The frontliners’ dilemma

By Nestor C. Punay, MD.

AS of today, the coronavirus disease 2019 (Covid-19) continues to ravage countries worldwide. Rich and poor countries alike are devastated in varying degrees by this pandemic. Many doctors, nurses, and other paramedical workers had succumbed to the virus. In Italy, around 60 doctors had died as of today while thousands of healthcare workers were reported to have been infected. In the United States, we are beginning to hear reports of nurses and doctors being infected. The fact is, I was saddened by whispers that a physician I know well succumbed to Covid-19

In the Philippines, the medical community has been shocked and mourned the loss of some of their well-respected peers to Covid-19 . If the report is accurate, there are now at least 17 physicians dead due to Covid-19 . Two of these are dear to me and my classmates from medical school.

Doctors are also humans. As such, we do fear for our lives. We have our own biases and beliefs. And not surprisingly, we do have our illnesses. We are therefore mortal like the patients we try to heal.

It is understandable of course that physicians in the Philippines are working scared in the fight against Covid-19 . The risks of infection and demise due to the virus is real. The lack of personal protective equipment (PPE) makes the risks even greater. Our doctors in many areas in the Philippines are like soldiers sent to the battlefield with guns but no ammunition. From messages exchanged through the internet, it is clear fear is among us.

Despite the fear of dying, our doctors, nurses and other frontliners continue to do their duties and obligations. Every day that they fulfill their duties they risked their own lives, especially without adequate protection. Their risks for infection and harm is so great. Thus, the news of 40 front liners from Northern Mindanao Medical Center (NMMC) negative for Covid-19 was a cause of tempered celebration among our peers.

The danger though has not passed. Thus, there are those among us that raised the possibility of refusing to treat patients without PPE in private conversations. This, of course, is easier said than done. With emotions running high, physicians like most people can be making irrational statements and entertain unimaginable scenarios. The lack of PPEs and the grave threat to the lives of frontliners had created an untenable situation for them. If they refused to work due to lack of PPE then they may be negligent of their duties and responsibilities. In this regard, they may face possible medicolegal complications as they may be liable to the possible poor outcome of their patients. The physicians in this instance may avoid being infected and save their lives but may end up facing potential lawsuits which can be costly.

On one hand, physicians continue to work and fulfill their duties and responsibilities. Many physicians worldwide do not shy away from performing their duties despite known risks to their lives and limbs with or without the pandemic. Indeed, we have taken an oath which by most part unconditional and we hold sacred. We all have taken the Hippocratic Oath: to treat the ill to the best of one’s ability, to preserve a patient’s privacy, to teach the secrets of medicine to the next generation, and so on. Thus, physicians fulfill their obligations unconditionally.

Nevertheless, physicians are humans and do have their own family to protect, support and defend in addition to themselves and their patients. They should protect themselves and preserve their lives. Thus, they have a dilemma of fulfilling their obligations and duties as physicians and protecting themselves from harm. There is no easy way to resolve this dilemma. There are enormous medicolegal and ethical implications that are hard to resolve especially in this pandemic. Which will prevail: their obligations to the preservation of their patient’s life or the preservation of their own life?

From the articles I read on this subject matter, this is a tough dilemma to resolve. The physicians, if they feel their lives are endangered with the performance of their duties, have the right to call the attention and demand the management to resolve the issue and to decrease their risks. If they adequately have done so and the issue is not resolved, they may be able to refuse to carry out duties that may endanger their lives. However, it was pointed out that this may not completely immunize them from legal complications. For many of our doctors, the hospital management and or the government have to resolve the issue and to provide the needed PPEs to protect the frontliners to fight Covid-19. Works of literature have pointed out that even if their safety can not be completely assured, the physicians’ ethical obligations to patients may not be completely resolved. The American Medical Association guidelines, for example, states: “First and foremost is the obligation to provide urgent medical care during disasters, an obligation that holds even in the face of greater than the usual risk to physicians’ safety, health or life.” 

As a physician, I am fully aware of this dilemma. Even with a casual conversation with friends, we are resolved to the possibility we will be infected and may lose our lives as we fulfill our duties. We know the risks are even greater when sans the PPE the community is also not cooperating in implementing mitigation measures. Thus, the citizenry can help resolve and minimize the risks to our physicians and other frontliners by cooperating with the strict social distancing measures. The local government has the role to implement the painful measures necessary to mitigate the spread of Covid-19 in the community by making sure the strict social distancing measures are implemented and complied with. By the implementation of these measures, the spread of the virus will be limited or prevented, limit the number of victims of Covid-19 and in turn limit the exposure of our front liners. We not only prevent people from dying but we also preserved one of our most precious resources in this pandemic: the lives of our physicians, nurses and other first responders!

There is no definitive answer to this dilemma. The residents can help resolve this dilemma by strict compliance with social distancing measures now. The local government unit can further help resolve this dilemma and preserve lives by mandating that everyone complies!