Commentary

The Duty to Care and Its Exceptions in a Pandemic

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I have no idea what’s awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.

—Albert Camus, The Plague1


 

References

As of April 9, 2020, the Centers for Disease Control and Prevention (CDC) reported that 9,282 health care providers in the US had contracted COVID-19, and 27 had died of the virus.2 Medscape reports the toll as much higher. Thousands more nurses, doctors, epidemiologists, social workers, physician assistants, dentists, pharmacists, and other health care workers from Italy, China, and dozens of other countries have died fighting this plague.3

The truth is no one knows how many health care workers are actually sick or even have died. State and federal governments have not been routinely and specifically tracking that data, making these already grim statistics likely a gross underestimation.4 While not all of these health care providers were exposed to COVID-19 in the line of duty, many were, and many more will be as the pandemic subsides in one epicenter only to erupt in another, and smolders for months until a vaccine quenches it.

Each of those lost lives of promise had a story of hard work and sacrifice to become a health care professional, of friends and family who loved and cared for them when ill, who need and grieve for them, now gone far too soon. Nor should we forget to mourn all of the administrative professionals, the line and support staff of health care facilities, who also perished fighting the pestilence. It is fitting then, that this second editorial in my pledge to write each month about COVID-19 until the pandemic ends, be about the duty to care and its limits.

The duty to care is among the most fundamental and ancient ethical obligations of health care providers. It is included even in modern codes of ethics like that of the American Medical Association and American Nurses Association. The obligation to not abandon patients is even more compelling for the Military Health System, Veterans Health Administration (VHA), and the US Public Health Service whose health care mission also is a public trust. The duty is rooted in the fiduciary nature of the health professions in which the interests of the patient should take priority over other considerations, including a risk to their own health and life. Prioritization though has exceptions. Physician and attorney David Orentlicher points out the unconditional obligation that bound physicians in the 14th century Black Death, or the 1918 Spanish influenza, now admits exceptions and qualifications.5

The exception that has become the object of greatest concern to health care workers is personal protective equipment (PPE). In modern public health ethics, health care systems and state and federal governments have a corresponding ethical obligation of reciprocity toward their employees whose work places them at elevated risk of harm—in this case, COVID-19 exposure. The principle of reciprocity encompasses the measures and materials that health care institutions need to provide to health care workers to reasonably minimize the risk of viral transmission. The reasonableness standard does not demand that there be zero risk. It does require that health care workers have adequate and appropriate PPE so that in fulfilling their duty to care they are not exposed to a disproportionate risk.

This last assertion has been the subject of controversy in the media and consternation on the part of health care professionals for several disconcerting reasons. First and foremost, a cascade failure on the part of government and industry has resulted in PPE being the scarcest health care resource in this pandemic.6 The shortage is as serious as that of the life-saving ventilators that are rightly at the center of most crisis standards resource allocation plans.7 Second, the guidance from the CDC and other authoritative sources continues to change. This is, in part, to adjust to the even more rapid pace of knowledge about the virus and its behavior and to adapt to the reality of insufficient PPE.8

Understandably, health care providers, especially those on the frontlines, may lose trust in the scientific experts and the leadership of their institutions, compounding the climate of moral distress in a public health crisis. Health care workers in the community, and even in federal service, have launched socially distanced protests and taken to social media to voice their concern and rally assistance.9,10 In response, VHA Executive-in-Charge Richard Stone, MD, admitted that VHA does have a shortage of PPE in a Washington Post interview.11 He outlined how the organization plans to address staff concerns. The article also reported only a 4% absentee rate of VHA staff as opposed to the 40% that plans predicted was possible. This demonstrates once more the dedication of VHA health care professionals and workers to fulfill their duty to care for veterans even amid fears about inadequate PPE.

In the epigraph, Albert Camus captures the uncertainty and fear that as humans all health care providers experience as they face the unpredictable but very real threat of COVID-19.1 Camus expresses even more strongly the devotion to duty of health care providers to care for vulnerable ill patients in need despite the inherent threat in a highly transmissible and potentially deadly infection that is inextricably linked to that caring. Orentlicher wisely opines that the integrity of the health professions and their respected role in society benefit from a strong duty to care.5 The best way to promote that duty is to do all in our power to protect those who willingly brave the pestilence to treat, and hope and pray someday to cure COVID-19.

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