Secondary Logo

Journal Logo

INSTRUCTIVE CASES

Commentary: changing professional values

Mayo, Thomas W. J.D.

Author Information
The Pediatric Infectious Disease Journal: December 2003 - Volume 22 - Issue 12 - p 1096-1098
doi: 10.1097/01.inf.0000101781.48372.d3
  • Free

In their article in this issue, Anderson et al. describe the case of a 10-year-old girl infected with monkeypox virus. They describe “difficulty in finding both nurses and physicians willing to care for the patient,” from which they conclude that the “tempo of [the past year’s] infectious disease assault combined with the lack of time for the professional health care community to acquire knowledge and come to terms with the handling of these frightening diseases has uncovered an apparent change in the traditional professional values of some medical care practitioners.” The authors go on to suggest various possible explanations for this shift away from “the public’s traditional expectation from professionals, who are expected to accept personal risk in the care of their patients.”

The “traditional professional values” to which the authors refer are embodied in the American Medical Association’s policy on the duty to treat patients with HIV infection: “A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is seropositive for HIV. Persons who are seropositive should not be subjected to discrimination based on fear or prejudice.”1 This policy can be grounded in a number of ethical precepts. Traditional principles of nonmaleficence (“do no harm”) and especially positive beneficence (which “requires agents to provide benefits”2) support a robust understanding of the duty to treat. Indeed as fiduciaries, physicians owe the highest duties of loyalty and care to their patients, including the duty to put their patients’ welfare ahead of their own. This is consistent with virtue ethics’ notion of “the good physician.” One account of “the good physician” includes the virtues of “fidelity, compassion, fortitude, temperance, integrity, and self-effacement,”3 all of which support a duty to treat even in the face of danger to oneself.

The duty to treat also finds support in the calculus of rule-utilitarianism, which asks “which [rules] are most likely to maximize happiness over the long run” and then obligates us to follow those rules “even if following them in a particular situation doesn’t maximize happiness.”4 If one accepts rule-utilitarianism as a cogent and coherent ethical theory, there is little doubt that it supports the duty to treat in the face of danger to oneself. The prospect that hundreds or thousands of patients could go untreated in a catastrophic (but treatable) plague because a relatively small number of health care professionals chose their own well-being over that of their patients is unsupportable by any imaginable rule of utility.

This conclusion is even plainer in light of society’s reliance on health care professionals—who alone are granted the exclusive franchise to treat the injured and afflicted—and its inability to fill the public health gap left when professionals do not shoulder this burden. Public safety employees do not get to choose which fires or brawls they will respond to, and a professional ethic that gave them such a right would be viewed as intolerable by the public they serve and protect.

These arguments in support of a duty to treat, however, are not seamless. “Traditional professional values” require a tradition, and as Zuger and Miles 5 have observed, the historical record reveals a medical tradition that is equivocal and inconsistent. They note that Galen left Rome just as an epidemic of plague was approaching, although Nuland 6 suggests that politics and the fear of assassination may have had more to do with it, “since the disease seems already to have been well established by the time of Galen’s departure.” Zuger and Miles also correctly observed that Thomas Sydenham (“acclaimed as the ‘English Hippocrates’ ”7) left the city when the Great Plague hit London in 1665. On the other hand Browne 8 has written that Sydenham “soon returned,… at risk to his own life to give what help he could to those stricken by plague.” Although many physicians remained in Rome and London during the plague years and continued to treat patients despite the risk to themselves, Zuger and Miles 5 conclude that “traditional professional duties may not be ideal for defining the optimal relation of the medical profession to patients with [AIDS].”

In addition to the mixed historical record, “traditional professional values” may not be the best guide to action for other reasons. There are few obligations that are absolute, few duties that admit of no exception or qualification, including the duty to treat. As Fox 9 has observed, the physician’s “role requires a degree of altruism, [but] it does not and cannot require martyrdom.”

The line between altruism and martyrdom was explored by a working group at the University of Toronto Joint Centre for Bioethics that considered the duty to treat in the context of their city’s severe acute respiratory syndrome outbreak. They observed: “While health care professionals have a duty to care for the sick, this must be tempered by a duty to care for themselves in order to remain well enough to be able to carry out their duties. [T]he fireman would not knowingly jump into a burning inferno.”10 This did not answer the question of the duty to treat, of course, but merely brought the Toronto group to the next question: “[w]here to draw the line between role-related professional responsibilities and undue risk”—a question the “working group struggled with but did not resolve.”

Fox has suggested that the presence of an emergency patient in a physician’s practice (including an on-call physician’s hospital emergency room) creates a “meaningful connection between the patient and physician” and gives rise to a prima facie obligation to provide care. 9 This obligation gives way, however, in the presence of a “potential for physical harm to the physician disproportionate to the expected benefit to the patient.”

This seems plainly correct. Fox cites the example of a drunken, belligerent patient who comes to the emergency department for evaluation of a subcutaneous cyst. When the patient threatens to “knock all of your teeth out if you come near me,” the physician is justified in saying “come back for an evaluation when you’re sober and cooperative.” On the other hand Fox writes, “As the potential for harm to the patient increases, so too does the physician’s obligation. When a human life is at stake, the stakes become very high indeed, and the physician’s justification for refusing to provide treatment must be exceptionally compelling.” On this account of the problem, therefore, if there is a reasonably effective means of protection from infection, or a reasonably effective mode of treatment for infections that are not prevented or preventable, there can be no justification for refusing to treat a patient, even (or especially) a patient mistakenly thought to have smallpox, for which reasonably effective precautions and treatment are available. Indeed a responding physician would be obligated to accept even greater threats to his or her health as long as the potential benefits to the patient were proportional to those risks.

REFERENCES

1. AMA, Council on Ethical and Judicial Affairs. Code of medical ethics, Policy No. E-9.131 (“HIV-Infected Patients and Physicians”).
2. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. New York: Oxford University Press, 2001: 165.
3. Lo B. Resolving ethical dilemmas: a guide for clinicians. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 2000: 17.
4. Steinbock B, Arras JD, London AJ. Ethical issues in modern medicine. 6th ed. New York: McGraw-Hill, 2003: 12.
5. Zuger A, Miles SH. Physicians, AIDS, and occupational risk: historic traditions and ethical obligations. JAMA 1987; 258: 1324–8.
6. Nuland SB. Doctors: the biography of medicine. New York: Knopf, 1995: 42–3.
7. Porter R. The greatest benefit to mankind: a medical history of humanity New York: Norton, 1999: 229.
8. Browne S, Sydenhan the physician. Available at http://www.cmf.org.uk/index.htm?nucleus/nucjan96/sydenham.htm.
9. Fox E, The physician’s duty to treat in emergencies: accepting patients in transfer. J Clin Ethics 1994; 5: 43–5.
10. Ethics and SARS: learning lessons from the Toronto experience (rev. Aug. 13, 2003). Available at http://www.utoronto.ca/jcb/SARS_workingpaper.asp.
Keywords:

Professional values; duty to treat

© 2003 Lippincott Williams & Wilkins, Inc.