Three different but overlapping types of sleep deprivation cause the mental and physical impairments one normally sees in response to periods of restricted sleep. They are classified as acute sleep deprivation, chronic partial sleep deprivation, and sleep inertia.

It has been difficult to address the problem of sleep deprivation because of the degree to which people suffer neurocognitive decline after periods of sleeplessness varies dramatically from individual to individual. Intrinsic factors, such as age and gender, as well as factors that can be modified, such as motivation and training, all interact to determine the degree to which an individual may be affected by sleep deprivation [16, 17].

In individuals, a nap for 30 minutes during a night shift can substantially improve overall cognitive performance and diminish feelings of fatigue [18]. For some, however, the sleep inertia that occurs after awakening can impair cognitive performance for variable periods of time following the nap [19]. In one study, a group of emergency room physicians took 40 minute naps during their night shifts. While they had memory impairment immediately upon awakening, they later showed improved attention and driving performance [20].

Cognitive enhancers such as caffeine and modafinil have been shown to improve neurocognitive function during episodes of acute sleep deprivation and fatigue [21]. Caffeine can make individuals feel more alert and allow them to stay awake for extended periods of time. In a study of novices receiving simulation-based training in laparoscopic procedures, 150 mg of caffeine (equivalent to about one cup of coffee) [22] reversed some of the neurocognitive effects of sleep deprivation [23] but higher doses, equivalent to about four cups of coffee, were needed to have any lasting improvement in cognitive function [24].

Modafinil is a pharmaceutical drug that, similar to caffeine, temporarily mitigates cognitive decline and the subjective sense of fatigue by improving attention, working memory, and cognitive flexibility [24]. Unlike amphetamines, however, modafinil is not known to cause behavioral excitation [25–27] or rebound hypersomnolence [27–29].

Shift pattern manipulation has been the primary means by which the medical profession has sought to ameliorate the effects of sleep deprivation. The Accreditation Council for Graduate Medical Education (ACGME) in the United States mandates that all residents in their first postgraduate year work maximum shift durations of 16 hours and have at least 8 hours each day free of clinical duties when working for extended periods of time. Currently, attending physicians do not have restrictions on the number of hours they may work.

The Principle of the Primacy of Patient Welfare is the ethical precept that requires physicians to provide patient care that primarily upholds the best interests of their patients and cannot be compromised by market forces, societal pressures, autonomy interests, or administrative exigencies [30]. A few of the Physician Charter “commitments” that correspond with this fundamental principle are relevant to the ethics of physician fatigue.

First, the Physician Charter declares a commitment to “professional competence,” which, among other things, mandates that the medical profession as a whole work towards “improving quality of care” and “strive to see that all of its members are competent” by “ensur[ing] that appropriate mechanisms are available for physicians to accomplish this goal” [30]. Second, the Charter not only mandates that physicians maintain clinical competence but also requires physicians to work with other professionals “to reduce medical error, and increase patient safety” [30]. Moreover, “[p]hysicians … must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care” [30]. And finally, the Physician Charter declares a third commitment to “maintaining appropriate relations with patients,” that includes avoiding the exploitation of patients for private purposes [30].

As discussed previously, sleep deprivation leads to substantially decreased neurocognitive performance that, in turn, may lead to considerably increased risks for patients. A fatigued physician who suffers from severe sleep deprivation – whether acute, chronic, or both – may display neurocognitive performance that is so impaired as to render the physician incompetent to treat patients [11, 31]. Physicians in such a state will necessarily provide a lower quality care to their patients. Thus, the Principle of the Primacy of Patient Welfare along with the commitments to professional competence and quality of care mandates that physicians should be properly rested in order to maintain levels of neurocognitive performance that would ensure the delivery of an adequate quality of care to patients.

Some ethicists, however, may argue that mandating physicians to be well-rested is unethical. Physicians, after all, have their own autonomy interests including the right to decide their own work hours [32]. Such a position is valid provided the physicians’ own autonomy interests do not lead to fatigue and the possibility of providing lower quality of care to patients. If physicians choose to work in a manner that causes their own fatigue, they are subordinating their patients’ best interests to their own autonomy interests that, in turn, violates their commitment to maintain appropriate relations with their patients and infringes on their ethical commitment to increase patient safety [32].

The second argument against any mandate relates to cost. Limiting physician work hours to ensure they are rested increases costs for hospitals, medical centers, and private practices [32]. In order to cover for the lost work hours of current physicians on staff, such institutions may find it necessary to hire more physicians at an additional expense. The Principle of the Primacy of Patient Welfare requires physicians to dedicate themselves to serving the best interests of patients in a manner that must not be compromised by market forces or administrative exigencies [30]. An interest in costs, therefore, cannot be superior to concerns for patient safety.

Finally, some ethicists may argue that, for the sake of continuity of care [32], physicians should not be required to be well-rested. They may assert that patients’ best interests are better served by the attention of the same physician over many continuous hours rather than by a series of physicians who provide fragmented observations and treatment [32]. Shorter working hours inevitably lead to more frequent transfers of patient information from one physician to the next that, in turn, increases the probability of errors in communication [32]. Under this patient’s best interest argument, the continuity of care may promote the Primacy of Patient Welfare by longer rather than shorter physician work hours. For this argument to succeed, however, the benefits to the patient must outweigh the increased risk of fatigue-related medical errors. Indeed, there may be cases in which continuity of care may benefit the patient more than being cared for by well-rested physicians but, at a certain point, the treating physician’s fatigue will become so severe and debilitating that the probability of harm from continued treatment would clearly outweigh the benefits of continuity of care. Thus, continuity of care arguments cannot justify allowing physicians to work in an unlimited capacity.