When Disaster Strikes

When disaster strikes, professionalism and heroism can be confused and conflated. Although professionals can act heroically, it is important to distinguish ordinary actions from extraordinary ones, lest we make heroism a normative expectation. In this essay, I pursue these distinctions through the guise of narrative ethics as understood through my personal experiences during 9/11. I then reflect on the challenges to professionalism that are associated with the provision of care during medical emergencies such as a pandemic flu or the Ebola outbreak. I argue that distinguishing professionalism and heroism is necessary to maintain the basic functioning of healthcare systems when they are stressed by catastrophic events.

9/11

I remember the morning well, as I suppose we all do. I was listening to the radio at home, preparing to spend the day studying for my upcoming recertification exam in internal medicine. I first thought the report of the plane striking the World Trade Center a spoof and then an accident. I turned on CNBC and watched the second plane strike the other tower as it happened. I knew immediately that this was not an accident and, more importantly, that there would be casualties. I scrapped my plans for study, put on a comfortable pair of khakis, grabbed a bunch of PowerBars, and rushed off to the hospital. I called my wife at work to tell her about the news but was only able to leave a message for her to be safe. She was in a meeting, and I was unable to get through. At that moment the routine tasks of the day were still more pressing than my warning.

Walking the three blocks to the hospital, I barely noticed the stunned faces of my fellow New Yorkers. I was deep in my thoughts, wondering how I could help. What precisely should I do when I arrived in the emergency room? I thought there would be thousands of wounded all needing services that would far exceed anything our academic medical center could provide. We would all have to stretch ourselves and work as hard as humanly possible. I hoped to work until I fell asleep and could not do any more.

But what would I do? Certainly, victims of trauma would need surgery. Perhaps I could help operate, but it had been years since I last scrubbed up and saw the inside of an operating room. I thought more about how I would self-deploy and admitted to myself that the assistance of a third-year medical student coming off his or her surgical clerkship would be more helpful than my well-intentioned hindrance. But was it that simple?

As I continued walking, I thought of professional limits and qualifications. What precisely would be the rules of engagement when all hell breaks loose? Obviously, under normal circumstances I would never be allowed to do the sorts of procedures I might imagine myself doing in the midst of 9/11. How does one modulate one’s response when circumstances are drastically in flux? At what point do rules and norms yield to context? And how far do they have to yield to move from an intelligent adaptation into Joseph Fletcher’s situationism,^{Footnote 1} an anything-goes response?

A devolution into situationism bothered me, yet I did not want the proverbial “perfect [to] be the enemy of the good,” or the good enough, when so much needed to be done. I began to see the question as one of harm reduction, a utilitarian response, given the mass casualties we were expecting. The goal, simply stated, was to prevent death and morbidity, and to do so the system needed to find a quick, albeit improvised, balance between an adherence to usual norms of practice and an ad hoc response that could itself engender harm. Professionals had to act at the extremes of their competence and not beyond, where interventions could cause disproportionate risk.

By the time I got to York Avenue I concluded that I really shouldn’t be operating. So what does an internist, and clinical ethicist, do in the midst of a disaster? After I quickly realized that surgery was not an option, I appreciated that I came to this conclusion through a process of ethical discernment, and, yes, it was that very process in which I should be deployed.

I would be a triage officer and team up with a surgeon to prioritize care and our use of what would soon be limited resources. This plan, which may seem obvious in retrospect, was not immediately clear as the tragedy of the morning was unfolding. It was clearly an improvisation.

I had never been a triage officer or served in the military and had only theoretical knowledge of the practice, but I figured that, as chair of the ethics committee, I might be well prepared for the task. I had written on medical futility^{Footnote 2,Footnote 3,Footnote 4,Footnote 5} as well as distributive justice and decisionmaking in intensive care,^{Footnote 6,Footnote 7} and these seemed legitimate proxies for direct experience as a triage officer, until someone more experienced came along to serve in this role.

As I arrived in the emergency room, I was greeted by an orderly pushing a stretcher to the morgue with one of the first fatalities from the World Trade Center. I can still see the toe tag on the body and the dread that it foretold about what was happening downtown in New York City. I was stunned that a place I thought so safe, so secure, had come under direct attack.

