“When pestilence prevails, it is their duty to face danger and continue their labours for the alleviation of suffering, even at jeopardy of their own lives” (American Medical Association 1847)

Less than a month into our project we learned that one of the deployed medical staff had contracted Ebola and was, with two colleagues, being flown back to the UK for treatment. Thankfully the patient, Anna Cross (a reservist and intensive care nurse), made a full recovery after being treated with an experimental drug.

The announcement that one of the team had been infected was a sobering reminder of the risks that have been taken by the healthcare workers who have responded to the Ebola crisis. Early on in the outbreak, the WHO reported that healthcare workers were disproportionately affected compared to other disasters and emergencies. As one of our early informants put it “Ebola feeds on the milk of human kindness”. The people most likely to be infected are those who nurse the sick – be these family members or professionals. Indeed, ensuring care for the carers (local as well as international) is a key driver in Operation Gritrock, which established dedicated beds for Ebola-affected healthcare workers. These were the beds being staffed by the medical military, and therefore presumably by Anna Cross.

Deciding on the extent of the duty to care for the sick, and then acting on one’s deliberations, is perhaps the first ethical challenge faced by those who travelled to West Africa. Humanitarian work is increasingly dangerous, with risks of violence as well as from environmental factors and accidents. But the need is great, overwhelming even. The World Medical Association International Code of Medical Ethics states that a doctor should “give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care”. But does the duty to care extend to caring regardless of the risks to self, as the early AMA code suggests? What about risks that can be brought home and visited upon one’s family and friends? What about the harms that result from never coming home at all? And, who should these ‘others’ be who might give aid to the sick and dying instead of me?

When disaster strikes at home, we expect our healthcare professionals to be the first on the scene. Indeed, on hearing of a major event, the first reaction of many professional and non-professional public sector care-workers is to report for duty. Not all disasters pose the same risks to those who respond, however. Responding to a major incident, such as a train crash or terrorist bomb may pose fewer risks to responders than responding to contagious disease or a chemical attack. The GMC tells doctors: “You must not deny treatment to patients because their medical condition may put you at risk. If a patient poses a risk to your health or safety, you should take all available steps to minimise the risk before providing treatment or making other suitable alternative arrangements for providing treatment…You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care.” And by and large this is precisely what doctors and other health-carers do. They respond because it is their job to respond. It is what they signed up for when they made their career choice. Far fewer, however, feel similarly obliged to help when disasters strike other countries.

The duty to care may, therefore, only be thought to extend to one’s local community. This interpretation accords with some of the arguments in favour of the duty of care at times of heightened risk, such as an influenza pandemic. In this context, it has been argued that healthcare professionals generally, and doctors in particular, enjoy an elevated status in society in part because they will treat patients regardless of the costs to themselves. In considering pandemic influenza it was noted that this willingness had not been tested for some years, but having enjoyed the status, healthcare professionals should be willing to deliver on the ‘contract’ during a pandemic. Some countries passed laws compelling them to do so. The same kind of reasoning has no purchase on a duty to care for those outside of the contract. Hence, claims that we ought to respond to need overseas tend to draw on arguments located in theories of global social justice. These arguments tend to be levelled at governments rather than individuals; though some individuals find them sufficiently compelling that they act unilaterally or outside governmental structures (e.g. by working for charities). Accordingly, those who undertake humanitarian service overseas are frequently volunteers. They are not regarded as ‘just doing their job’. And, of course, the risks can be greater. Foreign workers who responded to the Ebola outbreak have therefore been described as heroic, and rightly so.

But what of the military personnel who have deployed to the Ebola frontline? Military healthcare professionals are not volunteers in the same sense as the NHS workers who travelled with them to staff the hospital run by Save the Children. They went because they received orders to go. Unlike Non-Governmental Organisation (NGO) workers in other locations, they have been insulated from many of the non-Ebola risks of humanitarian work. Gritrock is a massive operation. Deployed staff are supported with a huge infrastructure including Ebola-insulated medical facilities for non-Ebola related sickness and injury, and have military protection in the event of any civil unrest. Properly so. Given that they have to go where ordered, those doing the ordering should minimise the risks to personnel following their orders. Military personnel, including health carers, know that they will sometimes be working in circumstances of risk, and degree of self-sacrifice comes with the territory. We might think that this is what they chose, what they agreed to when they signed up, what they get paid for and possibility even one of the attractions of the job. Does this mean that the military medical deployed to fight Ebola are not heroes in quite the same ways as the NHS volunteers who went to Sierra Leone?

There are several ways of answering this question. We might consider whether choosing a riskier profession displays heroic qualities, especially if the risks relate in some way to helping or protecting others, or doing work that others would rather avoid even though it is commendable work. We might draw a distinction between the obligatory and the supererogatory and on this basis determine what it takes to answer the call of duty and what is over and above the call of duty. We might look at how much courage is needed to undertake certain risks – even those one is obliged to face – and judge on this basis. Or we might think that the label ‘hero’ is serving a slightly different function in this context. It could be that the description is a part of our own duty of reciprocity. Again, thinking back to the debates around resilience planning for pandemic influenza, the duty of to care was often considered alongside what reciprocal duties were owed to those who answered the call. The demands of reciprocity included adequate personal protective equipment, prioritisation when it came to treatment/vaccination, protection from legal action when acting reasonably in an extended role, and compensation for loss of life, amongst other things. These are all ways in which the risks taken could be properly acknowledged – even though those concerned could be described as ‘just doing their job’. So perhaps what the term ‘hero’ suggests here is genuine moral admiration for undertaking morally worthy work, and perhaps this is what is reciprocally owed to everyone who does their job despite the risks and under difficult circumstances. After all, I have little difficulty in describing as heroes the West African local healthcare workers who cared for the Ebola sick, dying and dead with little or no personal protective equipment when they could simply have stayed away, and reduced their level of risk to that faced by the general population. They too were ‘just doing their job’.

Professor Heather Draper (PI on the project)