Clinical Ethics in Anesthesiology. A Case-Based Textbook
6. Anesthesiologists, the state, and society
45. Ethical principles regarding physician response to disasters: pandemics, natural disasters, and terrorism
Susan K. Palmer
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
The AMA opinion goes on to say that physicians are a limited resource, and the physician should balance the immediate benefits to individual patients against the ability to care for future patients. Similar duties are stated by the UK’s General Medical Council, which states:
Doctors must not refuse to treat patients because their medical condition may put the doctor at risk. The balance between protecting individual doctors and their families from harm, and ensuring patients are not put at unnecessary risk is best addressed at the local level, taking into account the principle that those who place themselves at additional risk should be supported in doing so and the risks and burdens minimized as far as possible.9
The limits of risk
Military physicians have a duty to put the requirements of the military “mission” ahead of the interests of themselves or of individual patients. Physicians serving in the military can be ordered to assume almost any level of risk and even be expected to serve in situations where they will likely die. Civilian physicians, however, are not obligated in the way soldiers may be to take unlimited risks.
In general, risks are more acceptable if they are proportionate to the benefits expected. When HIV/AIDS was becoming epidemic, some surgeons and anesthesiologists refused to provide care for infected patients or to treat them equitably in other ways. But actual risks to healthcare providers who take care of HIV positive patients are now known to be very low. It is therefore unethical for physicians to refuse to treat HIV/AIDS patients on the basis of maintaining their own safety. On the other hand, infections with the SARS virus are not only extremely contagious, but are associated with high mortality. In order to obligate physicians to be exposed, there must be a proportionate expectation that their response will result in significantly better overall patient outcomes, and/or in significantly better societal outcomes through containment of the disease.
The ethical obligations of physicians to respond in natural disasters or terrorist attacks, as well as what manner of response can be required of them, must be balanced between the probability that such participation will improve survival for more casualties, and the risks of mortality to the physicians themselves. Risks to casualties may be obvious early on, but the benefits of intervention unknown. Assessing the risks to physicians in such situations is complicated; routes of contamination during an epidemic and toxic exposure during natural or man-made disasters may be unknown, at least initially. The means of reducing risks to healthcare workers may not be fully understood, and the equipment to reduce such risks not readily available.
In general, it is not an ethical obligation to risk one’s own life to save another. Acts involving such risks are usually termed “supererogatory”– literally “payment beyond that which is owed or asked.” Many examples of supererogatory – or heroic – acts can be found among physicians responding to emergencies.10 Tse Yuen-man was the first physician volunteer in the SARS epidemic in Hong Kong in 2003 to die of SARS. She had volunteered knowing that SARS is highly contagious and very deadly. Anesthesiologists have been early responders in stabilizing patients in earthquakes and terrorist bombings, even at times providing on-site anesthesia when amputations are required for victim extrication. Structural instability, possible toxic contamination, and the risk of being injured or killed in aftershocks of an earthquake or additional terrorist bombs detonated in order to kill the rescuers present imminent danger for early responders.
What does society owe to physicians in mass casualty situations?
Society and hospitals have interests in having competent, seasoned and responsive physicians, and therefore have obligations to physicians, e.g., to provide physicians with personal protection, training and logistical support to minimize their risk while maximizing the potential benefit of physicians’ service to patients. Dr. Tse Yuen-man, for example, did not have protective gloves to wear when she responded to an emergency resuscitation of a SARS patient. The Asian Human Rights Commission offered the following words of condolence, and appreciation for Dr. Yuen-man’s sacrifice, and called upon healthcare authorities to recognize their own obligations to physicians responding to emergencies:
The right to life is at the centre of all human rights, and all efforts of the community should be geared toward its protection and promotion…The people in the medical profession, particularly those that work to save life, are at the centre of safeguarding people’s right to life. They become living witnesses of the commitment of human beings to the life of others, living symbols of the tremendous respect with which the supremacy of life and its dignity are upheld.
… It is perhaps pertinent for the community and Hong Kong healthcare authorities to ask some poignant questions, however, about their commitment to people that work on the front line to safeguard our right to life. Is adequate care being taken to safeguard their lives by providing the necessary protection for them in a timely manner, for instance? This is a vexing question that needs to be answered if our appreciation of their efforts is to make any sense.11
Emergency response workers have rights to adequate rest, updated information, and to participate in decision-making throughout the crisis. This not only assures their well-being, but enhances their ability to perform. Society has obligations to provide adequate housing and other basic needs for emergency responders.
