Do doctors have an uncircumscribed duty to serve?

If doctors have a duty to provide care then what about the value of reciprocity: does society not have a duty to support those who assume the burden to buttress the public good?

During the lockdown I come across a number of stories in the press that are in some way related. A woman in Bengal was refused admission into a government hospital and eventually gave birth in an autorickshaw. A medical student at Delhi’s Kasturba hospital tested positive for Covid-19 and was put in home quarantine. Closer home to me a doctor in Gandhinagar’s GMERS Medical College tested positive despite adhering to necessary precautions. And doctors in the Civil Hospital in Ahmedabad serving at the Gujarat Cancer Research Institute could not find beds to be quarantined for 29 hours after being tested positive for Covid-19.

Doctors we assume have a duty to treat and provide care. Yet there are stories of health workers who adhered to their professional responsibilities and cared for patients but later encountered social ostracism because others in the community feared that they and their families were potential sources of contagion. If doctors have a duty to provide care then what about the value of reciprocity: does society not have a duty to support those who assume the burden to buttress the public good?

But first, is the duty of a doctor without bound? Does she not have the freedom to remove herself from the possibility of treatment when the risk is high and the infrastructure of public health facilities is so limited that it is unable to protect care givers and not just the public from susceptibility to infection from the virus? We would normally think of applying a principle of proportionality, i.e., that individuals have the liberty to desist from providing services they normally do when it exposes them to risk and when they cannot adequately protect themselves from a threat to their well-being. In this case it begs the question as to whether an individual should be allowed to remove herself from the situation as that may cause a shortage of care givers and result in an increase in the risks borne by society.

Again, a care giver may consider that ventilators and isolation beds are in short supply leading to overcrowding in hospitals and is witnessing large numbers of sick patients who are overwhelming the availability of resources. In such a situation a care giver is entitled one would suppose to think that medical care being provided is not optimal and the possibility of things going wrong is enhanced. Then undertreatment or even an inability to treat may be construed by patients and their relatives as negligence for which the doctor would be held liable even though it is not within the doctor’s control. This would decrease the motivation of doctors to willingly be of service and indeed does the state or the profession have an overriding right to demand service when the correlative facilities are insufficient? Does a doctor not have the freedom to decide that the burden of negligence is unacceptable and it is better that she withdraw rather than be complicit in not taking adequate care of the needs of a patient?

There is plenty of evidence of the shortage of protective resources. Decontamination facilities at hospitals have a limited ability to handle a large increase in the inflow of patients. Personal Protective Equipment if available in sufficient supply, and even here there have been stories abounding of inadequacy, can be effective if training is provided as to how to work while outfitted in them. It is not often realized as doctors have pointed out how confining such protective equipment is and how factors such as the environmental temperature and the duration of use leads to slippages in safety. Even the reliability of N95 respirators is in question as their design works to filter out 95 per cent of viruses and other very small particles. With coronavirus which is an airborne organism that is usually carried on respiratory droplets and transmissible via wind currents for distances of probably two metres, in addition to N95 masks, it would probably require airborne infection isolation rooms to improve safety. These are not available and we do not know if such isolation rooms are existent in most hospitals.

Rather than address the problem of inadequate protective means the shortcut is taken to rely on the ethical responsibility of the profession to render services in times of public crises. But surely doctors and nurses also have a duty to protect their own health and the health of their staff as well as families. Professional codes of conduct and social dialogue is silent about the issue of obligations when in situations of personal risk. Instead we appeal to their sense of self sacrifice and heroism and sometimes indicate that it is what is necessitated because they chose a profession that requires them to put self-interest on hold.

That begs the question as to how much should one put self-interest on hold. Do medical care givers and doctors not have dependents and are their interests and that of their family members not important when they are coerced into being available during a public health crisis? What if they have elderly parents or young children at home who are in need of care themselves? Forcing a person who has such a family situation to work and possibly be quarantined herself for a duration of time and to put her life at risk could very well make her value her self-interest and duty to her family at home above her professional obligations. Would we as a society have high regard for someone who abandons her parent at home in order to cater to some professional duty? That seems inappropriate.

It appears that it is insufficient to appeal to virtuous and altruistic behavior by health care providers. It requires the state and the community to somehow assure such persons that their loved ones will be cared for if they were to be required to step out in extraordinary times and be available for work that only they are trained to provide. In that circumstance expecting an ethic of having a duty to serve would be credible. As a matter of policy then we have a duty to do much more than we currently do. We have obligations to fulfil for medical care givers ― that we will care for them adequately if they contract the infection they may imbibe in the process of serving those infected, that we will provide adequate protective equipment to prevent the spread of the infection to them and their families, that we will support their families when they are on the frontlines of the battle against the disease, and that they will not be unduly held for possible negligence as they go about their duty to treat. Then maybe I will not read the stories that I have been reading about treatments being meted out to patients who want to check in at hospitals and are being denied for fear of negligence or of health care workers who are not themselves being provided adequate care.

(Dr. Errol D'Souza is a Professor of Economics and the Director at the Indian Institute of Management Ahmedabad. Dr. D'Souza is on the board of several organsiations, among them the Rajasthan Shram Sarathi Association, Udaipur) (Through Foundation of The Billion Press) (e-mail: editor@thebillionpress.org)