This crisis is not a war It is what physicians are trained to do

Abstract

As the uncommon combination of ethicist and surgeon, I have great compassion for my colleagues in the proverbial trenches. Recent articles in social and print media have moved me by their emotion and passionate pleas for recognition of the current plight of healthcare workers. Articles identifying the lack of personal protective equipment, physicians contracting “COVID-19,” and a lack of action on the part of hospitals and government entities are commonplace in the media.[i]  Healthcare media predictions of a mass resignation by healthcare workers present seductive doomsday imagery. While I agree with many reports, others are specious and mere vacuous recriminations.

I disagree with reports that  compare COVID-19 and its impact on humanity, mortality, and morbidity with war,[ii] and Ebola, and that fail to articulate the obligations of physicians to provide care in a crisis. There is no rational reason for the comparison except to stoke fear of the contagion. In war, the enemy is not a natural event. In war, the enemy is human and the conflict is volitional, grounded in ideology, finances, power, or plain ego.[iii] Unlike the manmade factors that lead to war, the virus is an unthinking entity living only for its survival; we happen to be in its way. I have seen and heard comparisons to soldiers in war such as, “Allowing physicians and nurses to treat patients with COVID-19 without proper personal protective equipment (PPE) is like sending soldiers to war without adequate equipment.” I take some pause at the latter as the father of two Marine veterans.

We currently find ourselves in an environment where reason is inconvenient, annoying, and aggravating. I read articles with emotional pleas “that any mortality is unacceptable.” However, reason is of great importance when making decisions that impact society. The comparison between war and COVID-19 is an unintentional straw man argument. The premise is that the virus is somehow evil and has intent and purpose making it easier to hate and attack.

Comparisons made to Ebola, which created great fear in this country partly due to models predicting millions of deaths,[iv] serve to emotionally impact the reader to support the author’s conclusions and recommendations. In the Ebola panic, only two Americans died, proving the model’s failings. COVID-19 modelling has revealed a similar lack of accuracy.[v] Perhaps the impact of Ebola is an unfair comparison, but the fear was similar. Comparing COVID-19 to Ebola is an “ends justify the means” argument, fraught with moral pitfalls, and uses inaccurate imagery creating anger and fear in an already vulnerable population.

Another argument propelled by the media is an argument veiled and subdued in practically all current articles identifying the risk to physicians. The media fails to recognize the balance between physicians pressing hospitals to provide the right gear and the obligation of physicians to provide care. I have deliberately excluded other hospital workers that have never taken an oath for there is universal agreement that they are not bound by the same obligations. Opinion 8.3 of the American Medical Association ( AMA) code of Medical Ethics sets an ethical framework for physician action in epidemics, disasters, or terrorism. "First and foremost is the obligation to provide urgent medical care during disasters," an obligation that holds "even in the face of greater than usual risk to physicians' own safety, health or life."[vi]  Opinion 8.3 recognizes that the physician workforce itself is not an unlimited resource. “The risks of providing care to individual patients today should be evaluated against the ability to provide care in the future." It is rarely, almost never, acceptable to refuse to put yourself in harm’s way and especially unacceptable if no other physician is available. I suggest our colleagues are reminded of the duties imposed by the profession they chose. Doctors can always stay home and find others to take up the torch, a phenomenon occurring throughout the world. Refusal can be considered when the physician has a condition of such high risk that the doctor patient interaction would be a suicidal one. Institutions, governing bodies, and administrative entities have responsibilities to physicians’ safety and we must hold them accountable. It is our obligation to take an activist role and request, even demand, assistance with PPE, isolation, and support from our superiors. However, we must interact in good faith and resist the appearance of self-indulgence and vacuous recrimination. Society holds physicians, nurses, and all healthcare workers on a high pedestal. We should pay a price for that exalted position, although rarely with our life. No physician should be forced to risk his life but, in extraordinary circumstances, when the risk is accepted, we should accept it gracefully, humbly, and readily. I will try to counsel my anxious colleagues to the best of my ability but, I also must refer to our code of ethics above and fulfill my moral obligation. 

         In the past 24 hours an evolving situation brought a mist to my eyes and is an example of courage and commitment to our vocation. A 35 year old man with a pregnant wife and no prior medical problems had not responded to conventional therapy. He was on a ventilator with no further increase of oxygen possible. All available medications used to treat COVID-19 and one experimental medication on clinical trial had failed to improve his condition. His only chance to allow his lungs to heal was extracorporeal membrane oxygenation (ECMO), a complex, highly intense medical modality that provides oxygen directly to the bloodstream, bypassing the lungs. Selfless acts by nurses, intensivists, social workers, administrators and, yes, ethicists created the environment for the young man’s survival. Ten associates manually moved him from prone to supine until ECMO was initiated. I heard no complaints, I heard no recriminations, I heard no whining. I heard only, “Let’s do it, Doc.''

 The ten individuals acting to save the young man epitomize the principles laid down in the AMA code of Medical Ethics. I thank them for their service, and I pray they will someday be rewarded. We will not run out of providers. They will show up as they always have and provide patient care with dignity and compassion for their dedication to duty is boundless.

Photo by Luis Melendez on Unsplash

[i] Kirsch, Thomas, MD: “What happens if healthcare workers stop showing up?” , The Atlantic March 24,2020, https://www.theatlantic.com/ideas/archive/2020/03/were-failing-doctors/608662/

[ii] Stat Reports, “We don’t send soldiers to war without weapons” https://www.statnews.com/2020/03/21/give-doctors-what-they-need-to-fight-covid-19/

[iii] Optiv: “Using “MICE” to understand your adversary,

https://www.optiv.com/blog/using-mice-to-understand-your-adversary

[iv] Ebola Infections Fewer Than Predicted by Disease Models  https://www.scientificamerican.com/article/ebola-infections-fewer-than-predicted-by-disease-models/

[v] How mortality predictions in a leading coronavirus model dropped over time https://www.washingtonpost.com/politics/2020/04/14/how-mortality-predictions-leading-coronavirus-model-dropped-over-time/

[vi] AMA(American Medical Association) Code of Ethics, 8.3, Physicians’ responsibilities in disaster response and preparedness https://www.ama-assn.org/delivering-care/ethics/physicians-         responsibilities-disaster-response-preparedness