Physician Duties and Responsibilities in Pandemics

G. Richard Holt, MD, MSE MPH, MABE, DBioethics

Disclosures

South Med J. 2020;113(4):147 

To the Editor: In early February 2020, the World Health Organization declared the 2019 novel coronavirus infection (2019-nCoV) to be nearing a global pandemic. Not since the outbreaks of severe acute respiratory syndrome (SARS) of 2002–2003 and Middle East respiratory syndrome (MERS) of 2015 have population concerns and medical attention been so keen. The World Health Organization Director-General warned that the world may be dangerously unprepared for this coronavirus pandemic.[1]

Infected individuals are being treated in the United States, and although the number of patients at the time of this writing is low, that number is predicted to increase. The Centers for Disease Control and Prevention has provided a situation summary and interim advice to physicians regarding the triage and identification of and supportive care for patients presenting with symptoms that are consistent with 2019-nCoV infection.[2,3] Because person-to-person transmission of the virus has been confirmed, medical offices, urgent care centers, hospitals, and other medical facilities should be preparing an appropriate and ethically responsible patient care plan.

As with natural and terrorist disasters, a pandemic of this sort requires our contemplation of the ethical responsibilities of physicians to care for patients who may be ill with the virus or may soon be ill. These ethical considerations also include the propriety of patient quarantine and isolation, with its attendant emotional reactions in a democratic society.

The American Medical Association's Code of Ethics, Opinion 9.067, presents the argument that a physician has an obligation to provide emergency medical care in disasters and during pandemics.[4] The physician must recognize that this may place her or him at some level of risk, but that risk may be acceptable to serve injured or ill individuals. The ethical dilemma has always been determining the balance between care for afflicted people, and physician wellness to continue to care for patients in his or her own practice for years to come. A number of factors figure into that balance, in this case a viral pandemic: is the outbreak in the physician's own community; does the physician have a choice to care for victims, or is she or he one of a few potential responders; does the physician have the training and experience to treat these seriously ill patients; and does the receiving facility have the capability to provide resources for the safety of the providers?

The medical care experience during Hurricane Katrina demonstrated that physician and facility preparedness were inadequate for an overwhelming challenge to a community healthcare system.[5] Since then, particularly in the aftermath of the severe acute respiratory syndrome experience, physicians in general are increasingly knowledgeable in infection control and personal protection devices and protocols are more universal. What is unknown, however, is the state of willingness of physicians across the country to place themselves at risk by providing pandemic victims with medical care. I believe that physicians recognize the ethical responsibility for beneficence, altruism, compassion, and self-sacrifice, and will step forward to assist when needed.

The second challenge to the medical profession in pandemics is the need to subjugate individual rights to self-determination in favor of the overarching health of the public. Thus far in this 2019-nCoV outbreak in the United States, there has been no public outcry against the quarantine and isolation of exposed, suspected, and infected individuals. The American Medical Association Code of Medical Ethics, Opinion 8.4, outlines the public health responsibility for quarantine and isolation in the context of infectious diseases, as well as individual physicians' obligation to educate patients and the public, and support the public health plans that evolve in the face of the pandemic.[6] Ethical quarantine and isolation measures from the Centers for Disease Control and Prevention and the US Public Health Service are based on lessons learned historically and are sound in principle. We physicians should familiarize ourselves with the measures and be prepared to implement them—for both individual patients and populations of patients. In this, we are guided by our duties, responsibilities, and ethical principles.

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