There have been reports out of China, Italy and elsewhere of health professionals who have died of COVID-19 after caring for infected patients, leading some U.S. physicians to wonder what their ethical obligation is to their patients during a deadly outbreak. Two physician experts discussed this challenge and noted the obligation that society, in turn, has to physicians who put their lives on the line.
The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center or the AMA Journal of Ethics® COVID-19 Ethics Resource Center, and consult the AMA’s physician guide to COVID-19. The AMA Code of Medical Ethics also has collected its relevant ethical opinions to offer guidance in a pandemic.
Following are highlights from the AMA Journal of Ethics (@JournalofEthics) March podcast featuring an interview with Matthew Wynia, MD, MPH, professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado in Denver. Dr. Wynia also serves on the Forum on Medical and Public Health Preparedness for Disasters and Emergencies of the National Academies of Sciences, Engineering and Medicine. Earlier in his career, he directed the AMA Institute for Ethics.
In his conversation with the journal’s editor-in-chief Audiey Kao, MD, PhD, Dr. Wynia also discussed managing resource scarcity and the relative effectiveness of voluntary and mandatory quarantines.
Ebbs and flows in opinion
“There is a very interesting history here, because if you look back to the plagues of the Middle Ages, the Black Death, it was really very common for physicians to flee areas that were plague stricken, following the advice that they often gave to their wealthy patients as well, which was ‘Cito, longe, tarde,’ which means ‘Go fast, go far and don't come back too soon,’” Dr. Wynia said.
Although physicians at the time were not expected to practice in plague-hit areas, many chose to, he added. But professional duty was not the reason why.
“They stayed out of Christian charity. They stayed out of a sense that they would become famous. They stayed out of a sense that they would earn their entry into heaven by doing a good deed,” Dr. Wynia said. “But it was not really until the 1800s when the notion of professions as holding a social contract came about … that physicians and other health professionals had a responsibility that was not personal—it was professional.”
Articulated in the 1847 AMA Code of Medical Ethics, this professional duty to treat in the face of personal danger was strengthened in 1912 “to say there was an obligation to continue taking care of people who posed a contagious threat, even if you were not being paid to do so,” Dr. Wynia said. “And I think to some extent, that piece of our Code of Ethics was a critical component of really making doctors sort of heroic figures in American culture from the turn of the century through to the 1970s and ’80s.”
Read the updated Code opinion on providing urgent medical care during disasters.
Limits and incentives
The AMA reasserted this guidance following 9/11, saying it is a responsibility of health professionals to continue caring for patients even if doing so presents some danger to them. How much danger has been debated.
“If you know for a fact you're going to die as a result of doing something, then that might be heroic or a martyr-type action, but that can't be the professional obligation,” Dr. Wynia said. “On the other hand, saying, ‘You know, I'm afraid of HIV infection and therefore I won't take care of patients with HIV,’ that was found to be completely unethical and eventually unlawful.”
Patients and physicians seem to agree that there should be a middle ground, Dr. Wynia noted. There remains, however, the question of whether health professionals serving on the front lines should enjoy privilege in access to care themselves. Some argue that it would get them back to work earlier, while others have said that it is unlikely that seriously ill health professionals would recover in time to make a substantial difference to the emergency response.
“Both sides of that argument have fairly strong points to be made,” Dr. Wynia said. “From a pragmatic standpoint, there is something to be said for being able to tell nurses and doctors and EMTs and first responders, ‘Look, if you get sick, we will do our very best for you.’ I think that probably does make a difference in terms of people's willingness to show up for work.”