What is required of doctors?
A number of public guidelines and codes of ethics seek to clarify what can be required of doctors. The Hippocratic Oath does not mention doctors protecting their own health (8). Not until its most recent revision in 2017 did the Declaration of Geneva include the duty of doctors to take care of their own health (9): 'I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.' The reason for this is mainly instrumental (a sick doctor is a bad doctor).
The Norwegian Medical Association's ethical guidelines state that 'a doctor shall protect the health of humankind' and also that 'a doctor should attend to his or her own health and seek medical care when necessary' (10, 11). The reason for the latter has remained unspoken, and can be explained in practical terms, or justified on the basis of a person's inherent value (a doctor is a person who is valuable in himself or herself, just like other human beings) or as a combination of the two.
The Declaration of Geneva begins with the following words: 'As a member of the medical profession: I solemnly pledge to dedicate my life to the service of humanity' (9). An essential issue is how we should understand the idea to dedicate one's life to something. A moderate interpretation implies that doctors should devote a great deal of their time to the medical calling, while a more radical interpretation suggests that doctors should be willing to sacrifice their own health to some extent. In all cases, the declaration can be understood as saying that the medical calling has a self-sacrificial aspect which points to a positive response to our main question: Doctors should be expected to provide medical care even if it entails some risk to their own health.
Unlike the codes of ethics, Norwegian law focuses on the doctor as an employee. The Working Environment Act states that 'when planning and arranging the work, emphasis shall be placed on preventing injuries and diseases' and also that 'necessary aids shall be made available to the employees' (12). The Health Personnel Act states that 'facilities providing health care shall be organised in such a way that health personnel are able to comply with their statutory duties' (13), and the Norwegian Medical Association writes in a statement that healthcare personnel cannot be instructed to perform tasks that put their own lives in danger (10).
Legal provisions and statements from the Norwegian Medical Association may not instruct doctors to put themselves in harm's way, but the laws and codes of ethics mentioned above do not give us a satisfactory answer as to how we should balance dedicating one's life to the service of humanity with attending to one's own health. This ambiguity leads to a moral dilemma. In society at large, as well as in the medical profession itself, there is probably a tacit expectation for doctors to go beyond the call of duty, often further than the law requires.
Let us explore this further with two hypothetical examples. First: Imagine that you come upon a traffic accident. The first step is to secure the accident scene and your own safety before calling for help and then beginning life-saving treatment. The norm in the event of a traffic accident is to put your own safety first. Then imagine that you as a doctor are called to a patient with severe shortness of breath and fever. You are told that there is no more personal protective equipment, but you are expected to help the patient anyway, despite the risk of you and others becoming infected. The latter example is not unthinkable during a pandemic. Should we accept this latter type of risk but not the first mentioned?
There is a moral difference between the imposition of risk on the one hand and the undertaking of risk on the other
Of course, traffic accidents and infections are different. In traffic accidents, the causal relationship between the event and the injury is obvious, while in the case of infections, it is complex (with the body's immune system and the patient's comorbidity playing a part). Moreover, personal injuries in traffic accidents usually happen immediately. With infections, however, the disease can take a long time to develop into its most serious form. Additionally, while the extent of injury is relatively predictable in a traffic accident, the harm from COVID-19 is more unpredictable. With that said – if we assumed that the doctor had an equally high risk of health damage in both of the hypothetical examples, then why should we seemingly be more concerned about safety related to a traffic accident than to an infection situation?
There is a moral difference between the imposition of risk on the one hand and the undertaking of risk on the other. However, distinguishing between these two in clinical settings may be difficult. Most actions taken by doctors while at work are normally voluntary, but also subject to underlying tacit expectations or requirements and some fear of sanctions if the work is not performed properly.