Abstract
Background
Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world.
Discussion
Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions.
Conclusion
Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.
Keywords
INTRODUCTION
“Death has climbed in through our windows and has entered our fortresses; it has removed the children from the streets and the young men from the public squares.” Jeremiah 9:21
Today's physicians have multiple sources of moral guidance, including medical codes of ethics, professional society and institutional ethics policies, and legal rules that impose duties. Students and trainees are taught medical ethics in undergraduate and graduate medical education. These sources of guidance identify moral goals of medical practice and professional responsibilities needed to accomplish those goals. Physicians accept a primary duty to provide medical care, which can also be understood as both an implicit and explicit contract with society (
1
). Implicit components, often described under the rubric of “professionalism,” arise from the moral nature of medical practice and physicians’ internalization of “values and ethical reasoning so they can develop an altruistic disposition toward patients and colleagues” (2
,3
). Explicit elements include statutes and administrative rules that define physicians’ social obligations and privileges.Pandemics have, since antiquity, posed distinctive moral challenges for physicians that have barely changed over time (
4
). Despite this long history, normative standards to guide pandemic care remain a matter of considerable debate. In this article, we address the following moral questions present during pandemics (Table 1):- •What should be the goals of physicians and health care systems when pandemics strike?
- •How should physicians prioritize patients for treatment when resources are scarce?
- •What role should emergency physicians play in implementing pandemic triage protocols?
- •How should physicians act in the face of considerable risks to themselves or their families?
Table 1Moral Questions in Pandemics
| What should be the goals of physicians and health care systems when pandemics strike? | Promote scientifically sound preventive and treatment measures and combat misinformation. |
| Minimize risks to health care workers and those providing care to the elderly and the disabled. | |
| Allocate scarce health care resources equitably. | |
| How should physicians prioritize patients for treatment when resources are scarce? | Prioritize patients using algorithm-based rules. |
| Develop and adopt equitable, ethically justifiable triage rules to allocate scarce resources and to prioritize patients, including disadvantaged populations. | |
| Legally shield physicians who must use crisis standards of care, i.e., prioritize resource use? | |
| What role should emergency physicians play in implementing pandemic triage protocols? | Provide initial assessment and treatment for ED patients. Alert triage officers to ED patients’ needs for scarce life-sustaining treatments. Make rapid decisions regarding emergency use of life-sustaining treatments for ED patients in extremis. |
| How should physicians act in the face of considerable risks to themselves or their families? | Balance real vs. imagined pandemic risks. |
| Stay and participate if the risks are reasonable. |
ED = emergency department.
Rather than focusing on a specific pandemic, we will propose a set of norms to guide physicians when they confront marginally controllable illnesses, including those yet to emerge (
5
, Science Museum. Bubonic plague: the first pandemic. Available at: www.sciencemuseum.org.uk/objects-and-stories/medicine/bubonic-plague-first-pandemic. Accessed August 13, 2022.
6
, 7
). Among the norms we will propose and defend are the following:- •When the demand for treatment or preventive measures outstrips available resources, established rules and procedures, rather than ad hoc, individual decisions, should determine allocation.
- •Resource allocation rules should be based on utilitarian principles of distributive justice, knowledge about which interventions will have the most beneficial consequences, and avoidance of discrimination against underserved or marginalized groups.
- •Crisis standards of care should incorporate agreed-upon triage algorithms and provide legal protection for physicians who adhere to them in good faith.
DISCUSSION
We propose that health care systems and individual physicians should pursue the following four goals during pandemics:
- (1)Maximizing patient benefits by providing the most effective preventive and treatment measures,
- (2)Allocating limited available health care resources equitably,
- (3)Delivering accurate information to health care professionals and the public, and
- (4)Minimizing risks to those who provide patient care and essential services.
This section will examine each of these four goals.
(1) Maximizing Patient Benefits by Providing the Most Effective Preventive and Treatment Measures
Providing care that benefits patients is arguably the fundamental goal of health care systems and individual physicians. That goal persists during pandemics; it motivates efforts to diagnose pandemic diseases and to develop and disseminate effective preventive and treatment measures for those diseases. It also mandates ongoing care for patients with the full spectrum of other illnesses and injuries that occur during a pandemic. The increased overall burden of disease during pandemics, however, may compromise or overwhelm the ability of local or national health care systems to provide the full range of care to all those in need. To address a surge of pandemic disease patients, health care systems may decide to postpone elective treatments and divert human and material resources to the areas of greatest need. If scarcity persists despite efforts to conserve the available resources, pandemic health care will require rationing, with attention to equitable allocation of those limited resources.
