Law & Governance
Clinicians' Duty to Care; A Kantian Analysis
[No abstract available for this article.]
"On medical wards that treated patients with Severe Acute Respiratory Syndrome (SARS), some staff reported anxiety about infection and resentment about being chosen for the task. Nurses who were assigned to patients with SARS were not allowed to refuse the assignment … there were incidents of professional and nonprofessional staff refusing to care for patients with SARS in respiratory isolation on general medical floors."1
"WASHINGTON - The National AIDS Commission said Tuesday that a 'shocking' number of physicians and other healthcare professionals across the nation are still refusing to care for AIDS patients."2
These are two examples where clinicians' "duty to care" for their patients under unfavourable and unexpected circumstances came under discussion and started an ethical debate. I examine clinicians' (physicians' and nurses') duty to care for their patients under unusual circumstances especially - epidemics of new, virulent diseases - and analyze it using the moral philosophy of Immanuel Kant to support the argument that their moral responsibility does not change with changing disease scenarios.
Context - Duty to Care
The World Medical Association's International Code of Medical Ethics3, specifies in the duties of a physician that, "A physician shall observe the principle of the Declaration of Geneva." One of the clauses of the Declaration of Geneva is, "I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient. I make these promises solemnly, freely and upon my honour." Similarly, the Canadian Nurses Association's Code of Ethics for Registered Nurses4 stipulates, "Once care of a patient has been undertaken, a registered nurse has the ethical and legal responsibility to continue to provide care for the assigned period of time."
Do these stipulations define the duty to care beyond reasonable doubt, or is the concept still vague? There is not much ambiguity about what is meant by duty to care when a clinician is treating patients under routine, everyday circumstances. The controversy starts when the routine is changed to crisis, with its associated uncertainties. Recently, this issue was evoked in the context of SARS in Canada. Clinicians were expected to takecare of SARS patients in the line of duty and when some refused, citing personal risks as the reason, the discussion of the limits to the duty to care was initiated. One thing that transpired from this discussion was that the duty to care has no single unambiguous definition.5 There are no preset boundaries or limits to this duty, and it is subject to individual interpretations. The phrase "duty to care" is seldom used by medical ethicists, who resort instead to more specific rules and duties to underpin obligations. From 1975 to 2004, no article has included the phrase "duty to care" in its title in the Journal of Medical Ethics, and the Journal of Medicine and Philosophy has no result under "duty" in its 25-year subject index. The vague definition of the duty to care renders its use confusing and unhelpful. One way to reduce the ambiguity of the term is to have a detailed discourse around it. I examine the duty to care and its limits using Immanuel Kant's philosophy and hope that discussion will be furthered by similar or opposing points of view till we reach a conclusion.
Description - Duty to Care
Physicians and nurses have more stringent obligations of benefi- cence towards their patients than any other profession. The term "duty to care" refers to these special obligations. Part of this duty is to treat patients in spite of the inherent dangers associated with close physical contact, when physicians or nurses expose themselves to the possibility of contracting the patient's disease. This duty may vary among different specialties of medicine; for example, a physician working in the emergency department or intensive care unit is more exposed to virulent diseases than a radiologist. But physicians are expected to know the extended limits of their duty when they enter their field of choice. With the acquisition of additional duties and rights conferred by their professions, physicians and nurses relinquish certain rights enjoyed by others. By entering into the profession, a clinician agrees not only to abide by new rules but also to accept dangers that would be unacceptable to most.
Kant's Moral Philosophy and Duty to Care
Immanuel Kant was born in 1724 near Konigsberg, Germany. He is undeniably one of the most influential philosophers in the realm of moral thinking. In his book Groundwork for the Metaphysics of Morals, Kant defines the concept of "categorical imperative."6 Kant's philosophy deals with ethical duties of the individual moral agent, and he bases his system upon principles of universality. A moral obligation, according to Kant, must be universalizable, that is, applicable to all people at all times and in all similar situations. A system of morality must provide give a solid moral path regardless of the specific situation, and must be accessible and rationally acceptable to all.7 The distinct character of Kantian universalizability is its appeal to what can be willed for all rather than what actually is or hypothetically would be willed by all. His main thesis is that the moral worth of an act is related not to the outcome it brings but to whether it is done from a sense of duty or obligation. Kant states, "The moral worth of an action does not lie in the effect expected from it and so too does not lie in any principle of action that needs to borrow its motives from this expected effect." Duty is described as "that action to which someone is bound."
