Fr Joseph Tham is a Catholic Priest, has doctoral degrees in medicine and bioethics, and is a contributor to Biltrix. In this article he presents a four-fold model for assessing the medical professional’s role in society, based on some reflections ten years after the 2003 SARS epidemic.
In early September, I participated in a conference on “SARS epidemic: ethical reflection and prospects” in Hong Kong. The 2003 global epidemic of severe acute respiratory syndrome was particularly devastating in Hong Kong. About 1800 people were infected, 300 of whom died, including 8 medical personnel. The Bioethics Resource Centre of the Catholic Diocesan Committee for Bioethics of Hong Kong organized the education event with the sponsorship of different hospitals, nursing and doctor guilds.
After 10 years, we can now calmly look at the challenges medical personnel faced in risking their own lives to save of those infected with the virus. In this analysis, we look at four major paradigms of the doctor-patient relationship as different models of healthcare delivery applicable to SARS victims: Military, profession, business / legal and vocation /mission. These four conceptions of medicine will determine to a certain extent how healthcare providers would to SARS patients.
Military: Doctors and nurses are considered front-line soldiers defending the citizens from the plight of the SARS disease. Medical training has traditionally evolved from the military field of training; even the present-day terminology of nursing station, rounds, house staff, and triage is a reflection of this heritage. The medical person is called upon to win this battle against the enemy, and sometimes to sacrifice himself in this struggle. We see this in the training when medical personnel were asked to work long hours and stay up all night in their duty of patient care. In the SARS epidemic, this theme of battle resurfaced, as the army of doctors and nurses were prepared to leave the comfort of their homes, sometimes with self-imposed quarantine and putting their health at risk, in their titanic struggle against the virus.
Profession: This model emphasizes physicians’ and nurses’ duties to serve the public, not dissimilar to other professions such as the police force, fireman or ship captains who are called to serve the common good. There is a professional code of conduct that the general citizen expects from these public servants. In emergency situations, abandonment would be considered unacceptable and unprofessional. Just like it would be unacceptable for a fireman to leave a house on fire to save his own skin, it would be unthinkable that healthcare professionals abandon their patients when there is widespread contagious illness. We see this in the recent case of the shipwreck of Concordia, where the ship captain was reprimanded for abandoning ship when there were still passengers trapped on the boat. Hence, in the SARS epidemic, doctors and nurses who served dutifully were praised for their professionalism.
Legal/Business: In today’s world of commerce, the doctor patient relationship can sometimes become one of provider and client, bound by a pre-established contract. In this conception of medicine, patients are the ones who hire their doctors to provide a service and perform what is stipulated in the contract. According to this mentality, lawsuits can follow when there are errors or when medical service is unsatisfactorily delivered. In this vision, there is also a tendency towards utilitarian calculation of delivery of care, and financial and efficiency interests often override the patients’ needs. On the flipside of the coin, healthcare workers may choose not to put themselves or their families at risk, as they may opt out of this service in the contract.
Vocation/Mission: according to this paradigm, doctors and nurses receive a special calling which is not merely a professional duty but something more. Their work is more like a life mission that is greater than themselves. According to Dr. Edmund Pellegrino, this attitude would constitute a covenant relationship that binds the healthcare workers with their patients. Healthcare workers would need to practice certain virtues such as justice and prudence. In addition, the virtue of fidelity to trust is particular to medicine based on the fact that patients are vulnerable and are at mercy of the hands of the doctors and nurses to care for them. Another virtue is self-effacement which is expected of these providers because of their privileged positions and skills.
On the point of self-effacement, it does not mean that healthcare workers should blindly sacrifice their health or lives when treating their patients. Sometimes, they have to make difficult decisions like, Should they intubate the SARS patient or not? What to do when protective masks run out? In this last model, the treatment of patients requires a balanced risk-benefit assessment. Prudence is of primary importance in this assessment in order to arrive at the best course of action.
Being a virtue, it requires a constant effort to acquire the habit to act wisely and prudently in all circumstances. As the philosopher Josef Pieper says, “The decisions of prudence and the intuitions of providentia nevertheless receive practical assurance from several sources: from the experience of life as it has been lived; from the alertness and healthiness of the instinctive capacity for evaluation; from the daring and humble hope that the paths to man’s genuine goals cannot be closed to him; from rectitude of volition and of ultimate intention; from grace of direct and mediated divine guidance.”
The 10 years since the SARS epidemic have helped us learn from our experience and be wiser and more prudent in the future.
An interesting and penetrating analysis, particularly applicable to those areas of healthcare systems that are seen as operating more under the business model than the professional or mission models.
Thank you for this, Fr. Tham. As an RN in Toronto during the SARS crisis, I could cry reading this! 10 years later, SARS is still part of healthcare professionals’ vocabulary and many of the infection control practices we take for granted (here in Toronto, anyway) are the direct result of that challenging time. You are so right when you say that prudence is a virtue that healthcare professionals must practice since our care also extends to our families and ourselves.There is always that balance that we have to find and sometimes trying to address everyone’s needs is challenging. Sometimes, it just doesn’t happen.