w w w . a c m a w e b .

o r g

Case Management in a Pandemic: Has the Profession Codified its Obligations?

By Mark Repenshek, PhD and Jane Hounsell, MSW, LCSW

The potential threat of pandemic influenza is staggering (modeled on a 1918-like influenza pandemic): 1.9 million deaths, 90 million people
ill, nearly 10 million people hospitalized, with almost 1.5 million requiring intensive-care units in the United States.1 A critical question that
has surfaced in ethics literature concerns whether there exists a duty to provide medical care for patients in the midst of such a potential
threat to the health and life of the health care professional.2 Although there is a significant amount of literature which addresses the
extent of the physician’s professional obligations to the patient, little exists regarding the extent to which the health care team maintains
that same level of obligation. Where such discussions have focused on duty or obligation, many associations are calling for a turn to
professional codes of ethics to establish a basis for these duties and obligations.

This article will examine the social work and nursing codes of
ethics to provide an analysis of their respective adequacy of
response to the call – specifically, the National Association of Social
Workers’ (NASW) Code of Ethics and the American Nurses
Association (ANA) Code of Ethics. Most importantly, this article will
examine whether this turn to professional codes of ethics is
sufficient to address this special concern of the case manager in
pandemic preparedness planning.
The Professional Role of the Case Manager
The American Case Management Association (ACMA) Standards
of Practice and Scope of Services states the case manager “adheres to
professional standards of practice and his or her professional code of
ethics.”3 The standard of practice includes “facilitating care along a
continuum through effective resource coordination.”4
The critical question for this article is whether or not, or to what
extent, the standard of practice shifts in a pandemic. For example,
will the criteria for what constitutes a safe and appropriate discharge
be redefined? Will minimum standards of care for the professional
case manager be redefined? How will patient choice be constrained
when beds are needed (i.e. must the patient/family accept the first
available bed in a skilled nursing facility without the opportunity to
tour?) In considering staffing plans in a pandemic, how far outside of
their scope of practice would registered nurse (RN) case managers
and social work case managers be expected to work? To what extent
might RN case managers be diverted to more clinical nursing roles
and away from their case management responsibilities? Many of
these questions require an understanding of the professional
commitments made by case managers. Because of the ethical nature
of these questions, it seems relevant to begin by turning to the Code
of Ethics as a basis for understanding the duties and claims society
may make upon case managers when facing a pandemic.
Obligation to Provide Medical Care in a Pandemic
In 2006, G. Caleb Alexander, published results from a national,
cross-sectional, random-sample survey conducted in 2003
concerning physicians’ preparedness for bioterrorism and other
public health priorities. In order to gain a sense of physicians’
self-reported willingness to treat in the midst of public health
emergencies, Alexander asked three questions, two of which are
relevant here:
(a) Would [you] volunteer in medical reserve corps to serve in
the event of a public health emergency
(b) Would [you] be willing to put [your] self at risk of
contracting a deadly illness if it was the only way to save
others’ lives
Emergency physicians responded in the affirmative 54% and
48%, respectively, to these two survey questions, relatively mirroring
their primary care colleagues 51% and 50%, respectively.5
Yet these data do not offer any insight as to the motivation for
such willingness to treat, that is as a duty or otherwise. In fact, the
University of Toronto Joint Centre for Bioethics (JCB) Pandemic
Influenza Working Group found that while some health care
professionals did meet the needs of the public during the infectious
disease threat of severe acute respiratory syndrome (SARS) in 2003 in
Toronto, approximately 30% of the reported cases were among
healthcare workers.6 This fact lead to serious concerns among some
health care professionals as to whether or not they were obligated to
care for those infected with SARS, and for others a direct failure to
report to work.7
This reality was highlighted in a study which examined public
health agencies in Maryland. The study found that nearly half of the
workers for public health were not compelled by a sense of duty to
report for work in the face of a pandemic.8 Given the surge required
for a pandemic, the issue of whether a duty exists for health care
workers to meet public need has become a matter of paramount
concern for health care system planning.9
One group that has made an explicit claim with regard to a
professional’s obligation to provide medical care is the American
Medical Association in the document “Physician Obligation in
Disaster Preparedness and Response” adopted in 2004. The
document states:
National, regional, and local responses to epidemics,
terrorist attacks, and other disasters require extensive
involvement of physicians. Because of their commitment to
care for the sick and injured, individual physicians have an
obligation to provide urgent medical care during disasters.
This ethical obligation holds even in the face of greater than
usual risks to their own safety, health or life. The physician
workforce, however, is not an unlimited resource; therefore,
when participating in disaster responses, physicians should
balance immediate benefits to individual patients with the
continued on page 7

