The sweep of Covid-19 across the globe has raised a fundamental question about medical ethics: Do physicians, nurses, EMTs, and other health care workers have moral and legal obligations to risk their health and lives to treat patients during a pandemic?
It’s an important question, given the toll that Covid-19 is taking on medical professionals. As we write this, more than 100,000 health care workers have been infected in the United States alone and nearly 550 have died from Covid-19. The Centers for Disease Control and Prevention estimates that health care workers accounted for 11% to 16% of Covid-19 infections during the first wave.
To answer this fundamental question, we first need to define the ethical and legal duties of physicians during a pandemic or a war or a bioterrorist attack — and these aren’t necessarily clear. It is quite revealing that when students graduate from medical school, they all take various oaths modeled on the World Medical Association’s Declaration of Geneva. None of these include any statement that physicians must risk their lives in caring for patients.
There are conflicting perspectives on defining the responsibilities of medical professionals during an epidemic. Some have taken the position that medical professionals who refuse to work in hospitals during this pandemic should lose their jobs or even their licenses. This perspective is based on the idea that medicine is a humanitarian profession that requires health care workers to care for the sick under all conditions. By freely entering into this profession, so the thinking goes, physicians and other health care professionals have implicitly agreed to accept all dangers and risks.
This view is consistent with that of the General Medical Council in the United Kingdom, which asserts that physicians have an obligation to provide urgent medical care during disasters, even when there is a significant health risk to providing that care.
The American Medical Association takes a different position. Its 2020 update of Opinion 8.3 sets out physicians’ obligations in this pandemic to “provide urgent medical care during disasters … even in the face of greater than usual risk to physicians’ own safety, health or life.” Opinion 8.3 also recognizes that if the risks of providing care to individual patients are too dangerous, then physicians can refrain from treating Covid-19 patients because doing so may hinder their ability to provide care in the future.
The American Nurses Association offers similar advice, stating that during pandemics, nurses must decide how much care they can provide while also taking care of themselves. Nurses may refrain from working when they feel physically unsafe due to a lack of personal protective equipment or inadequate testing for infections.
Many ethicists believe that physicians and health care professionals may, at times, refuse to care for patients when their service conflicts with their own moral views. For example, physicians do not have to comply with a patient’s wish to terminate a pregnancy, or assist in euthanasia, if that conflicts with their moral framework. These ethicists recognize that emotions and motivations are integral parts of any moral decision-making process. There are no rigid rules. Choices must be adapted to the particulars of each given situation. For example, the moral duty not to harm or kill another person includes self-care for the clinician who is providing care to these highly infectious patients. It is akin to not requiring paramedics to enter a building on the verge of collapse to aid someone inside.
A health care professional’s specialty may also influence his or her moral obligation to treat a patient or refuse to do so. One who specializes in infectious diseases may not have the moral autonomy to refuse to treat Covid-19 patients, while one whose specialty is ophthalmology, cosmetic surgery, or dermatology can reasonably maintain a moral obligation to serve as a medical consultant or serve in some other capacity in the hospital, but not take on the risks of treating Covid-19 patients.
Physicians and other health care professionals must also balance their obligations as professionals with their duties as husbands, wives, parents, and children. The risk to personal health from the coronavirus is alarming enough, but the risk of infecting family members, especially those with a higher risk of infection, may be ethically and morally unacceptable. Health care professionals’ refusal to work in a state of emergency may be justified if their health or well-being is endangered because of medical susceptibilities such as heart problems, diabetes, pregnancy, and the like that place them at a high risk of contracting and dying from the virus, or if they reasonably believe that their work environment creates an unacceptable hazard by not providing them with essential personal protective equipment.
Historical lessons offer insight into this ethical conundrum. For example, the history of secular medical ethics reveals that the medical community has never come to a consensus on the nature and scope of its responsibilities during an epidemic. The lack of consensus may be due in part to the fact that medical ethics are embedded in various broader social and cultural fabrics.
Jewish law supports the view that a person is obligated to save another, though there are situations in which the dangers or risks are so high that these moral obligations are not mandatory. Rabbinical scholars have concluded that physicians have an extra obligation to heal the sick and are expected to accept a greater degree of risk than nonphysicians, due to their training and nature of their work. Yet they must also be prudent in their obligation to protect their families. Interestingly, rabbinical scholars maintain that treating Covid-19 patients is not mandatory but is considered to be a great act of compassionate professionalism and is highly praiseworthy.
We believe that the question of whether health care workers must risk their lives to treat Covid-19 patients does not have one uniform answer. We do believe that health care workers who specialize in infectious disease or respiratory medicine have a greater responsibility to treat Covid-19 patients than health care workers in other subspecialties of medicine. Moreover, most, but not all, health care workers have a professional obligation to provide some medical service during this pandemic. Society, however, should be understanding of those health care workers who may defer their medical responsibilities because of their own personal health risks or extenuating family responsibilities.
While it is important for physicians and other health care workers to explore and come to terms with their moral and legal obligations to care for patients with Covid-19, this will not be our last pandemic. That is why it is essential to incorporate these issues into the medical and health science educational curricula and get students thinking about them early. Professional education should help students — and practicing health care workers — learn how to balance their health risks with the immediate benefits to individual patients and the capacity to care for patients in the future.
The moral obligation, the courage, the compassion, and even the heroism of millions of clinicians on the front lines are what professionalism is all about.
Alan Kadish is a cardiologist, researcher, and president of the Touro College and University System. John Loike is a professor of biology at the Touro College and University System and writes a regular column on bioethics for The Scientist.