It is almost surreal to read hypothesizing about pandemics from pieces published less than two years ago:
One can hypothesize an easily transmitted, highly lethal virus that withstands all that modern medicine can offer, but until such an event actually occurs, it is difficult to see how the risk to physicians can justify limits on the duty to care for patients during a pandemic. The benefit to risk ratio seems to favor a strong obligation to treat.
It’s certainly understandable that Dr. David Orentlicher, writing in the American Journal of Public Health, would discuss a
benefit to risk ratio, and talk about a pandemic in terms of percent chance of infection.
Orentlicher names the catch to thinking about pandemics, and ethics in general:
but until such an event actually occurs… For characters in a story, as well as for healthcare providers in a pandemic, thinking about how one ought to act is quickly confronted by the reality in the moment.
The author discusses the historical extremes of ethical guidelines on treatment. This includes the AMA Medical Code of Ethics from the nineteenth century, which ominously states physicians should continue work
without regard to the risk to [their] own health … even at the jeopardy of their own lives.1 This contrasts with today’s more moderate AMA Opinion 8.3, that providers
also have an obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future.2
It’s possible to see the current AMA code as allowing physicians and other providers to remove themselves from danger. Orentlicher, though, lists outbreaks from modern history like influenza in 1918, SARS in 2003/4, and Ebola in 2014, and remarks that doctors, nurses, and other providers all behaved with
medical heroism,3 and the trend continues to our current pandemic.
The glaring example from the twentieth century of some physicians abandoning the “duty to treat” is the HIV pandemic of the 80s. This certainly has more to do with the patient than the pathology:
refusals to treat may be rooted in invidious bias rather than legitimate concerns about the risks to physician health.4
Thinking in terms of mortality rates and numerical odds of catching a disease while caring for patients is certainly not wrong. Orentlicher reminds us, though, that the word “but” and its cousins are powerful qualifiers. Notice how quickly the desire to fulfill nurses’ professional calling is placed in a real-world situation in this ethics code:
Nurses are morally obligated to care for all patients. However, in certain situations the risks of harm may outweigh a nurse’s moral obligation or duty to care for a given patient…5
Simply stating a “but” or “however” in these cases is not a dereliction of duty. It’s a reminder that ethics is not a percentage game, or even necessarily an analysis of risks and benefits. Ethics is making decisions about our own story under difficult circumstances, and realizing that the desires driving us face challenges.
We see this in the realities patients and providers face during the COVID-19 pandemic. Healthcare providers isolate themselves from their families: “I want to continue caring for the sick, but I have to protect my family.” Fathers and partners aren’t able to be present at the birth of their own children: “…but the baby has to start life in quarantine.” Physicians make contingency plans, in case they have to discontinue telemedicine, “…but I might have to go back to the front lines.”
The article reviewed: Orentlicher, David. 2018. “The Physician’s Duty to Treat During Pandemics.” American Journal of Public Health 108 (11): 1459–61. https://doi.org/10.2105/ajph.2018.304582.
1 Huber, Samuel J., and Matthew K. Wynia. 2004. “When Pestilence Prevails … Physician Responsibilities in Epidemics.” The American Journal of Bioethics 4 (1): 5–11. https://doi.org/10.1162/152651604773067497. ↑
2 Council on Ethical and Judicial Affairs. 2017. Code of Medical Ethics of the American Medical Association. Chicago, IL: American Medical Association. ↑
3 Zuger, A., and S.H. Miles. 1990. “Physicians AIDS and Occupational Risk. Historic Traditions and Ethical Obligations.” Health Policy 14 (1): 56–57. https://doi.org/10.1016/0168-8510(90)90354-g. ↑
4 Daniels, Norman. 1991. “Duty to Treat or Right to Refuse?” The Hastings Center Report 21 (2): 36. https://doi.org/10.2307/3562338. ↑
5 “American Nurses Association Position Statement on Risk and Responsibility in Providing Nursing Care” 2015. ↑
Featured Image: “U.S. Navy Lt. Gail Evangelista, nurse…” U.S. Air Force photo by Senior Airman Dylan Murakami. This photograph was taken by a member of the U.S. military during the course of the person’s official duties. Under United States copyright law, such images are public domain.