Heroes in white?

Espen Gamlund, Karl Erik Müller, Amalie C. Solberg, Carl Tollef Solberg About the authors
Artikkel

Do doctors have a moral obligation to provide medical care if they lack adequate personal protective equipment during a pandemic? Neither the Declaration of Geneva, the Norwegian Medical Association’s ethical guidelines nor the Norwegian laws give us a precise answer. We will argue that the answer is no. Doctors who provide medical care without sufficient protection against infection are going beyond the call of duty, and this can be viewed as heroic.

Illustration: Miss Boo / Bente Jørgensen

In late December 2019, the Chinese ophthalmologist Li Wenliang warned of a possible outbreak in Wuhan of an illness resembling SARS, and he strongly encouraged his colleagues to protect themselves. Dr Wenliang died on 7 February 2020, at the young age of 33, after becoming infected with SARS-CoV-2 (1). As of 23 September 2020, there were 31.4 million confirmed cases of infection and more than 967 000 confirmed deaths as a result of the COVID-19 pandemic, according to WHO (2). Many of those who have died are doctors and other healthcare workers (3, 4).

During the pandemic, many healthcare workers have had to put themselves at greater risk than usual in order to diagnose and treat patients with COVID-19 (5, 6). Hospitals in high-income countries normally have sufficient and appropriate personal protective equipment, but the pandemic quickly showed us that the situation in which we found ourselves was anything but normal. As a result, doctors and other healthcare workers have felt compelled to provide medical care to infected patients without being able to protect themselves adequately (5, 7).

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.

The hero

Let us say that doctors are, in fact, tacitly expected or required to be prepared to risk their own health to help those infected during the COVID-19 pandemic. Is this asking too much of them? This question touches on a deeper moral-philosophical discussion about what morality requires, a discussion around which there is considerable disagreement. Some believe morality demands that we humans should be willing to sacrifice part of our own well-being to help those in need (14). Others argue that morality only requires us not to inflict harm or the risk of harm on others. Nevertheless, most agree that we cannot demand that people sacrifice their lives and health to help others, regardless of how great their need is. The implication is that such self-sacrificial actions normally cannot be regarded as obligations. Rather, they are supererogatory, actions that exceed our obligations. A hero, in the sense we are discussing here, is precisely one who does something supererogatory. It can certainly be admirable if we put ourselves at risk to help others, but it is not morally wrong if we choose not to do so.

An obvious example of a supererogatory action is a doctor who volunteers to provide medical care in a region hit by natural disaster. We cannot require doctors to provide such care, but it is good and admirable if they do. The philosopher James Opie Urmson argues that a person who performs such heroic acts will feel that she is bound by a moral obligation to carry them out even though they are not actually obligations (15). There is therefore probably an asymmetry between the doctor’s feeling that she should provide medical care in spite of the personal risk entailed and the fact that providing such care is not morally required. Doctors who do not travel to natural disaster areas are not delinquent in their duty, but those who do so nonetheless deserve our praise and admiration.

Self-sacrificial actions cannot normally be regarded as obligations. Rather, they are supererogatory

Urmson asserts that heroes are looked up to and admired. They do more than what is required of them in many different ways (15). This picture becomes more complicated when we are talking about what is required and expected of professional practitioners such as doctors and firefighters. When the planes flew into the twin towers in New York City on 11 September 2001, the firefighters had to make an extraordinary effort to extinguish fires and save lives. The firefighters assumed a huge personal risk when they ran into the buildings to rescue the people inside, and many of them lost their lives (16). They were admired for their heroic efforts. On the other hand, they would probably have faced criticism if they had not been so courageous because they simply would not have done their jobs properly. The conclusion is therefore that it is expected, and perhaps also required, for firefighters to run a personal risk in the performance of their duties (sometimes a considerable risk). At the same time, their actions are heroic.

So, what about doctors? In recent months, healthcare personnel in many countries have had to do their work without adequate personal protective equipment (5). Like firefighters, doctors are expected and perhaps required to run a personal health risk in the performance of their professional duties. If they refuse, they risk being criticised, but if they do it, they are heroes. This may seem paradoxical, but it arises from the particular norms of certain professions. It is regarded as an implicit part of the medical profession to go beyond the call of duty, sometimes to the point of risking one’s own health. Doctors are both expected and sometimes required to do so. By the same token, such heroism is regarded as admirable within a universal moral context. This is because we neither expect nor require people to run a similar personal risk to help others.

Conclusion

We have argued that Norwegian doctors do not have a moral obligation to provide medical care in a pandemic when they lack adequate personal protective equipment. Although laws, guidelines and codes of ethics do not expect doctors to put themselves in harm’s way, there are many who both expect and demand that doctors provide medical care during situations that sometimes involve high risk of infection. Thus, there is reason to believe that some doctors probably go beyond the moral call of duty in their encounters with COVID-19 and other infectious diseases. Some of their actions are heroic.

The authors wish to thank the Fritt Ord Foundation for providing the grant to make the writing of this article possible, and Anna Therese Bjerkreim, Ingrid Neteland and Preben Sørheim for their comments on previous versions of the article. The authors have received funding from the Fritt Ord Foundation.

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