The Problem

Because society has allowed medicine to develop its specialized domain of knowledge and skills and has given medicine a monopoly over medical practice, and because physicians have pledged themselves through oaths, codes, and licensing to uphold well-known standards of medical professionalism, and because patients and society rely upon physicians to uphold those standards, doctors have distinctive professional responsibilities. The core of those responsibilities, which have remained unchanged since at least the time of Hippocrates, is physicians' commitment to the well-being of patients. So, because medical needs following a mass casualty event can be anticipated, medical ethics requires the participation of physicians in planning for catastrophes and the responsiveness of physicians in the aftermath of disasters. This much should be straightforward and incontrovertible.

Nevertheless, the AMA statement shows its stripes as a political document of compromise, rather than an assertion of professional ideals and commitments, when it hedges on whether individual physicians actually have those obvious duties. Instead of explicitly outlining physician responsibilities in a disaster, the AMA emphasizes “limitations to the duty to treat.”⁷

Obscurely tucked into the middle of the manuscript, that section contradicts what went before and what comes after by making medical service in a disaster an option, instead of something ethically required by virtue of being a doctor. There, after some discussion of vaccination and the unusual circumstance of great physician risks in the face of little compensating patient benefits, the authors hold that the job of responding to disasters falls to “teams of volunteers willing to accept greater risk.”⁸ The authors even seem to suggest that volunteering should be contingent upon the volunteers receiving due compensation “for their training, as well as their assumption of risks.”⁹

This position is a far cry from a statement of responsibility. When someone has a responsibility she is obliged, bound, required to act in a particular way. When someone has no responsibility she is free to do the thing or not, to volunteer or hold back, to accept the risks or decline them. They cannot both be true at once, in the same sense, about the same matter. An AMA Opinion that contains such a glaring contradiction amounts to saying that doctors may do whatever they choose in the face of a disaster because they have no responsibility to respond.

Medicine and Risks

Medicine's historical commitments make it clear that physicians accept responsibility to patients and society, and that part of being a doctor is acceptance of the concomitant role-related risk. Although self-preservation limits all responsibilities, the ethically crucial questions are: (1) How does medicine determine when a danger is great enough to overwhelm the default professional responsibility of responsiveness? (2) Who makes the call? The AMA suggests that these are matters of personal judgment. That answer, unfortunately, overlooks an important characteristic of medicine.

Through the ages, one distinguishing feature of medicine is its reliance on scientific evidence (broadly construed) and “the standard of care.” To explain very briefly, a gut feeling that something should or should not be done or that this is too little or too much is not enough to justify a medical decision. In medicine, hypotheses have to be supported by theory, judgments have to be supported by observation or data, and medical stands are acceptable positions when they are endorsed by a consensus of the profession. Even though Morin and her coauthors illustrate the scope of and the limitations on risk-related exemption from obligation by discussing the AMA's Opinions (2.23 and 9.131) that require doctors to provide treatment for patients with HIV or AIDS in their section on professional responsibility, they miss two significant points. (1) Those earlier Opinions rested on a theory of how the disease is transmitted and evidence of the low risk of transmission when precautions are taken. Also (2) those opinions reflected the position of the profession rather than the private judgment of individual risk-averse practitioners. In other words, in the face of risk to physicians, responsiveness should be the default presumption because that is the standard of care. A judgment that responding is too dangerous in a particular circumstance has to be left to the consensus of medical experts with the relevant specialized knowledge and experience. In our current age of speedy electronic communication, there is no justification for allowing decisions on recusal or response to turn on the personal fear, courage, or sense of duty of the individual physician.

By crafting a code and principles and by publishing opinions on controversial issues the AMA defines the standard of care for medical practice. As the authors elsewhere agree, the AMA's Code “is intended to put forth a uniform standard of conduct for individuals who belong to a profession.”¹⁰

In the critically important matter of response to the victims of a disaster, it is crucial that the AMA accept its responsibility for defining the standard of professional behavior as responsiveness.

Principle VI

In reaching their peculiarly inconsistent position, the authors invoke Principle VI of the AMA Code of Medical Ethics, which was only added to the code in 1957.¹¹

It states, “A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve … and the environment in which to provide medical care.” Whereas the rest of the AMA Code delineates physician responsibilities, Principle VI anachronistically declares that physicians are free in choosing whom to serve and their work condition. This statement means that, except for emergencies, physicians have no responsibility to serve anyone and no responsibility to provide medical care in a place that they choose to avoid. Apparently, if I am reading the statement correctly, the implications of Principle VI for disasters is that it is up to individual doctors to decide when a situation counts as an “emergency.” They have no duty to go to the scene of a disaster, they are free to leave the area of a disaster, and they do not have to provide care to those who are unable to pay their fees, particularly when the disaster has left people without access to bank accounts, ATMs, or insurance cards. Physicians are free to avoid education about how to respond to a disaster. They are free to avoid means of protecting themselves from hazards. They are free to opt out when they feel frightened.

