MANY of us are familiar with the parable of the Good Samaritan. An injured, unwell traveller lies on the roadside. Many other travellers pass him by, perhaps worried about their own safety and wellbeing, perhaps driven by religious and cultural requirements – including in relation to cleanliness and purity. However, one man stops to render aid.

This is the essence of the parable; a story that has had a lasting impact on considerations of ethical medical practice.

During the current coronavirus disease 2019 (COVID-19) pandemic, what constitutes being a Good Samaritan in the setting of contemporary medical practice?

The established principles of beneficence and non-maleficence merit consideration. A patient with COVID-19, who is unwell and highly infectious, is at risk if care is not rendered. Furthermore, there is a causal link between the treatment of this patient and the risk of infection of caregivers. This may increase the risk to multiple third parties – especially if an unknowing, infected medical practitioner inadvertently becomes a “super spreader” risk. This risk is not merely theoretical. In the current pandemic, multiple medical practitioners have been implicated as “super spreaders”, with nosocomial origins of infection being an important component in community propagation of COVID-19.

So, here is the dilemma in a nutshell: the established principle of beneficence invites conduct that is at variance with the equally established principle of non-maleficence. In these circumstances, what ought one do?

Consequentialist approaches determine such questions according to outcomes. The most famous example of this approach is utilitarianism. Although offered in various forms, the core idea is that one should act to bring about the greatest good and the least harm. As such, it is possible that a utilitarian might conclude that they are ethically obliged not to offer treatment to the infected patient.

Other practitioners will be more comfortable with a deontological approach, which stresses the need to do one’s duty irrespective of the consequences. Duty has many potential sources. For example, one can be obliged to keep a promise freely made. One can be obliged to act in obedience to divine commands. One can be subject to the dictates of reason. Under this approach, one will render aid to the patient – as a matter of duty – even if to do so risks causing adverse effects. Of course, one will seek to minimise the possibility of harm, but duty will prevail.

Health care is largely delivered, on behalf of society, by a health system that is largely funded by citizens. This gives rise to a “social contract” between society and health care workers, with obligations on both sides; for example, that health care workers have a prima facie obligation to offer treatment to the sick and injured from within society. However, society has a prima facie obligation to provide a safe workplace, including the provision of sufficient personal protective equipment (PPE).

What if society fails to meet its obligation and if sufficient PPE is not available? How should the system decide between those practitioners who may tolerate lack of adequate PPE and continue to offer treatment on deontological grounds, and others who adopt the utilitarian approach that becoming unwell and potentially a “super spreader” justifies not rendering care to infected individuals, for net societal good?

We argue that in circumstances where medical practitioners are not provided with adequate clean PPE, they have the right to exercise their personal conscience either to render care to the benefit of the patient before them, or to disengage in the name of mitigating community spread. Notably, we do not argue that a prima facie obligation to treat the patient can be offset on account of the personal self-interest of the practitioner.

However, we also stress that neither type of practitioner should be subject to duress or psychological pressure from others to adopt a particular ethical position (including other positions not canvassed here). As noted above, whether or not to treat an infected patient in the absence of PPE is a genuine ethical dilemma in which beneficence and non-maleficence are both legitimate but contending principles.

To force a medical practitioner to do other than act according to their conscience can cause real harm to mental health through a phenomenon known as “moral injury”. The best protection against moral injury is for health care teams to discuss their views on relevant ethical matters before any COVID-19 case surge. Should adequate PPE become scarce, individual ethical views will have been clarified, within a supportive environment, and contingent plans agreed.

The duty of health care Good Samaritans extends to our colleagues, including a care for their consciences during times when making impossible choices becomes the norm.

Ajeet Singh obtained his medical degree, masters, and doctorate from the University of Melbourne. He is a consultant psychiatrist at the Geelong Clinic and Honorary Associate Professor at Deakin Medical School.

