Physicians Harris and Green sit silently, each waiting for the other to speak first. The elder of the two by decades, Dr. Harris finally decides to open the conversation. “I’m tired. I’ve been practicing for years. I was lucky enough to recover from my MI but I just can’t imagine having to deal with something this big. It’s time for me to slow down—that’s why I brought you in.”
Dr. Green looks slightly past Dr. Harris, having already sifted through his arguments countless times. “My wife needs me. She’s pregnant and taking care of a 2-year-old. They’re leaving the city. I don’t have anywhere close to the medical expertise you have.” They stare at each other glumly; the flu pandemic that has brought them to this discussion hit quickly, violently, and without much warning. Each prays the other will take over and present himself as the reporting physician for the practice. Whoever stays will not only need to work tirelessly with the diseased population but will also be subjected to a strict quarantine.
Rather than arguing that one of the two physicians has a greater responsibility to shoulder, I would like to propose that both have the professional obligation to remain in the city and help care for the sick binds both physicians. First I will discuss the competing ethical duties presented in the scenario. Then I will review literature pertaining to physicians’ responsibilities in times of emergency. Combining the duties suggested in the scenario with the arguments advanced in the literature, I will conclude that both Drs. Harris and Green have ethical duties to help those in need of their medical expertise.
Duty
In the opening conversation, Drs. Harris and Green bring four (at times conflicting) duties to the fore. The first is duty to self. This duty comprises, for example, the right to defend oneself against that which one sees as harmful to one’s state of well-being. Dr. Harris expresses the duty-to-self position by stating his desire to live the rest of his life in as healthy and as relaxed a manner as possible. Though he has recovered from his heart attack, he feels he must protect himself from further stress. He would like to travel and spend more time with his family, all while living in semi-retirement.
The second duty is social in nature: duty to one’s family. This obligation spurs many salary earners to spend their incomes on their families’ needs rather than on themselves. In the conversation between the two physicians, Dr. Green invokes duty to family when he states that his wife’s desire to have him close by competes with the need to care for the victims of the flu pandemic. Rather than remain in quarantine for an unspecified amount of time, he would like to accompany his wife, who is pregnant, and their 2-year-old son to his parents’ home.
Physicians also have a duty to colleagues. This is more difficult to define but fundamental to contemporary medical education. The teamwork emphasized from the anatomy lab to the surgical suite helps foster professional unity and camaraderie. In a profession where one deals with taboos on a daily basis, from the dispensing of illegal substances to the cutting of a stranger’s skin, physicians must work together and support each other through times of emotional hardship and intellectual complexity. In this scenario, Drs. Harris and Green recognize that they cannot simply leave town without first meeting to discuss their plans and coming to a joint decision; they thus acknowledge their duty to each other as colleagues.
The fourth duty, to one’s patients, is integral to the medical profession. Both Drs. Harris and Green could have left town immediately. The very fact that they have stayed long enough to discuss the situation implies that they understand the seriousness of their professional obligation to their patients, even if they do not as yet know who these patients are. It is this duty that requires physicians to operate while sober, to report fairly and honestly, and to work towards their patients’ best interests. This fundamental duty is expressed in the Hippocratic Oath and the Maimonidean Oath. It is this fourth duty that will ultimately require both physicians to stay in the city.
Duty to Patients in an Emergency
In an article entitled, “Physician Obligation in Disaster Preparedness and Response,” members of the American Medical Association’s Council on Ethical and Judicial Affairs laid out the physician’s responsibility in the case of disaster, whether natural or human in nature. The article refers to several statements within the Principles of Medical Ethics, most directly Principle VII: “A physician shall, when caring for a patient, regard responsibility to the patient as paramount,” and Principle VI: “A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve” (emphasis added) [1]. It then claimed that the medical profession as a whole, as well as its individual constituencies, has a “professional commitment to assure adequate availability of care” in times of emergency [2].
Various measures are used to calculate the risks a physician ought to take in such circumstances: the need, the proximity of the event, the physician’s expertise in the field, and the presence of other forms of aid [3]. The true limit of a physician’s responsibility lies at the border of his own mortality. Should the physician find himself in a situation in which helping one person keeps him from helping anyone else (for instance, if the physician would die from exposure), the physician should not help. Strategies should be implemented to ensure a continuing level of medical care; for example, “the number of exposed physicians” should be curtailed so that the remainder can serve other patients after the emergency ends [4].
