Bioethics Forum Essay
Clinicians Have a Moral Duty to Care for All Patients–Including Lockdown Protesters
As the coronavirus pandemic continues to rage across the United States and around the globe, there has been significant pushback against restrictions. Protesters questioning the ongoing need for strict measures are marching in various capitals to make their concerns known. Some of these protests have used intimidating shows of strength, with arms and other military paraphernalia.
In response to the brewing frustration over restrictions, four ethicists–Dominic Sisti, Moti Gorin, Emily Largent, and Arthur Caplan–published an opinion piece in PennLive in which they assert, “Individuals who get Covid-19 while protesting the very public health measures necessary to stop its spread should not get a ventilator before those who have been playing by the rules . . . . Protesters who violate basic safety measures should, at a minimum, sign a pledge expressing their willingness to forgo scarce care in the name of their political ideals.” Had this piece been written in a satirical tone, it would have effectively thrown into relief the absurdity of the protesters’ logic with the equal absurdity of the authors’ proposed solution. But this was no Borowitzian humor piece. These ethicists were serious.
Our first objection is the authors’ failure to recognize health care as a universal human right. Human rights are entitlements due to every human being, regardless of race, gender, political affiliation, religion, or any other status. Every person deserves to have these rights protected from abrogation by other individuals and their governments. Though the United States has not become a signatory to the United Nations Human Rights conventions, there have been policies that reinforce universal access to medical care, though not as robustly as these authors have pushed for in the past. These ethicists have fervently argued for the rights to health care for a variety of patients–including the very old and patients with terminal illnesses, disabilities, and other effects of the social determinants of health. They have advocated for the development of algorithms and policies to try to prevent bias and discrimination in the treatment of patients. Laws like EMTALA ensure that emergency care and stabilization are always provided to any individual at any hospital that accepts federal aid. This has become a de facto “health insurance policy” for the uninsured and poor, ensuring that their health care rights are covered. If individuals do have a right to health care without discrimination or bias, they cannot be required to surrender that right simply because they have made use of their right to free speech.
Secondly, we believe it would be a dereliction of our duty as physicians to inquire into the beliefs or political affiliation of our patients, as this has no bearing on the medical care that we should provide. Expectations of physicians as professionals have been codified for millennia, at least since the Hippocratic Oath and down through hundreds of years of service in which the sick and suffering have looked to physicians for respect, attentive care, and treatment with dignity. We are expected to demonstrate a commitment to the virtues of fidelity and benevolence because “a covenant of trust, a special kind of promise to serve those who require [our] expertise,” as Edmund Pellegrino described, is intrinsic to the sound, ethical practice of our profession. Our professional and moral duty as physicians cannot be predicated upon our perceptions of the moral opinions and actions of our patients. Such weaponization of health care in the name of outrage goes against every obligation of ethics and professionalism we pledge to uphold as clinicians. It is, frankly, extortion, a form of violence in the service of our own affective discomfort and not of those we have taken an oath to serve.
The opinion piece by Sisti, Gorin, Largent, and Caplan opens with an appeal to that affective discomfort: “How will you feel when you find out that the hospital’s ventilators are being used by [protesters],” they ask, rather than allocated to our loved ones who have followed the rules? The answer for many of us is that we would rightfully feel angry, frustrated, and unjustly deprived. Yet feelings, however powerful and justified, are irrelevant here. Of course the protesters’ behavior is “dangerous to everyone.” Of course, it makes us want to throw up our hands in near despair. But neither how we feel nor how protesters feel should figure in the calculus of who should receive medical care. Like free speech, medical care is a right that belongs to all human beings regardless of their convictions.
One has to wonder why these ethicists have deemed a punitive response to their disagreement with people to be acceptable or even worthy of consideration. We appear to live in a culture in which meeting dissent with violence has become normalized, acceptable, and for some, even admirable. In some cases, even those who would reject strongman politics and polarization now regard distasteful opinions as defining their holders as unworthy of basic human care. We cannot perpetuate such an ethical downward spiral, least of all in medicine, which, as a profession in which the clinical and moral are often juxtaposed, must not be seduced by the gloating but spurious satisfaction of self-righteousness. When human lives are at stake, we cannot be punishing protesters for their stances, however odious or misguided, or implying that they should be punishing themselves. We can acknowledge our opinion that the protesters are being irresponsible and that they are needlessly putting their own and other people’s lives at risk; but political alignment, religion, or other beliefs should never tarnish the standards we hold for our own actions.
In our experiences in various environments in medical care, we have provided long-term care to alcoholics who have directly caused their own liver failure; emergency care to patients with poorly controlled diabetes who presented in shock from diabetic ketoacidosis; extensive trauma care to Taliban terrorists who were hurt by their own roadside bomb that exploded prematurely and were brought in by American soldiers; and multiple levels of care to individuals who have previously declined it, for instance by rejecting cancer treatment, needed surgery, blood transfusions, vaccination, or other preventative care. It is critical that everyone see our frontline health care workers always reaching out and ready to care for whoever walks in the door, with whatever problem they may have. In the throes of the most stressful global disease this generation of medical providers has ever seen, it would be easy to give in to despair and anger; but we fail to live up to the highest expectations for health care workers when we give in to wrath instead of showing mercy. Now, more than ever, our moral obligation is clear: as ethicists and clinicians, we must respond with reason and compassion rather than vindictiveness and spite.