(2) Allocating Limited Available Health Care Resources Equitably
In severe pandemics, scarcity becomes the norm, with health care resources insufficient to meet all demands. Ventilators, intensive care unit beds, medications, vaccinations, or other scarce resources, therefore, cannot be equitably distributed based solely on individual patient needs. How, then, should scarce resources be allocated, and who should make those decisions? We contend that the goal should be to distribute available resources to maximize benefits for the overall population.
Under nonpandemic circumstances, physicians are often guided by what bioethicist Albert Jonsen termed the “Rule of Rescue,” the imperative to save an “identifiable” patient from imminent death or other substantial harm (
8
). During pandemics, expending all available resources on one or a few patients without considering the needs of others is ethically suspect, so the paradigm must shift. In contrast to the Rule of Rescue's focus on responding to individual needs, the moral theory of utilitarianism defended by philosophers Jeremy Bentham and John Stuart Mill holds that an action should be judged by whether it results in the greatest net benefit for all persons affected (9
,). Philippa Foot's “Trolley Problem” illustrates this approach, asking whether it is acceptable to flip a switch to change a runaway trolley's path so that it kills only one person instead of five (11
). The solution seems obvious to most people (unless they have significant additional information, as, for example, they know the single person who is at risk). In pandemics, this situation is analogous to removing long-term intensive treatment from one patient so that it can benefit multiple other patients. Such a decision should be based on an ethically defensible, societally accepted, and previously established allocation plan rather than as an ad hoc bedside decision for a particular patient (12
).Utilitarian algorithms
We contend that the morally preferred approach to this rationing problem is to develop and apply algorithms to allocate scarce resources to the patients who are most likely to benefit from those resources. Physicians should follow these algorithms rather than make individual bedside decisions. Using justifiable algorithms to make triage decisions can relieve physicians of the burden (and potential feelings of guilt) of making ad hoc decisions to deny treatments to their patients.
These resource allocation algorithms should be designed to maximize the benefits of resource use, including minimizing the number of avoidable deaths. Several examples of such algorithms have been created (
13
, 14
, 15
). Algorithm developers for a particular pandemic should use available knowledge about which interventions are most likely to provide the greatest overall benefit, considering factors that directly affect survival, such as disease severity and pre-existing conditions. These recommendations should be disease-specific and will undoubtedly change as physician-investigators acquire more knowledge about the pandemic disease.Public officials, as representatives of the societies they serve, should review and endorse triage algorithms drafted by expert medical, public health, ethical, and legal advisors. Input from societal stakeholders is vital to provide consistency among triage decisions and to prevent discrimination against disadvantaged or underserved groups. Publicizing pandemic triage plan details also helps to ensure consistent rationing decisions and avoid subjective, arbitrary decisions that individual physicians may make at the bedside due to their “inability to maintain … consistent standards of care (resulting from] … the desire to satisfy patients’ preferences” (
16
).Straying from an ethically established utilitarian model for triage and treatment algorithms is morally problematic for several reasons. First, it departs from the public health goal of using society's resources to achieve the greatest social benefit. Second, it fails to recognize that triage systems are not the most effective or appropriate mechanisms for redressing societal inequities. As Benjamin Tolchin argues, “while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities … [Rather,] entrenched health disparities must be addressed through broader social change” (
17
). Tabery and Mackett suggest that a sound way forward is to use a hybrid-model, with initial sorting based on medical utility and, to a lesser extent, on social utility. When there is insufficient prognostic information to determine which patient should receive a scarce resource, an egalitarian mechanism such as a lottery might be employed (18
).Prioritization
Moral philosophers have engaged in lively debate over the question of whether maximizing the number of lives saved should be the overriding moral consideration in the allocation of scarce medical resources (,
20
, , 22
, 23
). As Francis M. Kamm has noted, “in situations of dire scarcity, we cannot save the lives of all those who seek our assistance, and we know that saving some lives is unavoidably linked with allowing others to die” (). In this debate, we side with the position defended by Kamm and David Ozar that maximizing the number of lives saved is the morally preferable goal (,25
). As Ozar observes, failure to help some individuals may be necessary to get “the best realization of value” for all affected (patients) (25
