The Case of the Salmonella Surprise

Identify one aspect of this week’s case study that intersects law, professionalism and ethics and explain your analysis.

 

Describe how you would apply your identified subject matter into your future work as a healthcare professional?

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Case Information

“It’s going to be a great day!” thought Joe Ascot, director of environmental services

for Peace County Health Department. Even though he struggled with having too few

restaurant inspectors for the restaurants in his growing county, Joe knew that public

health workers always soldier on and get things done. Then, the telephone rang.

The caller was the Director of Emergency Services at Peace County Hospital.

He said that his emergency department (ED) waiting room was full of vomiting patients.

He suspected that Salmonella poisoning was the reason for this ED rush. The most

severe symptoms occurred in eight children under the age of 5 and five women older

than the age of 70. Two of the children were in a serious condition. The ED nurses

were able to determine that the patients had all attended the Grandma and Princess

Luncheon at Aunt Tandy’s Restaurant in Peace City. This catered event featured a menu

of a fruit cup, chicken divan, French mashed potatoes, and green beans. For dessert,

there was Aunt Tandy’s chocolate cake and ice cream.

The ED director asked Joe to contact the Centers for Disease Control and

Prevention (CDC) immediately and check his records for inspection reports on Aunt

Tandy’s Restaurant. Joe was surprised about what appeared to be Salmonella poisoning.

He knew that poor kitchen hygiene was one of the sources of this problem, but he

was certain that Aunt Tandy’s was not to blame. After all, the restaurant had a great

reputation in Peace County.

Before Joe called the CDC to report a possible outbreak of Salmonella

poisoning, he searched his inspection database. “There’s nothing here!” he thought

as he searched and rechecked the database. There was no record of any inspection

of Aunt Tandy’s Restaurant during the past 6 months or even within the past

year. Immediately, he telephoned his restaurant inspectors. None had a record of

inspections for Aunt Tandy’s on their lists.

“What should I do now? There is no documentation for an inspection at Aunt

Tandy’s, and I have to call the CDC. Will I lose my job?” thought Joe. With great anxiety,

he picked up the telephone and followed the specified protocol. He dialed the number

for the state health department, which would then contact the CDC.

Note: The state health department, working in cooperation with the CDC,

conducted an investigation of Aunt Tandy’s restaurant based on the data from the

patient reports. Investigators found that Aunt Tandy assigned a new employee for food

preparation. This employee cut up the raw chicken for the chicken divan, then wiped

the board with a dishcloth and cut up the fruit for the fruit cup. This error allowed

transfer of the Salmonella bacteria from the uncooked chicken to the fruit. Those who

were most susceptible (children and the elderly) had the worst symptoms.

Commentary on the Case

What ethics issues did Joe have before the Salmonella surprise?

Think about the situation that Joe faced before the telephone call. He knew that he did

not have enough staff, which meant heavy caseloads. There was a high probability that

inspectors did not spend enough time in each of their restaurants. The lack of staffing

also increased the likelihood that there would be a failure in the system and potential

health problems for the community.

(continues)

Summary 229

Joe insisted that the Peace County Health Department hire more restaurant

inspectors and presented his rationale to the director. However, the director used

utilitarian ethics. For example, he weighed the community benefit of hiring more

restaurant inspectors against the benefit of hiring more public health nurses. Given

a limited budget, he chose to hire those who provided the greatest benefit to the

community. Therefore, the director favored hiring nurses over restaurant inspectors.

Joe was counting on the ethics of restaurant owners to be concerned with

nonmaleficence and justice for their patrons. Because it was in their best interest, he

assumed that they would meet public health standards and keep the kitchen sanitation

up to code. After all, it was in their self-interest to make sure that a negative health

event did not happen.

What were the ethics principles violations in this case?

To answer this question, consider the factors that contributed to this situation. The

restaurant owner, the employee in charge of the preparation, restaurant inspectors,

and Joe all violated ethics principles in different ways. In examining these violations,

one can see how things that appear to be unimportant can lead to serious healthcare

consequences.

Begin with the principle of staff justice. Aunt Tandy did not provide the

new employee with adequate training about kitchen sanitation and correct food

preparation. Perhaps Aunt Tandy assumed that he knew not to prepare raw chicken on

the same cutting surface as fruits and vegetables. Perhaps she also did not take time to

train this newly hired employee. Whatever the reason, Aunt Tandy placed the employee

in a disadvantaged position. He was not trained but was accountable for the outcomes

of his actions. Certainly, this employee contributed in a major way to the Salmonella

poisoning outbreak, but was he solely to blame?

Aunt Tandy also contributed to the harm. Her lack of due diligence in protecting

the public through training and engagement in food preparation led to her serving

contaminated food to her customers. Although she did not intend to cause harm, her

decisions contributed to this harmful event. In addition, the reputation of Aunt Tandy’s

restaurant could suffer. Negative publicity from the Salmonella surprise could cause

Peace County residents to choose other restaurants. Her potential lack of business could

lead to staff layoffs or even the closing of this once well-respected restaurant.

