social goals, including the protection of people
from heightened risk of disease or death, which their jobs
promote. For this reason, individuals couldwork through
epidemics or respond to emergencies without in the least
accepting an occupational risk in normal circumstances
similar to that faced during the epidemic. Reid also pro-
vides us with a reason to suppose that there is an obliga-
tion to work. The consequences of no-one working are
unconscionable, even if working carries risks.
It may be against the national interest to give people
the choice of working or not working in a pandemic.
Martin (2009: 249) reports that
Employees and public servants in France currently
have the right to withdraw from their workplace
if they reasonably believe that their work situa-
tion presents a grave and imminent danger to life
and health, provided that they have alerted their
employer to the danger and provided that their
leaving does not create a new risk for others. Un-
der the new Code, which only applies in the par-
ticular case of pandemic influenza, this right of
withdrawal will not apply in circumstances where
the employer has taken all foreseeable measures to
reduce the risk of exposure to disease.
In the case of A&C workers, as we have already noted,
it is not obvious that they should bear all the burden of
supporting the work of clinical staff in high-risk areas,
except where they have unique skills that others could
not acquire to a reasonable degree. To the extent that this
burden can be shared by anyone able (and available2)to
do so, then it should be. Evenly applied conscription is
fairer than condoning a greater than necessary burden
on non-specialist A&C workers in high-risk roles.
For countries that decide to rely on volunteering, other
measures may be justified that may be coercive in effect
even if not in intention. For instance, if A&C healthcare
workers refuse to do their normal jobs during a pan-
demic, they might be regarded as resigning their posts
(or taking leave of absence) and therefore forfeiting pay
during their absence (though they would of course be
free to seek alternative means of employment). On the
other hand, they should not lose pay for refusing to take
on different, more burdensome or risky roles than the
ones they usually perform, and they should be rewarded
for‘actingup’tomoreresponsibleorbetterpaidroles.
Reciprocity
The willingness of everyone to pull together in a time of
crisis may not depend solely on a shared sense of how
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NON-PROFESSIONAL HEALTHCARE WORKERS ’ DUTIES •31
much worse things might be if they don’t do so. It may
also depend on trusting others to do the same, since it
is only by joint effort that the crisis can be averted or
lessened. In our focus groups we found that low morale
might have an effect on levels of trust and also work-
ers’ willingness to do more in an emergency when the
demands of normal times were already considerable:
A2P7: I mean we have problems staffing the unit
on a day to day, you know ...
A2P7: Yeah we’re the same
A2P7: ...when you’re up to full strength staff and
we still have trouble staffing the beds we’ve got.
A1P2: ... some people think, ‘well why should I
bother, what have they ever done for me’...
Some participants were of the view that even if they
did work during a pandemic, their efforts would go
unrecognised:
A1P1:...if everyone came in and if we all did our
jobs and as things got worse and nurses started
dropping out, we started pushing patients around
and doing frontline ancillary nursing
A1P1: yeah Okay
A1P1: ...and at the end of it all—like normal—all
the credit would go to the clinical staff, the doctors,
the nurses ...
A1P5: Umm and we would get nothing ...
A1P1: ... and no one would remember our in-
volvement
A1P5: No [of agreement]
A1P6: Yeah.
Participants in both A&C focus groups were concerned
that they would not receive sufficient information and
training about how to protect themselves against the
virus:
A1P7 It’s a two-way thing as well, because we’re
obliged to come into work, we feel morally obliged
cause that’s what you know, I think that’s why we
are in this profession [sic] really. But the health
service are obliged to teach us how to protect our-
selves and provide all the methods of protection
that they can, reasonable methods. I mean, at the
moment I’m not sure whether that’s being done
and nobody seems to know.
These views were reflected in the survey responses, where
available vaccination (along with the provision of PPE
and more information) was reported as most likely to
influence the decision to work (Figure 1).
Healthcare workers of all kinds who are exposed to
greater risks than the rest of the population should
be confident that whatever can be done to minimise
the risk of infection and the burdens of working will
be done (World Health Organization, 2007). Our par-
ticipants did not seem to be confident that their ex-
tra efforts during a pandemic would be reflected in
extra support from employers. This is partly because
they reported feeling unvalued for the work they cur-
rently do. There is, therefore, something of a break-
down of trust between themselves and the NHS as well
as between themselves and their managers. For non-
professional workers to act on any sense of obligation
to work, a sense of reciprocity—of a willingness to
recognise effort with effort of one’s own—needs to be
restored.