It would have been easy to become overly emotional about the tragedy, to contemplate our collective loss of innocence, but as I turned the corner and entered the main core of the emergency room, my musings began to feel self-indulgent and out of place. As I looked down the bay of the ER, I was greeted by three hundred colleagues working to ready the place for the patients whom we soon expected. It was a mosaic, a mix of colored surgical garb and white lab coats. Everyone was intensely focused on the mundane tasks of preparation. Their most obvious handiwork was a room full of IV poles bedecked with bags and tubing, awaiting all those who would need fluid replacement to stem the hemorrhage and shock of trauma.^{Footnote 8}

As we waited for the patients to arrive, fear was in the air as rumors began to circulate. We heard that the towers had collapsed, and then, because both the Internet servers and New York’s television transmitters were now under the rubble, we were cut off from the news. First we heard the White House had been bombed. Then we heard that a bomb had exploded on the 59th Street Bridge, just down the road from the hospital. We all felt that we were in real danger. The threat was shrouded in mystery, and it seemed as if the front lines were close.

I recalled thinking that we were at war, and strangely I wasn’t afraid. I told my colleague, a neurologist, that if we died doing what we trained to do, that would be okay. Neither of us had kids at the time, and we had a strong sense of duty. I thought of the heroism of my dad, a decorated combat medic in World War II. Although my time in the ER could never equate with what he had done as his unit fought its way through France and Germany,^{Footnote 9} I was relieved that I was ready to accept whatever might happen to me.

So we all waited. Only a few patients arrived, those who been evacuated from the towers before they fell. But it was nothing like what we expected. We wondered why everyone was delayed. Was transport a problem? Were there enough ambulances? Were the roads destroyed? We could not even imagine that 3,000 people had been etherized and that the cloud of debris covering Manhattan embodied our collective loss. We would learn that in the aftermath.

In the clutch of denial—or, better, disbelief—we waited, full of anticipation, eager to use our skills to make this horror a bit better, to repair and restore what had been broken, and, short of that, to be a balm to the suffering. That was our collective wish.

And then, around eleven o’clock, some three hours after the first plane struck, the head nurse of the ER stood on a chair and addressed us through a bull horn. We should go back to our offices and wait there. They would call us when the patients arrived.

When I went back to my office, I heard about what my colleagues had been doing. Administrators and hospital leadership were putting the medical center in a position to receive mass casualties. Again, this was improvisation, as professionals who had never been exposed to such monumental challenges drew on their experience to respond. At our hospital, and others in the area, patients who were well enough for discharge were sent home. Those who still needed care but not necessarily a hospital bed were moved to the outpatient clinic, which had been hastily staffed to accommodate inpatients. The cafeterias were set up with additional beds for the staff members who anticipated long hours and were now marooned on the island because all the bridges had been closed.

The response I had seen in my hospital extended beyond our walls. Situated north of the disaster and designated the city’s burn unit, we planned to receive patients from downtown. Colleagues around the country quickly contacted us to provide mutual aid: burn surgeons from the U.S. Army, nursing staff from Brown University, and supplies from the Midwest. It was a collective display of collaboration, the usual marketplace competitions suspended in the pursuit of a common purpose and values.

Months later I met with Michael Whitcomb, then editor of Academic Medicine (oral communication, 2002). We shared memories of 9/11 and the following months. He told me that the improvisation I had seen at my hospital was a process that repeated itself throughout the country. Dr. Whitcomb felt that the response—whether at the level of individuals or healthcare systems—was the essence of professionalism, highly skilled practitioners drawing on their training to adapt to unanticipated circumstances in a creative and novel way because of urgent need. As I recall, Dr. Whitcomb felt that this latent capability of the healthcare systems, and the individuals that make them work, was the often unseen benefit of rigorous—and often redundant—training, which is a component of professionalization.

Although these professionals were departing from the script, and conventional protocols, they were still acting professionally. Indeed, it could be said that, in drawing on all their knowledge, skills, and experience to respond, they were living up to the highest aspirations of their profession, with their actions and intent serving as model behavior for the next generation’s study and emulation.

Sadly, all the preparation was for naught. The disaster was nearly complete, and the wounded who were expected to flood our emergency room and surgical suites never materialized. By noon it was clear that there would be few survivors. The destruction downtown was total, and the streets were now full of refugees. First Avenue was closed, full of dazed pedestrians walking against nonexistent traffic. Clutching briefcases and water bottles, they were covered with the grime of the explosion. Their procession was quiet and solemn, and they only looked up when they thought they heard another plane.

