Physician autonomy in crisis: examining the right to refuse commitment

Figures & data

Table 1. Examples of texts dealing with the legal aspect of physicians’ duties during health crisis.

Country	Most discussed texts	Comments
USA There is no specific federal law explicitly exempting physicians from the obligation to treat in case of direct risk to their lives.However, several laws and regulations, including those related to public health and occupational safety, may influence how physicians manage situations presenting a risk to their own safety	1.American medical association code of medical Ethics (opinion 8.3: Physicians’ responsibilities in disaster response and preparedness) [11]: ”Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This obligation hold seven in the face of greater than usual risks to physicians’ own safety, health, or life”.	Recall the ethical principles, the principle of implicit consent which implies acceptance of risks even ‘greater than usual’.
	2.EMTALA (Emergency medical treatment and active labor act) [3]: It obliges participating hospitals to provide emergency services to all patients (regardless of their condition or ability to pay) and to stabilize their health status before transferring or discharging them.	Hospitals have the responsibility to treat individuals with highly infectious diseases if their condition is deemed an emergency. There are no exceptions under EMTALA regarding direct threats or significant risks to the safety of physicians [3]. However, physicians’ duty to treat under EMTALA is voluntary insofar as it applies only to physicians who have contractually agreed to provide emergency care. As the 5th circuit notes, a physician ‘is free to negotiate with [a hospital] regarding his responsibility to facilitate a hospital’s compliance with EMTALA’ [3].
	3.ADA (American with disabilities act): Federal law that prohibits all forms of discrimination [3].	The ADA requires physicians to treat all patients without discrimination, including those who are highly infected with infectious agents (the example is often cited for human immunodeficiency virus, while the debate persists for certain types of viral infections).
	4.OSHA (Occupational safety and health administration): It establishes standards for workplace safety and health and can intervene in situations where physicians are exposed to risks to their health or safety [12].	These are safety standards applicable to employers and workplaces, not individuals (physicians). However, OSHA can serve as a defense argument for physicians who have refused to engage [3].
	5.MSEHPA (Model state emergency health powers act) (Article VI, section 608) [13]: a) ‘To require in-state health providers to assist in the performance of vaccination, treatment, examination, or testing of any individual as a condition of licensure, authorization, or the ability to continue to function as a health care provider in the State.’ b) The appointment of out-of-state emergency health care providers maybe for a limited or unlimited time	It grants considerable executive and legislative powers to state governors in times of emergency, allowing them to suspend or modify laws in order to address health risks^5. This legislation gives the governor the right to ‘call up’ physicians to serve the authority. In case of refusal to comply, the physician risks license revocation [14].
Canada The legislation varies considerably depending on the provinces [7].	1.The Canadian medical association code of ethics [7]: “Physicians have a fundamental ethical responsibility to ‘consider first the well-being of the patient’ but also to promote and maintain [their] own health and well-being». In Canada, physicians owe a duty of care only to their existing patients, even in an emergency [7].	Physicians have ethical responsibilities to their patients, to society, to the profession and to themselves [7].
	2.Labor boards across Canada have affirmed that workers must satisfy 4 criteria to justify a refusal to work because of unsafe or dangerous conditions [7]. Workers must honestly/reasonably believe that their health or wellbeing is endangered. The danger must be sufficiently serious to justify the action; it must be immediate and more than a matter of repugnancy, unpleasantness or fear of minor injury.	Exceptionally, the province of Quebec has a legislation stating that ‘every person must come to the aid of anyone whose life is in peril, unless it would put his or her life or another’s life in jeopardy’ [7]. Similarly, the occupational health and safety statutes of Ontario, Quebec, Nova Scotia, Yukon Territory and the federal government state that ‘workers may not refuse to work if such refusal puts the life, health or safety of another person in danger’ [7].
	All Canadian provinces have legislation that outlines the government’s powers during a state of emergency [7]. This legislation permits the government to authorize or, in some provinces, require physicians to provide services they are reasonably qualified to provide if a pandemic is declared [7].	The right to refuse treatment is a constitutional right in Canada [7]. Physicians have the right to refuse care if their workplace safety is not assured. This right protects them from any disciplinary action. The legislation does not negate physician’s right to refuse to work in unsafe conditions [7].
France	Article L3131–15 of the public health code [15]: ’In territorial jurisdictions where a state of health emergency is declared, the Prime Minister may, by decree order the requisition of any person and all goods and services necessary to combat the health disaster.’	These are legal provisions that grant the power to ‘requisition’ healthcare professionals in the event of an emergency.
Tunisia	The Tunisian medical code of ethics imposes on physicians [16]: To respect life and the human person, which constitutes a primary duty of the physician (Article 2). To assist and treat those in need (Article 5). Not to abandon their patients in case of public danger, except on formal order from qualified authorities (Article 6). To adopt a behavior in line with the general principles governing the practice of the profession, notably to ensure the safeguarding of life and human health (Article 29). Not to refuse care to the patient for professional or personal reasons in case of emergency (Article 37).	The general spirit of Tunisian laws imposes on healthcare professionals, in times of crisis, a primary obligation to act in the best interest of patients despite limitations in therapeutic means and/or working conditions. The physician has the duty to deal with the conditions imposed by the crisis by giving priority to the patient’s interests. It has always been and remains to the credit of physicians not to flee from danger.

Table

TO TAKE HOME MESSAGE: In times of crisis, physicians face complex moral and legal dilemmas regarding their duty to treat. Despite societal pressures and legal obligations, there remains ambiguity surrounding physicians’ rights to withdraw from risky situations. While historical and ethical considerations often drive physicians to continue their work, the lack of consensus within the medical community highlights the need for cautious decision making amidst legal uncertainties.

American medical association (AMA) code of medical ethics. Opinion 8.3: physicians’ responsibilities in disaster response and preparedness. [cited 2024 Mar 26]. Available frorm: https://code-medical-ethics.ama-assn.org/ethics-opinions/physicians-responsibilities-disaster-response-preparedness

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U.S Department of labor. Occupational safety and health administration. Law and regulations. [cited 2024 March 26]. Available from: https://www.osha.gov/laws-regs

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The center for law and the public’s health at Georgetown and Johns Hopkins universities. The model state emergency health powers act. [cited 2024 Mar 26]. Available from: https://publichealth.jhu.edu/sites/default/files/2023-06/msehpa.pdf

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Davies CE, Shaul RZ. Physicians’ legal duty of care and legal right to refuse to work during a pandemic. CMAJ. 2010 Feb 9;182(2):167–170. doi: 10.1503/cmaj.091628

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Legifrance. Article L3131-15-public health code. [cited 2024 Mar 26]. Available from: https://www.legifrance.gouv.fr/codes/article_lc/LEGIARTI000042103698/

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National council of the order of physicians. Code of medical ethics. [cited 2024 Mar 26]. Available from: https://www.conseil-national.medecin.fr/sites/default/files/codedeont.pdf

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Data availability statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.