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Introduction

The sudden emergence of severe acute respiratory syndrome(SARS) in April 2003 caused much concern and reaction.Refereed medical journals ever since have been rife witharticles about SARS. The eventual containment andtreatment of SARS has seen a diminution of the massivemedia publicity and overt public concern. However, fearshave recently surfaced about the potential for re-emergenceof SARS in the near future. As we confront the potential needto return to more stringent infection control measures onceagain, this is an appropriate time to reflect on the ethicalvalues that underlay the strict visitation restrictions imposedin hospitals in Ontario during the SARS outbreak and themoderate restrictions in place since SARS. This reflectionwill facilitate future decision making with respect to visitationrestrictions.

When public health trumps civil liberties: thecollateral damage associated with victims ofSARSOur infectious disease colleagues are adamant thatrestricting the movement of people into and around thehospital setting are effective clinical and epidemiologicalstrategies that will help protect both the vulnerable patientpopulation and health care providers themselves, who needto stay healthy so that they may care for their patients. Onemight argue, then, that visitation restrictions are both

enhancing and supportive of public health protection. Thisposition recognizes that there are times when public healthprotection overrides the protection of individual freedom. Itcould be argued that visitation restrictions, in light of apotential outbreak of a contagious disease, are ethicallysound because of the compelling need to protect publichealth.

However, even when public health concerns trump individualliberties, the ethical operationalization of this value woulddemand that ‘those whose rights are being infringed’ need tobe managed in ‘an ethical and even-handed manner so thatthey are not unfairly or disproportionately harmed by suchmeasures’ [1].

This is an important and far-reaching consideration becauseSARS caused collateral damage and we know that theimplementation of visitation restrictions will have an impacton a broad range of individuals. Understandably, thosepatients who were confirmed or suspected of being carriersof contagious pathogens were easily and directly identified.However, there were people who had not demonstrated anyrisk or epidemiological link to a contagious disease but whoexperienced quarantine, restriction of movement,inconvenience, loss of pay, and inability to access importantand sometimes vital services within the health care system. Infact, there was a general trend within the populace toward

CommentaryWhy can’t I visit? The ethics of visitation restrictions – lessonslearned from SARSSharon Rogers

Director, Patient Relations (The Hospital Ombudsman), University Health Network, Toronto, Ontario, Canada

Corresponding author: Sharon Rogers, sharon.rogers@uhn.on.ca

Published online: 31 August 2004 Critical Care 2004, 8:300-302 (DOI 10.1186/cc2930)This article is online at http://ccforum.com/content/8/5/300© 2004 BioMed Central Ltd

Abstract

Patients want, need and expect that their relatives will be able to visit them during inpatientadmissions or accompany them during ambulatory visits. The sudden outbreak of severe acuterespiratory syndrome (SARS), or a similar contagious pathogen, will restrict the number of peopleentering the hospital. The ethical values that underlie visitor restrictions are discussed here.

Keywords ethics, public policy, sars, selective provider restrictions, visitors to patients

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avoiding meetings/gatherings, as well as kissing, huggingand even hand shaking. Clearly, these restrictions arereflective of a loss of civil liberties in the general populationand render expressions of caring difficult at a time whenpeople may need them the most.

In a health care institution, visitation restrictions not onlyaffect inpatients but also have an impact on ambulatorypatients who must come for diagnostic tests or interventionsand who, if deprived access, might develop urgent oremergent conditions. Restrictions are likely to cause distress,anxiety and increased complaints. In fact, on review of theUniversity Health Network corporate complaint database,SARS 1 (period March 28–April 20, 2003) and SARS 2(period May 12–August 10, 2003) generated a 27%increase in complaints over the expected number ofcomplaints for that time period. Specifically, during this timeperiod there would normally have been 770 calls ofcomplaint, but with SARS 1 and 2 a total of 1052 calls ofcomplaint were received. It should be stressed that thesedata are over and above the complaints received at each siteof the corporation, which were not captured in the database.Ultimately, this is a set of problems that must be managedwith sensitivity and clarity (Nyhof-Young and colleagues,unpublished data).

In view of the magnitude of implications of visitor restriction, itis important that policy decisions, at the micro or macro level,consider issues of equity, publicity, transparency and theappeal process. Issues of equity must take into considerationthe known facts from a scientific perspective as well as therange of approaches considered. In terms of transparencyand due diligence, the rationale behind the policies and howthey will be implemented should be as clear andunambiguous as possible. Feedback should be sought fromthose individuals who would be affected by visitationrestrictions, such as staff, patients and family members. Thepolicy must be made accessible, printed and broadlycirculated throughout the hospital so that people understandthe rules, the rationale for those rules, the processesavailable to them to assist them in ‘living with those rules’ andways to appeal in special circumstances.

