The call comes over the commuter train loudspeaker. “If there is a medical professional on-board, please come to the rear car to assist with a sick passenger.” In deciding whether to respond, a physician might silently ask him or herself a series of ethically charged questions. What obligation do I have to respond in such a situation? Am I suitably qualified to manage a medical emergency outside of a clinic or hospital setting? What if I don’t respond? What would I want for myself if I were sick and vulnerable in a public setting?
This example, and others like it, may prompt physicians to consider the scope of their professional and ethical obligations. What are physicians’ professional obligation to advance the health of the community they serve? Are they obligated to enhance access to care for underserved communities by donating their time to a local free clinic?Must physicians work to address the socioeconomic conditions that affect the care of patients in their community? Should they promote public advocacy for health care? We can begin to address some of these questions by considering the framework of ethical commitments that professions historically have had to society.
A profession like medicine has unique status in modern society because of its specialized, complex body of knowledge that is used in the service of others. The profession has achieved its societal position through what has been termed a “social contract.”1 In exchange for providing necessary expert services and committing itself to competence, integrity, and altruism, the social contract between society and the profession grants the profession a high level of prestige, a monopoly on its service, and autonomy in its practice, the latter usually enacted through the privilege of self-regulation. The profession maintains its accountability with the public (thus strengthening the social contract) by acting according to a transparent set of rigorously derived standards. These include developing and adhering to clinical practice guidelines, practicing evidence-based medicine, and establishing and following codes of ethics.
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The professional obligation to promote the health and wellbeing of the members of society is central to the legitimacy and integrity of the profession and to maintaining the social contract. Society expects and relies on the medical profession to advocate for and promote its health. Indeed, as a central defining principle of medical practice, the AMA Code of Ethics states in its preamble, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”
Identifying where professional and ethical obligations begin is easier because they are based on professional practice standards and codes of ethics, but pinpointing where these obligations end for individual physicians can be more challenging. What are individual physicians responsible for and can reasonable limits be set? In answering this question, physician scholars make a distinction between professional obligations and aspirations.2 Physicians should not be obligated to provide services to their community that exceed their ability to intervene. It might be laudatory and aspirational to do so, but it is not an ethical duty.
For example, a physician’s role in promoting human health encompasses not just the medical aspects of illness, but also its social determinants. A patient’s kidney disease can progress if it is not treated adequately by his physician, but if the patient does not have health insurance or sufficient access to a nephrologist, the effect of these socioeconomic factors will be greater. Therefore, assisting patients with improving their access to care may fall within a professional’s obligation. However, addressing broader economic and educational disparities related to health (such as reducing poverty or improving education) would be aspirational, but not obligatory. This is because there is less direct causality between those socioeconomic conditions and health.
Should every physician be obligated to serve their community? Yes, and no. All physicians should contribute to that ideal and provide support where they can consistent with their skills, abilities, and expertise. But this collective professional obligation to society does not require every member of the profession to fulfill that responsibility. At the same time, consider that if individual physicians continually fail to rise to that obligation, the profession can eventually lose the trust of the public. The profession may be a diffuse entity, but it is still made up of individual members with ethical commitments.
Returning to the earlier case discussed, what are medical professionals’ obligations to respond to a medical emergency outside of a hospital setting?3 In this case, as with many ethical challenges, the context matters. A pathologist 20 years out of internship or a physician working in an administrative role may not be able to serve the needs of a sick individual on a commuter train or an airline. Furthermore, an obstetrician may not be best suited to manage a seizure disorder when it occurs on the subway, but he or she may be skilled in managing clinical emergencies and can help establish calm and a normalizing presence for a public that might be unfamiliar and frightened by witnessing acute illness. If you can help, you should.
Still, for all of the ethical analysis, one of the most convincing reasons for taking the opportunity to provide a service to those in need is that it feels right and good: the same reason physicians originally entered the field of medicine. Providing care for those who need it and seeing their appreciation for your expertise and service often provides its own motivation. That can be an easy answer to a complex problem.
David J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
References
1. Cruess SR, Johnston S, Cruess RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74-76. Review.
2. Gruen RL, Pearson SD, Brennan TA. Physician-citizens—public roles and professional obligations. JAMA. 2004;291:94-98.
3. Eastwood GL. What should I do when I hear the call for medical assistance in a plane? JAMA.2017;318:907–908.