).We contend that the appropriate focus for pandemic triage should be medical need and the likelihood to benefit from treatment. Nonmedical considerations, such as social status, wealth, race, or prior contributions to society, should not play a role in prioritization for scarce resources in a severe pandemic. Arguably, one exception might be to prioritize those whose work is vital to controlling the pandemic and those charged with maintaining social stability. Caring for these workers will enable them to resume providing essential social services, thus maximizing the overall social benefit of treatment. This includes, but is not limited to, frontline health care workers, lay caregivers for the elderly and disabled, essential government workers (e.g., firefighters, Emergency Medical Services personnel, and law enforcement officers), food producers and distributors, and public utility workers (e.g., power, water, sanitation, and vital communication). We have argued elsewhere that “during pandemics … emergency health care and public service workers [should be among those who] receive priority for treatment since they will, when they have recovered sufficiently (or in the case of vaccination or preventative medication, kept healthy) act as multipliers of beneficial effects for future patients” (
26
).The concept of medical futility as a criterion for denying access to treatment has been controversial for decades. Some professional organizations and health care institutions, and several states, have addressed futility in policy or statute (
27
, American College of Emergency Physicians (ACEP). Nonbeneficial ("futile") emergency medical interventions. Available at: www.acep.org/globalassets/new-pdfs/policy-statements/nonbeneficial-futile-emergency-medicine-interventions.pdf. Accessed August 13, 2022.
28
, 29
). Yet the controversy continues, and disease- or condition-specific futility guidelines are uncommon. Pandemic conditions of extreme scarcity, however, may require acknowledgement of medicine's limitations (Texas Health and Safety Code § 166.046. Procedure If Not Effectuating a Directive or Treatment Decision. Available at: https://codes.findlaw.com/tx/health-and-safety-code/health-safety-sect-166-046.html. Accessed August 13, 2022.
30
,31
). In circumstances of dire resource scarcity, pandemic treatment algorithms should recognize the likely futility of available treatments for some patients. Effective algorithms may limit or deny those treatments to patients least likely to benefit, instead providing only comfort care to them.When designing algorithms for treatment priority, special efforts should be taken to avoid insidious forms of discrimination (
18
). We support triage and allocation protocols that promote equity in distribution of resources so traditionally marginalized groups are not negatively affected by overt or implicit bias. These measures should not, however, provide resources to those less likely to survive than other patients (28
). During the COVID-19 pandemic, some states revised their triage protocols so as not to discriminate against disadvantaged persons, including using the narrow goal of maximizing survival to hospital discharge, although we believe the broader goal of long-term survival is more appropriate (32
, Department of Health and Human Services (HHS). OCR reaches early case resolution with Alabama after it removes discriminatory ventilator triaging guidelines. April 8, 2020. Available at: www.hhs.gov/about/news/2020/04/08/ocr-reaches-early-case-resolution-alabama-after-it-removes-discriminatory-ventilator-triaging.html. Accessed August 13, 2022.
33
, 34
, 35
, Bebinger M. After uproar, Mass. revises guidelines on who gets an ICU bed or ventilator amid COVID-19 Surge. April 22, 2020. Available at: www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus. Accessed August 13, 2022.
36
).Department of Health and Human Services (HHS). OCR resolves civil rights complaint against Pennsylvania after it revises its pandemic health care triaging policies to protect against disability discrimination. April 16, 2020. Available at: https://www.hhs.gov/guidance/document/ocr-resolves-civil-rights-complaint-against-pennsylvania-after-it-revises-its-pandemic. Accessed August 13, 2022.
A particularly controversial decision is the reallocation of potentially life-sustaining measures from one patient to another. An example is removing a ventilator, if in limited supply, from someone who is very likely (though not certain) to die and using it for another patient whose potential for survival is significantly higher. Many commentators support using triage systems (rather than first-come, first-served) for the initiation of potentially life-sustaining measures, and a lesser number assert that reallocation of life-sustaining measures from one person to another in times of resource scarcity is ethically justified, although this is controversial and has not been resolved by legislation or in the courts (
37
, 38
, 39
). We believe that effective triage criteria and evaluation procedures can be developed for both the initial allocation of scarce intensive care resources and determination that continuing intensive care will not be successful. If that can be done, both initial allocation decisions and reallocation decisions can justifiably serve the goal of maximizing the benefits provided by those resources.The American College of Emergency Physician's Code of Ethics for Emergency Physicians recognizes that emergency physicians have both unique expertise and a moral duty to respond to societal emergencies (
40
). The Code addresses the challenge of allocating scarce resources in disaster situations, and it explicitly endorses the use of utilitarian triage criteria in the following passage:In a situation where the resources of a health care facility are overwhelmed by epidemic illness, mass casualties, or the victims of a natural or manmade disaster, the prudent emergency physician must make important triage decisions to benefit the greatest number of potential survivors. When the numbers of patients and severity of their injuries overpower existing resources, triage decisions should classify patients according to both their need and their likelihood of survival. The overriding principle should be to focus health care resources on those patients most likely to benefit, who have a reasonable probability of survival. Those patients with fatal injuries and those with minor injuries should be made as comfortable as possible while they await further medical assistance and treatment (40).
