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.