We may distinguish between two elements here: what
is owed to A&C healthcare workers out of reciprocity
and what might need to be done in order to restore
(perhaps even to build) workers’ trust that obligations of
reciprocity will be honoured.
PPE and Vaccination
The most obvious thing that is owed is some protection
against infection. Vaccination is the preferred form of
protection; effective PPE runs a close second. A vaccine,
however, is unlikely to be available during the first wave
of the pandemic (WorldHealth Organization, 2006) and,
depending upon the scale of the pandemic, PPE may be in
short supply. Does this count against a duty to work? Not
necessarily. Reciprocity is a matter of motivation to do
the best possible, not a guarantee that people will deliver
the impossible. Reciprocity dictates how resources ought
to be distributed and the priority that should be given to
obtaining particular kinds of resources. If A&C staff are
expected to work with infected patients then they must
have the same access to PPE (and vaccination, if and
when it becomes available) as professional healthcare
professionals, and better access than others whose risks
of infection are lower.
Reciprocity before and after the Pandemic
Strikes
The decision to work during a pandemic may be akin to
Poundstone’s (1992) game theory, Prisoners’ Dilemma.
We will all be better off if we work as normally as possible,
but to work normally requires us to take risks that are
greater than if we all go into voluntary quarantine. But, if
not everyone works, the risks remain heightened for those
who do work and the benefits for the public as a whole are
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32 •DRAPER et al.
decreased. For any given individual, the best option is to
be the only person who doesn’t work—thereby reaping
the benefits but avoiding the risks. If, however, everyone
does this, no one will benefit. Thus, the best thing for all
of us is to ensure that as many people as possible work.
Conscription is one means of doing this. Building trust is
a non-coercive alternative. What our study participants
seem to suggest is that there is a lack of trust. They are not
confident that others show reciprocity. They do not feel
valued, do not think their actions will be acknowledged
or rewarded, and they feel threatened by the possibil-
ity of future litigation. In a situation of low morale, it
is difficult for individuals to trust those who promise
reciprocity, especially when planners also have to admit
to great uncertainty about the nature and impact of the
virus.
There is no reason, however, to limit reciprocity to
actions during a crisis. Reciprocity can work by providing
goods in lieu of future benefits or by providing benefits
after receiving the goods. Demonstrating ahead of the
crisis that workers are valued, offering them recognition
for their current roles, involving them in planning—all of
these things build trust for the future as well as a stock of
goodwill that may be drawn upon during the pandemic.
They increase the probability of mutual, voluntary, co-
operation.
In addition, planners could begin to address the fears
about litigation post-pandemic, which were prominent
in our focus groups:
A1F1: I think one that’s be interested ... what
the NHS Department of Health probably should
look at is what happens in a legal ... legally in a
situation if someone is called in to do a job such
as portering, and they ... they’ve never done it
before and they ... or they have to lift someone
and they lift them incorrectly or they ...you know
...because it’s an extreme situation and everyone
is working without ... outside their remit and if
you said, ‘I’m not gonna do it because I haven’t
been trained’, you could end up with people just
lying there for days and days and days, you know,
if everyone said ‘Oh sorry, I’m not trained’. So
how do ...they need to look at how they’re gonna
get over that barrier and what position ... you
know, is there some sort of I don’t know ...dis ...
youknow,wholedisclaimerthatinanemergency
situation you can’t sue someone for ...
This view was reinforced in the survey results, where the
guarantee that an individual would not be held liable
for mistakes in a role for which they had not been ade-
quately trained was seen as a motivator for working for
many A&C respondents (63.7 per cent; n=114) (Fig-
ure 1). The growth in litigation is clearly a multi-factorial
phenomenon beyond the scope of this paper to explain
or address. It would be glib to argue that society needs to
demonstrate its appreciation for the efforts of others by
thinking twice about bringing legal action against health-
care providers. On the other hand, more could be done
to reassure all of those who work in health services that
the threshold for settling cases resulting from extreme
circumstances during the pandemic will be very high in-
deed, and that workers will be protected from claims that
are brought as a result of rationing decisions sanctioned
by government or management.
