When water is unsafe, physicians must take up public health roles

AMA Wire
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The ongoing Flint, Michigan, water crisis illuminates questions about the nature and scope of clinicians’ obligations to identify, assess and respond to patients’ and communities’ health risks from harmful microbial and chemical levels in their water supply. Clinicians should be trained to recognize symptoms of contaminated water use, but how should they be trained to help prevent contamination and execute other public health duties?

This month’s AMA Journal of Ethics® explores clinicians’ roles in defining and enforcing the parameters of what constitutes “safe” water and in addressing barriers to safe water access.

Take a moment to consider this question: A patient insists that water contamination is causing her persistent rash even after her physician tells her it’s unlikely. How should the physician respond to the patient?

  • A: Repeat that the water is an unlikely cause and suggest another course of action.
  • B: Ask the patient to explain why she believes her water is contaminated.
  • C: Test her for waterborne microbes and lead.
  • Both A and B.

Give your answer and find responses to this question in the October issue of the AMA Journal of Ethics.

Articles include:

Lessons for Physicians from Flint’s Water Crisis.” In the Flint water crisis, physicians can be credited with playing critical roles in both uncovering the crisis and providing leadership when government failed to respond effectively. Yet most physicians in Flint were not formally trained in advocacy or leadership and might have recognized the health implications of the crisis more quickly had they received formal environmental health training.

Furthermore, connections to other professional disciplines—and to the community—are vital for effective responses to environmental health threats. The authors explore some lessons learned in Flint that might help expedite resolution of future environmental health crises, particularly those involving aging infrastructure and diminished or dysfunctional regulation or oversight.

Expanding Ethics Review Processes to Include Community-Level Protections: A Case Study from Flint, Michigan.” As the Flint community endeavors to recover and move forward in the aftermath of the Flint water crisis, distrust of scientific and governmental authorities must be overcome. Future community engagement in research will require community-level protections to help ensure that no further harm is done to the community.

A community ethics review explores risks and benefits and complements institutional review board (IRB) review. Using the case of Flint, the author describes how community-level ethical protections can reestablish a community’s trust. All IRBs reviewing protocols that include risk to communities and not merely individual participants should consider how community members are engaged in the proposed research and identify and respond to questions and domains of concern from community members.

The Importance of Clinicians and Community Members Receiving Timely and Accurate Information about Waterborne Hazards.” It is important for clinicians and community members to receive up-to-date information about the microbiological and elemental composition of local water supplies. Clinicians play an important role in helping their patients to interpret water quality data and understand the potential impact of water quality on their health. Expanding the medical school curriculum to include environmental health, public health and health disparities—including disparities related to environmental quality and waterborne hazards—is key to clinicians’ fulfilling this role.

Water Safety and Lead Regulation: Physicians’ Community Health Responsibilities.” This article reviews the regulation of lead in drinking water, highlighting its epidemiological, engineering, and ethical aspects with a focus on the Flint water crisis. The authors first discuss water quality policy and its implementation with a focus on lead contamination of water, primarily from pipe systems between a water treatment facility and a tap.

The authors then discuss physicians’ roles and ethical responsibilities regarding safe drinking water using a human rights framework. They argue that physicians can play an important role in safeguarding drinking water in their communities by being vigilant, honoring the community’s trust in them, and warning, educating and empowering patients and broader communities so as to protect tap water safety and public health.

What the Code says

While the AMA Code of Medical Ethics does not explicitly address clinicians’ roles in preventing water contamination and treating patients who have been harmed by contaminated water consumption, it addresses clinicians’ roles in preventive care and community health promotion, including their obligations not only to individuals but also to at-risk populations. Read more.

Listen to the journal’s October podcast, “How Clinicians Can Use Their Skills and Authority to Promote Health Equity: An Interview with Dr. Mona Hanna-Attisha and Dr. Camara P. Jones.” Subscribe to the podcast, “Ethics Talk,” in iTunes or one of many other podcast-subscription services.

Journal discussion

Starting Oct. 23, visit the AMA Journal of Ethics Discussion Forum to join a dialogue with experts on the question, “How to Respond When Your Patient Says Her Drinking Water is Unsafe?

Submit manuscripts and artwork

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

A look ahead

In November, the AMA Journal of Ethics will focus on the ethics of collaborative health systems design. In December, the journal’s theme is health care ethics and professionalism in the era of climate change. Sign up to receive email alerts when new issues are published.

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