After reading Dr. Alpert's commentary, we suspect art inspires life but not consistently with historical fact. Duty to serve, a hallmark of professional medicine, is not always exhibited during pandemics. The perception is that physicians provided care to others without personal regard in pandemics. Yet, Camus's physician did not view himself as heroic. Rieux stated “there is no question of heroism in all this. It's a matter of common decency” and it was about “giving people a chance,” trying to alleviate suffering (p. 278).
Since the mid-1980s, medical historians have accepted the Zuger-Miles hypothesis, arguing there was no “strong or constant” tradition of physicians rendering care in epidemics because of a sense of professional responsibility. Most physicians treated patients who sought help often at great cost and personal risk. Other physicians fled in time of plague. During yellow fever and cholera outbreaks, physicians refused to visit patients who were acutely ill. Overtreatment with dangerous and ineffective therapies was worse than abandonment. Some physicians acted on the basis of monetary or contractual agreements. Other physicians became itinerant: “frequently bills were set up upon their doors and written, ‘here is a doctor to be let’ . . . several of those physicians were fain for a while to sit still and look about them, or . . . remove their dwellings, and set up in a new place and among new acquaintance” (p. 361).
Modern debate over physician duty occurred during the century-old Spanish influenza pandemic wherein more than 600 US civilian physicians died. Recent concerns about duty have occurred during the HIV, SARS, Ebola, and current COVID19 outbreak. Hundreds of health care workers in West Africa died during the Ebola outbreak, and numerous health care workers have succumbed during the current pandemic.
Even with social and organizational changes in modern medicine, with conflicting duties and roles for physicians in complex economic and contractual settings, the Zuger-Miles hypothesis is confirmed. We were heartened by selfless efforts of house staff in the current pandemic, placing patient care and duty above personal and family obligations. We witnessed fear of contagion among providers—translated into refusal to provide care but also translated into significant morbidity and mortality for providers. Colleagues reported feeling sidelined; physicians wanted to do more. We heard concerns regarding institutional exploitation: the duty to do more. Physician duty and obligations toward patients should not be exploited, placing physicians at risk and in circumstances considered morally, psychologically, or physically unacceptable. Our observations confirm that duty during pandemics is not a heroic, dichotomous, individual choice but rather a complex, nuanced decision, influenced by conflicting, competing, and overlapping goals, moral obligations, and institutional and contractual concerns.
Camus's Plague reminds physicians that dead rats are everywhere—epidemics, wars, and natural disasters—creating refugees, illness, and untold human suffering. Despite social, political, and scientific progress, these threats persist and repeat. Camus's physician protagonist compiles his chronicle so that he can “bear witness in favor of those plague-stricken people; so that some memorial of the injustice and outrage done them might endure; and to state quite simply what we learn in a time of pestilence” (p. 278). Camus's protagonist continues to remind physicians of the duty to care for patients and of pandemic lessons from history.
The American journal of medicine
Creative Commons Attribution 4.0
Barreiro, T., & Gemmel, D. (2021). Physicians and Duty During a Pandemic: A Response. The American journal of medicine. https://doi.org/https://doi.org/10.1016/j.amjmed.2020.07.011
Barreiro, TJ, and David Gemmel. 2021. “Physicians and Duty During a Pandemic: A Response”. The American journal of medicine. https://doi.org/https://doi.org/10.1016/j.amjmed.2020.07.011.
Barreiro, T., and D. Gemmel. Physicians and Duty During a Pandemic: A Response. The American journal of medicine, Jan. 2021, doi:https://doi.org/10.1016/j.amjmed.2020.07.011.