In a Medical Catastrophe: Excusable Professional Abandonment ?

I would like to expand the previous thread regarding the ethics involved in professional responsibilities of physicians and whether they have choice or no choice in certain situations such as an infectious disease pandemic.

Ken Kipnis, an ethicist at the University of Hawaii, recently wrote to a bioethics listserv the following, with extracts from his previous paper, dealing with the issue of professional abandonment in a medical catastrophe. He has kindly given me permission to reproduce his posting below. Also is included is his link to the full text of the paper. In a medical catastrophe, should physicians and other healthcare providers be punished if for personal reasons they are forced to abandon their patients? Is such abandonment excusable? ..Maurice.

I addressed the issue of physician abandonment in a paper that, among other things, considered conditions that may have obtained at Memorial Medical Center in New Orleans following Katrina. What follows are two brief passages from that article. In the first, I distinguish between disasters and medical catastrophes. The ethical implications of the latter have not been well studied. In the second, I list considerations that could support "excusable" abandonment: It is not that abandonment is justifiable in a medical catastrophe (i.e., the right thing to do) but, rather, that clinicians in extremis who abandon patients should not be ethically or legally condemned for what they have done.

It is assumed in what follows that it is not possible to evacuate the sick.

#1In a medical disaster, the resources of a healthcare setting are overwhelmed. Triage helps to solve the problem. In contrast, a medical catastrophe occurs when a health care delivery system collapses [Kipnis, pages 95-107,"Overwhelming Casualties: Medical Ethics in a Time of Terror," in In the Wake of Terror: Medicine and Morality in a Time of Crisis, edited by Jonathan Moreno. MIT Press 2003. Reprinted in Accountability in Research: Policies and Quality Assurance, Volume 10, Number 1, January-March 2003, pp. 57 - 68
. The hospital (or any setting where medical care has been provided) has somehow become hazardous to the point where all must relocate to safety. Though this may or may not have occurred at Memorial Medical Center, there are scenarios where this condition would be met. Here are three. (1) An earthquake and ongoing aftershocks have caused structural damage and are threaten ing to topple occupied sections of a now burning hospital. (2) Biological, chemical or radiological agents have contaminated the buildings even while the clinical staff are unprepared to protect themselves. And (3) a deadly epidemic is fueling riots by angry mobs who believe that essential supplies are being hoarded inside. In all three cases, clinicians and patients are present in the hospital and, for different reasons, it is not safe for them to remain.

#2[In the context of a medical catastrophe, the duty of non-abandonment] tests the commitments of physicians, nurses and others. While the obligations that clinicians have to their patients are weighty, it would be hard to defend the proposition that they are absolute: to be honored regardless of the costs to the caregivers and to others with competing claims. To be sure, the continuing presence of healthcare professionals may extend somewhat the lives of dying patients, may make the dying process more endurable, and may express a community's commitment to respect the dignity of those in the greatest need. But whatever the sources and the weight of the duty to remain with patients, it is an open question what burdens health care providers must shoulder in order to fulfill this professional obligation, and what expectations others (clinician 's families, other patients) must forfeit. A catastrophic collapse of a health care system can require doctors and nurses to work without proper equipment in uncontrolled environments; without adequate food, water, or sleep; and amidst hazards that threaten their own lives and health. What they can accomplish by remaining may be precious little and far less than what they might do elsewhere. At some point they may have done everything required of them.

There appear to be two distinct justifications for setting a limit to the obligation to remain with patients where leaving them would constitute abandonment. In the first place are unreasonable personal burdens that healthcare professionals and their families would have to take on were they to remain. Family members and others may also suffer significant derivative loss. In the second place are competing professional obligations. As with the doctor in the Burma narrative, other patients may have weightier claims than the black-tagged patients. In a disaster, allocation rightly shifts resources to where they can do the most good. Accordingly, any decision to remain with victims who are beyond saving may violate weightier obligations to attend to salvageable patients i n urgent need of vital care. For these reasons, I will assume in what follows that the prohibition on abandoning patients cannot be absolute.

One other consideration is worth mentioning. Consider the risks routinely taken by fire fighters, soldiers and police officers. Notice that the community helps them do their jobs in reasonable safety. Fire fighters receive breathing equipment and protective clothing. The burden of remaining at one's station despite hazards does not fall solely on their shoulders. Society must support essential services if it is to expect men and women to act heroically when the need arises. Now whatever the social obligation of firefighters to enter burning buildings, it is arguably diminished when a community fails to provide protective equipment and other forms of support. Likewise, if a community expects healthcare professionals to remain steadfast during a catastrophe, it must be prepared to s support them through the darkest hours, so they can keep at their work while protecting themselves. But when health care professionals are abandoned by the communities they serve, the duty to brave hazards may be attenuated.

The full article is available at

this link

The paper -- "Forced Abandonment and Euthanasia" -- was originally published a year ago in the journal Social Research.


Ken Kipnis
kkipnis@hawaii.edu