Headed north, the survivors had a direction. They were fleeing the destruction and a past they would never forget. In contrast, those of us at the hospital were directionless. Suddenly, we had nothing to do. The energy that had motivated our mobilization was now replaced by a weariness and dread.

Later that day, as in the morning, we were bolstered by a final act of professionalism. Al Mushlin, our chairman of public health, gathered us together for our monthly meeting and showed courage when spirits were flagging. He thanked us for our efforts, as frustrated as they had been. He told us that our intentions were important. We had been ready to help and sacrifice. That’s what matters. That is what doctors and nurses do; we try to bring a dose of sanity to mindless destruction. And then he let us talk about our feelings. He concluded the meeting by asking those of us who lived in Manhattan to put up our outer-borough coworkers until they could get home. If we had an extra bed or a sleeping bag, perhaps we could extend a bit of hospitality?

Dr. Mushlin’s simple gesture, one of common purpose and civility, reminded me of the philosopher Phil Hallie’s work on cruelty. Writing in his masterwork, Lest Innocent Blood be Shed, of the rescue of Jewish children by the Huguenot community of Le Chambon-sur-Lignon during the Nazi occupation of France, Hallie maintained that the opposite of cruelty was hospitality.^{Footnote 10,Footnote 11} I never quite understood what Hallie meant until I considered my chairman’s gracious request to invite a colleague to be a guest in my home.

Discernment

In the years since 9/11, all of us have had the occasion to think about disasters, both natural and manmade. We have the legacy of Katrina and the SARs epidemic, the ongoing scourge of Ebola, and the lingering threat of an H1N1 influenza epidemic as referents to consider the place of professionalism when catastrophes shake our routine and norms.

I must confess that my thoughts about professional obligations have evolved since the collective trauma of 9/11. Now that I am a father, I wonder if my first destination that morning would have been the emergency room or my son’s school. Would I really abandon my child when the threat was near? Wouldn’t I want to be sure that he was safe and protected? Whereas I was willing to serve without reservations in 2001, I could not neglect my obligations to my son at this stage in my life.

Although I admire the courage exhibited by my younger self, we should not mistake heroism for professionalism, especially when the former was an artifact of what Homer described as the winged words of Rumor. The scene in the emergency room as we readied for casualties reminded me of the scene in the Iliad as the troops of Agamemnon assembled for battle:

Even though the threat to our emergency room was founded on false information, the fear that day was real. It had the potential to turn the provision of ordinary care into acts perceived as heroic. And therein lies the challenge. We should not expect clinicians to be heroes, lest we set up expectations for professional comportment that will only be attainable by heroes. Professionalism, by contrast, can be normative for those engaged in the practice of medicine: it may include competence in practice and the professing of a corpus of specialized knowledge; adherence to a collective set of norms and values, such as honesty and integrity and placing the interests of the patient above self-interest; respect for confidentiality, patient self-determination, and the rights of surrogate decisionmakers; responsibility and reliability when called on to aid the sick and injured; and personal and collective self-regulation in light of these aforementioned expectations pertaining to knowledge, values, and comportment.

Despite the consensus on these elements of professionalism, the lines are not always so clear, because both heroes and professionals operate within a virtue ethic in which one of the shared virtues is excellence. The pursuit of excellence applies to both the hero and the nonhero.

This expectation explains, I believe, the often overlooked conflation of professionalism with heroism. But there is a difference. Heroes by definition are exceptional; they defend ideals, principles, and peoples, often at the risk of self-sacrifice. As such, their actions are only accessible by a select few. They could never be both heroic and ordinary, although, as Hallie notes, most heroes do not think their actions are extraordinary.

Those who respond in these uncommon ways are often modest about their actions. They are surprised to be viewed as heroes, as they see their actions as normative. In the context of a healthcare professional, this can make the distinction between heroism and professionalism difficult. From heroes’ reference point, their heroism does not seem special. They view their actions as a responsibility, a binding obligation that cannot be waived or delegated. And it may be that, given the mix of constitution and context, they had no choice but to act in ways that others would view as heroic.

