I’ve been thinking about the obligations that attend taking responsibility for others’ health care, and how they dovetail with the moral obligations we all bear to one another.

Hurricane Katrina has brought that issue sadly to the fore in stories of the abandonment of patients to their deaths by nursing home administrators who failed to take action to evacuate, of terminal sedation/euthanasia of doomed patients – possibly at risk to their careers or liberty – by caregivers who had no other options; and, more heartwarmingly, of intense devotion to others, beyond duty, in the face of crisis. These stories are not necessarily better or worse than others we hear from that disaster zone, but that they feature the acts of healthcare workers who had accepted – or in some cases voluntarily took on, during the disaster – responsibility for others, and either met or failed the obligations they thereby entailed, makes these stories particularly salient for our concerns.

Traditionally, healthcare workers, and especially doctors, were seen as having a special obligation to patients – not merely the Hippocratic obligation of only seeking others’ welfare, but also an obligation of non-abandonment. Doctors were said to have braved contagious fevers during influenza and cholera epidemics of the 18th and 19th centuries, out of duty to the public health – and this tradition was cited in determining the obligations of providers to accept HIV+ patients in the early days of the AIDS epidemic. Doctors were also expected to provide pro bono care, and to pitch in in any emergency.

The historical veracity of these traditions is open to question, however. It has been said that many doctors did, in fact, flee the epidemics. We know that many doctors have opted out of treating HIV patients, and others have refused to perform abortions in the face of harassment and death threats from anti-choice terrorists; anecdotally, some doctors are said to eschew “MD” license plates and other insignia out of fear that they would be held accountable for failing to render aid in emergencies if they were seen driving by without stopping. And the rise of the “conscience clause” movement has elevated the refusal to treat patients not merely above the level of a moral failing of professionalism but, amazingly, to the height of an actual moral principle itself! Not only is the historical grounding of medical obligation somewhat shaky, but the contemporary recognition of that trend as morally binding has all but disappeared.

In large part, the free-marketization of the health professions has driven this trend. As medicine (and to some extent nursing) has become more lucrative, it has been seen more as a career choice for studious test-takers and less as a calling for the selfless. As with any career, its perks and benefits are jealously guarded, and the demands it makes can be resented. Why should medical-school graduates toil in fever swamps and brave terrorist bombs to serve their patients when graduates of the law schools these doctors would otherwise have gone to face no such obligation? As well, the grinding selfishness of contemporary society – part of, but distinct from, the market ethos that has swallowed everything in its path – no doubt contributes.

However dismaying the current state of healthcare providers’ ethical senses may be, however, I find it hard to argue for a distinct moral obligation to serve under duress, arising from membership in the healing professions per se. The reason is that I do not recognize healthcare ethics as a distinct form of ethical reasoning (that is, I do not recognize what Dr. Edmund Pellegrino, now of the President’s Council on Bioethics, calls “the internal ethic of medicine”).

I do call myself a “bioethicist” and a “medical ethicist” (depending on how neological I’m feeling that day), and certainly believe that there are particular questions to be asked about the ethics of healthcare. But I also think that those questions must be resolved by reference to the same old, familiar theories of ethics that we all know from general philosophical studies. What is distinct about “medical ethics”, as opposed to “general ethics”, is the characteristic situations and conflicts that it treats, not the ethical principles it calls upon. And thus, when we do cite particular principles of healthcare ethics – confidentiality, truth-telling, the four principles of the “Georgetown Mantra”, or what have you – we are merely citing shorthand references to broader principles that must be grounded in traditional ethical reasoning. There is a “medical ethics” in exactly the same way as there is a “legal ethics”, “business ethics”, “plumber’s ethics”, and “person-on-the-street ethics”, and with exactly the same content at the level of fundamental ethical beliefs.

Thus, any obligation that impinges uniquely on healthcare providers does so as a consequence of the unique circumstances of their practice, not the mere fact that they are healthcare providers. Confidentiality, for instance, is of great consequence in healthcare, and thus its violation is a grave moral harm – and thus, also, healthcare providers who come into possession of confidential information in the course of their duties incur a strong obligation not to disclose it, because of the general moral principle that there is a strong obligation not to do grave harm to others. I believe that an identical obligation of confidentiality obtains to any person who comes into possession of sensitive medical information. It would be just as wrong, and for just the same reasons, for an ordinary citizen who happened to fine someone’s confidential medical records (improperly disposed of, let’s say) to disclose them as it would be for a healthcare giver to do so. (To be sure, there are further reasons for the healthcare provider not to do so, that do not obtain in the case of the private citizen: it may be a breach of an explicit promise of confidentiality, it may harm the provider-patient relationship, it may drive the patient out of treatment, etc. But disclosure pure and simple is no better nor worse in one case than in the other.)

And so, in cases of extreme distress, such as natural disasters or war, we have far to seek to find a principle that requires providers to do more than private citizens must do. If they have taken on particular obligations to particular patients – as these nursing home administrators did – then of course they are obligated to carry them out. If they have a public duty to fulfill, as military personnel do, or the New Orleans cops who abandoned their posts did, they are similarly obligated to perform that duty. These duties are especially strong given that the presence of these individuals precludes others from playing the same role until it is too late (there are only so many cops, and no new ones can be obtained during a crisis, so if officers make the implicit promise that they will provide for the public order in times of need, and then renege on that promise when the time comes, they have left the public much worse off than if they had never made such a promise in the first place). But do doctors with no specific pre-existing obligations to patients or to public service have a duty to exhaust themselves, or even risk themselves, in emergencies and disasters?

It is difficult to answer “Yes” without appealing to some ethical principle emergent from the mere fact of being a member of a profession – principles which for the life of me I can’t identify, and which, it seems to me, raise grave dangers of professional hegemony and moral grandstanding (the likes of which we are now seeing with infuriating results).