Our response to crisis defines who we are. Many around the world have understood that pandemics require sacrifice for the collective good, and the sacrifices have not been small: physical proximity and human touch, togetherness with loved ones, livelihoods, meaningful events, the sight of each other’s faces. But we cannot sacrifice our morality and professionalism for the sake of our feelings. We cannot jettison our commitment to serve because the people we have promised to serve have disagreed with us, or have maligned, betrayed, or endangered us. The pandemic is not over; if and when this catastrophe is behind us, another will follow. Sisti, Gorin, Largent, and Caplan ask us to consider how we would feel as we face the cruelties of such crises. How would we feel, indeed, if we have chosen punitive backlash over service and care? We prefer to look ahead in a spirit of hope and unity rather than cynicism and division, to a future in which we can say we have behaved with grace and honor, set our anger aside, and fulfilled our moral obligations to provide the best care for our human family, regardless of how they came to us. We choose a future in which we as physicians can be counted on as caregivers unswervingly committed to protecting the health, safety, and dignity of every human being, without exception.
Isabel C. Legarda, MD, MBE, is part-time faculty in the department of anesthesia, critical care, and pain medicine at Massachusetts General Hospital. Samara Peters, DO, is a pediatric hospitalist and U.S. Army veteran and an MBE candidate at Harvard Medical School.
[Editor’s note: A response to this essay from Dominic Sisti, Moti Gorin, Emily Largent, and Arthur Caplan appears in the comments.]
Isabel Legarda and Samara Peters have written a passionate response to our PennLive essay. Yet, what has drawn their passion—indeed their ire—is a triage policy that we never proposed. The views they attribute to us are not only incorrect, they represent ugly mischaracterizations.
We did not argue that hospitals should refuse to treat people on the basis of their political views, nor have we argued that protestors should be punished for their behavior by losing their access to health care.
What we did argue is that lockdown protesters are behaving as free riders who simply assume they will be able to benefit from the same health care system they are actively undermining, a system that may not have sufficient resources to provide care both for them and for the majority of people who sacrifice their liberty for the benefit of all by adhering to public safety measures. We contend protesters should understand the foreseeable consequences of their actions—to wit, that there may not be enough resources to go around—and that they should pledge to voluntarily forgo medical care in the event that they get COVID-19 and critical care resources are scarce.
The claim that lockdown protesters should decline critical care is completely different from the claim that Drs. Legarda and Peters wrongly attribute to us, namely, that doctors should refuse to treat protesters. Drs. Legarda and Peters have provided objections to the latter claim, objections with which the four of us are in fact sympathetic.
It is regrettable that Drs. Legarda and Peters directed their essay against a straw man.
-Dominic Sisti, Arthur Caplan, Moti Gorin, and Emily Largent
While I myself continue to quarantine and relentlessly ridicule the irrationality of quarantine protester rhetoric, after coming across the two respective pieces in question here I can’t help but quell this strong desire to navigate the equally shocking and disappointing misunderstanding that seems to have somehow eluded us.
I say “us”, but I confess I’m being quite generous. Without any better explanation, I have to surmise that Sisti et al. seems to misunderstand their own ethical proposal, extrapolating that misunderstanding to the response by Drs. Legarda and Peters, then crash landing in the comments sections of the response in comical fashion. Here’s why:
-Sisti et al. wrote a piece structured as such:
1. Introduction establishing context and emotional appeal for thesis
3. Minimum proposed solution to satisfy thesis proposal
4. Additional context explaining the error of quarantine protesters
Their thesis was quoted in the piece above, but for consolidation’s sake is, “Individuals who get COVID-19 while protesting the very public health measures necessary to stop its spread should not get a ventilator before those who have been playing by the rules”. The rest of the original essay focuses on why protestors should forgo medical care, a practical stipulation of their initial proposal.
But hold on, if we look at their comment, Sisti and crew claim, “We did not argue that hospitals should refuse to treat people on the basis of their political views, nor have we argued that protestors should be punished for their behavior by losing their access to health care.” Instead, their claim is “that they should pledge to voluntarily forgo medical care in the event that they get COVID-19 and critical care resources are scarce.”
The problem is, you’re changing your argument now. Originally, that was simply what protesters should do “at a minimum”. At a minimum to do what? At a minimum to satisfy the overarching principle of your original piece, found in your thesis. I feel the urge now to requote the thesis a second time in this comment to prevent you from missing it the way you did in Dr. Legarda and Dr. Peters’s response, as that itself is the misunderstanding on full display. Their response was to the initial principle you set forth, and then seemingly forgot about, that “Individuals who get COVID-19 while protesting the very public health measures necessary to stop its spread should not get a ventilator before those who have been playing by the rules”. See? I couldn’t help myself. Let’s break that down.