More controversial is the issue of whether reciprocity
requires that those most at risk of infection when caring
for the sick should be guaranteed treatment if they them-
selves fall ill. When the issue arose in the focus groups,
participants in general made the assumption that they
would get priority for treatment. This assumption was
partly based on the fact that they regarded themselves as
essential workers who needed to be returned as quickly
as possible to the pandemic effort. They also assumed
that this was the least that could be done for them if they
had fallen ill through working with the sick. Some even
assumed that the same would be true if their families
fell ill too. This view was reflected in the survey results:
80.5 per cent of all respondents and 68.2 per cent (n=
122) of A&C workers disagreed with the suggestion that
healthcare workers should not be given any special pri-
ority for treatment.
Giving priority for treatment to healthcare workers
during a pandemic on the grounds of reciprocity is con-
troversial for two reasons. First, it would be difficult to
put into operation. Resources for treating those affected
are expected to be very scarce. If the driving principle
here is that it is because someone became infected in
the line of duty that they are owed treatment, then this
would be something owed only to those healthcare work-
ers who work in close proximity to infected people, not
to healthcare workers in general. It would not be fair on
this basis, for instance, to give priority treatment to a
healthcare worker who had refused to work but became
infected anyway away from work. Equally, someone who
had been willing to work with the sick may have been
infected outside work. Either way, it will be difficult to
establish categorically who deserves priority on the ba-
sis of reciprocity, particularly given the testing circum-
stances likely to prevail during the pandemic. More-
over, given the pressure on the health service, the ma-
jority of those who fall ill will have to be cared for at
home by family and friends (Department of Health,
2008). The same argument could be made for giving
these carers priority should they become infected as a
result.
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NON-PROFESSIONAL HEALTHCARE WORKERS ’ DUTIES •33
The second reason that it is controversial to prioritise
healthcare workers is that, as the WHO (2007) notes,
scarce resources have to be used where they will be most
effective, where no one is likely to be receiving optimal
treatment by the standards of normal times. Given that
people, who in normal times would have been success-
fully treated, will die, the criteria for rationing must be
open, transparent and applied equally to all (Depart-
ment of Health, 2008). Giving treatment to a healthcare
worker who is unlikely to survive rather than to another
person (or several other persons) whose chances of sur-
vival are better could be difficult to justify under such
circumstances. Arguably, it might be justified by appeal-
ing to an unbreakable duty to keep promises to healthcare
workers, or by citing the damaging effect on healthcare
workers morale of withholding treatment. It is, however,
not obvious that even in emergencies all promises have
to be honoured, and that morale must be kept high even
where eroding it saves lives.
It may be equally difficult to justify special treatment
on the grounds that healthcare workers need to be fit to
treat others. In a pandemic, many workers’ roles will be
vital not just to the health effort, but also to maintaining
social functioning in general (Selgelid, 2009).
Conclusions
We have discussed some of the arguments that sur-
round the question of whether non-professional health-
care workers have a duty to work during a pandemic.
General philosophical considerations concerning both
the requirements of social co-operation and the fair dis-
tribution of risk have been brought into play. Further-
more, we have shown that these arguments are not just
theoretical but are also reflected in the reported views of
our focus group participants and survey respondents.
Arguments that support a duty of A&C workers to
work during an influenza pandemic also support a
duty of others who are able to do what A&C work-
ers do—others who would not be otherwise exempt by
virtue of their own special skills or particular health vul-
nerabilities. We have therefore suggested that when coer-
cive measures would otherwise target non-professional
healthcare workers, it would be fairer to consider con-
scription from the whole available population to the roles
that these workers carry out.
Notes
1. Parents may have some obligation to their childrento
celebrate their birthdays with them but this may not
be a sufficiently serious obligation to out-weigh the
obligation to help, if one can, when the repercussions
of a failure to provide aid to patients may be an
increase in suffering or even death.
2. ‘Available’ means: not already occupied in an equally
necessary role.
Acknowledgements
This research was funded by the National Institute for
Health Research (NIHR) Research for Patient Benefit
programme. This report presents independent commis-
sioned research by the National Institute for Health Re-
search. The views expressed in this report are those of
the authors and not necessarily those of the NHS, the
NIHR or the Department of Health. This work was sup-
ported by the National Institute for Health Research UK
through the Research for Patient Benefit Programme,
PB-PG-0906-11088.
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