In the wake of SARS and with the possibility of bioterror, pandemic avian influenza, and other emerging infections looming, bioethicists are exploring the extent of a health professional's duty to treat the victims of such an infectious outbreak, even at some substantial risk to the caregiver's own health or life. The World Health Organization announced in August 2003 that 20 percent of all persons known to have been infected with SARS were health care workers. Three of the forty-one people who died of SARS in Canada were health professionals, as were six of the 180 who died in Taiwan. (1) Dr. Carlo Urbani of Medecins Sans Frontieres, who with others initially identified SARS as a new infectious disease in Hanoi, voluntarily quarantined himself and eventually died of SARS, leaving a widow and three children. (2) Should we regard Dr. Urbani as a medical hero, or as a physician simply doing his duty?
Physicians' moral duties arise from at least two sources. As members of society, they owe the same general duties to others as any citizen. In addition--as one of us has previously argued--they assume a further set of moral duties connected with the nature of medicine as a practice. By announcing to the community that they are practitioners of medicine, physicians implicitly accept and undertake these duties. (3) Although the core features of the internal morality of medicine persist over time, the interpretations of these duties are not static and are implicitly renegotiated with society as the practice of medicine evolves. (4)
The internal morality of medicine consists of both goals and ethical side constraints. The goals of medicine, which physicians ought to promote, include healing and curing but also extend to prevention, rehabilitation, palliation, reassurance, and health education. The side constraints distinguish the appropriate from the inappropriate ways of pursuing those goals. Physicians should be technically competent and truthful about the nature of their craft, avoid causing harm that is disproportionate to anticipated benefits, and serve as loyal patient advocates. (5)
Our account of the internal morality of medicine provides a prima facie answer to whether physicians have a duty to treat pandemic illness. All members of society have an ethical duty to rescue others in dire need of help when they are in a position to do so. Physicians arguably have a role-specific duty of rescue by virtue of their medical competence to provide the help that victims of infectious outbreaks require. The goals of medicine include curing when possible and minimizing patients' suffering when curing is not possible. Physicians are duty-bound as fiduciaries to the interests of their patients. It therefore appears that physicians cannot, with integrity, refuse to serve the victims of an infectious outbreak out of fear of contracting the disease. This duty to treat is strengthened by organizational structures related to professional status that assign to physicians exclusive control over many resources and skills needed to assist patients, such as the right to prescribe medication. Having effectively denied non-physicians the means to assist victims of pandemics, physicians appear even more duty-bound to help.
This prima facie account, however attractive initially, turns out on further exploration to be insufficient to sustain a robust duty to treat. Recent work that attempts to apply lessons from the SARS outbreak to a possible avian influenza pandemic provides some illumination. The discussion must be broadened from physicians to include not only all health professionals, but also the nonprofessional service workers without whom any hospital would soon cease to function. (6) The health care worker's other obligations, especially for the care of family members, must be considered alongside duties owed to patients. Finally, a deeper account of the professional's duty to treat will eventually have to address in detail important concerns of social solidarity. Three levels must be addressed: Solidarity among health workers within institutions, solidarity between health professionals and the community, and the commitment of the community as a whole to its most vulnerable members.
Justifying a Duty to Treat
Despite the strong prima facie case for a robust duty to treat, providing an ethical justification for this duty has proved more daunting than many anticipated. Lawrence McCullough, for instance, offers one of the few systematic treatments of physicians' legitimate self-interests that counterbalance their professional responsibilities. He includes among these interests sufficient time to engage in hobbies and other leisure activities. (7) If hobbies constitute an ethically acceptable self-interest, preserving one's own life would seem to be a more compelling one. But recognizing that interest would pull the rug out from under any meaningful duty to treat in the face of substantial risks to life and health.
Many assume that the historical traditions of medicine provide at least a partial justification for a strong duty to treat. Careful analysis of the historical record, however, reveals a decidedly mixed picture. (8) Between the early nineteenth and the mid-twentieth centuries in the United States, a duty to treat even at considerable personal risk was widely accepted by physicians. Before that, from late medieval times into the eighteenth century, physicians commonly fled the city when an epidemic struck.
If the historical record is univocal on any point, it would seem to be that the duties that physicians accepted were contingent upon the physicians' place and role in society, and on a negotiation between the medical profession and the community at large. Usually this negotiation was implicit, but occasionally it was conducted explicitly. For example, when plagues afflicted Europe between the fourteenth and seventeenth centuries, the civic authorities often compensated for the flight of the town's regular physicians by paying enough to at tract a cadre of "plague doctors" to replace them. (9)
The AIDS crisis of the 1980s surprised those who had assumed that the duty to treat still held. They did not anticipate the effect of the soothing myth, promulgated during the 1960s, that epidemics had been conquered and so risking death while treating patients was no longer a part of the physician's job description. Told that there was a small chance of contracting a disease thought then to be 100 percent fatal from treating an HIV-positive patient, at least some younger physicians said in effect, "Wait a minute--I never signed up for this." This disconnect between traditionally accepted ethical obligations and actual physician behavior led to a flurry of …