Emergency physicians will assume multiple roles in the care of patients during pandemics. They will provide initial assessment and treatment for patients who present to the emergency department (ED) with pandemic disease and other life-threatening conditions. They will be responsible for alerting institutional triage officers of ED patients’ needs for scarce life-sustaining treatments, such as intensive care, mechanical ventilation, and extracorporeal membrane oxygenation. They will also need to make rapid decisions for and against emergency use of life-sustaining treatments to prolong the lives of ED patients in extremis, and enable those patients to be considered for continuing treatment under the institution's pandemic triage protocol. All these roles require that emergency physicians understand their institution's pandemic triage protocol and their responsibilities under that protocol. Emergency physicians’ expertise as triage officers will, moreover, make them valuable members of institutional pandemic triage planning teams.
(3) Delivering Accurate Information to Providers and the Public
As important as it is to practice optimal clinical medicine during pandemics, physicians also have a moral responsibility to promote sound public health measures and combat pandemic denial and misinformation. Physician–sociologist Nicholas Christakis notes that “denial and lies about what's happening [are themselves] almost an intrinsic part of an epidemic … everywhere you see the spread of germs for the last few thousand years, you see right behind it the spread of lies … partly … because the person on the street wants to deny what's happening. And partly, it's because our political leaders don't want to take it seriously either” (
41
). Scapegoating of minority populations also frequently occurs, as was seen in attacks on some of these communities during the severe acute respiratory syndrome 2–coronavirus disease (SARS 2-COVID) pandemic, the early human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic, and the 1918 influenza pandemics, among others (42
, Kanno-Youngs Z. Biden announces actions to combat anti-Asian attacks. The New York Times. March 31, 2021, p A15. Available at: www.nytimes.com/2021/03/30/us/politics/biden-anti-asian-violence.html. Accessed August 13, 2022.
43
, 44
). As professional healers and teachers with societally conferred roles and privileges, physicians have a duty to educate the populace and model optimal behavior during health crises ().During crises, accurately assessing risks requires identifying genuine threats and discounting those that are theoretical or imagined. Physicians may need to provide reassurance in settings with limited verifiable information, emotional volatility, and a plethora of rumors, speculation, assumptions, and inference. Without their calming influence, panic may drive people's actions. People may assume that their perception is accurate, although it has more to do with fear and lack of knowledge than with the actual probability and magnitude of risk (
46
). This defines “an unstable information environment” in which distorted perceptions may supplant reality, making ethical reasoning difficult (47
). Internet and social media sites that instantaneously and broadly spread lies or misinformation amplify these problems.Accurate and complete information is especially vital for frontline workers. In times of crisis, hospitals, health care systems, and societies have a duty to provide their workers with transparent communication about the current situation, measures being taken to maintain a safe working environment, and available personal protection (
48
). Using risk communication methods increases health care professionals’ willingness to participate in pandemic care (Table 2) (49
,50
).Table 2Elements of Effective Health Care Risk-Communication in Pandemics
|
|
|
|
|
(4) Minimizing Risks to Those Providing Patient Care and Essential Services
During pandemics, frontline medical personnel are among the groups at highest risk. Those who treat patients with virulent pandemic diseases before the causative agent is identified, or before preventive and treatment measures are available, are often viewed as heroes, that is, those “who attempt to save others from physical harm or death while knowingly putting their own lives at risk” (
51
). In health care settings, this group also includes environmental service workers, security guards, transporters, ward clerks and other team members. In return for their beneficent service to others, societies have a duty to provide these workers with effective methods to minimize their risks. Protective measures, which change as scientists acquire more information about the nature of a particular pathogen, include respiratory and barrier protections as well as prophylactic measures such as vaccines, antibiotics, antivirals, monoclonal antibodies, or other novel agents. Specific risk mitigation tools vary with the infectious agent. Failure to employ available protections signals that society does not value workers’ well-being and may spread the pandemic to other patients and workers’ families.Consistent with utilitarian principles, policymakers should decrease health care workers’ exposure by limiting high-risk, low-benefit, resource-intensive procedures. During a severe pandemic, this may include forgoing medical or traumatic cardiac resuscitation and intensive care for patients with multi-organ-system failure and other terminal conditions (
52
, 53
, 54
, - Nolan JP
- Berg RA
- Andersen LW
- et al.
