This cross-sectional survey enrolled 318 Lebanese physicians, including men and women of different ages and specialties, practicing in many regions and having multiple socio-economic and cultural backgrounds.
According to the literature, medical doctors, like the general population, may have an exaggerated perception of their personal risk during a pandemic (4). However, during this COVID-19 pandemic, a high proportion of healthcare workers became infected with the virus, with numbers reaching 20% in Italy, making this increased risk an alarming reality rather than a perception (11).
In this perspective, when asked about the risk of contracting COVID-19, the majority of family doctors or medical specialists considered themselves at higher risk of infection, they attributed it to the divers symptoms and manifestations related to this viral infection; patients may seek consultation with any type of medical specialty: family medicine, internal medicine, infectious disease, pulmonology, emergency medicine…. At the same time, anesthesiologists considered themselves to be the most at risk during work compared to other specialties, which could be related to airway exposure during intubation in the operating, or intensive care unit. Surgeons, however, considered themselves at a lower risk of contracting the virus relatively to other specialties, since elective surgery are postponed and they are often face covered with surgical mask when interacting with patients in the operating room. and this.
In general, the risk of infectious disease is an inevitable consequence of caring for patients who may be asymptomatic carriers (20%) or who do have mild disease. Over the years and during pandemics, many types of airborne infections have been transmitted to health care workers and many lives have been lost among the medical staff. For instance, the world still remembers Carlo Urbani, the World Health Organization physician who investigated and alarmed the world over the SARS epidemic before the virus killed him in 2003 (12). With that in mind, doctors have major concerns with airborne or air droplets epidemics , but as our study shows, the vast majority of them fear spreading the virus to their families first, then to their patients, and finally to themselves. Only 3.8% of physicians were not afraid when dealing with infected patients.
Therefore, faced with these real concerns, do healthcare workers have a choice and avoid treating infected patients in the perspective of limiting their personal risk and that of their families? In this survey, more than 90% of physicians considered that treating patients with COVID-19 was not an option it was an obligation. For them, this was widely seen as a duty, then a medical mission, then an obligation. In fact, these terms are often used interchangeably, but they do not mean the same (13).
The duty to treat is considered to be the natural consequence of a social contract between doctors and the public. This contract empower the medical profession as they are the one in charge of the medical treatments (4). So, if we accept the duty to treat, could there be limitations to this duty (14)? During past pandemics such as the Spanish flu, doctors were considered to have a “mission”. They were the “heroes” whose mission was to take care of patients and save the world. No single reason should have compromised their principle of altruism (4,14). Does this mean that it is an obligation, just as the military are most at risk in wartime? Don’t doctors have the right to choose which patients to treat? After lengthy debate, the American Medical Association (AMA) implemented in 2004 new wording for “Physician’s Obligation in Disaster Preparedness and Response” (14). However, since no personal or professional duties are ever absolute, the AMA’s code listed the exceptions that physicians can use, on an individual level, to refuse treating in the event of a severe pandemic. Specific examples were listed for four themes: physical health, mental health, competing personal obligations and unacceptable levels of personal risk (4,13).
Nonetheless, as is widely seen, and in line with the beneficence ethical principle, physicians and health care professionals rarely refuse to provide care during a pandemic. In our survey, the vast majority of doctors declared that they were even willing to help if they were requisitioned in the event of a lack of specialists in the main specialties dealing with the disease, such as intensive care, emergencies and infectious diseases. In addition, the majority of doctors said they were ready to adopt an “on call” system during the crisis period. However, this “on call” system should be organized to limit the spread of the disease to all health care workers, but should not let the burden fall on a small number of physicians, nor encourage some of them to opt out from their duties (4).
To prevent patient harm, and thus respect the non-maleficence ethical principle, decisions need to be based on evidence, principles, and values. Regarding treatments, contrary to what is observed in other known diseases for which drugs have been approved after thorough clinical studies and requiring the FDA and/or EMA approval for prescription, the actual pandemic and crisis state shed light on the global need for immediate treatment which prompted doctors to prescribe drugs with a possible benefit, albeit small, for treating affected patients. In the era of evidence-based medicine, decisions for treating patients infected with COVID-19 are not always supported by evidence and recommendations but by expert opinion that demonstrate an efficacy of drugs that are proven safe in the treatment of another disease or that have well known adverse events. Doctors in this investigation were in favor of such an approach. However, in the absence of randomized control trials and clear-cut evidence, these drugs are usually used as a “last resort” or in the context of clinical trials. Therefore, beneficence and non-maleficence are two overlapping principles that can be argued from different angles (7,15).
Justice is also a debatable ethical principle during pandemics. Should we treat the patients by priority? In which case, who would be the priority? The people most likely to recover, the patients suffering the most or the most commendable people (16)? In fact, although no doctor wants to see a patient not receiving the best medical care, in times of pandemic, contagion means additional pressure on limited medical resources which can become saturated, and physicians may find themselves obliged to choose which patient to treat. When asked in the survey, 60% of doctors stated that patients should be treated by priority, considering pregnant women as a first priority, then immunocompromised patients followed by young patients and the elderly. Still, 40% of them declared that no patient should be prioritized over another. On another note, in this questionnaire, physicians revealed a neutral position concerning the withdrawal of mechanical ventilation from a patient with a poor prognosis if the latter is needed to treat a higher “priority” patient. Again, the occurrences of the latter term are difficult to interpret and is based on personal values, but this largely shows the impact of societal, moral, and ethical issues that doctors faces and that are hardly resolved by a simple answer or in a same manner by different physicians.
Autonomy is another primordial issue always adressed, especially during pandemics. Breaking medical privacy by disclosing the identity of sick patients is known to be discordant with the ethical principles of medical practice; however, during this crisis, the majority of physicians were in favor of revealing the identity of patients who refuse to adhere to strict recommendations in order to protect their families and communities. This is indeed is in accordance with ethical guidelines and laws that allow and require us to marginalize the privacy of patients for the greater good of the population (7,16).
Finally, concerning the management of the crisis in Lebanon, physicians seem to adopt a neutral position with regard to the country’s capacity to manage such a pandemic, probably because of the uncertainty of the evolution of the disease, which remains a worldwide problem. The medical staff remains ethically responsible for putting the interests and well-being of the patient first.