Half a league, half a league,
Half a league onward,
All in the valley of Death
Rode the six hundred.
“Forward, the Light Brigade!
Charge for the guns!” he said.
Into the valley of Death
Rode the six hundred.
“Forward, the Light Brigade!”
Was there a man dismayed?
Not though the soldier knew
Someone had blundered.
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die.
Into the valley of Death
Rode the six hundred.
The generals repeated the old lie, “Dulce et decorum est, propatria mori!” Sweet and becoming it is, to die for one’s country
“Hippocrates and Galen, are still renowned for their wise and innovative advice on medical matters. When it came to plague, they offered guidance, rendered in Latin as ‘Cito, Longe, Tarde,’ which translates as ‘Leave quickly, go far away and come back slowly.’ When the Black Death swept over much of Asia, Europe and parts of Africa in the mid-1300s, such advice was about as good as it got.” Bought to Life
Some did stay, out of Christian duty, desire for fame or because they got ‘hazard pay’ from local communities. The idea of a social contract didn’t come around until the 19th century.
At the start of the 20th century the American medical code of ethics stated, “when pestilence prevails it’s the physician’s duty to continue ministering to the sick even in peril of their own lives”
In 1912 the language was strengthened to say there was, “an obligation to continue taking care of people who posed a contagious threat even if you were not being paid to do so.” Ethics Talk podcast
But how far should this duty reasonably extend? Doctors are already dying from Coronavirus infections contracted in the course of caring for infected patients. Many, if not the majority, lack the recommended protective equipment.
Doctors have always placed themselves at risk in the course of their work. In 2003-4 I joined Medecins Sans Frontieres (Doctors without Borders) and I accepted a job in North West Afghanistan knowing that there were risks including death, because of ongoing conflict. While I was there some of my colleagues were assassinated very close to where I was working. Since then I have chosen not to go back to work in conflict zones, but other doctors continue to do so. Doctors’ attitudes to personal risk in the line of duty vary considerably.
At one end of the spectrum are those, like David Nott, the war surgeon, who wrote, “I have travelled the world for 25 years in search of trouble. It is a kind of addiction, a pull I find hard to resist. It stems partly from the desire to use my knowledge as a surgeon to help people who are experiencing the worst that humanity can throw at them, and partly from the thrill of just being in those terrible places, of living in a liminal zone where most people have neither been, nor want to go.” Others are risk averse and under the current circumstances are avoiding all clinical contact while their colleagues continue to work in intensive care units with patients who have coronavirus infections.
I find myself somewhere in the middle of the spectrum. In 2003 I was single and in search of adventure and I felt invincible. In 2020 have young children and I feel more mortal.
We all have reasons for where we might find ourselves on the risk-taking spectrum. One is what motivates us. Not all doctors are primarily motivated to take risks by the desire to save lives or help people less fortunate than themselves. The motivation may be extrinsic rewards like money or fame. Other motivations include intrinsic values like caring, social justice or self-sacrifice which may derive from upbringing, life experiences or religion. Caring can be viewed as a positive motivation; for example, someone bought up in a caring environment with positive experiences of care and caring, for whom caring is an integral part of their identity.
The need to care for others and sacrifice oneself may also come from a need to repair something flawed, damaged or shameful about oneself, to compensate for low self-esteem. Growing up in a relationship with parents who made someone feel inadequate may result in these feelings persisting into adulthood. The adult tries to compensate by self-sacrifice and risk taking. The sense of being flawed or ‘bad’ drives the need to ‘do good’ while the risk-taking is driven by a sense of ‘just deserts’.
There is a strong sense of this when listening to the war surgeon David Nott who places himself not just in high risk, but unnecessarily high-risk situations. Risk for him is both euphoric and addictive. He is the archetype of a heroic doctor, putting the lives of his patients above concerns for his own life. We might hope for him to be our surgeon in a life or death situation, but we might feel differently if we worked with him.
Doctors work in teams; with other doctors, nurses and health professionals as well as admin staff. It’s easier and perhaps more comforting to imagine that the patient is their only, or at least primary concern, particularly in relation to a war surgeon. A GP has to care for individual patients as well as their practice population. We have to support widows who are grieving and be sure that all the children registered are fully immunized. As a senior partner in my practice I am responsible for over 26000 patients and 40 members of staff. The more I sacrifice myself in the services on one person the less I am available for others.
Brain surgeon Henry Marsh is another heroic doctor whose concern for his patients described in his book First Do No Harm runs to commandeering hospital beds and over-riding clinical colleagues and an open contempt for hospital managers whose concern is the smooth running of the hospital. From an individual patient perspective, you’d want him on your side, but if you happened to need a hospital bed for something other than neurosurgery you might feel differently.
Obligations to individuals and populations come into conflict all the time in medical practice and the extent to which our sphere of responsibility diminishes with distance varies considerably between doctors and between individualistic and communitarian cultures. We live in an individualistic culture that valorizes heroes. We are conservative; suspicious of foreigners and socialism having voted for Brexit and 10 years of Tory rule. We are looking for heroes to save us from Coronavirus.
For the last week I have been self-isolating – with what feels like a typical cough and cold. I don’t have breathlessness or a fever. There’s no way of knowing if it is a mild case of coronavirus. Under other circumstances I would be at work. Presenteeism – the phenomenon whereby healthcare professionals come to work in a state of ill-health that they would advise their patients to stay at home, is rife. But this might be Coronavirus. As the pandemic unfolds we might reach a situation where medical professionals are more likely to be infected than their patients. Dr Gordon Caldwell a consultant physician in Oban, has written about what should happen if he requires ventilation because of coronavirus infection.
If I survive to be weaned off the ventilator (1 in 5 chance) it would be at the expense of 1 staff member with severe Covid 19 and 3 others infected, who in turn could infect other staff, patients, and their own family and friends. Until someone can counter this argument with a convincing statistical, not emotional, case, I have stated that I am “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR” and “Do Not Intubate and Ventilate (DNIV)”
Hospitals as well as doctors might soon become the hubs for transmission of coronavirus in the UK if we continue to follow Italy’s lead. The hero who remains on deck after all the passengers and crew have left the sinking ship is not suited to the present epidemic. Our present-day heroes will have to relinquish the helm while they isolate themselves to protect their colleagues and their patients. They will have to trust their colleagues to take over. They will have to show that we can carry on without them.
Michael West – an organizational psychologist who leads on compassionate leadership for the NHS recommends that the priorities should be listening to staff, removing obstacles to safe and effective work, and providing for their basic needs: safety, rest, nourishment and connection. The lesson from this is that during this crisis every single one of us, will at some point have to be a new kind of hero.