Visitation policy developers must realize that there may beexceptional circumstances that demand exceptional latitude.The development of criteria for exceptionality must recognizethe need for proportionality, ensuring that criteria are‘relevant, legitimate and necessary … and should be appliedwithout discrimination’ [1]. Furthermore, to be consistent withexpectations of transparency, the criteria by whichexceptionality to the rules of visitation restriction exists shouldalso be published openly throughout the organization forstaff, patients and visitors. From our experience with SARS, acorporate policy was developed and there was anexpectation that there would be compliance with thiscorporate policy. However, it was also acknowledged that

local patient needs would dictate more or less stringentadherence to these rules, and that the degree of adherencemight change quickly without the opportunity for broadnotification. For example, although current policy allows forspecific times of visitation and numbers of visitors per day, asudden outbreak might dictate a quick lockdown of the facilitywithout patients or family members receiving prior notice.

Health care workers’ duty to care and theduty of institutions to support themA health care professional has a duty to care, based onseveral ethical considerations [1] such as professional codeof conduct, intrinsic requirements of the work and theacceptance of risk as part of the decision to do a specifictype of work. Part of this duty to care for patientsencompasses a broader duty, in that one must care for theirfamily as well. Visitation restrictions impede this abilitybecause health care providers find themselves in theawkward position of conveying very private, personalmessages between patients and family members, ofproviding updates and of breaking bad news over the phone,thus losing their ability to convey empathy or judge theamount of support required effectively. Moreover, health careworkers, being in direct communication with patients andfamilies, bear the brunt of their anger and frustrationregarding any restriction in visitation.

There is an implicit acceptance that reciprocity existsbetween the hospital organization and the individual staffmember [1]. To this end, it is the organization that mustaccept responsibility for making rules and communicatingthem broadly to all staff, patients and visitors. Similarly, it isthe responsibility of the organization to enforce compliancewith these rules; it is not the responsibility of staff, whoseprimary responsibility is to discharge the duty of care to thepatient. The organization also has the responsibility ofdeveloping a set of criteria outlining exceptionality and aprocess to receive, review and adjudicate requests. Aprocess must be developed (together with appropriateresources) so that staff members know who to access forsupport and are able to do this is in an easy and expeditiousmanner.

Naming names, naming communities: privacyof personal information and public need toknowIn the interests of the public good, there may be times wheninformation must be shared publicly, thereby impinging on therights of the individual to privacy and confidentiality. Withrespect to restricted visitation, an ethical argument could bemade that visitation restrictions (or latitude thereof) can beinstituted generally, without specifically naming names.Although the vigilant observer might be able to identify aspecific person from a changed application of the rule, theorganization cannot reasonably be expected to guard againstevery possible identification, but every effort should be made

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to protect the individual from easy identification. For example,if a family is allowed to visit a patient whose death ispresumed to be imminent (within the next 24 hours), then thepatient’s identity should be protected by using privacystrategies. Efforts to protect the patient’s identity areconsistent with the ethical value of ‘protection ofcommunities from undue stigmatization’ [1].

SARS in a globalized worldGiven the risks associated with contagious pathogens andthe easy mode of transmission globally, it is important thatthere be consistency in management. The ideal situationwould be a consistent global approach to the management ofeach and every contagious pathogen. The notion of universalmanagement strategies is very sensible (e.g. universalprecautions with blood-borne conditions such HIV).However, given the political and economic disparities acrossthe world as well as the lack of knowledge (particularly ofnewly evolving pathogens), a standardized approach is notpossible.

The experience of SARS indicates that some patientpopulations require a level of vigilance that is more stringentthan that required in others. For example, those individualswho reported recent travel to high risk areas, and those whoworked in quarantined or contaminated hospitals or whoexhibited clear symptoms (e.g. fever, persistent cough) werescrutinized with more vigilance and were in fact treateddifferently than other visitors, until they were cleared throughthe screening process. This type of variability in vigilancedemands ethical management of differences, and there is aneed to guard against overt bias or discrimination creepinginto the process.

It is difficult to expect that both standardization of approachand variability in approach can easily coexist, but theoperational challenge is to exercise awareness of the ethicalvalues discussed above and the appropriate due diligence inthe implementation of processes.

ConclusionIt is ethical to accept that public health protection trumpsindividual rights to liberal visitation. The rationale for thisposition must be fully outlined to patients, visitors and staff.

In responding to visitors who may be deprived of visitation, itis ethical to recognize that there may be exceptionalcircumstances that demand exceptional latitude. A set ofcriteria outlining exceptionality should be developed, asshould a process to receive, review and adjudicate requests.In the interests of equity, an appeal process should be madeexplicit and transparent to all. This information should be wellpublicized to staff, patients and visitors in a consistent andsensitive manner. Every reasonable effort should be made toprotect the individual patient’s identity and their specifichealth status should exceptionality be considered.

It is ethically the responsibility of the organization to enforcecompliance with restricted visitation and a corporatedepartment should be assigned this task.

Although it is recognized that standardization in theapplication of visitation restrictions is necessary, there isrecognition that there may be circumstances that wouldrequire deviation from the corporate position.

Competing interestsThe author declares that she has no competing interests.

AcknowledgementsThanks to Dr Laura Hawryluck, Co-Editor of the medical ethics com-mentaries section of Critical Care, for her patient editing and insightfulcomments.

References1. Ethics and SARS: Learning Lessons from the Toronto Experi-

ence. Available from the Centre for Bioethics Website[http://www.utoronto.ca/jcb/home/news_SARS.htm]