6
 C O L L A B O R A T I V E
Case Management in a Pandemic: Has the Profession Codified its Obligations?
ability to care for patients in the future [emphasis added].10
Whether this position can be extrapolated to include health
care professionals in general is still unresolved. In fact, it is unclear
whether an organization in which only about 25% of U.S.
physicians are members creates enough of a force to ground the
obligation for all U.S. physicians.11 However, the expectation is
clear: “physicians have an obligation to provide urgent medical care
during disasters.”
Professional codes
of ethics form the
benchmark against
which professionals
judge their competencies
and behavior, and create
normative standards to
which the professional
ought to strive.
The JCB working group has gone further, but with the same
tenor of obligation, extending the obligation or duty to provide
medical care in a pandemic or similar disaster to all health care
workers. The JCB working group, under C1 Health Care Workers’ Duty
to Provide Care During a Communicable Disease Outbreak, notes:
The duty to care for the sick is a primary ethical obligation for
health care workers for a number of reasons, including:
1. The ability of physician and health care workers to provide
care is greater than that of the public, thus increasing their
obligation to provide care
2. By freely choosing a profession devoted to care for the ill,
they assume risks
3. The profession has a social contract that calls on members
to be available in times of emergency. (In addition, they
largely work in publicly supported systems in many
countries)12
Despite expanding this duty to provide medical care to health
care workers in general, the document does go on to note that,
“health care workers’ ethical codes should provide important
guidance on such issues as professional rights and responsibilities.
It is important for health care professionals, from doctors to nurses
to hospital and ambulance staff, to articulate codes or statements of
7
C A SE M A N A G E M EN T
(continued from page 6)
ethical conduct in high-risk situations, so that everyone knows
what to expect during time of communicable disease crises.”13 It is
unclear if these “codes” should merely provide guidance on the
implications of a presumption of a duty to provide medical care
among varying healthcare professionals in light of competing
duties such as families, friends and co-workers, or whether that
very presumption is one to be addressed by each disciplines’ code.
Whatever the case, it is clear that the expectation of a code of ethics
for health care professionals should speak to
1. The matter of a duty to provide medical care
2. Any limits to that duty (i.e., level of risk to self and others)
The Case Manager’s Duty to Provide Medical Care
in a Pandemic
Given the multidisciplinary nature of case managers’
professional background, this article will explore both The NASW
Code of Ethics, as well as the ANA Code of Ethics.
The NASW Code of Ethics Section One: Social Workers’ Ethical
Responsibilities to Clients states,
Social Workers’ primary responsibility is to promote the
well-being of clients. In general, clients’ interests are primary.
However, social workers’ responsibility to the larger society
or specific legal obligations may on limited occasions
supersede the loyalty owed clients, and clients should be so
advised [emphasis added].14
Section 6.01 follows titled: Social Workers’ Ethical
Responsibilities to the Broader Society; Public Emergencies,
Social workers should provide appropriate professional
service in public emergencies to the greatest extent possible
[emphasis added].15
At first glance it appears that the NASW has addressed both of
the JCB working group’s goals for a code of ethics related to the duty
to provide medical care and appropriate limits to that duty. However,
this code of ethics for the NASW falls short on both accounts. First,
note that although the code suggests “clients’ interests are primary,”
the subordinate clause that precedes this statement qualifies that
obligation as “in general.” One may infer from this context that
outside the context of pandemics or other public health
emergencies the primacy of the clients’ interests may not necessarily
be primary as it relates to the case managers’ obligations.
In fact, the code goes on to make this inference more explicit by
noting “responsibility to the larger society or specific legal
obligations may on limited occasions supersede the loyalty owed
clients.” Without stating explicitly the type of responsibility that
might be owed the “larger society” at the sacrifice of the individual
client, one could envision any number of social goods that could
potentially be constructed (i.e., the good of family, the good of
continued on page 8
 w w w . a c m a w e b . o r g

Case Management in a Pandemic: Has the Profession Codified its Obligations? (continued from page 7)

