Medical professionalism in times of COVID-19 pandemic: is economic logic trumping medical ethics?

Dear Editor,

Medical professionalism faced a crisis of identity prior to the current COVID-19 pandemic, with unresolved issues of conflict of interest and notions emphasizing professional and academic misconduct dominating its discourse [1]. Declining trust among all stakeholders emphasized the need for professional accountability and integrity while encouraging control by external agents, logics and mechanisms [1]. In response, medical professionals committed to stewardship and just distribution of finite resources and provision of high value, cost-conscious care. To meet these challenging issues, medical professionals need to examine their roles and responsibilities above and beyond their “office”, serving as an immediate actor of change and improvement in health care systems. However, the ongoing pandemic setting exposed the tragic limits of such professional aspirations.

The COVID-19 pandemic caused a temporary global collapse, and an ongoing severe disturbance of health care systems by creating a surge of demand for all forms of medical care that cannot be adequately and safely addressed. In response, comprehensive and restrictive public health measures were applied that continue to exert deleterious side effects [2, 3]. Issues regarding (re)allocation of scarce health care resources are omnipresent, with medical professionals not only struggling to tackle the virus, but also reducing availability and level of care for all other patients, raising inherent ethical problems of equality and equity. The pandemic created the complex matrix of personal, professional and societal demands and obligations for medical professionals, while their abilities to care for their own health and safety and of their patients’ are profoundly undermined. Medical professionals are being pressed to provide care outside the limits of their professional expertise, often being forced to make previously unimaginable and unprecedented choices, such as to choose whom and when they should allocate lifesaving treatments [3]. One should not be mistaken that these issues concern only those on the “front lines”.

These efforts were not unnoticed by the public, a critical beholder of medical professionalism. One of the images that every physician will easily remember is a show of support by members of the quarantined public through public applause and song resonating throughout eerily empty public areas. This was followed by many stories about the exceptional bravery and commitment of medical professionals that are pushing themselves beyond the limits of their health and safety by filling all the gaps of ill-prepared health care systems. Some of them made an ultimate sacrifice by losing their lives.

Medical professionals must be able to exert both categorical rationality (ability to identify and prioritize goals) and instrumental rationality (ability to select and adopt suitable means to reach set goals) at all times, and especially in a crisis [4]. To be both professionally accountable and morally correct, guidance control (ability to perform a planned task) and legislative control (ability to choose between alternatives) are necessary [4]. This implies that guidance control is an inherent quality that is susceptible to valid logic and arguments and not a blind, unresponsive mechanism.

It would appear that this pandemic exposed the fact that medical professionals systematically lack instrumental rationality as well as legislative control due to various restraints, such as economic and organizational ones, imposed by non-medical agents. In this pandemic, and perhaps in the entire medical profession, utilitarianism underpinned by economic values was (and often still is) placed above medical ethics.

In COVID-19 setting medical professionals were praised for their impossible effort in a situation where they cannot fulfill their fiduciary deontological responsibility and purpose – care for those in need. These fundamental responsibilities were concerned with (re)allocating treatment and guided predominantly by a utilitarian logic. As a consequentialist approach, utilitarianism has a lot to do with how and who does define a pressing need and what counts as the desired outcome. Utilitarianism is not wrong in itself, especially not in an acute crisis in which demands exceed supplies, but it begs the question whether this context is illustrative or even paradigmatic for issues plaguing medical professionals in general.

Medical professionals must be recognized as moral agents with inherent worth and responsibility. This responsibility cannot be altered or suspended by the issues of resource scarcity. The commitment to provide ethical care in a crisis may only be sought from a medical professional if he/she is allowed to exercise power and control over the effective means necessary to provide effective care [4, 5].

If these requirements are set aside by non-medical concerns, such as political or economic ones, as currently widely witnessed, moral agency and the responsibility of medical professionals in some other, future context, should be discussed and renegotiated ab ovo. Otherwise, loss of control and undermined professional autonomy will continue to have a detrimental impact on medical professionals by causing moral distress, moral injuries, burnout and various other psychopathological phenomena. This does not mean that medical professionals should be univocally granted the position of unquestionable authorities, but should be spared the backlash of rationing and prioritization strategies put into motion by non-medical agents.

The central tenet of medical professionalism, and every helping profession, is the welfare and wellbeing of the person in need. The wellbeing of every individual patient must be paramount, and the fundamental question is how physicians, given only predetermined choices in difficult circumstances, can effectively be its advocates [1, 3, 5].