Simon Longstaff is a Cambridge-educated ethicist, and Executive Director of The Ethics Centre Sydney and Honorary Professor at the Australian National University.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


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One thought on “Good Samaritans: an ethical perspective during COVID-19

  1. Ian Hargreaves says:

    The authors conflate maleficence with inadvertent harm. In the case of Dr Chris Higgins, who was berated by the Victorian health minister and chief medical officer, he was treating patients while unaware he was infected. In that circumstance, the lack of intent to harm/allow harm is crucial, as opposed to say, the Tuskegee syphilis researchers.

    Maleficence only comes into consideration where the doctor is aware he is infected (or probably infected) and continues to treat non-COVID patients. Even then, a grey area exists for the isolated/rural doctor who has treated a COVID patient without appropriate PPE, then is called to a non-COVID emergency like an MVA.

    Similarly, the governments’ bans on elective surgery mean that surgeons are legally required to provide suboptimal treatment to their patients, for the greater good of the health system. This could perhaps best described as non-maleficent dutiful utilitarianism, where I sit idle and allow my patents to suffer, for the sake of preserving supplies of gowns, gloves, and masks to protect my colleagues. Much the same applies to HCWs in worst-hit areas like Northern Italy, where ambulances refuse to transport older patients to over-full hospitals. Triage by birthdate has been legislated.

    However, in repeated instances such as nurses assaulted on psychiatric wards or murdered in remote communities, prison officers injured in riots, or injected with HIV+ve blood, there exists a clear legal (and consequent ethical) obligation for the employer to provide a safe workplace, however difficult that may be. Such failure on behalf of state governments to protect their hospital staff will no doubt play out in the courts for years to come.

    I agree with the authors’ suggestion: “we also stress that neither type of practitioner should be subject to duress or psychological pressure from others to adopt a particular ethical position (including other positions not canvassed here)”, but would take issue with their comment: “Notably, we do not argue that a prima facie obligation to treat the patient can be offset on account of the personal self-interest of the practitioner.”

    In a recent outbreak of a different kind, three baboons escaped from a Sydney teaching hospital. I infer that the authors would consider that the doctor who planned to perform a vasectomy on the large male baboon would have a duty of care to catch it, irrespective of the danger to self. I would argue that in a situation where the treatment (catching a baboon without adequate training or PPE) was likely to be futile, and the risk of personal injury/death significant, it would not be unethical to refuse to capture/treat one’s patient, out of personal self-interest.

    In the same light, the authors omit the admonitions of the various regulators like Medical Boards, which impose ethical standards as part of good medical practice. Such Boards advise that each doctor should not self-treat, but have his own GP, and thus presumably follow the advice of that GP. For a doctor with a personal health issue, which for COVID includes hypertension, diabetes, lung disease, and probably immunosuppression such as cancer treatment, his own GP may advise him against treating COVID patients.

    There would be a sliding scale of risk, e.g.the 25 yr old well managed Type 1 diabetic ED RMO may be low risk, compared to the 75 yr old doctor being coaxed out of retirement, with significant cardiovascular disease, poorly controlled type 2 DM on insulin and an SGLT-2 inhibitor, and a biologic for his arthritis. The older doctor, strongly advised not to work by his GP, would be in breach of ethical standards for registration.

    No doubt we will all wrestle with the ethical issues, as we did in the early days of AIDS, knowing it was 100% lethal and transmissible to family and patients, especially in the 3-6 month window period of undiagnosed infection. At least COVID has low risk to one’s young spouse/ unborn baby.

    The Good Samaritan analogy breaks down in that he was a volunteer who gave time, effort, and money, to aid a (hostile) stranger, without significant additional personal risk. He was not a salaried employee with an omnipotent monopoly employer, without whom he had no career prospects, which is the situation for hospital junior doctors.

    Those at the frontline could best be protected by a simple requirement, as practised at Mc Donald’s. All senior McDonald’s staff, including the CEO, have to spend a half-day shift per month in the restaurant, flipping burgers, cleaning toilets, etc. Knowing that the Health Minister, Chief medical officer, and hospital CEO were all doing a shift on the COVID ward would not only raise morale, but I suspect help speed up acquisition of high quality PPE.

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