By Udo Schuklenk.

Even a cursory look at the news tells us that many doctors and nurses are reluctant to provide care to COVID-19 patients. Personal protective equipment (PPE) levels in Australia’s state of Queensland are very low, writes the state’s Clinical Senate Chair Alex Markwell. Bulgaria has seen a wave of doctors resigning, Zimbabwean doctors have gone on strike over the lack of protective equipment, and UK medics warned repeatedly that the lack of appropriate protective equipment puts their own lives at risk.

These professionals sadly have every reason to be concerned for their own well-being. As of today, more than 60 doctors who provided care to Italian COVID-19 patients have died as a result of contracting the virus on the job. Many more have fallen very seriously sick. An incomplete list of ‘Fallen Coronavirus Heroes’ maintained by Michael C. Gibson, a Harvard University medical school professor, lists (as of March 31, 2020) 119 health care professionals who lost their lives as a result of COVID-19 infections they acquired while caring for infected patients.

The number is almost certainly significantly higher, and it is bound to increase daily, for some time to come. There can be no doubt, the death toll among health care professionals caring for COVID-19 patients the world all over will be significant. In response to concerns about the availability of health care professionals during expected COVID-19 case surges, a state government in one of Germany’s most populous states, North-Rhine Westfalia, is seriously considering introducing a draft kind of compulsory service for health care professionals. Little did doctors know when they joined the profession, that at some point further down the road, government was planning to draft them into compulsory service, much like soldiers.

What health care professionals owe us

What is it then that health care professionals owe us in a crisis like the current one? As patients, we depend on doctors and nurses to provide professional care to us, because they have the specialist training, and they have a monopoly on the provision of these kinds of services. It’s not as if we could turn around and go elsewhere if the local hospital’s ICU has an insufficient number of doctors on call.

Most doctors in their graduation ceremonies do take a public oath to serve the public good, oftentimes modelled on the World Medical Association’s Declaration of Geneva. Up to the 1994 version of that influential document doctors promised to provide emergency care, without any ifs or buts. However, you won’t find that promise repeated in the current version of that document, so that approach doesn’t address the question at hand. Unsurprisingly, the world’s doctors woke up to the dangers of making wild promises they could not realistically live up to.

A different argument could be to say that there is an implied consent to risk-taking when doctors accepted the deal their profession cut with society. Monopoly powers, high societal standing and oftentimes high salaries don’t come without a price. Doctors knew, if they paid attention to the subject in their global health classes, that infectious agents like Ebola and others were going to raise their ugly heads during their lifetime, and joining the profession meant accepting a duty to provide care. During the early days of the HIV pandemic, when an infection with that virus meant certain death, doctors’ statutory bodies declared in most countries that doctors had an obligation to treat. Given COVID-19’s much lower mortality risk this should settle it, or so one might think. That is a mistaken view.

What makes COVID-19 different is that the HIV-response was predicated on the availability of PPE to health care professionals. In such a reality, if health care professionals followed universal precautions and had the right protective equipment, the odds of them picking up HIV would have been negligible. With COVID-19 we are, in most countries, in a very different situation.

Yes, we must talk about neoliberalism and the fetishization of ‘efficiency’

One feature closely linked to the functioning of globalisation and capitalism is efficiency. Nobody wants to waste money and resources. There is a virtue in running ‘lean’ operations. Most countries in the global north, that operate public health care systems, saw the re-election of cost-cutting governments running successfully on election campaigns promising to ‘return money to our back pockets’, and away from big government. And as taxpayers we did get money returned to our back pockets by low tax regimes.

As neoliberal election campaign lore has it, we know best how to spend our hard-earned money. Such policies were anything but cost neutral, as those of us in need of public services have known for a long time. They succeeded in hollowing out the health care delivery infrastructures in most countries. There is today not much of a difference between Australia, Germany, Canada and the UK. The principle that drove public policy was the same. In the UK citizens were treated to many years of low-tax, small-state austerity, effectively rendering the NHS unable to cover regular flu season case loads without great difficulty. In Germany the German finance minister’s Black Zero signified the fiscal paradigm requiring the state not to run budget deficits, leading equally to a hollowing out of the state infrastructure required to respond efficiently in times not normal. In the USA where publicly funded health care delivery is close to non-existent and for-profit, operators often dictate the levels of care that will be provided. The results were quite similar, except in this case the availability of health care infrastructure was dictated by profit objectives driving many hospitals, as well as for-profit insurers reimbursing for-profit and non-profit hospitals alike for particular services.

Implications for health care professionals’ obligations

The endpoint was the same: democratically elected governments across the global north have left hospitals woefully unprepared for the current onslaught of patients, not only in terms of ICU beds and ventilators, but also in terms of PPE. If the lack of available PPE for frontline health care professionals would have been due to a natural occurrence, one could argue that doctors should be prepared to accept a certain higher degree of risk, but in the current situation that lack of protective equipment is truly deliberate: it is by human, cost-cutting design. It was quite a remarkable sight to see on global news programmes the UK Chancellor and Prime Minister standing outside 10 Downing Street, wildly applauding the country’s health care professionals’ heroism. The heroism, however, that they were celebrating is a direct, avoidable consequence of their own government’s austerity policies. An adequately resourced NHS would not have required a significant degree of beyond-the-call-of-duty heroism by health care professionals.

We live in democracies, and we elected politicians who promised us that we could have our cake and eat it. It turns out, unsurprisingly, we can’t have that. There is no reason why doctors and nurses should be seen to be professionally obliged to risk their well-being today, because we chose governments that starved them of the necessary resources to do their job safely. Elections have consequences.

We should be grateful to any health care professional willing to care for COVID19 patients, in the absence of PPE, but we have no reason to take for granted that there will be one when we need them.

Paper title: What healthcare professionals owe us: why their duty to treat during a pandemic is contingent on personal protective equipment (PPE) FREE ARTICLE

Author: Udo Schuklenk

Affiliation: Professor of Philosophy and Ontario Research Chair in Bioethics, Department of Philosophy, Queen’s University, Kingston, Canada

Competing interests: None

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