The terrorist attacks of 2001 were a reminder that individual and collective safety cannot be taken for granted. Since then, physicians, alongside public health professionals and other healthcare professionals as well as nonhealthcare personnel, have been developing plans to enhance the protection of public health and the provision of medical care in response to various threats, including acts of terrorism or bioterrorism. Included in those plans are strategies to attend to large numbers of victims and help prevent greater harm to even larger populations.1
Wynia MK, Gostin L. The bioterrorist threat and access to health care. Science 2002;296:1613.
It is important to recognize that unique responsibilities beyond planning rest on the shoulders of the medical profession. Indeed, irrespective of the cause of harm—whether it arises from natural disasters or otherwise—physicians are needed to care for victims. In some instances, this will require individual physicians to place their health or their lives at risk. Many physicians demonstrated their sense of duty and courage by participating in the rescue efforts that followed the events of September 11, 2001, and more recently the aftermath of Hurricane Katrina. These and other circumstances, such as the debate regarding smallpox vaccination of front-line responders and the SARS epidemic, require the medical profession and each of its members to reflect anew on ethical responsibilities that arise in the face of adversity.
A Brief History of Ethical Obligations in the Face of Risks
Prior to the events of 2001, the most recent profession-wide debate regarding a duty to treat despite personal risks arose when there was limited understanding of HIV transmission. Those who believed there was a duty to treat appeared to rely in part on historical evidence of the role physicians had played during epidemics. However, some historians remained cautious in making any claim that such a duty existed.2
Fox DM. The history of responses to epidemic disease in the United States since the 18th century. Mount Sinai Journal of Medicine 1989;56:223–9; Fox DM. The politics of physicians' responsibility in epidemics: A note on history. Hastings Center Report 1988;18:S5–10.
Zuger A, Miles S. Physicians, AIDS, and occupational risk: Historic traditions and ethical obligations. JAMA 1987;258:1924–8, see reference 15.
By the time standards of medical ethics became codified, starting with the 1803 code developed by Thomas Percival, a growing sense of the duties owed by professionals had developed. In this vein, the AMA's 1847 code stated that: “When pestilence prevails, it is [physicians'] duty to face the danger, and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives.” This clear mandate may have been moderated by the introduction of a separate notion that physicians should be free to choose whom to serve in later editions of the code. However, the AIDS epidemic led to a strong reiteration of the obligation to treat.
Much of the historical analysis regarding physicians' obligation to treat despite personal risk has focused on the treatment of infectious diseases. However, threats to personal safety, health, or life come in many different forms, for example, when a natural disaster strikes or during armed conflicts. Along the spectrum of threats, all physicians are confronted with the same question: whether the care needed by a patient or a group of patients calls for the assumption of personal risk.
Ethics of the Medical Profession
The AMA's Principles of Medical Ethics recognizes that many situations in medical care call for a delicate balancing. In the context of a physician's general obligations, the preamble notes that: “As a member of this profession, a physician must recognize responsibility to patients, first and foremost, as well as to society, to other health care professionals, and to self.” Principle VIII emphasizes physicians' obligations to patients in the following way: “A physician shall, when caring for a patient, regard responsibility to the patient as paramount.”
Arguably, the obligation to treat may be counterbalanced by Principle VI, which 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.” However, several Opinions limit physicians' choice in light of medical need. (See, for example, Opinions 9.06, “Free Choice,” 9.065, “Caring for the Poor,” 8.11 “Neglect of Patient,” and 10.015 “The Patient—Physician Relationship,” AMA Code of Medical Ethics.)
In the context of infectious diseases, two opinions clarify the ethical obligation of physicians to provide medical care to patients infected with HIV or AIDS. Specifically, Opinion 2.23, “HIV Testing,” states that: “It is unethical to deny treatment to HIV-infected individuals because they are HIV seropositive.” Opinion 9.131, “HIV-Infected Patients and Physicians,” also states that: “A physician may not ethically refuse to treat a patient whose condition is within the physician's current realm of competence solely because the patient is seropositive for HIV.”
The Principles not only consider the role of the individual physician vis-à-vis an individual patient, but also recognize the role of physicians regarding the patient population. Specifically, Principle VII calls for participation in activities contributing to the improvement of the community and the betterment of public health, and Principle IX calls upon physicians to support access to medical care for all people.
Emergencies: Individual Heroism or Professional Obligation
It often appears that responsibilities to provide emergency care arise in the context of an individual patient. However, an epidemic, a large-scale disaster, or a bioterrorist attack could result in a significant portion of the population within a community requiring urgent medical care. Under such extraordinary circumstances, it is possible that a number of physicians would exhibit personal courage and provide medical care in the face of risk. However, would the personal courage of individual physicians be sufficient to assure that availability of medical care would not be compromised?