Look at the actions of the food preparation employee. Certainly, his actions

violated the principle of nonmaleficence. Perhaps he was in a rush and took the

shortcut to speed up his preparation. Maybe he actually thought that wiping the

cutting board with a towel would make it sanitary. Whatever the reason for his actions,

he was a major contributor to the Salmonella outbreak and the harm to the children

and their grandmothers.

The food preparation employee also violated the intent of the principle of justice.

His actions did not demonstrate fairness to the customers, who relied on his integrity

to produce safe food. In addition, he was not fair to his fellow employees because his

actions caused harm to their collective reputation and to their potential livelihood.

Assume that this employee had no negative intent; he was careless and did not think

beyond the moment. Aristotle’s practical wisdom should have been present. Had he

thought about the potential consequence of his decision, the Salmonella poisoning

would not have occurred.

What about the inspectors and their violation of ethics principles? First, the principle

of autonomy for Aunt Tandy was honored because they assumed that she was following

A CASE FOR ETHICS (continued)

230 Chapter 13 Public Health and Ethics

correct food protection protocols. Therefore, they also assumed that the restaurant was up

to code and did not inspect her business. In their defense, with their busy schedules and

their knowledge of Aunt Tandy’s positive reputation, they may have decided to use their

limited resources to inspect restaurants with a less stellar reputation. This action might be

a form of utilitarianism, but their assumptions led to a failure to protect the public. With

this decision, the inspectors also violated the principle of justice. Treating Aunt Tandy’s

restaurant differently meant that they did not provide fair treatment to all.

What about Joe? In this case, he violated several ethics principles. Joe had the

authority to supervise the staff in his department and meet the goals of the Peace

County Health Department. This authority allowed him autonomy over his actions and

those of his staff. However, Joe did not use his autonomy appropriately. For example,

when he checked his database, he could not find any record of an inspection for Aunt

Tandy’s Restaurant. This omission demonstrated a lack of responsibility on his part, as he

should have checked the system frequently.

In addition, Joe contributed to violations of justice. For example, he did not review

which restaurants his inspectors were evaluating. Had he done that, he would have

seen that Aunt Tandy’s restaurant was not on their lists. Given this information, he could

have followed up to make sure that all restaurants were treated fairly. Even though Joe

was not directly responsible for the actions of the restaurant preparation employee, the

owner of Aunt Tandy’s Restaurant, or his inspectors, he held a position of responsibility

for the safety of all restaurants in Peace County. Therefore, his actions violated the

principle of nonmaleficence. His actions not only contributed to the patients’ harm, but

also potentially harmed the community and its reputation.

Should Joe lose his job?

The answer to this question relates to the policies and procedures for Peace County

Health Department. In all likelihood, the Health Department director will hold

someone accountable for the Salmonella poisoning outbreak. Even though Joe was

facing staffing shortages and had many other problems in his department, he had the

authority and autonomy to make decisions for the safety of restaurants in the county.

Joe might consider it unjust, but it is likely that he will lose his job because of the

Salmonella surprise.

The Case of Pox on a Plane

Case Information

Flight 1414 was 1 hour away from its destination of Newark. It was a 7-hour flight

from London; flight attendants Cindy, Mari, Eva, and Jason were tired and ready to

land. “No one wants to land more than those kids and their sponsors in second class,”

thought Mari as she approached the back of the plane. She knew that these high

school students and their three adult sponsors were returning from a missionary trip to

Gambia, Africa. When she reached the missionary group section, one of the sponsors,

Mrs. Stanley, stopped her.

“Stewardess,” said Mrs. Stanley, “I am worried about Patti, LaDonna, and Fred.

They are feverish and sweaty. Look at their arms; they have a rash that looks all bumpy.

Can you help them? I am afraid that they have monkeypox.” Mari went to the galley

and brought the students water and a snack. Then she remembered her training on

prevention of contagious diseases. Could this be smallpox? What was her responsibility

in this situation?

Mari went to alert the captain. She explained that the missionary group was

returning from a trip to Gambia, Africa. From her training, Mari knew that Gambia was a

(continues)

Summary 231

source of cases of monkeypox, a disease that is similar to smallpox. Although smallpox

vaccinations protect most people from this disease, monkeypox was contagious and

could spread to the passengers. It also looked a lot like smallpox. “What should we do?”

she asked.

The captain had also received training on controlling contagious diseases

and immediately contacted the airport. The authorities at Newark airport took the

report seriously and contacted the CDC. Within a few minutes, the captain received

instructions to prevent all passengers from leaving the plane after it landed. The CDC

quarantined all passengers and staff until they investigated and ruled out smallpox.

Because she knew that these passengers were going to be very unhappy, the captain

made the announcement about this process. She apologized for the inconvenience on

behalf of the airline and explained what would happen as accurately as she could.