According to Kant, "All duties are either duties of right, that is, duties for which external law giving is possible, or duties of virtue, for which external lawgiving is not possible." In the Groundwork, Kant's principle of morality classifies duties into four categories: duties to oneself and to others, and perfect and imperfect duties. Perfect duties are prohibitions of specific kinds of actions, and violating them is morally blameworthy. Imperfect duties are recommendations of certain acts, and fulfilling them is praiseworthy. In the later Metaphysics of Morals,8 Kant writes about duties in a similar pattern, but with one key distinction: duties of justice are those that can appropriately be enforced by means of coercion, and the remainder are duties of virtue, by which a person can be morally assessed but not coerced. Kant considers freedom to be of main value for a human being, and he permits coercion only where it is both essential to protect freedom and possible for it to do so. This means that only a small subset of our duties, namely some but not all of our perfect duties to others, are duties of justice, thus proper subjects for public legislation. The majority of our moral duties are duties of virtue, which are not appropriate subjects for coercive legal enforcement. 9 The reason the latter cannot properly be made the subject of public legislation is that they relate to an end or purpose which is a duty upon the individual. But no public legislation can cause anyone to adopt a particular intention, or propose to him or her a certain purpose, for this depends upon an internal condition or act of the mind itself. However, certain external actions to enforce such a mental condition may be commanded.
Duty to care for a patient by physician is a duty of virtue. A person who decides to become a physician takes on the promise of using his or her abilities to the best advantage. Such a promise can be explicit (e.g., taking an oath) or implicit, but there is no denying its existence. This promise is a duty in itself, and the physician is morally bound to fulfill that duty. It is based on and oftentimes limited by the capabilities of a physician; for example, an anesthesiologist can anesthetize patients but cannot perform surgery on them. It is definitely not based on the patient's circumstances. For example, an anesthesiologist cannot refuse to anesthetize a patient who is suffering from a communicable disease, presents to the hospital and requires surgery. The physician can take all necessary precautions to protect self and others from that disease but is duty-bound to anesthetize the patient. If the physician chooses to refuse this duty, external conditions - for example, peer pressure or a reminder of commitment to one's duty - can be applied.
On the other hand, one of Kant's assertions is that the moral worth of an action depends on the moral acceptability of the "maxim" or rule of obligation on which the person acts. Kant emphasizes that one must act not only in accordance with but for the sake of obligation. To Kant, a person's actions can be morally worthy only if his or her intentions are what is morally required. In the case of duty to care, if clinicians perform their duty only because of peer pressure or because the public expects them to do so, their actions will not be morally worthy. For their actions to be morally worthy, clinicians must perform their duty to care for their patients with an obligation of fulfilling a promise to their profession and towards their patients.
One of Kant's most important claims is that the moral worth of an individual's actions depends exclusively on the moral acceptability of the maxim on which the person acts. For Kant, rationality implies something much different than the rational pursuit of desires and preferences with foresight and critical reflection.10 Rationality requires logical consistence such that one could will that the maxims of one's actions become universal laws. If the physician wants to state his or her duty as, "I will fulfill my duty to my patients, when and where I see appropriate, and abstain from it when I sense a personal danger," this maxim, according to Kant cannot pass a test that he calls the categorical imperative.
Kant formulates his categorical imperative in at least three different ways.11 Each formulation, he says, is strictly equivalent to the others. That is, each will pick out the same actions as morally wrong, and each will allow the same actions as morally permissible. His first formulation - "I ought never to act except in such a way that I can at the same time will that my maxim should become a universal law" - is a test for logical consistency. To see how Kant would judge the moral worth of an action, imagine a Western physician trained in infectious diseases, who takes an oath to treat a patient that he is capable of treating according to the best of his abilities at the time of his graduation. He is aware of all the protections that are available to him in case of treating a patient suffering from a communicable disease. He also knows that there are newer diseases erupting every so often, for which medical knowledge is limited. Now imagine the same physician employed by a hospital where several patients suffering from an epidemic disease are brought for treatment. This physician cannot refuse treatment to these patients even if it entails exposing himself to the risk of contracting the disease, without breaking his promise (oath). He cannot break his promise to fulfill his duty whenever he foresees an obstruction to smooth sailing in his professional life. By the standard of Kant's first formulation of the categorical imperative, a physician who abstains from duty of selfconcern cannot universalize his maxim.
Kant's second formulation states, "Act in such a way that you always treat humanity, whether in your own person or in the person of another, never simply as a means, but always at the same time as an end." For Kant, all rational beings are genuine participants in the realm of morality. It is their rationality and autonomy (the ability and requirement to "give the law unto oneself") that makes them creatures worthy of respect. One should never use other people merely as means because one would not accept as legitimate any reason for an unacceptable action directed at oneself. Therefore it would be inconsistent to treat another rational being any differently than one would want to be treated. If the physician in the above example were suffering from the same epidemic disease, he would expect another capable physician to treat, and if possible, to cure him. He should treat his patients in the same way that he wants to be treated if he himself were a patient. In short, for Kant rational beings are creatures that both give and require respect on a reciprocal and equal basis.
The third formulation of Kant's categorical imperative is, "So act as if you were through your maxims a lawmaking member of a kingdom of ends." Treat yourself and every other rational being as jointly constituting a community of agents who, as ends in themselves, can accept only those laws that they have given themselves.12 If made into a law, the physician's oath, "I will fulfill my duty to my patients, when and where I see appropriate, and abstain from it when I sense a personal danger" would not be acceptable to patients, as it would make their treatment unpredictable. There would also be no one to care for patients whenever an epidemic struck. The community of physicians could not accept this law either, owing to its inconsistency in fulfilling the promise of duty to care for patients indiscriminately and also because physicians must accept the same law when they are patients themselves. It can be argued that the abandonment of patients by healthcare personnel would result in the harm or even death of these patients. Public trust in them would therefore diminish as people realize that they might, as soon as the risk reaches a certain level, be left on their own.