And therein lies the definitional challenge. Determination of what constitutes heroism usually falls to others, and to history, which evaluates one’s actions and lauds one’s courage. Although these actions start as a personal decision by the individual, determining whether they rise to the level of heroism is a comparative judgment made by others who relate what was done with what most of us would do if similarly challenged. By definition, heroism is neither routine nor conventional. It is special and deserves not to be confused with the ordinary expectations we have of professionals.

Although some professionals surely are heroes, we should not expect the heroism of self-sacrifice and bravery to be a requirement for professionalism. Expecting heroism when we should accept professionalism can also make the altruistic reconsider their obligations, because the heroic is only obtainable by the few. This is counterproductive to efforts to maintain the workforce,^{Footnote 13} as setting the bar at the level of heroism means that only a few will attain it.

These concerns are more than theoretical. First responders, when surveyed about a hypothetical small pox epidemic, reported their hesitancy to report for duty if they did not have adequate protective gear, if a vaccine were unavailable, or if their service placed their family at risk.^{Footnote 14} Similarly, only 17.6 percent of a mix of Australian healthcare workers reported that they would “work unconditionally” during an influenza A (H1N1) epidemic. This number increased marginally if they were told they had access to antiretroviral treatment and prophylaxis; these responses often stemmed from healthcare workers’ overestimation of the mortality threat posed by pandemic flu.^{Footnote 15} A study from Japan revealed similar data. Only 18.8 percent of staff would “perform their duties as usual, unconditionally.”^{Footnote 16}

These transnational manpower issues demonstrate that if healthcare workers believe that they need to act heroically in order to fulfill their professional obligations, a majority will cease to meet minimal expectations of professionalism. Although it is necessary to properly educate staff about risks and benefits so they do not falsely inflate their perception of risk, data suggest that this will not sufficiently remediate these challenges.^{Footnote 17} It is equally important to differentiate usual notions of service and sacrifice from placing staff in situations that confer untenable risk.

Richard Zaner, writing about the right-to-die case of Dax Cowart, makes a useful distinction in the context of “heroic measures.” He observed the following: “Even if, in a word, our heroic measures . . . could save a life, we must first consider whether by doing so we have thereby made it necessary that only a hero could live that life. While we cherish heroes, it is surely no part of our duties to force another person to be one.”^{Footnote 18} To extend Zaner’s point, although we honor professionals who act heroically, we should not force heroism on professionals. Such an imposition would be definitionally impossible and harmful to the public health when disaster can make acting professionally difficult enough.

To expect fathers or mothers to be heroic and not have concerns about their personal safety and the welfare of their family can have dire implications for the workforce. Better to not have unrealistic expectations of clinicians, lest they disappoint, cease to act as professionals, and fail to fulfill more normative expectations, like simply showing up. Equally important is prospectively establishing criteria for staff to volunteer for riskier tasks and for conscientious objection within a framework that allows clinicians to hold onto their professional identities.

Distortions, Justice, and Ventilator Allocation

There is an additional risk to the kind of exceptionalism that comes with confusing heroism and professionalism. If we expect clinicians to be heroes, we may inappropriately treat them as such. This not only diminishes the contributions of the truly heroic by false conflation. It can also lead to dangerous distortions related to distributive justice and collegiality. False veneration can lead to the expectation that physicians receive special treatment, a tendency that can threaten health equity when deciding who should be the beneficiary of scarce medical resources during a time of crisis.

My colleagues and I on the New York State Task Force on Life and the Law confronted this question when considering whether or not special priority should be given to doctors who might become ill in a H1N1 influenza epidemic.^{Footnote 19} Projections suggested that during an epidemic, a log deficit in the number of available ventilators would quickly develop, making allocation of this scarce resource necessary.

The Task Force adopted a triage protocol that was based on physiologic criteria and the correlative likelihood of recovery. It was in large part a population-based approach adopting a utilitarian framework designed to save the maximal number of lives. But the question of whether to grant special status to physicians remained: would the doctors who became ill fighting the epidemic be exempt from the criteria we had recommended for everyone else?