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry template for in-hospital cardiac arrest: a consensus report from a task force of the International Liaison Committee on Resuscitation.
Circulation. 2019; 140 (e746–57)
55
). For example, during the COVID-19 pandemic, the American Heart Association issued interim guidance that limited basic and advanced life support, stating that prior to beginning a procedure, it is reasonable to consider the likelihood of success “against the risk to rescuers” (56
).- Edelson DP
- Sasson C
- Chan PS
- et al.
Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. from the emergency cardiovascular care committee and get with the guidelines-resuscitation adult and pediatric task forces of the American Heart Association.
Circulation. 2020; 141 (Available at:) (Accessed August 13, 2022): e933-e943
Medical educators and policymakers also should assess the activities of medical students and other trainees during pandemics. Although there is uncertainty about risk–benefit assessment in many situations, it is morally unacceptable to expose trainees to significant risk of harm unless the experience provides both significant education to trainees and present and future benefits to their patients that outweigh those risks.
Liability protections
`In addition to increased health risks, physicians may also face increased risk of liability in pandemic situations. Physicians are ordinarily required to adhere to the legal standard of care that defines what a reasonable and prudent practitioner would do in similar circumstances (
57
). Standards of care can change as available resources fluctuate, even in nonpandemic settings. There is no clearly established a priori standard of care during times of crisis. When the normal standard of care cannot be maintained, such as during a disaster when treatment needs exceed available resources, physicians must operate under a different standard. Crisis standards should be designed to direct scarce, resource-intensive treatments to those patients most likely to benefit from them and to provide supportive care to those less likely or unlikely to benefit (30
,31
,58
,American Medical Association. Crisis standards of care: guidance from the AMA Code of Medical Ethics. Available at: www.ama-assn.org/delivering-care/ethics/crisis-standards-care-guidance-ama-code-medical-ethics. Accessed August 13, 2022.
59
).Most U.S. states have recognized some form of crisis standards of care with at least limited civil immunity, though few have invoked those standards, and their ability to shield clinicians from liability is uncertain (
60
, 61
, 62
). When policymakers adopt rules under which physicians, health care institutions, and other clinicians can employ crisis standards of care, we maintain that they should also enact a legal liability shield for those who use them in good faith without conduct deemed “gross negligence” or “criminal negligence.” Providing this legal protection reinforces physicians’ ethical duties to provide care at the level that scarce resources allow (63
). These protections should end either at a predetermined time or at the termination of a declared emergency (Gostin LO Hanfling D Hanson SL Stroud C Altevogt BM Institute of Medicine (US) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. National Academies Press,
Washington, DC2009
63
).Gostin LO Hanfling D Hanson SL Stroud C Altevogt BM Institute of Medicine (US) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. National Academies Press,
Washington, DC2009
How Should Clinicians Act in the Face of Extraordinary Risks?