In his thesis, Healthcare Workers' Duty to Care and Severe Infectious Diseases,13 Daniel K. Sokol writes, "Religion, financial gain, reputation, personal character, social context, geographical location, severity and nature of disease, the climate of fear - these are all influential factors in doctors' decision to treat, perhaps more so than in any other historical period." Kant would disagree with this statement. According to Kant, persons have "autonomy of will" if and only if they knowingly act in accordance with the universally valid moral principles that pass the requirements of the categorical imperative. He contrasts his moral autonomy with "heteronomy," which refers to any controlling influence over the will other than motivation by moral principles.14 If, for example, people act from passion, ambition or self-interest, they act heteronomously, and not autonomously. Kant regards acting from desire, fear, impulse, personal projects and habit as no less heteronomous than actions manipulated or coerced by others.
Utilitarian View - Duty to Care
Duty to care could also be evaluated from a utilitarian perspective. The agent in this case is relegated to the background and the focus shifts to outcomes. If the suffering prevented by the duty to care causes more suffering to others, then this would be grounds for not fulfilling the duty. The limits of duty to care are dictated here by calculating which option will produce the maximal outcome. That would be acceptable if taking care of one patient would mean failing to care for other patients, as the conflict would be between the duty to care for this one patient and the duty to care for all the other patients. Clearly, all other things being equal, the latter is the preferable option. Needless to say, the practical dif- ficulties of calculating maximal outcomes seriously limit the use of the utilitarian argument to resolve problems in real life scenarios.
Kantian ethics has been influential in formulating bioethical theories for moral guidance of healthcare professionals. It is apparent from analysis of his moral philosophy that Kant would have emphasized a uniform duty of care for all healthcare personnel under all circumstances. Kant's philosophy does not permit changes of limit to duty to care with changing disease scenarios. He would consider a physician's duty to care for patients binding without any considerations of a personal nature. Healthcare personnel are usually aware of the perils of treating infected patients. The appearance of a new, highly virulent disease, therefore, should not cause them to challenge their duties. Although outbreaks of infectious diseases in the Western world are still a rare occurrence, with globalization, this situation is bound to change. Does this change the responsibilities and loyalties of doctors to their patients? Should physicians in the West have different limits of duty to care than physicians in the East because Westerns have less chance of exposure to an epidemic due to availability of better healthcare services? Will that reasoning satisfy the universalizability of ethics that we all try to achieve? Kant would give a negative answer to all these questions.
About the Author(s)
Robyna Irshad Khan is a consultant anesthesiologist at the Aga Khan University in Karachi, Pakistan.
She can be reached at: firstname.lastname@example.org.
1 Maunder R., J. Hunter, L. Vincent, J. Bennett, N. Peladeau, M. Leszcz, et al. 2003. The Immediate Psychological and Occupational Impact of the 2003 SARS Outbreak in a Teaching Hospital. CMAJ; 168(10):1245-51.
2 Cimons M. 1990. "Panel Criticizes Doctors Who Won't Treat AIDS Patients-- Health: U.S. Report says a 'Shocking' Number Avoid the Disease. It Adds That Such an Attitude is Unacceptable." Los Angeles Times. Orange County Edition Page: 3.
3 World Medical Association. 1983. International Code of Medical Ethics. www.wma.net/e/policy/c8.htm
4 Canadian Nurses' Association. 2004. Code of Ethics for Registered Nurses. www.cna-nurses.ca/pages/ethics/ethicsframe.htm
5 Sokol D. 2004. Healthcare Workers' Duty to Care and Severe Infectious Diseases. www.medicalethicist.net/Thesis3.doc
6 Immanuel Kant - About the philosopher. Essays on Kant. 2004. www.kant-essays.com/about.html .
7 Universalism in Ethics. 2004. www.caae.phil.cmu.edu/Cavalier/80130/
8 Introduction to the Metaphysics of Morals. Division of the Metaphysic of Morals as a System Duties Generally. Translated by W. Hastie. Source: Steve Palmquist's website.
9 Guyer P. Kant, Immanuel. In E. Craig (Ed.). 2004. Routledge Encyclopedia of Philosophy. London: Routledge. www.rep.routledge.com/article/ DB047SECT10 .
10 Beauchamp T.L., J.F. Childress. 2001. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press. p 349-350.
11 The Internet Encyclopedia of Philosophy. The Categorical Imperative. 2004. www.nd.edu/~rbarger/categorical-imperative.html
12 Kantian Ethics. www.duke.usask.ca/~wib289/PHL235/
13 Sokol D. 2004. Healthcare Workers' Duty to Care and Severe Infectious Diseases. www.medicalethicist.net/Thesis3.doc .
14 Beauchamp T.L., J.F. Childress. 2001. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press. p 349-350.
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