Instead of relying on individual heroism, physicians have a professional commitment to assure adequate availability of care. Indeed, professional ethics, as embodied by a code of conduct such as the AMA's, is intended to put forth a uniform standard of conduct for individuals who belong to a profession. When large-scale disaster strikes, physicians individually and collectively should use their knowledge and skills to address medical needs.
In the context of a threat to the health and safety of a population, the unavailability of healthcare professionals to provide needed medical care, due not to casualties among them but rather to individuals' refusal to assume personal risk, could be viewed as a serious failure of medical professionalism. Is this view of professional obligation morally justified?
Professional Obligations in the Face of Personal Risk
One leading philosopher in healthcare argues that relevant expert knowledge gives rise to professional acceptance of “known” risks and that it would be disingenuous to accept the privileges of professional status but not to fulfill the obligations.4
Daniels N. Duty to treat or right to refuse? Hastings Center Report. 1991;21:36–46.
Such a perspective may explain in part that the risks of HIV infection needed to be understood before they could be assumed. This could lead to the conclusion that, although physicians faced unknown risks at the time of the 2001 terrorist attacks and acted beyond their professional obligations, similar conduct is now becoming part of the professional commitment. In this regard, Alexander and Wynia have shown that physicians who felt that they were well “prepared to play a role in responding to a bioterror attack [were more] willing to work under conditions of personal risk.”5
Alexander GC, Wynia MK. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Affairs 2003;22:189–97.
Another compelling justification for a professional commitment in providing medical care in the face of personal risk can be derived from four general factors that give rise to a widely acknowledged moral obligation to render aid.6
This analysis is adapted from a presentation by Chalmers Clark, while he was a visiting scholar at the Institute for Ethics, which refers to the work of various commentators on the case of Kitty Genovese, who died in 1964, as more than 30 people heard her being stabbed.
Limitations to the Duty to Treat
An obligation to treat need not be absolute. To the extent that reasonable steps can be taken to protect oneself, it is important that physicians avail themselves of such measures. In the context of infectious diseases, vaccination has played a significant role to minimize risk, along with universal precautions. However, instances where individuals fail or refuse to avail themselves, outside appropriate guidelines, of protective measures may be problematic. For example, if a large number of physicians refused certain vaccinations and if they subsequently claimed that they were unwilling to care for infected patients, a considerable burden would likely be placed upon vaccinated physicians.
Another limitation may exist to the obligation to treat, but needs to be carefully circumscribed. Physicians should not be expected to place themselves at greater risk than the benefit they can provide. Indeed, if the nature of the risk is so lethal that there is little likelihood that a physician can provide care to more than a single patient, then limiting the number of exposed physicians at the onset of an event may be necessary to ensure that a sufficient number remain available to treat patients who can reasonably be expected to survive beyond the acute event.
To address these various possibilities, sound preparedness strategies need to be established through broad physician consultation. This could lead to the preidentification of teams of volunteers willing to accept greater risk. These teams could receive specialized training to respond to specific threats instead of each and every physician being expected to possess the necessary knowledge and willingness to respond to any and every threat. Additionally, as the focal points of preparedness, volunteer teams could be offered due compensation for their training, as well as their assumption of risks. Other physicians' responsibilities would become more clearly defined—namely, to refer patients knowledgeably according to the nature of the threat.
Although such strategies would not eliminate all risk to individual physicians under all circumstances, they could help limit undue risk and assure coordinated, effective, and prompt responses. These strategies also could facilitate the education of patient populations regarding the appropriate actions to take according to various threats. In turn, this could help establish realistic societal expectations toward physicians and other healthcare professionals, alleviate unnecessary confusion or fear, and ultimately help minimize morbidity and mortality.
Another important dimension to consider as planning efforts move forward is the legal environment in which medical care is provided. Specifically, the medical profession should advocate for the establishment of legal protections that facilitate the provision of medical care by all available and specifically trained physicians, expanding upon laws that protect physicians against liability in special circumstances.
Conclusion
Preparedness for the threat of epidemics, disasters, or terrorism requires physicians to express a renewed commitment to the ethical foundation of the practice of medicine. Indeed, when the health of large populations is threatened, society should expect that the medical profession will be prepared to provide medical care in a cohesive and comprehensive manner. To accomplish this goal, the obligation to provide care must reside not only with individual physicians, but with the profession as a whole.
Recommendations
National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future.
In preparing for epidemics, terrorist attacks, and other disasters, physicians as a profession must provide medical expertise and work with others to develop public health policies that are designed to improve the effectiveness and availability of medical care during such events. These policies must be based on sound science and respect for patients. Physicians also must advocate for and, when appropriate, participate in the conduct of ethically sound biomedical research to inform these policy decisions. Moreover, individual physicians should take appropriate advance measures to ensure their ability to provide medical services at the time of disasters, including the acquisition and maintenance of relevant knowledge.