Although it is easy to understand why AMA members have repeatedly decided to keep Principle VI in their code and why they feel comforted by the license it allows them, it is legitimate to ask whether that provision is consistent with the ethical responsibilities of being a physician. It is hard to see how Principle VI can be reconciled with the commitments espoused elsewhere in the AMA Code (or in the Hippocratic Oath or in the Oath of Maimonides or in the Geneva Code) without either eviscerating the concept of physician professional responsibility or contorting and deflating the meaning of Principle VI. For that reason, it is surprising that the authors embraced the Principle in their reasoning. In light of its untoward implications that counter the positions they espoused in both their introductory and concluding remarks, a more appropriate response would have been to debunk its inclusion in the AMA Code.

Culpability

In discussing the importance of knowledge in these decisions, the authors refer to a study by Alexander and Wynia on the relationship between physicians' disaster response preparation and their willingness to respond. They note that those who felt “prepared to play a role in responding to a bioterror attack [were more] willing to work under conditions of personal risk.”¹²

That coincidence invites another line of speculation. Are those who recognize their responsibility for responding more likely to make themselves prepared to respond? Again, is preparing oneself to competently fulfill responsibilities a matter of personal choice or professional duty? In the early days of AIDS, some health professionals exempted themselves from the responsibility to care for patients who might be infected by saying that they lacked the necessary expertise.¹³ Quickly, the profession decided that ignorance was no excuse. Knowledge of “universal precautions” was part of what every doctor should reasonably be expected to know. There is no obvious reason to presume that the particular additional knowledge needed for a physician to respond to patient needs in time of disaster is either so vast or so esoteric that individual physicians should be exempt from responding on account of ignorance.

If there are particular things that every responsible physician should know in order to effectively respond during disasters, then continuing in ignorance is culpable. Instead of excusing physicians from an important component of their professional responsibility, the AMA should be taking steps to assure that every physician is prepared. Courses should be designed and required to update physicians in what they need to know and medical school curriculums should be adjusted to plug the gaps. After 9/11 and after Hurricane Katrina, no physician and no organization of medical professionals can legitimately turn a blind eye to this crucial aspect of medical responsibility.

Society's Responsibilities

The AMA's statement on “Physician Responsibilities in Disaster Preparedness and Response” mentions some areas where society has significant responsibilities. This important topic deserves further elaboration, and the AMA should be investing significant effort in advocating for the needed changes.

Medicine has the expertise that is crucial for useful and effective preparation for disasters. For that reason, medicine must be critically involved in planning and must be given the authority for implementing required preparatory measures. Medical experts in areas such as infectious disease, public health, emergency medicine, and toxicology can envision the kinds of health problems and medical needs that can arise in the aftermath of a disaster. Planning and preparation require their input along with the collaboration of police, fire departments, transportation departments, utilities, communications, and numerous other local, regional, and national agencies and institutions.

Furthermore, in many circumstances, some portion of the response to a disaster should be decided by medical experts. For example, determination of when it is safe to breath the air or drink the water requires medical expertise. Decisions on when an area must be quarantined because of the threat of infection require medical expertise. Decisions about when a population should or should not be vaccinated should turn on medical expertise. The authority for such decisions should, therefore, be left to medicine and not politics. Other related decisions, such as when to declare a state of emergency or evacuate an area, may require medical input along with the expertise of other agencies. Social measures should be taken to ensure an improved alignment of responsibility and expertise with authority.

In disasters, medicine and medical institutions are called on to do all that they can to address the medical needs of victims as well as the ongoing medical needs of patients. Under these remarkable conditions, some of the everyday rules that govern usual medical practice should be suspended. As part of disaster preparation, society owes healthcare providers and medical institutions legislation that makes the relaxation of rules legally explicit so that responders are not burdened by worries of legal liability as they try to meet pressing medical needs. In this regard, legislatures need to address questions such as the relaxation of rules governing credentialing, licensing, negligence, documentation, and reimbursement. In the same vein, medical institutions should not be called upon to bear an undue share of the expense for disaster response. As part of disaster preparations, legislatures should also set policies that make reimbursement for such expenses an explicit social responsibility, perhaps by extending Medicaid benefits to all disaster victims.

Principles of using what you already use frequently and investing in resources that have multiple uses are important concepts in disaster preparedness. That said, society has to accept responsibility for investments in planning, equipment, and training. Even though we hope to never have a disaster, and even though it is hard to divert resources to projects that may never be used when faced with immediately pressing needs, because they can help avert horrific outcomes, the investment in disaster preparedness must be made. We should keep in mind that the extensive advance planning and training in New York City made for an efficient and effective response to the 9/11 attacks on the World Trade Center even though the command center was destroyed in the first hours after the attack. Although the Department of Homeland Security has recently begun to make some effort toward preparation,¹⁴

the experience of Hurricane Katrina demonstrates that far more needs to be done.