Healthcare workers are on “the front lines” and should be among the first to receive effective preventative treatment, such as vaccines in the event of pandemics or bioterrorism situations. Additionally, society has obligations to provide physicians made ill, injured or disabled during emergency response with appropriate medical care and social support, much as it has an obligation to provide such things for wounded soldiers.
The situation in the introductory case presents extreme potential risk to rescuers. An anesthesiologist who responds performs an act that is “above and beyond the call of duty,” i.e., one that cannot be required of him or her. No rules, moral or legislative, can obligate a civilian to risk sacrificing their life for another.
On the other hand, the broader context of this emergency will require responses that do not necessarily place physicians at great personal risk. Anesthesiologists will be needed at the hospital, both to triage and to care for patients who may require immediate surgical intervention. Reporting for duty at the local healthcare facility may present an individual healthcare provider with personal challenges, such as making alternative arrangements to fulfill family obligations, as well as personal discomfort, such as prolonged work hours to manage multiple casualties. The “special” positive duties incurred by entering the medical profession and acquiring special skills impose greater obligations of response. Even if unwilling to go into the subway to help extricate the trapped victim, the anesthesiologist is ethically obliged to respond to the general call for help and report for duty.
• Ethical obligations of physicians to respond to mass casualty incidents have arisen in modern times, as medical care has developed the potential to improve outcomes of casualties.
• The unique skills of anesthesiologists make them valuable in early emergency response – for in-the-field management of casualties, triage, and intensive care unit and operating room management of victims.
• Everyone has general positive moral duties to help others in peril, particularly if there is low personal risk in doing so.
• Special positive moral duties occur when certain “relationships” exist between the actor and the recipient of action: one such relationship is the physician–patient relationship.
• Physician ethical duties in disaster are based in part on the special skills they acquire that are needed in emergency situations. Those duties are strengthened by the restricted pool of qualified responders, due to the limitations on who can be trained in the medical profession.
• Physicians are not ethically obliged to risk their lives in emergency situations, but do have ethical duties to respond and perform non-life-threatening duties.
• Society has obligations to physician emergency responders, such as providing appropriate protective equipment, first line therapies such as vaccines, and treatment when illness or injury results from emergency response actions.
1 Wallis, P. (2006). Plagues, morality and the place of medicine in early modern England. Eng Hist Rev, CXXI (490), 1–24.
2 Ehrenstein, B., Hanses, F., and Salzberger, B. (2006). Influenza pandemic and professional duty: family or patients first? A survey of hospital employees. BMC Public Health, 311.
3 Mahoney, P.F. and Carney, C.J. (1996). Entrapment, extrication, and immobilization. Eur J Emer Med, 3, 244–6.
4* Malm, H., May, T., Francis, L.P., et al. (2008). Ethics, pandemics, and the duty to treat. Am J Bioeth, 8(8), 4–19.
5 Anantham, D., McHugh, W., O’Neill, S., and Forrow, L. (2008). Clinical review: influenza pandemic – physicians and their obligations. Crit Care, 12, 217–21.
6 Bostick, N., Levine, M., and Sade, R. (2008). Ethical obligations of physicians participating in public health quarantine and isolation measures. Public Health Rep, 123, 3–8.
7* Sawicki, N.N. (2008). Without consent: moral imperatives, special abilities, and the duty to treat. Am J Bioeth, 8(8), 33–5.
8* American Medical Association. Opinion 9.067 – Physician Obligation in Disaster Preparedness and Response. Adopted June, 2004. AMA. Council on Ethical and Judicial Affairs. Chicago, Il.http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml.
9* General Medical Council. (2009). Good Medical Practice. Pandemic Influenza: Responsibilities of Doctors in a National Pandemic. London, General Medical Council.
10 Tai, D.Y. (2006). SARS plague; duty of care, or medical heroism? Ann Acad Med Singapore, 35(5), 374–8.
11 A Statement of the Asian Human Rights Commission Offering Condolences and Deep Appreciation for the Life and Work of Dr. Tse Yuen-man, 2003.
Simonds, A.K. and Sokol, D.K. (2009). Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. Eur Respir J, 34, 3003–9.
Trotter, G. (2007). The Ethics of Coercion in Mass Casualty Medicine. Baltimore: The Johns Hopkins University Press.