Opinion 11.1.1, "Defining Basic Health Care," in the AMA Code of Medical Ethics holds that health care is "a fundamental human good," and that society has "an obligation to make access to an adequate level of care available to all its members..." It calls on physicians and the profession to advocate for fair policies that "[p]rotect the most vulnerable patients and populations..."
Opinion 11.1.4, "Financial Barriers to Health Care Access," likewise calls on medicine and its practitioners to "work to ensure that societal decisions about the distribution of health resources safeguard the interests of all patients and promote access to health services." Opinion 11.1.3, "Allocating Limited Health Care Resources," forbids using "social worth" as criteria for allocating medical care.
Individuals who are homeless, incarcerated or in detention are the most vulnerable among us because they lack the freedom or opportunity to make meaningful choices about their situation and face significant challenges in access to care under the best circumstances.
In the context of a pandemic, those challenges are exacerbated, even as these individuals face greater risk of becoming infected and, if they do, the prospect of developing more serious disease than others. Moreover, members of these populations may be skeptical of the good intentions of physicians or the health care system and mistrust efforts to engage them in protecting their own health.
In setting out physicians’ responsibility to contribute to the health of the community, Opinion 8.11, "Health Promotion and Preventive Care," calls on physicians to promote health through a "collaborative, patient-centered process that promotes trust." It enjoins the profession to "[a]dvocate for community resources designed to promote health and provide access to preventive services."
In its background report ("Health Promotion and Preventive Care"[PDF]), the AMA Council on Ethical and Judicial Affairs observes that this requires physicians to "be aware of how individual patient circumstances may impact the effectiveness of health promotion efforts"—circumstances such as difficulties in transportation, accessibility or mobility, or access to healthy food. The report notes also that "[w]hen an individual patient experiences preventable medical problems, the community’s health deteriorates as medical resources are diverted from other areas of care."
Opinion 8.4, "Ethical Use of Quarantine and Isolation," addresses ethical responsibilities when quarantine and isolation are deemed necessary to protect the health of individuals and the public during outbreaks of infectious disease. Individual physicians have a duty to educate, persuade patients to "adhere voluntarily with quarantine and isolation," support mandatory measures when patients do not, and "inform patients and comply with mandatory public health reporting requirements." The profession as a whole has the responsibility to ensure that the "least restrictive means" possible are used to control disease based on sound science and further that measures are employed "without bias against any class or category of patient."
Finally, Opinion 1.1.8, "Safe Patient Discharge," calls on physicians to “resist any discharge requests that are likely to compromise a patient’s safety," and to "[c]ollaborate with those health care professionals and others who can facilitate a patient discharge to establish that a plan is in place for medically needed care that considers the patient’s particular needs and preferences." "Physician Responsibilities for Safe Patient Discharge from Health Care Facilities" (PDF), notes that "[p]hysicians should not discharge a patient to an environment in which the patient’s health could reasonably be expected to deteriorate due solely to inadequate resources at the intended destination."
Taken as a whole, this guidance argues that in a public health crisis, decisions about how to distribute medical and public health resources must
- Recognize that failing to give equal consideration to the needs of all populations within the community, and especially those who are most vulnerable, threatens not only the health of individuals but equally the health of the community as a whole
- Take a comprehensive approach to identify and address not only medical needs, but also structural factors that heighten risk to members of vulnerable populations, including support for recovery following an episode of crisis medical care
- Employ the least restrictive means possible to achieve individual and public health goals
- Implement objective measures to assess need and prioritize resource allocation evenhandedly across all populations in the community