collegiality, the good of client placement to increase system public health emergencies, natural disasters, pandemics or
efficiencies, the good of the health systems’ sustainable otherwise.18 The ANA’s “Disaster Preparedness & Response” website
infrastructure for public health delivery). Depending on the good offers a link to the Institute of Medicine (IOM) report on
owed to the “larger society,” the primacy of the patient may be “Establishing Altered Standards of Care in Disasters.”19 Although
absent any corresponding duty or obligation on the part of the this IOM report does address the duty to provide medical care in
case manager. One could easily envision that a professional’s disasters, it is unclear whether this is intended to be simply a
obligations to deliver certain services likely would be constrained preparedness planning document, a position consistent with the
by the circumstances of a pandemic or other public health disaster. ANA’s position, or merely an available resource.
To suggest that the obligation to the patient herself can be
diminished or “trumped” by competing goods is a complete Conclusion: Codes of Ethics and Public Health
shift in the endpoint or recipient of that obligation. Disasters - An Appeal
Section six of the NASW Code of Ethics attempts to address the Carly Ruderman and colleagues argue “the continuing silence
issue of a duty or obligation to provide medical care in public of codes of ethics [on the matter of pandemics and the duty to care]
emergencies by directly is greatly problematic, both
addressing the issue of a public clinically and normatively.”
emergency. Again, however, use of Professional codes of ethics form
a qualifying phrase, in this case the benchmark against which
“to the greatest extent possible,” The challenging context of professionals judge their
makes the obligation less clear. a pandemic, which differs so competencies and behavior, and
Where possibility creates the greatly from the day-to-day create normative standards to
contingency upon which which the professional ought to
obligation hinges and the very reality of case management strive. The challenging context
nature of a public health practice, demands a code of a pandemic, which differs so
emergency, or more specifically a have been worked out well greatly from the day-to-day reality
pandemic, presents the de facto of case management practice,
reality of limits, section 6.01 of the in advance so as to “increase demands a code have been worked
NASW Code of Ethics does not awareness and comfort out well in advance so as to
provide clear guidance.16 levels, perhaps resulting “increase awareness and comfort
Unfortunately, ANA’s code of levels, perhaps resulting in
ethics for nurse case managers in increased willingness to increased willingness to provide
suffers from some of the same provide care in uncertain and care in uncertain and risky
inadequacies as NASW’s. risky conditions.” conditions.”20 Such a defined code
Provision 2 of the ANA Code of that responds explicitly to the
Ethics reads, matter of a case manager’s duty to
the patient in the context of a
The nurse’s primary
public health disaster or pandemic
commitment is to the patient, whether an individual,
also reinforces public trust.
family, group, or community. 2.1 …where conflict persists
Therefore, case management leaders should revisit
[related to this primary commitment], the nurse’s
17 established codes of ethics specific to the matter of a duty to
commitment remains to the identified patient.
provide medical care in a pandemic. While such codes can, and
In contrast to the NASW Code of Ethics, the ANA Code of Ethics hopefully will, be established on a national level in the future, in
does not qualify this obligation. Additionally, the ANA Code of the interim period case management leaders can establish
ethics does note that were there competing claims against this standards at their own facilities. In doing so, case management
primary commitment, the patient’s interests supersede. Overall, the leaders proactively define the expectations of their staff during a
ANA Code of Ethics seems to meet both of the expectations of the pandemic or disaster scenario.
JCB’s appeal to association’s codes of ethics. When establishing codes, case managers should consider the
Still lacking from this code of ethics, however, is explicit JCB’s recommendations outlined above as a starting point in order
advisement in the context of public health emergencies, or for to assist in clarifying their role and multiple competing obligations
pandemics specifically. In a review of ANA’s position statements during a pandemic. An effective code should address the following
since 1991, no statement addresses nursing’s responsibility in factors and key considerations:
continued on page 9