According to the definitions in this article, Drs. Harris and Green are in an emergency situation. Their care is surely needed—all available primary care and infectious disease physicians have been called upon by the State Department of Health to volunteer their services. They live in the very city being swept by the pandemic, so their proximity is guaranteed. Their primary care area has been recognized by the State Department of Health as a field of expertise that is needed in the emergency. Finally, without further knowledge of other physicians’ situations, Drs. Harris and Green cannot help but admit that other sources of aid might not be sufficient. In this case, they have access to prophylactic vaccination and quarantine facilities, so their personal risk is not so great as to counter their duty to serve. Even if only one were to serve, while the second remained outside the city to ensure continual medical care after the pandemic ended, the second would be required to stay proximal to the pandemic area in case the first suddenly became unable to serve (for instance, due to illness). In other words, as summarized in the concluding paragraph of a commentary on the AMA article, these “physicians should be considered to have a duty to treat” due to “their role as public servants” who, in their distinct position between “ordinary citizen” and specially trained responders, owe their service to the community in which they live [5].
Dr. Rosamond Rhodes lambastes the AMA article for taking a “peculiarly inconsistent position” [6]. Rhodes finds that the article advocates for individual choice within a medical emergency, thereby destroying the original concept of ethical medical care presented in the introduction and conclusion. In other words, the very fact that each physician can volunteer to help in an emergency seems to contrast with the duty the medical field has to care for those in dire situations. This duty stems from the societal acceptance of and reliance upon medicine as a privileged profession with a unique knowledge and set of skills, as well as from physicians’ acceptance, “through oaths, codes, and licensing,” of certain standards of care [7]. According to this opinion, Drs. Harris and Green have no choice but to serve together, in collaboration with all other physicians in the area. Indeed, to leave the city without helping would be to act unethically and to shirk medical responsibility.
A third commentary written by Zwi et al. emphasizes Van Hooft’s model of “deep caring” over the Kantian notion of duty expressed in the AMA paper [8]. In the Van Hooft ethical code, physicians volunteer out of the goodness of their hearts, and in doing so reaffirm that which “is significant about human beings”—their desire to help others even when such response might harm their own being [9]. Thus, when emergencies are so hazardous as to pose risk to physicians (as in this case of contagious disease), Drs. Harris and Green should be guided by their hearts, rather than codes and have the right to volunteer as well as the right to leave town. Zwi et al. seem to hope that the two would volunteer because of “a deep humanitarian impulse to help others” [9].
The Zwi et al. model relies upon the human instinct in times of acute, immediate danger to others; this instinct was recently highlighted in the report of a stranger saving another man in a New York subway station by rolling himself and the victim under an oncoming train [10]. Were the hero of the story to have been three blocks away, still with two daughters in hand, he probably would not have left the two, sprinted three blocks, rushed down the subway stairs, and jumped onto the tracks in order to save the victim. The story changes simply by the spatial separation between the two men. Drs. Harris and Green are like the man in the second version of the story. They are not are not yet sick, have not been exposed or quarantined, and they have the option to leave town. How many other doctors like these would choose to stay due to deep caring? It seems one must continue to rely upon the ethics of professional duty, even while appreciating the ethics of deep caring.
Conclusion
Drs. Harris and Green are part of an ethical dilemma known to all doctors in situations of emergency response, whether that emergency is due to nature, to war, or to microbe. However, the competing duties to self, family, profession, and patients do not have equal value in times of emergency. Able physicians have an obligation to push aside competing desires and duties. In some situations, this obligation will be surpassed by greater obligations, such as that of continual care. Should a doctor know for a fact that helping in an emergency will cause his own death, the decision to help would stem from inappropriate over-zealousness. The desire to leave on the parts of Drs Harris and Green is not based, however, upon their fear of dying so much as on their desire to live better during that specific period of time. In their situation, the ethical decision for both would be to report to the hospital as collaborating colleagues.
Notes and References
- Morin K, Higginson D, Goldrich M, Council on Ethical and Judicial Affairs. Physician obligation in disaster preparedness and response. Camb Q Healthc Ethics. 2006;15(4):418.
- Morin, Higginson, Goldrich, CEJA, 419.
- Morin, Higginson, Goldrich, CEJA, 419-420.
