Acoronavirus that normally occurs in some nonhuman animals infected humans and caused what came to be called severe acute respiratory syndrome (SARS). In 2003, not long after the initial infections occurred in Guandong, China, SARS spread to almost thirty countries. By the time the disease was contained, about eight thousand people had contracted the virus, and approximately eight hundred had died.
The course of the disease in Taiwan was typical. The first cases were people who returned to Taiwan from China. Health care professionals tried to identify and isolate these people to prevent transmission, and for two months this seemed to work. Then a series of outbreaks originating in seven different hospitals led to many more infections. By the end of the epidemic, Taiwan had about four hundred confirmed cases of SARS.
At the beginning of the outbreak, no one knew how infectious SARS was and what course the disease would take. The evidence at the time suggested a respiratory infection with a mortality rate of about 10 percent. Transmission of SARS appeared to be airborne, both through large droplets and tiny droplet nuclei, implying that incidental as well as close proximity to infected patients might result in transmission. The rate of infection in hospitals was high, and around 30 to 40 percent of reported cases were health care workers.
At this time, when knowledge was limited and fear was strong, the dean of each medical school in Taiwan had to consider the role of students during the epidemic. Many parents and even some politicians called to ask that medical students be excused from school or kept from contact with patients until the outbreak ended. Each dean listened to these requests, consulted with various people, and reviewed the facts before making a decision.
What should the dean decide? What is the ethically appropriate role for medical students during an epidemic?
The dean must make a decision that will affect many lives and perhaps save some of them. If she allows her students to help in the care of SARS patients, some of them may contract SARS and die. Without question, the dean must be troubled by the prospect of placing her students in a situation that exposes them to a significant risk of severe illness or death. She has undoubtedly heard from students, parents, faculty, community leaders, the press, and others, all expressing opinions and trying to influence her decision. She should consider their input and share with them her view of the situation; but in the end, she should make it clear that she will decide herself, and that her decision will apply to all her students.
More than twenty-five hundred years ago, Hippocrates declared, "The health and life of my patients will be my first consideration." More than nine hundred years ago, the rabbi-physician Moses Maimonides said, "I have been appointed to watch over the life and death of my fellow human beings." These principles, enduring today, mean that the physician's obligation to the patient outweighs obligations to self, and the physician's responsibility to the patient encompasses the full continuum of life, including death's approach.
The ethical obligation of physicians to place the patient's welfare before their own may be modified by particular circumstances. During past epidemics, some physicians have tried to suspend their obligations to care for patients presenting risks to their own health by invoking duty to self, family, or future patients. Also, physicians vary in their abilities to care for certain diseases-for example, the skills of emergency medicine physicians and specialists in infectious diseases would be more relevant in the care of patients with SARS than those of radiologists or pathologists.
However, the question here is not what the ethical and professional obligations of fully trained physicians competent to treat SARS patients are, but rather what the dean should require of students in this situation. To paraphrase Maimonides, the dean has been appointed to watch over the lives of her students, and arguably their welfare should be her primary consideration.
What applies to fully trained, competent physicians may help inform the dean's decision but must be modified...