Such special status has often been granted, because a military unit without its doctor or a community without its physicians is especially vulnerable. It is in the collective best interest to return physicians to health and to restore their ability to function. But our conclusion was different when considering projections of how an H1N1 epidemic would proceed. We learned that it would take more than six weeks for a patient with H1N1 to recover enough functional status to resume medical practice, if recovery was achieved at all. Unlike the situation of physicians in battle, whose needs are pressing, by the time this recovery occurred, the epidemic would have moved on to more distant locales, making the recovery of physicians stricken weeks earlier irrelevant for the provision of care. Given this, the Task Force decided not to recommend exempting physicians from ventilator triage, because it would not facilitate the provision of care.

And beyond this practical concern, we also argued against preferential status for physicians because we worried that it could also exacerbate hierarchies among healthcare workers and worsen health disparities in the community, a clear risk during times of scarcity.^{Footnote 20,Footnote 21} We argued for solidarity among all those involved in the provision of care, instead of favoritism toward physicians, because first responders, nurses, and housekeepers all have a critical role in responding to the needs of patients and minimizing the spread of contagion, all critical services during an epidemic.^{Footnote 15,Footnote 16} Although healthcare workers would have preferential access to measures to prevent disease and to maximize their ability to provide necessary care, social solidarity and logic called for a more equitable response when considering who would have access to ventilatory support.

Ebola: A Duty to Question and Plan

These considerations about the provision of tertiary care during an epidemic bring me to more current questions raised by the recent Ebola pandemic. When the first cases of Ebola came to the “developed” world, it struck me that no one had written about the question of the proportionality of care in tertiary care settings—and, specifically, about the question of cardiopulmonary resuscitation.

On October 10, 2014, days after the death of Ebola patients in Dallas and Madrid, I wrote a commentary for the Hastings Center blog, Bioethics Forum, about emerging questions related to cardiopulmonary resuscitation.^{Footnote 22} Given the quick pace of events that fall, I decided to place my essay there instead of in a more conventional medical or bioethics journal, where publication could be delayed for months.

I called for hospitals and state and federal government to review laws—and policies—on presumed resuscitation as they relate to Ebola, clinical practice, and the public health. I argued that these policies should emphasize proportionate and compassionate practice and should set realistic goals of care.

My overarching goal in starting this discussion was to bring these questions out of the shadows and to initiate a dialectic that would be refined over time. Someone had to initiate that process with a grounding Hegelian thesis, leading to a more synthetic analysis. In the short term, I wanted to avoid institutional and governmental ad hoc responses related to the question of resuscitation that might be idiosyncratic to one institution or another, thus treating people who were similarly situated differently. This would violate due process concerns and thus be discriminatory.

Somewhat controversially, I argued that we should consider the place of unilateral do-not-resuscitate (DNR) orders in patients critically ill with the virus, if appropriate surrogates did not otherwise consent to forego cardiopulmonary resuscitation (CPR) and pursue a more palliative approach. I believed then, and still do now, that I had a professional obligation to initiate a discussion about this critical issue, even though our knowledge base was evolving, and thus contingent. Given the pandemic, we collectively had a duty to question and plan, notwithstanding the discomfort it might engender, as we questioned established norms of practice.

I raised the question of the ethics of resuscitation in patients gravely ill with the virus and the usual presumption of the appropriateness of cardiopulmonary resuscitation in patients who sustain a cardiac arrest. The argument gained wider notoriety on October 20, when Lawrence K. Altman featured my Bioethics Forum article in the New York Times.^{Footnote 23}

I maintained that patients with Ebola should receive all standard medical measures and experimental interventions, including ICU care, massive fluid replacement, and dialysis, efforts that can forestall and prevent electrolyte abnormalities and circulatory collapse. I urged hospitals to discuss the utility of CPR as they would for any other patient with a fatal disease; to be transparent about the limits of available care; and, given the grim prognosis of patients with advanced disease, to provide an assurance that all intensive care and comfort measures would be made available while questioning the usual default presumption of cardiopulmonary resuscitation. I later learned that this was the policy of the designated Ebola center at the University of Nebraska Medical Center, which cared for three patients medevaced from West Africa (Angela Hewlett, M.D., M.S., email communication, 21 Jan 2015).

My argument was based on questions of safety, feasibility, efficacy, and utility and its correlate, futility. Finally, I considered the risk of contagion to staff and the broader public health. First let us address the question of safety. Because Ebola is a hemorrhagic fever, in which some patients have uncontrolled bleeding, chest compressions could make matters worse and could prompt more rapid exsanguination. Since I made this argument, evidence has emerged that the strain of Ebola originating in West Africa seems far less hemorrhagic than predecessor strains, although “limited charting” made it difficult for researchers to definitely exclude this sign.^{Footnote 24} Nonetheless, for those patients with a severe bleeding diathesis, CPR would be contraindicated.