- Morin, Higginson, Goldrich, CEJA, 420.
- Alexander GC, Lantos JD. Commentary: Physicians as public servants in the setting of bioterrorism. Camb Q Healthc Ethics. 2006;15(4):423.
- Rhodes R. Commentary: The professional obligation of physicians in times of hazard and need. Camb Q Healthc Ethics. 2006;15(4):426.
- Rhodes, 424.
- Zwi AB, McNeill PM, Grove NJ. Commentary: Responding more broadly and ethically. Camb Q Healthc Ethics. 2006;15(4):430. Quoting Vann Hooft S. Caring: An Essay in the Philosophy of Ethics. Boulder: University of Colorado Press; 1995.
- Zwi, et al., 430.
- Buckley C. Man is rescued by stranger on subway tracks. The New York Times January 3, 2007. http://www.nytimes.com/2007/01/03/nyregion/03life.html?ex=1325480400&
en=bfb639ecfb906ab5&ei=5088&partner=rssnyt&emc=rss. Accessed June 24, 2007.
Lora Rabin Dagi is a second-year student at Mount Sinai School of Medicine in New York.
Re: flu (Letters to Memphis)
Michael Bennett
December 12
Hey Dan,
How’ve you been man? I guess we last talked when Jenny got pregnant, so it’s been almost five months now. Sorry about that—things have been pretty nuts around here between Steven walking now (falling, mostly) and the house hunting. I told you we’re moving, right? You’ve seen our condo. If one kid can manage to crash into almost everything in it, I don’t even want to think about what two would do. We’ve got to have more space to accommodate that kind of entropy.
The reason I wanted to get in touch with you now is that I’m curious what you’re thinking about this flu scare. I’m sure you saw the CDC warning about this one being particularly virulent and there already being a serious shortage of Tamiflu. Our practice has a pretty good supply, but there’s no way we have enough for all our patients if it gets bad. A lot of them have been asking for prescriptions already, but we’ve been advised against handing them out since there haven’t been any cases in Nashville yet. With yesterday’s death in Atlanta, though, I am concerned that we may be failing our patients. I know we need to keep enough for our staff and for those who actually get sick, but it feels like we’re hoarding our riches. All I can do now is strongly advise my patients to get vaccinated, but it looks like that may not be very effective against this one. What are you doing over there?
The thing is, while I’m obviously concerned, I have trouble being convinced that it’s really going to be that bad. Remember when we were interns and everyone was freaking out about bird flu? That turned out to be a below-average year for mortality. I’m still fairly optimistic.
Do you and Meghan have plans for the holidays? We’re going out to my parents’ place, assuming things don’t get out of hand here. Like I said, optimism.
Hope you’re doing well, and give Meghan my regards.
Mike
December 20
Dan,
Yes, you’re right, it’s kind of hard to be optimistic now. Did you see the numbers from Atlanta this week? Holy crap. They’re filling up at UT in Knoxville already, and it’ll certainly be here in a couple days at the latest.
I’m glad you asked about the department of health’s call to duty. It sounds like you and Meghan had a pretty similar conversation as Jenny and I did. I also had a long talk with Jim Harris, whose opinion I hold in very high regard, obviously. You remember him I’m sure—he’s the one who actually hired me here, and he’s been a mentor to me ever since. Because of the quarantine situation, I’ve had to make a decision really quickly, which has been extremely difficult. I hope I can help you with your choice. We’ve always been fairly alike in our thinking, so I’m guessing you’ll come to the same conclusion I did.
I’m staying. Ultimately, the more I thought about it, the more it became clear that that was the only ethically appropriate choice, even though it conflicts with my best personal interests. I sensed some resignation to that in your e-mail, if I’m not mistaken, so you know what I mean. As Jim said, “Every doc in the city has some reason to leave, and we can’t all do it.” He’s right of course. We all think our situations are unique, but how can we decide whose obligations count the most? And really, this is what we signed up for when we went into medicine.
Actually, I’d go as far as to say this may be the most important part of what we signed up for. I mean, it’s never really okay for people in our profession to just up and leave, since our patients and colleagues are relying on us to play our parts so the system runs smoothly. But when things are normal, at least it’s likely that someone else could pick up the slack. There might be snags, but people would for the most part get the care they need. In times like these, though, there are going to be a ton of snags even if we had twice as many doctors and nurses. We’ve all suddenly become essential.