Throughout recorded history, some physicians have ignobly abandoned their patients in the face of widespread contagion (
64
). Epidemics in which physicians fled in the face of personal risk include the Antonine Plague of 165 to 180 AD, during which Galen and colleagues fled Rome; Black Plague episodes in Europe; a yellow fever epidemic in Philadelphia in 1793 (though notably, Benjamin Rush remained and treated patients); and the AIDS epidemic of the late 20th century, during which some physicians refused to treat HIV-infected patients (65
).Despite these notorious historical examples, the American Medical Association (AMA) promoted physician courage in its first Code of Medical Ethics in 1847, stating that “When pestilence prevails, it is the duty of physicians to face the danger, and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives.” The AMA now recommends that “physicians should balance immediate benefits to individual patients with [their] ability to care for patients in the future” (
66
). As this AMA statement suggests, there is wide contemporary agreement that physicians and other health care professionals should accept some risk in caring for patients. This is, however, a prima facie and not an absolute duty—that is, it may be overridden by stronger duties to protect oneself or one's family, or by other competing moral duties.Although physicians are generally expected to provide care in medical disaster and crisis situations, including pandemics, despite heightened danger to themselves, there is no consensus about the degree of risk they should accept (
67
). Identifying one's actual duty in specific circumstances depends on accurate risk assessment. It should not be based on irrational fear or a lack of knowledge about known risks. Physicians must therefore balance conflicting personal and professional moral responsibilities, basing decisions on their assessment of the consequences of those decisions for themselves and their families, patients, colleagues, and others (39
).When does personal risk and one's responsibility to self and family outweigh the professional duty to assist? A clinician's duty to respond may diminish as the level of personal risk increases and the anticipated benefit to patients decreases (
66
). Clinicians need not assume potentially lethal risks to care for patients, although, as seen in the West African Ebola epidemic (2014–2016), some have done that (39
,46
,49
,68
). Whereas some individual physicians perform actions that go far beyond the “call of duty” as delineated in ethical oaths and codes (i.e., supererogatory actions), such actions are neither ethically nor legally required.From a social perspective, some actions physicians take may be predicted by models based on decisional (game) theory. The Prisoner's Dilemma, a well-known example, explains why individuals or groups may act against their best interests despite the risk of worse outcomes. Eschewing ethical norms, some clinicians may shun their responsibilities or fail to adhere to social safety protocols. Others must then assume the extra work and additional risks these “shirkers” create. Referred to as the tragedy of the commons or the free-rider problem, this model posits that many individuals will pursue their own self-interest, the game-theory optimal behavior, rather than cooperating as a community (
50
). Increased knowledge alone has not been shown to decrease shirking behavior (69
). Ways to overcome this behavior include pointing out that an individual's social group will suffer from his or her selfish behavior and that many other people are not shirking, providing incentives, using persuasion, and appealing to altruism (70
,71
). When deciding what to do in a risk-prone situation, each of us will ultimately rely on our fundamental personal and professional ethical values (Table 3) (47
,72
).Table 3Physicians’ Professional Responsibilities and Expectations
| Assume risks comparable with those of similarly situated colleagues. |
| Assess the consequences of not helping. |
| Fulfill the professional duty to help those in need. |
| Contribute to community welfare. |
| Fulfill public expectations and trust. |
| Provide medical care using their societally underwritten special training and professional status. |
CONCLUSION
Physicians, together with other health care professionals, including health system leaders and public health officials, have a professional duty to prepare for and respond to future pandemics. When pandemics occur, we have argued that their ethical responsibilities include the following:
- •In situations of resource scarcity, after exhausting all avenues to obtain additional equipment and supplies, physicians should provide available preventative measures and treatments to those who are most likely to benefit from them, using a utilitarian principle of distributive justice. Patients retain the right to refuse treatment, though societies may mandate preventive measures, such as immunization, in some circumstances (73).
- •In advance of pandemics, institutional and public policymakers should adopt disaster planning criteria and rules that allocate resources to maximize overall benefit. Physicians should use these criteria for allocating treatments rather than making bedside decisions that may be arbitrary or discriminatory.
- •Emergency physicians should be familiar with their institution's pandemic triage protocol and be prepared to carry out their responsibilities under that protocol.
- •Policymakers should give extra consideration to those workers essential to maintain public welfare, including certain health care personnel.
- •Physicians should carefully assess and balance risks to their own and their family's health and welfare against the benefits they can provide to their current and future patients.
- •Risk assessment must be based on the best available information about both the pathogen and the at-risk population.
- •Policymakers and educators should protect health care trainees from significant risk unless their services provide benefits to patients that outweigh the personal risk.
- •Physicians should model optimal public health practices and stay up to date with scientific advances so that they can help educate their patients and the public.
- •Health care institutions should advocate for legislation that includes immunity from the potentially heightened liability risks of implementing crisis standards of care.
- •Physicians, institutions, and policymakers should transparently communicate all known information with health care workers and the public using standard risk-communication methods.
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Jacobson v. Massachusetts, 197 U.S. 11 (1905).
Article info
Publication history
Published online: February 28, 2023
Accepted:
February 17,
2023
Received in revised form:
January 14,
2023
Received:
August 30,
2022
Publication stage
In Press Uncorrected ProofIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
