Detsky is a general internist and Professor of Health Policy Management and Evaluation, and Medicine at the University of Toronto. A member of the Order of Canada, he was Physician In Chief at Mount Sinai Hospital in Toronto during the SARS outbreak of 2003.
The risks physicians, nurses and other health care workers face, by reusing masks and gowns, resemble the risks soldiers faced over 15 years ago when patrolling Iraq in unarmored vehicles. A shortage of personal protective equipment (PPE) is one of the defining characteristics of the COVID-19 pandemic, a crisis many compare to a war.
However, an ethical danger exists in the overly simplistic language comparing our fight against COVID-19 to a war, and equating doctors and nurses with soldiers.
Unlike soldiers, who enlist with the very specific obligation to lay down their lives when so ordered, medical professionals are under a different set of ethical obligations. They are required to provide emergency care to any patient in a hospital but are not required to work in hospitals that cannot adequately mitigate risks to their own lives. How much risk are they obliged to take on? This question is currently front and center in the COVID-19 response.
In 2003, the SARS outbreak in Toronto started when an infected woman returned from Hong Kong and transmitted the virus to her son. She died at home, but he went to a hospital where the staff had no idea he required strict isolation. SARS, which had a 10% mortality rate, was mostly a nosocomial infection, one primarily transmitted inside health care facilities as opposed to within communities. This fact gave rise to a renewed conversation about the ethical responsibility of health care workers to put their lives on the line. Were they required to keep their offices open when their patients could infect them, their staff and other patients? Were hospital-based physicians and nurses required to show up to work in the same hospitals where most of the spread of SARS occurred? Throughout history, health care personnel have been vulnerable to the infectious agents that afflict their patients. During the start of the HIV epidemic, there was debate about whether health care professionals could refuse to care for people who were suspected of having HIV.
In the aftermath of SARS, much was written about whether physicians and other health care workers were obligated to place themselves at risk of infection. The bottom line was they were not. An extensive 2008 paper published in the American Journal of Bioethics, after reviewing the arguments, concluded that none of these “provides a convincing basis for asserting that health care workers (or even health care professionals) have a duty to treat” during events like a pandemic.
The health care professionals currently fighting COVID-19 are, in many cases, doing so outside the scope of their normal duties. Doctors and nurses have traveled to hot spots as volunteer replacements, while others who are not emergency or ICU doctors are working in those settings. These health care professionals are running toward a fight that has all the intensity of a war. And they’re doing so with all the attendant heroism. In the years ahead, as our society will surely implement initiatives like the September 11th Victim Compensation Fund for COVID-19 responders, the balance of what they were obliged to do vs. what they volunteered to do will have ramifications for disability support. Presenting those responders as soldiers does them a disservice. It whitewashes the elective nature of their sacrifice and, potentially, normalizes their deaths as the inevitable consequence of any war.
Like all wars, COVID-19 will eventually end. The physicians, nurses and others employed in hospitals will return home. For some, that will mean being reunited with the families they’ve had to remain distant from; for others, it will mean a return to practicing medicine outside of a crisis. For all, it will mean a reckoning with the psychological costs of this pandemic. If our society can’t provide health care workers with adequate protective equipment, we can at least provide their experience with its own framework and not simply analogize it to being a soldier in a war. So let’s not diminish what they’ve done for us by assuming they had to do it. That would inflict a final wound, one familiar to any soldier: the moral injury of attempting to reintegrate into a society that doesn’t understand what it’s asked of you.
Ackerman, who served as a Marine, is the author of the forthcoming novel Red Dress in Black and White; Detsky was the physician in chief at Mount Sinai Hospital in Toronto during the 2003 SARS outbreak
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