Blog 10 | HEaL Institute & IJME Covid-19 Insights | May 30, 2020
Doctor’s duty to care and shortage of personal protective equipment: the ethical debate | Sanjai Subha
Amid this global crisis of Covid-19, I had a wonderful opportunity to watch an interesting web-debate on the motion “Do doctors have a duty to care during the Covid 19 19 pandemic despite shortage of personal protective equipment?” organized by the Debate Society and the Institutional Ethics Committee of the ESIC Medical College and PGIMSR, KK Nagar, Chennai on 22nd May 2020. I would like to make a note that I am not working in a hospital where Covid-19 patients are being taken care of, and the following are some of my reflections as an observer of the debate and also as a doctor in a Non-Covid-19 treatment hospital.
India, with a huge population of 1.30 billion, a poorly organised public health system, poor budgetary allocation for health and an economy at the verge of collapse, is currently in the top ten of the worst hit countries in the world. Shortage of PPE is one among the large number of resource crunches that India is facing during this time.
Debating points based on research
Both the teams, who argued for and against the motion, had done thorough research. The ones who argued for the motion spoke on the idea of duty to care and how it is the most important ethical consideration. The ones who argued against emphasised that the safety of the health care professionals was the bedrock of an efficient and effective health system response to the pandemic. I am presenting some of the points that emerged in the debate from my point of view (with my own biases embedded).
- The invincible ‘social contract’:
The proponent team argued that when we chose the medical profession, we have willingly entered an unbreakable social contract that assures the society of good quality care during all times, including during times of emergency. It is in return for this ‘social contract’ that the doctor gets subsidised education, based on society’s tax money, and also receives an exalted status in the society. This social contract stands even during pandemic times, even when PPE is short.
- Reciprocal responsibilities of the society:
The opponent team countered the previous argument by highlighting the importance of service provider’s safety. A government or a society has reciprocal responsibility in protecting front line workers, especially during emergencies. They argued that the social contract has this reciprocal responsibility embedded in it.
- The inherent knowledge asymmetry
The proponents argued that the sheer advantage of knowledge about the human body and diseases makes health care professionals morally obliged to use it for the greater good of the society.
- Not using PPE is reckless disregard to safety of other not just the self
The opponents pointed out that a reckless act of not wearing a PPE makes the doctor vulnerable and puts her family as well as other patients at risk of contracting the virus, particularly if she is asymptomatic. In addition, it overburdens her co-workers in the system and compromises their efficacy. The opponent team argued that not using PPE can thus be seen as a reckless disregard for the safety of the society.
A health care provider, who believes that she might be immune, or superhuman, without proper PPE, may harm herself, her near and dear, and spread the disease to everyone. On the other hand, someone who thinks of her safety over others may deny or delay their duty, which could harm patients. Whether a health professional is the former or the latter seems to be largely an individual trait shaped by their value systems.
My experience on inadequate PPE
In the context of this debate, I must mention the following incident that happened in my hospital a week ago. As I said earlier, our hospital is not taking care of Covid-19 patients. Therefore, our primary responsibility is to provide uninterrupted care to patients with other conditions even during the lockdown. We have a triage area for fever, and the goal of this area is to assess patients with fever and refer them to the nearby Covid-19 treatment hospital. Mr. X was brought to our casualty ward with a sudden offset of symptoms of difficulty in breathing, and his blood oxygen saturation was way too low, in the range of 30-40%. The normal blood oxygen saturation is 100% and anything less than 95% is a reason for concern. He was too breathless to give a proper history, and his attender, a neighbor, was also unable to give us details. We did a basic examination that did not reveal much. His air hunger was so severe that we decided to intubate him. For this purpose, we called up our anesthetist for intubation, and since we do not have an Intensive Care Unit, Mr. X was referred to the tertiary care center with the tube in place. I was helping my friend, who was overseeing casualty ward on that day. The dramatic presentation triggered the fear of Covid-19 among all the healthcare workers on that day. I cannot forget the fear on everyone’s face that I observed that day. The consequence of this fear is that making a lifesaving intervention like intubation gets delayed. In an emergency, time is all that matters. Availability of full PPE could substantially reduce the fear and improve the efficiency.
No clear decision
Based on my casualty ward experience and my contemplations on the debate proceedings, I have come to an understanding that there are two poles in this debate. There are individuals who place larger societal interest above their own self-interest. For them altruism is an important value. However, such individuals could suffer from a ‘hero complex’ without realising the fallibility of medicine. Their over-rated sense of duty and heroism could lead them to perform reckless acts with disregard for the larger safety of the system. Other individuals believe that their own safety and welfare is the basis on which larger social good is built. They believe that the all-important social responsibility begins at home and with the self. They believe that a healthy and well protected health care provider translates into an efficient health system and good quality service during the pandemic times. These value systems are shaped by our society, religion, culture, education, and environment. These value systems are the foundations of our thoughts, beliefs, decisions, and actions. Healthcare providers carry with them these same value systems and it is unreasonable to believe that they may be value-neutral in their actions. At the close of the debate there was no clear judgment regarding this issue. The judging panel themselves were split in the middle between the proponent team who spoke of support of duty to care and the opponent team who spoke in support of personal protection.
Continuing the conversation…
When the debate session ended, I was left with further questions:
- Do health care professionals have the right to individual autonomy and to uphold their value systems even if they are strongly divergent from societal expectations?
- Does altruism have a role in medical professionalism? Does performing duties during pandemics count as altruistic acts?
Finding an ideal solution for all the above questions is probably not possible. And as a wise man once said to me, there are no middle grounds, only polarizing ends. At the same time, we cannot force someone to leave behind their values at the doorstep, and work like a machine. In the end, having conversations or questions about these issues is what matters. If we are lucky, we might find a solution. The importance of these conversations is not about finding solutions but in exposing ourselves to vulnerabilities, identifying our weakness, and addressing them.
Blog editor: Supriya Subramani