The president’s personal physician has to navigate a plethora of unusual ethical issues, and while those might seem hypothetical in ordinary circumstances, the coronavirus pandemic and President Trump's COVID-19 diagnosis and treatment this fall has planted them squarely in the here and now.
Foremost among them: What right does the public have to know about the commander in chief’s health and health care?
“The president’s health status carries significant implications for the security and well-being of the polity nationally,” wrote Elliott Crigger, PhD, director of ethics policy at the AMA, in an essay recently published online by The Hastings Center, the venerable New York bioethics think tank. “The public, therefore, has a strong interest in being informed about the president’s health status and should be able to trust that the information will be timely and accurate.
While every patient in the U.S. has the right to keep their health information confidential, that right is not absolute, Crigger wrote. Patient information may be shared without consent for, say, billing and quality improvement activities. And in some cases, it must be shared—“for example, mandatory reporting for public health purposes or to protect a patient or third party when the physician believes the individual poses an imminent risk of harm to himself or herself or threatens serious harm to others.”
Of course, the president is unlike every other patient, Crigger noted, which forces the White House physician into unfamiliar ethical territory.
But, he added, “we can make the case that because the president is not only a public figure but [also] has enormous authority and responsibility to the people of United States as a whole, there is a certain sense in which the president should be willing to disclose—and the public has a right to expect disclosure of information about—a health condition, at least when that health condition may impair the president's ability to fulfill his or her responsibilities.”
So which parts of the president’s health information ought to be shared with the public? As a rule, Crigger wrote, disclosure should be restricted to “the minimum information necessary to serve the public interest.”
But even that can be difficult to qualify or quantify. Should the physician stick to the president’s status and prognosis or, say, include a summary of the care plan?
“Precisely what information is truly in the public interest will surely vary with circumstances,” he wrote. “The severity of the president’s condition, including the risk to the president’s ability to function, and prevailing social and political conditions, such as a public crisis of some sort, would need to be taken into account.”
“But in all cases,” he added, “the public’s ‘right to know’ is not the right, carte blanche, to have curiosity satisfied.”
This dual role of physician and publicist itself poses ethical challenges for the White House physician.
“He has a patient in front of him to whom he owes all the respect and rights that any other patient will receive,” Crigger said in his “AMA COVID-19 Update” interview with AMA Chief Experience Officer Todd Unger. “And yet at the same time, he's in something of the role of a public figure. He's mediating between this patient and the rest of the world.”
A military doctor, which each of the last five White House physicians has been, is accustomed to balancing dual loyalties—to patient and to military mission.
“Which of those loyalties should, ethically, prevail is the subject of ongoing debate,” Crigger wrote.
But caring for one’s superior is inherently complicated, especially in the armed services.
“To not follow the patient's preferences is to disobey a direct order from your commander in chief,” Crigger said, “so physicians in the White House are in an uncomfortable position much of the time.”
Crigger also explored the ethical challenges and unintended consequences of offering innovative therapies to the president, including encouraging the public to seek ill-considered unproven interventions, thwarting public participation in clinical trials and undermining physicians’ obligation to be responsible stewards of resources.
The AMA has developed more than 20 resource pages with guidance on ethical issues that are central to the COVID-19 pandemic, including prescribing medications responsibly in a pandemic, fair access to limited critical care resources and caring for patients at end of life.