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45 Ethical principles regarding physician response to disasters: pandemics, natural disasters, and terrorism
The Case
During morning rush hour, a subway station in a major metropolitan area is rocked by a sudden explosion. The train platforms and several cars that were in the station at the time of the explosion are severely damaged, and the structural integrity of the underground system is compromised. The scene is chaotic. There is concern that the subway tunnel may collapse. The cause of the explosion is unknown – the smell of gas may indicate a potential cause, or may be the result of gas leakage after the explosion. There is concern that if this is a terrorist attack, there may be additional bombs awaiting detonation timed to kill rescuers.
A live victim cannot be extricated from one of the trains because her leg is entrapped in the wreckage. Her injuries appear otherwise not life-threatening. An anesthesiologist is requested by rescuers to provide airway support and analgesia for an immediate on-site amputation in order to free the victim.
The idea that physicians have ethical duties during mass casualty incidents is a relatively modern one. During episodes of the plague in Europe, for example, clergy and magistrates were expected to remain in the cities to minister to the sick, but physicians generally were not. Most did in fact leave the cities, arguing that they needed to live to serve the greater good by taking care of survivors.1 Ideas about the ethical duties of physicians during pandemics, natural disasters and other mass casualty incidents have changed, now that modern medical practice can positively impact survival. But contemporary studies indicate that physicians as a group continue to be reluctant to respond to “societal” medical emergencies. In one study, 45% of surveyed physicians felt that it would be ethical to abandon their workplace in the event of an influenza pandemic.2
The unique skills of anesthesiologists as experts in airway management, fluid and blood resuscitation, and intraoperative anesthesia make them particularly desirable as early emergency responders. Anesthesiologists sometimes serve in pre-hospital treatment, including in-field airway management and administration of anesthesia to facilitate victim extrication,3 in early hospital triage of victims according to available resources, and in the management of intensive care patients and patients who need immediate surgical intervention.
Physician’s ethical obligations to respond in public health emergencies
General and special positive duties
Common moral theory holds that we all, by virtue of being a part of humanity, have a duty to help others in peril – particularly if we can do so without great risks to ourselves. For example, we should all prevent a toddler on the sidewalk from running out in traffic, and we should all call 911 if possible when we witness an accident. These are termed “positive” duties, since they require us to take an action, rather than to refrain from taking an action. An example of a negative duty – in which there is an ethical obligation to refrain from an action–is a general duty not to kill. Malm and colleagues*4 differentiate general positive moral duties, which morally bind all persons, from special positive moral duties, which require a special relationship between the actor and the recipient of their actions. They use the example of the relationship between a lifeguard and swimmer as a special relationship. The lifeguard has a special positive duty to rescue, based on their skills and the general expectations of their work. Such special positive duties also exist between physicians and victims of disaster who require medical care.
The special positive duties of physicians are generally argued to exist based on several considerations. First, physicians freely choose to enter a profession whose primary function is to serve the sick; they therefore agree to some degree of exposure to illness and the resulting personal risk. The medical profession enjoys a privileged position in society. In order to enjoy those privileges, physicians must accept certain responsibilities that go with them. Second, special skills are needed in mass casualty incidents, and physicians are members of a restricted group that have those skills. Third, physicians owe a debt to patients and to society. Not everyone can be trained to be a physician. The resources needed to teach physicians are both limited and expensive. Training every physician involves the consent/cooperation of the hundreds of patients who allow trainees to work with them. There is therefore a societal contract which obligates physicians to reciprocate by serving both patients and societal needs.5,6
Although physicians enter the medical profession of their own free will, it is nevertheless difficult to convincingly argue that they therefore are obliged to assume unlimited risks. Such an argument relies on an “implied consent” of all physicians to a strong duty to treat – but actual evidence that implied consent exists is lacking. Only about 55% of physicians now believe there is such a “profession-wide duty to treat patients despite risk to one’s health.”7
The idea that physicians have special abilities that increase their obligation to respond in emergencies has more traction. While people with special skills may not be ethically obliged to serve the public good all the time, communitarian principles do acquire more authority in times of emergency. As Sawicki points out:
“As the risk of harm grows more imminent, as the gap between harm to the rescuer and harm to the public widens, and as the pool of available and qualified rescuers shrinks (particularly where state regulations preclude unlicensed individuals from developing special abilities to rescue), potential rescuers may indeed find themselves obliged to subvert their own interests for the public good.”7
This type of argument is based on rights-based, or deontologic, theories in which one generally should act in a manner that promotes beneficence and respect for the lives and autonomy of others. Such duties, however, are not restricted to the medical profession itself.
The American Medical Association’s Code of Medical Ethics states that:
Because of their commitment to care for the sick and injured, physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life.8
Related posts:
Informed consent and the pediatric patient
The use of ethics consultation regarding consent and refusal
Revising the Uniform Anatomical Gift Act – the role of physicians in shaping legislation
Animal subjects research Part I: Do animals have rights?
Disclosure of medical errors in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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