Should doctors risk their lives when responding to a disaster?

Should doctors risk their lives when responding to a disaster?

Doctors must balance their duties to individual patients with their duties to protect themselves, other patients, staff, colleagues and the wider public from harm.

On 5 March 2021, Amnesty International announced that at least 17,000 health care workers globally have died from COVID-19 over the last year, forcing doctors both in Australia and around the world to confront the very real question of whether they are willing (or should be expected) to put their own lives at risk to treat real or potential COVID-19 patients.

The AMA’s Position Statement on Ethical Considerations for Medical Practitioners in Disaster Response 2014, currently under review by the Ethics and Medico-Legal Committee (EMLC), briefly addresses doctors’ risk of personal harm when responding to a disaster.

The position statement affirms that doctors must balance their duties to individual patients with their duties to protect themselves, other patients, staff, colleagues and the wider public from harm, highlighting that during ‘ordinary’ clinical practice, these duties do not generally come into conflict, but during a disaster, tensions between these duties may very well eventuate.

The current pandemic has turned this potential eventuality into a stark reality for doctors in Australia and worldwide where doctors must weigh up their duty to treat individual patients infected with COVID-19 with their duty to ensure they do not develop COVID-19 themselves and become unable to work or risk infecting other patients, staff or those in the wider community.

In addition to the professional duty to reduce risk of personal harm, doctors also have their own personal duties and interests in not becoming infected and risking sickness or even death or spreading the virus to their own family members and friends.

So what level of risk of personal harm should doctors accept? While there is a general expectation within the community that doctors will accept a certain amount of personal risk when responding to a disaster, this risk is not unconditional or without reasonable limit. The current position statement says that doctors are entitled to protect themselves from harm and should not be expected to exceed the bounds of ‘reasonable’ personal risk.

But the global pandemic has made it clear that ‘reasonable’ risk is highly subjective, and the level of risk that governments, employers, patients and their family members and others expect doctors to accept when responding to a disaster may not be ‘reasonable’ to the medical profession or to individual doctors or their loved ones.

Globally, professional regulators and associations set varying standards regarding the expectations of doctors in relation to risk of personal harm when responding to disasters.

For example, the Medical Board’s Good Medical Practice states that:

Treating patients in emergencies requires doctors to consider a range of issues, in addition to the patient’s best care. Good medical practice involves offering assistance in an emergency that takes account of your own safety, your skills, the availability of other options and the impact on any other patients under your care; and continuing to provide that assistance until your services are no longer required.

The UK’s General Medical Council is more explicit in their own Good Medical Practice, stating that:

58 You must not deny treatment to patients because their medical condition may put you at risk. If a patient poses a risk to your?health or safety, you should take all available steps to minimise the risk before providing treatment or making other suitable alternative arrangements for providing treatment.

While the American Medical Association’s Code of Medical Ethics, Opinion 8.3 Physicians’ Responsibilities in Disaster Response & Preparedness, advises that:

Whether at the national, regional, or local level, responses to disasters require extensive involvement from physicians individually and collectively. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This obligation holds even in the face of greater than usual risks to physicians’ own safety, health, or life. However, the physician workforce is not an unlimited resource. Therefore, when providing care in a disaster with its inherent dangers, physicians also have an obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future.

While the expected standard of doctors’ risk of personal harm may be addressed differently in these examples, at least they are all consistent that what is unreasonable is for doctors to be placed at risk of significant harm because of inadequate or inappropriate safety and protection, and advocacy to improve that protection is an important duty for medical professionals and those who control any aspect of workplace safety. Doctors with apparently less agency or power, such as doctors-in-training or those in temporary employment, must be protected from any implied or overt obligation to practice in conditions that are not as safe as it is reasonably practicable for them to be.

Employers, managers and workplace safety regulators have a duty to ensure that corners are not cut, and peer group or management pressure is not acting to decrease safety for any doctor.

Doctors’ willingness to risk significant personal harm when treating patients in disasters has also experienced a temporal shift. Where doctors once entered the profession seemingly willing to sacrifice their own lives to care for patients, as exemplified in the American Medical Association’s Code of Medical Ethics in 1847, which directed:

and when pestilence prevails, it is their duty to face the danger, and to continue their labours for the alleviation of the suffering, even at the jeopardy of their own lives.

Many of today’s doctors are not so willing to lay their lives on the line and will need to consider their own personal morals and values when deciding how much risk is reasonable to them.

As the EMLC examines this issue during our policy review, we will identify a range of factors that doctors should consider when determining what constitutes a reasonable risk of personal harm and what they can do to mitigate their personal risk. While it is not unreasonable for doctors to accept a certain amount of personal risk when responding to disasters, that risk is not unconditional, and we will continue to advocate that governments and the wider community have an obligation to protect doctors and reciprocate and support doctors (and their family members) who suffer harm when caring for patients.

About the author

Dr Andrew J Miller is the Chair of Federal AMA Ethics and Medico-legal Committee and Immediate Past-President of AMA WA.