Sunday, 18 April, 2004
How about that?

Via Alwin, I see that the New York Times Magazine investigated a subject near and dear to my heart -- the responsibility of health care providers in times of contagion:

For the past generation, few doctors and nurses in the Western world have worried much about their profession killing them. But with the appearance of AIDS and SARS, a new medical generation has begun to wrestle with old questions. When an unfamiliar and infectious disease stalks through your city, must you treat the affected patients? What are the consequences if you do? And if you don't?

This is, of course, the essential question that spawned last semester's research. The paper that grew out of that research is being re-worked, slightly, in preparation for shopping it around to various journals for consideration, so I can't print long excerpts from it, but here's a general extension of some of the issues touched on in the NYT article.

The earliest implied proscriptions against fleeing during epidemics were several documents within the Plague Tractates, a collection of some 300 documents written for and by medieval physicians as a guide for treating plague victims. Several of these documents reference a doctrine known as debent curare infirmos, the idea that medical professionals ought to cure for the sick and infirm, with the implicit tack-on statement "regardless of risk." This probably came as a reply to Galen's act of cowardice in 166 AD when he fled Rome for Pergamum rather than stick around town when bubonic plague hit the place. There was a general feeling that the prestige of medicine as a profession suffered thanks to conduct like Galen's, and the authors of the Tractates might have been trying to counterbalance some of that damage.

1666 saw apothecary William Boghurst write what I believe is the first explicit declaration of physician responsibility during epidemics:

Every man that undertakes to bee of a pression or takes upon him any office must take all parts of it, the good and the evill, the pleasure and the pain, the profit and the inconvenience altogether, and not pick and chuse; for ministers much preache, Captains must fight, Physitians must attend upon the Sick, etc.

I've been unable to locate an earlier declaration that was as clear in its statement of principles; Boghurst's comments were striking because they drew a sharp line between medicine and other professions, and because he argued that as a result of that difference, medical professionals cannot elect to shirk responsibilities they find unpleasant or inconvenient. In 1846, the American Medical Association published its first code of medical ethics; buried in a section entitled "The Duties of the Profession to the Public" was a clause that read, in part, "when pestilence prevails, it is [the duty of physicians] to face the danger and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives." This was the first time a medical society -- rather than independent professionals -- had ever said something along those lines, at least within the Anglo-American tradition. Some authors believe the strong prescription had more to do with establishing the prestige of medicine rather than actual ability, but no matter -- it was there, and it had become part of the ethical tradition.

And there it stayed, for some time. Diseases came and diseases went; Pax Antibiotica made us feel safe and think we had the bugs beat. In 1957, the AMA withdrew the clause I cited above -- the thinking being, I believe, that North American physicians would never face another widespread epidemic with the potential to kill them. (Bear in mind that during the era in which the AMA was drawing up its ethical code, the United States dealt frequently with outbreaks of yellow fever, which resulted in physicians alternatively staying at their posts or fleeing; as in medieval England, the deserters were not viewed kindly.)

You know what happens next: HIV reared its ugly head, and as with most things not well understood, myths and rumors spread. HIV became a lifestyle disease, with a stigma attached; where physicians might have been willing to accept the risks of hepatitis B infection (indeed, pre-HIV, hepatitis was the leading nosocomial infection among health care workers and it was rare to find surgical staff that didn't have significant occupational exposure), they suddenly wanted to withdraw services to HIV seropositive patients. Never mind that the actual risk was an order of magnitude lower -- the risks of seroconversion and dying were much higher with hepatitis B than with HIV (this is still true today, by the way), though HIV was and still is universally lethal. (Quick, name the only other infectious disease that matches HIV for lethality!)

There were, during the mid-to-late 1980s, a flurry of articles that talked about HIV and physician responsibilities towards HIV patients. A surprising number of them featured people trying to weasel out of having to deal with seropositive patients; Zuger and Miles (JAMA 1987;258:1924-1928) and Daniels (Hastings Center Report 1991:21(5):36-46) are probably the two best survey articles if you want to do some primary-sourcing. The debate was over quickly -- whether this was attributable to the high quality of the refutation articles or the exponential growth of understanding about HIV is unclear. But a statement about duty of care was put back into the AMA code of ethics, the dissenters shut up and went back to work, and we figured we had this problem licked. Again.

