Posted on May 28, 2020 at 7:05 PM
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.
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