Cindy, Mari, Eva, and Jason worked to calm the passengers and assure them that

they would be able to leave the plane as soon as possible. They explained that the

quarantine was to protect everyone. However, several passengers in the first-class cabin

complained that they had important things to do and that the airline could not hold

them against their will. They had rights! Some of the passengers demanded to talk with

the captain and the airport authorities about this matter. Cindy, Mari, Eva, and Jason used

patience and respect while explaining the necessary actions. They also asked the captain

to confirm that arrangements would be made for passengers who had continuing flights.

Imagine the surprise when the Flight 1414 passengers saw vehicles from the

Newark Emergency Medical Services, Newark Fire Department, and Newark Health

Department, and the CDC rolling onto the tarmac. The CDC and Newark Health

Department staff went to the back of the plane to evaluate Patti, LaDonna, and Fred and

question the rest of the students and their sponsors. Using their iPads, the investigators

took pictures of the rash and sent them to the CDC. In about 30 minutes, they received

confirmation that the three students had monkeypox, not smallpox. They could lift the

quarantine for the rest of the passengers. However, they needed to advise all members

of the missionary group and those who were seated around them to get immediate

medical care.

Before allowing the passengers to deplane, the Health Department staff

member informed all of the passengers about the situation. If not vaccinated against

smallpox, they needed to seek medical help. Even though they were not at great risk

of monkeypox, the Health Department staff advised that passengers practice healthy

habits. As a precaution, the airline would collect detailed contact information for each

passenger. Most of the passengers were greatly relieved to be ending their journey.

However, many in the first-class section threatened to sue. As for Cindy, Mari, Eva, and

Jason, they would never forget this flight.

Commentary on the Case

What ethical principles did Mari and the captain demonstrate?

First, Mari used her autonomy and training to make the best decision given the

information that she had available. She knew that monkeypox was not as severe as

smallpox. However, she also understood that the diseases presented similar symptoms

and that there was a need to differentiate one from the other. Therefore, she felt a duty to

protect the passengers on the plane and the community itself by reporting the incident.

A CASE FOR ETHICS (continued)

232 Chapter 13 Public Health and Ethics

In addition, Mari, along with the other flight attendants, used the principle of

beneficence when dealing with the missionary group and the passengers on the plane.

The flight attendants tried to make all of the passengers as comfortable as possible. Mari

answered their questions with accurate information and provided justification for the

quarantine. In addition, she asked the captain to check with the airline regarding flights

for passengers with continuing travel plans.

The captain used the autonomy of her position to make a decision. She had to

weigh many factors in doing so. For example, there was a chance that she could lose

her job if her decision was determined to be inappropriate by the airline. She also

knew that there was a potential for a high number of complaints from inconvenienced

passengers. However, she trusted Mari’s judgment and training. Therefore, she made the

call to Newark authorities, which led to the CDC order of the quarantine.

The captain also practiced nonmaleficence and beneficence in her decision.

In taking this action, she prevented what could have been an outbreak of a serious

disease. Even though the affected passengers’ condition was determined to be

monkeypox and not smallpox, she was instrumental in making sure that passengers

on the plane received correct information about prevention and treatment. In doing

so, the captain decreased potential harm to passengers. Likewise, her treatment of the

situation exhibited beneficence. The captain fully informed the passengers about the

need for the quarantine and explained the procedures as she knew them. In addition,

she apologized on behalf of the airline and assured the passengers that the airline

would make every effort to accommodate their needs. Providing this information

demonstrated kindness as well as good business sense.

Why did the airline choose to notify the CDC before the plane landed?

The airline had to consider its duty to the passengers and to the city of Newark itself.

To ensure the health and safety of the passengers, the CDC and the Newark Health

Department had to confirm that the passengers were suffering from monkeypox and

not smallpox. In addition, they had to protect the city of Newark from exposure to

smallpox, if it was present. In making the decision to call the CDC, the airline took risks.

The publicity generated by the incident could produce benefit or harm to the company

depending on how people viewed it. For example, the public could consider the airline

a hero because it made a decision to protect both the passengers and the city of

Newark. Alternatively, it might view the airline as being hyper-reactive to a situation that

meant nothing. If this were the case, there could be a reduction of credibility and ticket

purchases. Despite the risks, the airline decided that the most ethical decision would be

to contact the CDC and risk the consequences of doing so.

Which ethical position did the passengers in the first-class cabin demonstrate?

Some of the passengers in the first-class section put their needs above others and

lacked beneficence and justice. They believed that they were more important than

other people on the plane are and did not demonstrate compassion or patience. These

passengers also felt that their rights included protection from inconvenience even

if their inconvenience protected others from exposure to disease. They did not base

their ethics decisions on duty toward others or on the greatest benefit for the greatest

number. Instead, they only thought about themselves and demanded action that

benefited them as individuals. They also planned to voice their displeasure by writing

complaint letters to the airline, the CDC, and the Newark Health Department and by

calling their lawyers.

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