What happened? I think it's because the generation of physicians worrying about HIV in 1985 was the same generation that came of age under the doctrine of Pax Antibiotica. We were almost criminally naive in hindsight about how well that whole scheme would work, but the theory seemed reasonable at the time, and I can find no evidence that consideration of physician duty during epidemics was given much air time in the contemporary undergraduate teaching programs; a generation of physicians whose only fault was not considering this possibility had to be re-taught in the ethical ways of their profession. And, amazingly, it happened fast -- testament to medicine's ability to change when it needs to. (He said, trying to keep a straight face.)

The arguments in favor of saying no generally centered on the issue of consent: Has a physicians given previous consent to being exposed to potentially dangerous pathogens? "Of course she has," is the obvious answer -- physicians treat sick people, some sick people are contagious, and therefore physicians sometimes have to treat contagious people. This tautology is obvious to my dog but it ignores the fact that for all of human history the bugs have managed to figure out new ways to kill us. There are a couple of diseases we have now that weren't around when I started my medical career, and by the time I leave the profession I fully expect there to be several more; could I reasonable say "well, you know, I agreed to this HIV thing, but SARS? I dunno, man."

The argument doesn't work. Medical history is replete with the emergence of novel diseases, and if it is reasonable to expect that a new disease is might become prevalent and endanger a population (and, by extension, the phyisicans who serve it), it is ridiculous to argue that you could choose not to participate in the care of that population simply because the agent causing disease was unknown at the time you entered practice.

Resolving this conflict is interesting and carries some very peculiar problems of its own, but I won't get into it here. There is one other interesting problem facing us today that isn't addressed in the NYT article and that I haven't seen mentioned anywhere else: Medicine is a monopoly.

I don't mean in the sense that the Canadian health care system has a monopoly on patients in this country, though indeed it does. I mean that in the sense that allopathy is the One True Medicine in western societies. Other traditions -- notably osteopathy but chiropractic with some minor qualifications and naturopathy with some serious qualifications -- may present alternative routes to access health care resources, but by and large if you say you need to see a doctor, you're asking for an allopath; few alternatives exist. As a result, the socieities that have been established to support the operations of allopathy are medicine. And that means they have a nifty little responsibility.

As a monopoly, medicine must ensure that its services are always available; it may not, in other words, withdraw services if a suitable replacement is unavailable. (The BCMA's RAD tactics are OK under this doctrine because although the GPs closed their doors, we were still around to pick up the slack. Note this is also why I so intensely dislike the RAD tactics.) And if services are unavailable to a particular segment of society, there is a collective responsibility on the part of the members of the profession to provide the missing service.

(Here I am certain some of my libertarian bretheren will quibble with me. This is where you and I part company, o pals of mine; health care ethics often fly in the face of sacrosanct libertarian dogma. Frankly I want it that way, and so do you, even if you don't consciously realize it.)

As you might expect, this has profound implications for epidemics. If an outbreak of disease in a particular community has caused all the local physicians to flee in a most unethical fashion, the profession itself -- the collective assembly of physicians in whatever organization you would care to use -- continues to have an obligation to provide the community with assistance.Presumably there will be volunteers to go, but it isn't inconceivable to think of a situation so dire that volunteers will be in short supply. And here is where it gets very interesting: Under those conditions, it would be ethically permissible to force individual physicians to attend to patients within the hot zone, with or without appropriate gear, as long as the risk was not unduly born by one subgroup of physicians or another.

I've brushed over a lot of the background material here, and I've completely overlooked the pluarlistic deontological perspective of medical ethics from which I write (so if you don't understand pluralistic deontology, you're kind of screwed -- sorry). The take home message: This is an old problem within medicine itself and is a point of some considerable tension between personal responsibility and professional duty, and yet it is resolved in the majority of individual patient contacts in such a seemless fashion we barely even notice it is there.

How cool is that?

Epilogue: Two years later, still unpublished. Ah, me.