8
 C O L L A B O R A T I V E
Case Management in a Pandemic: Has the Profession Codified its Obligations?
• Case management’s obligation to provide care
• The risks case managers assume by choosing their
profession, and the implications of such risks upon the case
manager’s duty to provide care
• Possible limits to case management’s duty to provide
medical care, such as level of risk to self and others
• Case management’s professional rights and responsibilities,
so that expectations of case management in the event of a
pandemic or disaster scenario are clear
• Staff input is critical, as each member of the case
management department may provide unique perspective
from their personal experience
Case managers serve as advocates for both the patient and the
organization they serve. By proactively defining case management’s
responsibilities and duties in the event of a pandemic or disaster
scenario, case management leaders enable their staff to fulfill their
obligations to both parties, even when the correct course of action
may be unclear.
Mark Repenshek, PhD, is currently the Health Care Ethicist at
Columbia St. Mary’s in Milwaukee, WI, where he serves on an
Institutional Review Board, multiple Ethics Committees and offers
numerous educational opportunities for medical faculty and staff. He
earned his PhD in Health Care Ethics at Saint Louis University at the
Center for Health Care Ethics. In addition to his role at Columbia St.
Mary’s, Mark teaches at the Medical College of Wisconsin, University
of Wisconsin-Milwaukee, and at the Columbia College of Nursing. He
has authored numerous articles and a book in healthcare ethics.
Jane Hounsell, MSW, LCSW, is currently the Lead Medical Social
Worker in the Case Management Department at Columbia St. Mary’s,
where she also serves on the organization’s Ethics Committee. She has
worked in hospital case management for 22 years. She earned her
MSW from the University of Wisconsin-Milwaukee.
Endnotes
1 U.S. Department of Health and Human Services. HHS pandemic influenza
plan part 1: strategic plan. The pandemic influenza threat. U.S. Department
of Health and Human Services. 2005.
2 Heidi Malm, Thomas May, Leslie P. Francis, et al., “Ethics, Pandemics, and
the Duty to Treat.” AJOB 8 (2008): 4-19; Carly Ruderman, C Shan Tracy,
Cecile M. Bensimon, et al., “On pandemics and the duty to care: whose
duty? Who cares?” BMC Medical Ethics (2006): 1-6 accessed at http://www.
biomedicentral.com/1472-6939/7/5; Karine Morin, Daniel Higginson,
and Michael Goldrich for the Council on Ethical and Judicial Affairs of
the American Medical Association, “Physician Obligation in Disaster
Preparedness and Response.” Cambridge Quarterly of Healthcare Ethics 15
(2006): 417-431.
3 American Case Management Association, Standards of Practice & Scope
of Services for Hospital/Health System Case Management, (Little Rock, AR:
ACMA, 2007) 12.
C A SE M A N A G E M EN T
(continued from page 8)
4 ACMA, Standards of Practice & Scope of Services for Hospital/Health
System Case Management, 2.
5 G. Caleb Alexander, G. Luke Larkin and Mathew Wynia. “Physicians’
Preparedness of Bioterrorism and Other Public Health Priorities.” Academic
Emergency Medicine 13 (2006): 1238-1241.
6 L.M. Fleck, “Are there moral obligations to treat SARS patients?” Medical
Humanities Report 25, no. 1 (2003): 3-4; Malm, et al., “Ethics, Pandemics,
and the Duty to Treat,” 5; World Health Organization, “Consensus
document on the epidemiology of severe acute respiratory syndrome
(SARS).” Available at http://www.who.int/csr/sars/en/WHOconsensus.pdf
(accessed on November 2, 2009).
7 Ruderman, “On pandemics and the duty to care: whose duty? who cares?” 2.
8 R.D. Balicer, S. Omer, D. Barnett, and G. Everly Jr., “Local public health
workers’ perceptions toward responding to an influenza pandemic.” BMC
Public Health 18 (2006): 99.
9 GC Alexander and M.K. Wynia. “Ready and Willing? Physicians’ sense of
preparedness for bioeterrorism.” Health Affairs 22 (2003): 189-197; CC
Clark. “In Harm’s Way: AMA physicians and the duty to treat.” J Med Philos
30 (2005): 65-87; L. Reid. “Diminishing returns? Risk and the duty to care in
the SARS epidemic.” Bioethics 19 (2005): 348-361.
10 American Medical Association: physician obligation in disaster
preparedness and response. http://www.ama-assn.org/ama/pub/
physician-resources/medical-ethics/code-medical-ethics/opinion9067.
shtml (accessed November 2, 2009).
11 CC Clark. “In Harm’s Way: AMA physicians and the duty to treat.” J Med
Philos 30 (2005): 65-87.
12 University of Toronto Joint Centre for Bioethics (JCB). “Stand on Guard
for Thee: Ethical considerations in preparedness planning for pandemic
influenza.” JCB Bioethics Pandemic Influenza Working Group (November
2005): 9; http://www.jointcentreforbioethics.ca/publications/documents/
stand_on_guard.pdf (accessed November 2, 2009).
13 University of Toronto JCB, “Stand on Guard for Thee,” 10. http://www.
jointcentreforbioethics.ca/publications/documents/stand_on_guard.pdf
(accessed November 2, 2009).
14 National Association of Social Workers. Code of Ethics http://www.
socialworkers.org/pubs/code/code.asp (accessed on 11-04-09).
15 http://www.socialworkers.org/pubs/code/code.asp (accessed on 11-04-09).
16 Ruderman, “On pandemics and the duty to care: whose duty? who cares?,” 3.
17 http://www.nursingworld.org/MainMenuCategories/
HealthcareandPolicyIssues/DPR.aspx (accessed on 11-04-09).
18 http://www.nursingworld.org/MainMenuCategories/
HealthcareandPolicyIssues/ANAPositionStatements/
EthicsandHumanRights.aspx (accessed on 11-04-09).
19 http://www.nursingworld.org/MainMenuCategories/
HealthcareandPolicyIssues/DPR/IOM-Report-on-Standards-of-Care.aspx
(accessed on 11-04-09).
20 Ruderman, “On pandemics and the duty to care,” 3; see also, J Gommans.
“Coping with severe acute respiratory syndrome: a personal view of the
good, the bad and the ugly.” NZ Med J 116 (2003): U456; A Campbell and K
Glass, “The legal status of clinical and ethics policies, codes ,and guidelines
in medical practice and research.” McGill L J 46 (2000): 473.