You propose the argument that one classification of people deserves preferential treatment over another. This is categorically unethical and is the focus of the response that you believe is directed at a strawman. Not much breaking down to do.
You then said, “The claim that lockdown protesters should decline critical care is completely different from the claim that Drs. Largarda and Peters wrongly attribute to us, namely, that doctors should refuse to treat protesters”. If you believe, as shown in your thesis (which I will show restraint by not quoting a third time), protesters should not get a ventilator before “those who have been playing by the rules” (damnit!), who exactly did you think would be making that call? Again, you elaborated that it should be the protesters who forgo care, but that was “at a minimum”. At a maximum, I can only assume you believe hospitals should refuse to treat protestors before non-protestors. Even if that is not what you believe, your stipulation is built on a false premise. No category of people should receive preferential treatment, provided the category is not based on a medical condition. This is what Drs. Legarda and Peters tried to explain to you by bringing up anecdotes of “extensive trauma care to Taliban terrorists who were hurt by their own roadside bomb that exploded prematurely and were brought in by American soldiers”.
I have no idea how this misunderstanding happened. Perhaps through some method involving ghostwriting or oration (corroborated by your repeated misspelling of one of the author’s names) you were more disconnected from your paper than you realized, causing you to forget or not fully appreciate the rhetoric you put down. Either way, it is regrettable that your claims are not supported by the basic principles of medical ethics.
I totally agree that these protestors should waive their access to health care. Although we would like say that healthcare is a right, it is not in America. Every effort to move in that direction is thwarted by the political right wing. To say that these protestors have a right to be treated is, in my opinion, incorrect. It is the healthcare workers who have the right to be protected and not exposed to this contagious disease, potentially be infected, and perhaps die because these individuals do not want to wear a mask or social distance. The public’s health surpasses choice. Behavior that puts others at risk cannot be tolerated nor explained as a right.
Perhaps Sisti et al were using hyperbolic language and did not intend to suggest that doctors should refuse to treat protesters.
However they did write: “Individuals who get COVID-19 while protesting the very public health measures necessary to stop its spread should not get a ventilator before those who have been playing by the rules.” It’s hard to interpret that sentence in a way which squares with human rights or the Hippocratic Oath.
I am delighted to learn that their true position is more compassionate.
I also agree that protestors should forfeit their right to healthcare. I am a front line health care worker, intubating and caring for Covid Positive Patients. This illness has a high moribidty and mortality rate. Public Health has recommended use of social distancing to minimize transmission. Out of respect to each other as human beings, we have been told the spread of Covid 19 can be markedly reduced by simply wearing a mask. The purpose of wearing a mask, is not to protect the individual wearing it. but to protect others, since I could be an asymptomatic carrier. If I am respecting your” right to health” by wearing a mask, can you not respect my” right to health” by also wearing a mask? During a pandemic, everyone should have a right to health first, then liberty. Any decision that violates this right to health, could result in the death of an innocent, and thus should have consequences.
Surely, I believe the reply of Sisti, Caplan, Gorin and Largent is ok. They don’t deny to protesters the right to healthcare, but rather their priority in access to scarce vital resources. And I think that is not as a punishment to their freedom or right to free speech, but as a question of responsibility. Protestor are against measures of social distancing, and they put it into practice, so they don’t collaborate in the measures for general security before COVID-19. Coherence should lead them to give up the priority that may apply if reach exceeded the treatment capacity.
But there is still another reason, which Woodhouse’s reply points to: healt professionals’ safety. Would health professionals have the obligation to assume the risk of caring for these patients when in many cases they do not receive adequate protective equipment? Health professionals have personal interests, like the rest of citizens, and as important as portesters’ freedom: their own freedom, their security, the safety of their family and friends… Can all those interests be put at risk without taking any responsibility?
I think no.
MIGUEL ÁNGEL GARCÍA. MD, PhD. Madrid (SPAIN)
This is the passage that seems to be causing the most trouble: “Individuals who get COVID-19 while protesting the very public health measures necessary to stop its spread should not get a ventilator before those who have been playing by the rules”. This has been interpreted by some to mean that we think protesters should be denied care. But “should” implies no such thing. Think of a case where, say, you are in a queue and the clerk calls on you before someone you know was waiting before you were. You might say, “they were here first. I shouldn’t be next.” This is the sense of “should” we have in mind here, as the rest of the op-ed makes clear, in addition to the publications cited by Legarda and Peters. I concede, though, that this sentence could, especially in isolation, be misinterpreted by a reader, especially one looking for an easy position to attack.
“At a minimum” refers to the possibility that some stronger measures may be justified; in particular, asking protesters to sign advance directives–this is the measure contained in earlier drafts. We then decided to weaken the claim to say they should sign pledges. “At a minimum” does not entail any particular maximum, as much as critics would like to think it does. It means quite simply what it says, “at a minimum.” There are stronger options available that don’t rise to the level of refusing care to protesters, such as advance directives.
I hope this clears up any remaining confusion on our position, which is not, and never was, one that would seek to deprive anyone of their health care without their consent.