Jim reminded me of another thing about our profession that I feel like we sometimes forget. Even though we’re private citizens and work in private companies, we’re very much public servants. If we were cops or firefighters, we wouldn’t even be having this discussion. Can you imagine? If they started breaking ranks and heading for the hills tomorrow, there’d be total pandemonium when this thing hits. People would die as a direct result. Lots of people. They’re putting themselves at the same risk we are in staying here, and they’re not even getting first dibs on the Tamiflu. This is our job, and we have to do it or people will die who otherwise wouldn’t. Maybe lots of people.
I told Jenny all this, and of course she understands, but she’s very upset and I think angry with me. She’s driving out to my parents’ with Steven first thing tomorrow, as we’d planned, only without me. What’s so hard about this is that I know I’m letting my family down, and that’s something I signed up for too. I’ve always promised her, and promised myself, that we come first and work second. This is exactly the kind of time when we should stick together, stay safe, and be there for each other. What if it gets out there and she gets sick? Steven’s only two, plus she’s pregnant. More likely, what if I’m stuck here for months? I’d miss our daughter’s birth, and I’d be the cause of a lot of worry and strain on our family. What if I get sick? What if I die, Dan? My family’s only just getting started, and I’d be gone. It really feels like it’s my responsibility to make sure that doesn’t happen. I can tell that’s what Jenny thinks, even though she knows why I have to stay here.
As hard as it is to admit, it seems to me that our obligations as professionals outweigh our personal responsibilities. I wish that wasn’t the case, and I don’t know that it ordinarily would be. For instance, if there was someone else who could do it and was willing to do it, it could be seen as a heroic sort of choice. Now, though, it’s just what we have to do—it’ll take all of us, and that still won’t be enough. Maybe if I was a single parent and didn’t have anyone else to take care of Steven, it would be different, too. I’m not saying no one has a reason that could compete with this kind of obligation, but mine just isn’t compelling enough. My chances of surviving are pretty high, my family can get by without me (I know, that’s a hard thing to type), and I have a trained ability that most people don’t have to relieve a great deal of suffering here. Morally, how can I leave?
If it hasn’t already started yet in Memphis, get ready for some serious panic. I know it’s constantly on the news everywhere in the country, but the sense of imminent doom here is new. A lot of people are scrambling to get out of town, and the grocery stores are running out of everything. I think literally all my patients have asked me for Tamiflu. I’m not sure it’s helpful the way they keep reporting that it works on this strain, because there just isn’t enough to give it out prophylactically. I feel terrible saying no, and a lot of my patients are pissed at me. I can’t say I blame them. I have misgivings that we may be costing lives. I’m trusting Jim’s judgment on this, which is that not having it when people are in here with symptoms will cost more. But I gave some to Jenny…
Let me know what you decide to do. Here’s hoping it doesn’t last long.
Mike
December 21
Dan,
We had our first case today. I guess any doubts I still had are moot now—I’m not leaving because I’m not allowed to. I’ve been exposed. In a way, that makes it easier. Jenny actually got out of here last night—we thought it’d be safest to not wait—and got to my parents’ place early this morning. It feels better also knowing they’re most likely out of harm’s way.
December 22
I knew that’s what you’d decide. It’s nice that Meghan is staying there with you—I take it you were able to convince her there was a pressing need for lawyers too. That must have been a scary choice for her, but I guess without kids she thought it was worth it to stick it out with you. Lord knows why….
Since you mention it, yes, I’m worried about Jim. He turned 70 a few weeks ago, so he’s at a lot higher risk of getting sick than the rest of us. And if he gets sick, he’ll have a lot more trouble getting well. When we talked about whether I should stay, I actually tried to convince him he should be the one to leave. I mean, he had a heart attack three years ago! Get out of here, go spend time with your grandkids like you’ve been saying, I said.
He wasn’t having it. He said that after stressing to me how important it was that we honor our commitment now more than ever, he’d be damned if he was going to abdicate his position now. He said if it’s his time, it’s his time. I admire that. But I worry that he’s going to try to do too much because of how he is. It’s clear we’re going to be short-staffed all over town—not everyone weighed their responsibilities the same way we did, so we’ll all have to pull long shifts. Jim needs to realize he can’t do what he used to—he’s a few years further removed from residency than you and me.
