By Jonathan M. Marron, Louise P. King, and Paul C. McLean
In medical ethics, we often speak of duties, such as the duty one has to patients, to society, to our families, to ourselves. In fact, deontology is a moral theory often cited in medical ethics based primarily on the consideration and application of such duties.
But we typically speak of duties under “normal” circumstances, and normal certainly does not describe the current COVID-19 pandemic. It is unclear whether and how our typical conceptualization of duties – the duty of clinicians, of health care institutions, and of the public – apply under these unprecedented conditions. These questions are being considered in our hospitals, living rooms, the lay press, and on social media.
What follows is an edited version of a Twitter dialogue between surgeon Louise P. King and pediatric oncologist Jonathan Marron, both faculty members at the Harvard Medical School Center for Bioethics. Drs. King and Marron were responding to a tweet by Paul McLean, social media editor at the Center for Bioethics, on his personal account.
— Paul C. McLean (@paulcmclean) March 28, 2020
Great question @paulcmclean I’m biased but see a plea for public to take need for distancing seriously. Too hard to explain the numbers to people who deny. A cry for help – we can’t handle the number of patients that will come our way unless u help by staying home.
— Louise Perkins King (@louise_p_king) March 28, 2020
Ha rant well received 🙂
This is such uncharted territory, particularly in the US, where we put such a premium on individuality, self-determinism, & unobstructed autonomy. To your points, what is the duty of HCWs both w & w/o proper protection/support? And what is public’s duty?
— Jonathan Marron MD MPH (@JonMarronMD) March 28, 2020
Paul: Nurses and doctors around the country are going on the news and taking to social media to encourage the public to stay at home, with such messages as, “We stay here for you — please stay home for us.”
Louise: I see this as a plea for public to take need for distancing seriously. It’s too hard to explain the numbers to people who deny. It is a cry for help — we can’t handle the number of patients that will come our way unless you help by staying home. Alternatively, you could argue that we, as clinicians, are taking huge risks for you and yours (there’s a much higher infection and mortality rate for health care workers and those without adequate PPE). It’s our mission and we are deeply committed, but it’s still a choice to be here to save you or a loved one if needed.
Jon: Your wording is important there. Is this best viewed as a personal choice? Is it a duty (or obligation)? How do we think differently about personal rights in the setting of a public health emergency?
Louise: I believe it’s an obligation, assuming that we have appropriate equipment and training. For example, surgeons have training and equipment to protect ourselves during cases when the risk of transmission is high (e.g., HIV or hepatitis C). We don’t expect surgeons to operate without gloves, and we don’t expect a physician without appropriate training to lead such a case or to provide care they aren’t equipped to provide.
Jon: This is such uncharted territory, particularly in the United States, where we generally place a high premium on individuality, self-determinism, and unobstructed autonomy. To your points, what is the duty of health care workers, both with and without proper protection and support? Generally, we say clinicians have a fiduciary duty to patients, but that duty is not without limits. If my patient was going to be evicted, for example, I certainly am not obligated to give them money for rent. I could choose to do that, for sure, but that would be above and beyond the call of duty (pun slightly intended). Does that change when clinicians don’t have adequate protection, such as PPE? Well, if there is no intrinsic, unconstrained duty to begin with, I find it hard to see one existing in the absence of adequate protections.
Paul: What, then, is the duty of the institutions to their clinicians?
Jon: I would argue that the institution does have the duty to protect its clinician and staff, likely even more so in a public health emergency than typically. Health care institutions are nothing without the “worker bees,” and these institutions ultimately are public health organizations, meaning that they are tasked with (i.e., have a duty to) protecting the health of the public, which certainly includes protecting the health of clinicians and staff. But it’s also important to remember that only when clinicians and staff are healthy can they maximally serve the public. If nurses, for example, are contracting COVID-19 from having inadequate PPE, not only will they themselves get sick, but they won’t be able to help protect the health of others. So, in a way, you could argue that protecting clinicians and staff is actually a “double duty” for institutions!
Louise: I agree, the institution absolutely has a fundamental duty to provide adequate equipment and specifically PPE. Clearly, institutions have failed in this regard around the country and at times have even found themselves thwarted in their efforts to obtain needed supplies. Yet, their duty is absolute. Without meeting it, I can’t see a duty to care existing for health care providers.
Jon: I completely agree with you — this aspect of the pandemic is really troubling, for a variety of reasons. I was pleased to see how many medical societies recently endorsed the statement from this past week by the Council of Medical Specialty Societies (CMSS) about PPE, stating among other things, that “physicians and other health care professionals can and should expect their institutions to provide appropriate means to limit occupational exposure.” It’s not perfect, but it’s a start.
Paul: But what about the public? Doesn’t the public have a duty in this? If you have a right to care when you need it, isn’t there a responsibility to the people providing it?
Louise: I don’t think the public has a duty any more than we [clinicians] do in this crazy mess. If they plan to present for care if they become ill, then perhaps they have a reciprocal duty to stay out of harm’s way? But we don’t require that of the public generally, though I wish I could argue differently. I feel a strong duty to stay home while my colleagues are risking their lives. But I can’t find an argument within our typical frameworks for why I would impart that same duty to all. This probably would be different if we lived in a less individualistic society. I think those in the public who are not staying home are doing so in response to misinformation or out of fear for their livelihoods, not because they don’t value and support health care workers.
Jon: This might be the hardest question, in my opinion. Typically, we wouldn’t say the public has any duty to others, though we always hope that people will put the greater good over their own self-interest. Unfortunately, we don’t have a wonderful track record with this in the United States lately. Look no further than vaccines for a great example: a tiny potential risk to yourself (or your child) with great potential benefit to the group, yet many refuse to “take one for the team.” What about in a public health emergency? I’m not sure the public duty changes, but I certainly hope that the internal motivation changes for most. So does the public have to reciprocally serve the greater good in response to health care workers’ selflessness? I find it hard to argue that they must do so, but like you, I hope that most do so willingly. I suppose that the coming weeks will tell us all we need to know, though. Fingers crossed…
Louise: As members of a society we give up some individual liberties in exchange for some common security. It seems reasonable to think that the freedoms we are willing to compromise in the short term should be commensurate with the dangers we face. Our current circumstances are so dire that our social contract demands that, at the very least, the public adhere to social distancing. To really recover from this catastrophe, we will probably have to accept periods of distancing and tracking of our movements to control spread. Americans typically don’t take kindly to suggestions their individual liberty will be curtailed, but maybe these images of our health care workers will reach the public and inspire them. Our health care workers are ready to do their best to care for us if we fall ill — staying home is the least we can do in exchange.
Jonathan M. Marron, MD, MPH is a pediatric oncologist, researcher, and bioethicist at the Dana-Farber Cancer Institute and Boston Children’s Hospital and Teaching Faculty at the Harvard Medical School Center for Bioethics. @JonMarronMD
Louise P. King, MD, JD is an affiliate faculty member at the Petrie-Flom Center, assistant professor at Harvard Medical School and director of reproductive bioethics at the Harvard Medical School Center for Bioethics @louise_p_king