Beards and COVID-19 in the healthcare setting

By Dr. Liji Thomas, MDApr 1 2020

A new opinion piece in The BMJ published in March 2020 discusses whether healthcare professionals should wear beards because of the risk that they could harbor the novel coronavirus.

The beard question

Are doctors who wear their facial hair long obliged to remove it in the interests of protecting their patients against the transmission of the coronavirus. Could a long beard make it more difficult to wear an FPP3 respirator and thus put patients and other staff at risk?

Staff wearing beards and covid-19: trickier than it looks. Image Credit: Asha Natasha / Shutterstock

The FPP3 mask is recommended for use to protect against the coronavirus and other germs that are in the form of aerosols. They are different from standard surgical masks in that they have an inbuilt filter that keeps out large respiratory droplets that could carry the virus. However, they need a clean seal between the mask and the face to work well. In the absence of experimental evidence as to their efficacy, their use is supported by the opinion of specialists.

The burning issue is about how to balance the rights of the doctor and the patient. Patient safety is to be foremost, as always. Any patients approaching a health service have the right to "be protected against avoidable harm," according to the paper. Beard-wearing is seen in this light – if wearing one is a risk to patient safety. The healthcare provider must make sure that those treating patients do not wear beards.

New NHS guidelines say, "Beards, stubble and facial hair cause a common problem when using PPE face masks, as this can prevent the mask from being able to seal to the face and passing the fit-test."

On the other hand, employers also have an obligation to their staff, in the form of identifying and minimizing risks posed by the workplace to them. This includes discussing the risks, training, and advising them on the best way to manage these risks, and may include advice to remove facial hair if required.

Employees also have the right to be dealt with in a fair and equal way, without discrimination on unlawful grounds. Conversely, they expect that this right on the part of others will not entail an undue burden of risk on them. Thus, if a bearded doctor chooses to wear his beard, in the current situation, women and doctors who don't wear beards will be forced to cover for him in seeing COVID-19 patients or those who are potentially infected. Isn't that unfair?

The resolution

In short, if the reason for wearing a beard is purely personal, the employer would be right to insist on its removal for the sake of patient safety. However, if it is a religious duty, asking them to shave could raise the issue of indirect religious discrimination. However, the authors point out, "Under the Equality Act 2010 a rule or policy that has a particularly negative impact on a group (Muslim or Sikh men, for example) can still be justified if it is a proportionate way of achieving a legitimate goal—in this case controlling the risks to patients and staff safety and, as far as possible, preventing the spread of the infection."

In case of a requested religious exemption, therefore, the employer can first think about how shaving would impact the individual. They could discuss with local faith groups to work out an acceptable way to engage with the issue.

Secondly, what are the alternatives? In the current COVID-19 situation, could employers reasonably provide a powered air-purifying respirator that doesn't need a tight fit, unlike the FPP3 mask, and can be partnered with a covering over the whole head? If so, this could be an option – provided the resources are available, and it is possible to allocate sufficient time to train staff to use, clean, and re-use it properly.

A third option is to remove such men from the frontline of treating COVID-19 patients – which could work in a large facility and with few cases, but not in a pandemic situation. The NHS guidance also recommends that all trust hospitals look carefully into the situation before recommending a blanket shave for all staff. They should evaluate where it is needed and how many would be affected. If there is a "legitimate business need to insist that employees be clean-shaven," in which case the risk assessment should decide the approach to be "agreed and implemented consistently."  

What does this mean for bearded doctors and their employers?

In the ordinary case, doctors would be asked to remove their beards or other feasible solutions offered. If patient safety is compromised at any point, doctors ought to remove their beards for the sake of ordinary morality. If religious reasons are still cited, legal advice is recommended to handle each case individually, balancing health risks with equality rights. Very often, personal distress and a past history of faithful patient service will weight the scales against requiring beard removal. On the other hand, given the pressing health situation, unlawful religious discrimination cannot really be argued. Hence the need for legal advice on how to deal with each case.

And it's not just doctors, laymen with beards beware too!

In the US and Australia, too, men are being warned to shave off beards of all sizes because they don't allow respirators to fit well. Mostly, however, the respirators envisaged by this order are used by healthcare workers dealing with potential COVID-19 patients. The rule is, no hair at the part of the face where the respirator forms a surface seal. While this would rule out stubble, full beards, mutton chops, and Dali mustaches, it's okay to wear goatees, horseshoe, and villain mustaches as long as they are kept in trim. An infographic released a month ago by the Centers for Disease Control and Prevention (CDC) shows the full range of acceptable and unacceptable facial hairstyles. Medics and paramedics are being urged to shave off or at least trim their facial hair to allow a proper face mask fit.