December 25
Hey Dan,
Yeah, it’s pretty out of control here. We’re affiliated with Vanderbilt Hospital, so I’ve been splitting my time between there and the clinic. Both are totally swamped—we’re pushing gallons and gallons of fluid, handing out Tamiflu to sick people like candy, and just trying to get everyone well enough to go home so we have room for the next in line. I saw a couple of your partners running around at Baptist on the news, so looks like it’s the same for you. It’s really bad over at the VA; seems like they’re losing more than they’re saving.
Jim’s sick. He got a fever today, and it was all I could do to get him to get some rest. Jenny and Steven are doing fine, but I miss them a lot. I wish I was there, or honestly, I wish I was anywhere but here. It almost seems futile sometimes, and I’m not even sure I’m helping by staying here.
Merry Christmas to you too….
Mike
January 2
dan,
jim died today. i thought you’d want to know.
mike
January 10
Dan, sorry I haven’t been able to write. It’s just been so frantic, and so crushing. Finally it’s starting to look like the worst might be over. I’m sure we’ll be dug in here for a while longer, but for the first time I’ve got some hope that I’ll get to be there when Jenny gives birth. I think this was the right thing to do, but I’m not sure I could do it again. It’s hard without Jim around. I hope things are looking up over there, and I’ll talk to you soon.
Mike
Michael C. Bennett is a second-year student at Vanderbilt University School of Medicine in Nashville, Tennessee.
To Treat or Not to Treat?
Monica Hsiung Wojcik
What is the extent of the physician’s ethical obligation to care for patients during an infectious disease pandemic? In this paper I will examine the historical precedent for a duty to treat, the contemporary thinking about the duty as outlined in professional codes of conduct, and philosophical justifications that underlie the duty. Next, I will look at the limitations of this duty as they pertain to the case of Drs. Harris and Green and draw a conclusion about whether either, both, or neither has a duty to remain and treat the pandemic flu virus patients.
A Duty to Treat
It is widely noted that, historically, physician response during epidemics of infectious disease has been “erratic”[1]. Emmanuel notes that Galen himself fled the plague in Rome [2], and Wynia and Gostin state that “…physician performance during epidemics, from the black plague to the HIV epidemic, has been notoriously spotty,” further asserting that it is “almost certain” that some physicians will refuse to treat in the face of great risk [3]. Current data uphold this legacy of spotty behavior and conflicting attitudes towards the duty to treat when facing personal risk. A study by Alexander and Wynia in 2003 showed that while 80 percent of physicians stated that they would continue to treat patients infected with an unknown and potentially deadly illness, less than 55 percent believed that they were obligated to do so [4]. Thus, historical precedent and current data suggest that, while it is admirable to put oneself at personal risk of infection in order to care for patients and many physicians are willing to take the risk, those infected by a serious contagious disease must rely upon the virtue of certain physicians rather than on a professional obligation that binds all.
But the theoretical concept of a duty to treat is more exacting. This “quasi-biblical commandment” [5] has been made explicit in the American Medical Association’s professional code of conduct for physicians, although the evolution of the AMA’s stance on the extent of the duty to treat is quite telling. The 1847 version of the AMA code, based on Percival’s Medical Ethics, states that “…when pestilence prevails, it is their [physicians’] duty to face the danger, and to continue their labours for the alleviation of suffering, even at the jeopardy of their own lives” [1]. The duty to treat thus became “an integral part of social expectations,” until increasing government intrusion into the realm of medicine and a decreasing threat of infectious disease caused many physicians to see the duty to treat “when pestilence prevails” as an “historical anachronism” [1].
By the mid-twentieth century the duty to treat stipulation had been removed from the AMA code. It was not until the emergence of HIV infection in the 1980s that the degree of professional obligation in the face of infectious disease was once again examined, although this time the duty was couched in a statement of nondiscrimination (“A physician shall support access to medical care for all people” [6]), and so “…the profession largely avoided re-endorsing a broad duty to treat during epidemics” [1]. Thus the current official position of the medical profession regarding the duty to treat is one of nondiscrimination; many see current policy statements as “compromises” that allow individual physicians to determine for themselves the extent of their professional obligations [7].
