Physicians have special professional obligations to respond to medical emergencies. A bioterrorism attack would be a medical emergency. Thus, it seems that physicians would have an obligation to respond to a bioterrorist attack. However, the scope of those obligations, and their limits, are vexed topics. General rules may be comforting but the details and nuances of particular situations will always be relevant.
Consider two scenarios. In the first scenario, a patient is near death after a rapid course of a highly contagious and incurable viral illness. A physician is nearby, knows of the patient's infection, and is able to determine with reasonable certainty that the patient will soon die even with medical intervention. In addition, the physician realizes that any attempt to provide palliative treatment for this rapidly dying but suffering patient would likely lead to the physician's becoming infected, which would mean a certain death for the physician as well. In the second scenario, a patient is suffering from fevers, malaise, and a painful blistering rash after infection with smallpox. The physician, although unvaccinated, knows that vaccination is available postexposure, and that her long-term likelihood of personal injury, as well as limitations on ability to serve others, is quite low. Although she can't cure the patient's disease, she can provide symptomatic treatment that would ease the patient's suffering.
We believe that a physician has no obligation to treat the first patient because the risks to the physician far outweigh the benefits, and the net result would likely be two deaths instead of one. We believe that a physician has a clear-cut obligation to treat the second patient.
One of the challenges with moral discussion regarding physicians' duty to treat in the setting of bioterrorism is that all scenarios are probabilistic and thus all the action is in the moral gray zone. Few would argue physicians have no duty to treat, but few would argue that there are no limits to the physician's obligations to respond. The challenge is in evaluating the basis for and extent of the duty in different settings, many of which involve numerous factors of unknown, and unknowable, risk. In cases like these, the devil is in the details, because it is the details that allow calibration of a sliding scale of duty.
Even if one grants that a duty to treat exists in a setting such as the smallpox scenario above, one can do so with an intuitive appeal that does not formally articulate the basis for such a perspective. However, moral arguments that physicians have a duty to treat have generally been made on one of three grounds—either based on patients' rights (the obligation placed upon physicians arises from the rights of patients to receive treatment), virtue (it is virtuous of physicians to perform such acts), or a social contract (physicians undertake a contract with society whereby they agree to provide care for the sick and needy, even when at some risk to their own health, and in return are compensated with income and privileged social status).
Each argument has its proponents and detractors. Although it is indeed virtuous of physicians to perform acts of heroism or to put themselves in harm's way to treat the injured, this does not clearly distinguish physicians from others where such actions may be equally or even more virtuous. Rights-based arguments founder on the difficulties of transferring a general moral claim of an individual patient to a specific claim against individual physicians. Similarly, challenges to social contract theory have been made based on the difficulty of transferring an obligation of an entire profession to the obligation of individuals within the profession. Unwritten contracts are, by their very nature, unclear.
Despite limitations of a contract-based approach to the duty to treat, a review of other disciplines, and a modest conception of physicians' roles as public servants, suggests that it would be more useful from a policymaking perspective to conceptualize physicians' obligations in the face of bioterrorism using a model of public service, rather than by using a model of professionalism. Although many physicians may report a willingness to undertake risk, it seems unlikely that more than a few enter the profession acknowledging and embracing such risk. Unlike, say, firefighters or police, most doctors do not enter medicine today with any expectation that they will be expected to undergo significant personal risk as part of their job.
Public servants, by contrast, have a contract-based duty to serve. It may be a virtue, but it is also an expectation. Although firefighters may take an oath in order to define their obligations, they also sign a contract. In our view, a subset of doctors should be designated first responders to bioterrorism. Their obligations should be made explicit, their training should be different, and they should be compensated for taking on this excess risk. In short, their role would be similar to that of other public servants such as firemen and policemen.
What would this mean? Firefighters (1) are paid by the state (i.e., not in business for themselves), (2) are paid whether there are fires or not, and (3) are deemed negligent if they do not respond appropriately, even at some personal danger. The limits of appropriateness are determined by experts in the field of fighting fires; these experts make the standards by which other members of their field are judged.
To develop such a model for physician responses to bioterrorism would take a significant societal commitment. One way to think about this would be to imagine a Medical National Guard. Governments would contract with small groups of physicians who would be paid to periodically participate in training programs designed to give them the skills and techniques necessary to manage various bioterrorism scenarios. In the event of a bioterror attack, these public servants, rather than the medical profession as a whole, would have the primary obligation, and the requisite skills, to respond.
Despite the appeal of a medical reserve corp, the existence of such a group still begs the question as to what level of risk physicians should more generally undertake as servants to the public. This level of risk must always be framed within the context of a sliding scale as highlighted by the two scenarios discussed above. It lies between that of an ordinary citizen and those of a physician specially trained and compensated for bioterrorism preparedness. Defining this level of risk, given the uncertainty involved in any bioterrorism attack, is a difficult, if not impossible, task. Nevertheless, all physicians should be considered to have a duty to treat—and one that is based on their role as public servants, rather than as virtuous professionals confronting personal risk.