Philosophical Justification for the Duty
One way to view the responsibilities of physicians to their patients is to see the relationship as a social contract of sorts, involving an ethical obligation inherent in the assumption of the profession. At its most basic, this social contract provides that, in exchange for certain professional privileges, physicians have an obligation to provide care. The privileges accorded physicians by society include social status and, more importantly, a monopoly over the practice of medicine in return for their pledge to uphold certain standards and their receipt of a license recognized by the law and their profession [7]. Lynette Reid says, “The social contract forming the professions leaves us no one but licensed healthcare professionals to turn to in an emergency” [8]. In addition to the contractual duty, philosopher Chalmers Clark argues that the duty to care is a “primary ethical obligation” for physicians by virtue of their specialized training—this training increases the value of their aid and consequently their obligation to give aid [2]. Clark adds that physicians have chosen a profession with inherent risk, so that, in addition to a duty to serve, they have “…consented to greater than average risk by their very choice of profession” [9].
To many, however, evoking the idea of a social contract is unsatisfactory. True public servants are paid by the state whether or not an emergency exists and are deemed negligent by the state if they do not respond to emergencies. Physicians are not [10]. Furthermore, it is difficult to derive an individual duty to treat from the concept of a patient’s right to health care, which lays moral claim to the profession as a whole [11].
Zuger and Miles establish a duty to treat based on the concept of the “virtuous physician”—if medicine is seen as a moral enterprise (and it is), then physicians act out of virtue when they fulfill their professional duty by treating patients [11]. Arras further suggests that a moral tradition has been established in which the physician is viewed as virtuous [10]. He states that folk wisdom views a duty to treat as inherent in the role of the physician, even if historical deviations have occurred [10]. This, in addition to a sense of duty-as-virtue deeply rooted in the “medical conscience,” moral tradition suggests that the burden of proof lies with those who would argue against, rather than for, a duty to treat [10].
Limitations of the Duty to Treat
As the above discussion shows, Drs. Harris and Green are not easily absolved from their obligation to care for those afflicted by pandemic flu. While the Model State Emergency Health Powers Act has not been enacted in the case we are discussing, “all available” primary care and infectious disease physicians have been called to report for duty on a volunteer basis. As primary care physicians, Drs. Harris and Green have particular responsibilities—the director of the state department of health has not called for radiologists and dermatologists to report, for example. Since Drs. Green and Harris have chosen to be primary care physicians, and “any informed reading of the medical literature of the last 20 years has shown that infectious diseases remain ubiquitous and problematic” [9], they have inherently consented to assume risk, although within reasonable limits. As the burden of proof lies in the argument for their departure rather than against it, I will now examine particular considerations that could limit the duty to treat and determine whether any of these limitations applies to the case at hand.
Risk Analysis
One consideration that could limit professional obligation involves the risks of providing care, which must be weighed against the potential benefits. There are two physicians in this case: Dr. Harris, at age 70, has recently recovered from a heart attack and is “thinking about slowing down.” Dr. Green is only a few years out of residency and has a young family. Assuming they are of equal medical effectiveness at present, to say that one of them must assume the risk of illness and the other need not is to suggest that there is less benefit to preserving the health of one than of the other. But each doctor values, and has an equal right to value, “the rest of [his] life,” which is of indefinite duration [12]. Each doctor therefore would suffer the same injustice were the rest of his life to be taken from him [12].
It is true that Dr. Green may have more years of life ahead, but time is irrelevant in this matter, as “people value particular events within their life disproportionately to the time required to experience those events” [13]. Dr. Harris has just as much right to see his grandson graduate from high school as Dr. Green has to see his son graduate. Neither has a greater claim on the rest of his life than the other. In terms of the potential injustice to future patients by putting the younger doctor at risk, the previous argument can be re-applied: value cannot be calculated based upon an indeterminate future. While Dr. Harris has stated his desire to slow down, what is to say that Dr. Green will not soon leave the profession altogether? This analysis does not support a case for one doctor’s remaining to treat.
As for the actual risk to their lives incurred by caring for the pandemic flu patients, the existence of the prophylactic drug Tamiflu serves both to attenuate the risk to the physicians’ health and to increase the benefit for the patients treated. There has been mention neither of a limit to the supply of this drug, nor to its effectiveness in vivo, so we can infer that patients will benefit significantly from its use as long as doctors are present to prescribe the drug and monitor the patients. At the very least, health care workers can use Tamiflu to protect themselves as they do their best for the afflicted. This analysis therefore suggests that Drs. Harris and Green have no compelling reason to refuse to treat patients on these grounds.
Competing Obligations
But physicians have lives outside of the professional realm and must balance competing obligations to their practice and to their families. Sokol notes that the limits to the duty to treat are “…also defined by the strengths of competing rights and duties” [5]. Physicians certainly have the right to protect the health of their wives, children, and grandchildren, as well as their own [8]. Drs. Harris and Green will be quarantined at the hospital to treat patients, thus leaving their families. Dr. Green’s wife has suggested that his duty to his “young and growing family” outweighs his professional responsibilities. It is not stated that the Harris or Green families are unable to survive at least temporarily without their husbands and father. To treat the pandemic flu patients in this case is hardly a death sentence, so it can be expected that the physicians will return to their families.
Physicians also have a professional responsibility not only to their patients, but to their colleagues, in order to fairly distribute the burden of duty. Each physician who chooses to abrogate his duty places additional burden and risk upon the remainder of his colleagues [14]. From a Kantian perspective, if the choice of personal over professional obligation were to be made into universal rule (as Dr. Harris points out, “Every doc in the city has a reason to leave,”) no physicians would be left to care for patients. This consideration of competing obligations suggests that it is unethical for either physician to make a decision to refuse to care for patients in this case.
Conclusion
Historical and theoretical precedent, while not unequivocal, has established a duty to treat, albeit with limits. In the case at hand, limits such as unreasonable levels of personal risk and unsatisfactory potential benefit to patients do not preclude Drs. Harris and Green from presenting for work at the hospital, nor do competing personal obligations. In fact, it would be unethical for either not to fulfill his professional obligation, not only because the benefits outweigh the risks, but because to flee from providing care would be unjust to both their patients and their colleagues upon whom an unfair burden would be placed. While this conclusion would not hold in every pandemic outbreak of infectious disease, the characteristics of this particular case lead to the conclusion described.
References
- Huber S, Wynia M. When pestilence prevails. Physician responsibilities in epidemics. Am J Bioethics. 2004;4(1):W5-W11.
- World Health Organization. Working draft (Sept. 2006). http://www.who.int/ethics/PI_Ethics_draft_paper_WG3_14Sept06.pdf. Accessed Feb. 27, 2008.
- Wynia M, Gostin LO. Ethical challenges in preparing for bioterrorism: barriers within the health care system. Am J Public Health. 2004;94(7):1096-1102.
- Zwi AB, McNeill PM, Grove NJ. Commentary: responding more broadly and ethically. Camb Q Healthc Ethics. 2006;15(4):428-431.
- Sokol DK. Virulent epidemics and scope of healthcare workers’ duty of care. Emerg Infect Dis. 2006;12(8):1238-1241.
- American Medical Association. Principles of medical ethics. Code of Medical Ethics. Chicago, IL: American Medical Association; 2006. http://www.ama-assn.org/ama/pub/category/2512.html. Accessed February 27, 2008.
- Rhodes R. Commentary: the professional obligation of physicians in times of hazard and need. Camb Q Healthc Ethics. 2006;15(4):424-428.
- Reid L. Diminishing returns? Risk and the duty to care in the SARS epidemic. Bioethics. 2005;19(4):348-361.
- Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and the duty to care: whose duty? Who cares? BMC Medical Ethics. 2006;7:5. http://www.biomedcentral.com/1472-6939/7/5. Accessed Feb. 27, 2008.
- Arras J. Fragile web of responsibility: AIDS and the duty to treat. Hastings Cent Rep. 1988;18(2):S10-20.
- Zuger A, Miles SH. Physicians, AIDS and occupational risk. Historic traditions and ethical obligations. JAMA. 1987;258(14):1924-1928.
- Harris J. The Value of Life. London: Routledge; 1985:87-102.
- Harris J. Micro-allocation: deciding between patients. In: Kuhse H, Singer P, eds. A Companion to Bioethics. Oxford: Blackwell Publishing Ltd; 2001:293-305.
- Morin K, Higginson D, Goldrich M, Council on Ethical and Judicial Affairs. Physician obligation in disaster preparedness and response. Camb Q Healthc Ethics. 2006;15(4): 417-421.
Monica Hsiung Wojcik is a first-year student at Harvard Medical School in Boston.
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
© 2008 American Medical Association. All Rights Reserved.