A second challenge was that of the feasibility and the logistics of CPR, given the competing challenges of ensuring both a rapid response and that staff be properly garbed in personal protective equipment (PPE). Distinguishing professionalism from heroism, I asserted that no one should expect the typical rapid response of a “conventional” code, because physicians, nurses, and respiratory therapists would need time to don their PPE. Incidentally, after I first wrote the article, the Centers for Disease Control and Prevention (CDC) guidelines for PPE were enhanced, given that the medical staff treating Mr. Thomas Duncan in Dallas contracted the disease.^{Footnote 25,Footnote 26,Footnote 27}

My third concern related to efficacy and medical utility. First, I worried about the amount of time it took to don protective gear, estimated to be ten minutes. This delay could risk hypoxic brain injury or anoxia for patients who were not yet intubated and on a ventilator. Because brain death can occur within eight minutes and anoxic brain injury over a shorter interval,^{Footnote 28} such delays in ventilation prompt the question of whether resuscitative efforts under these circumstances would be futile with respect to protecting cognitive function. Although subsequent practice requires that one fully garbed nurse remain in the room with Ebola patients at all times, a code would require a team of healthcare workers all needing to get into protective equipment, and a true epidemic would prompt manpower issues, during which this level of staffing might not be possible.

More fundamentally, turning to medical utility, I asked about the impact of resuscitation on the course of the underlying disease process. This was an important prognostic question. Would resuscitation make a difference in survival for patients with end-stage disease and cardiovascular collapse? I did not think so, because there is no available therapy for Ebola; this is all the more true for patients in extremis, making resuscitation in this context an exercise in futility.

We often resort to analogic reasoning when making ethical arguments, and it is important to note when analogies fail, namely, the comparison of the care of the patient infected with Ebola versus one with gram-negative sepsis or HIV/AIDS. The septic patient can receive supportive care until antibiotics can exert their effect. This is also true for the HIV patient.

The lack of available therapy for Ebola also contrasts with patients who have HIV/AIDS. Even in the pre-HAART (highly active antiretroviral therapy) era, when I was a medical resident in training, resuscitation of patients with HIV had therapeutic utility. Neither then nor now have I been a proponent of unilateral DNR orders in HIV/AIDS; in this regard I point to the importance of inductively grounding ethical arguments within a clinical context.

I willingly participated in the resuscitation of these patients, if that was consistent with patient and family wishes, because it was not a futile intervention. HIV-related conditions like Pneumocystis carinii (now called Pneumocystis jiroveci), which could lead to pneumonia, respiratory failure, and cardiac arrest, could be treated with temporizing ventilatory support, steroids, and antibiotics. All interventions for Ebola, such as the use of convalescent sera and ZMapp antibodies, remain experimental and unproven.^{Footnote 29}

A final distinction between HIV and Ebola is that of contagion and disease containment. The viral load of Ebola patients increases—and is greatest—as they are closer to death. This makes the risk of transmission to healthcare workers greatest in patients prone to cardiovascular collapse and cardiac arrest. The public health risk of widening the epidemic is increased when the heightened contagion of end-stage disease is admixed with the setting of a code, when emergent central line placement and endotracheal intubation can expose clinicians to blood and secretions in an often chaotic and uncontrolled setting. This risk is further heightened when a patient presents to an emergency room and is not in the more controlled setting of an isolation unit.

This multivariate assessment of safety, feasibility, efficacy, utility, and contagion risk coalesces into a question of burdens and benefits or proportionality, an evaluation that could change as new treatment strategies improve, as I hope they will. The ethics of Ebola care and resuscitation will need to evolve over time and remain reflective of how the pandemic reached such levels. Any debate about cardiopulmonary resuscitation in the resource-rich West needs to note that these concerns are but a sidebar to a global pandemic whose resource-starved opponents are still working to achieve containment and eradication. These concerns only came to our attention when the virus breached the Atlantic and came to our shores; it is a neglected disease that gained only brief attention because it arrived for a brief time in the developed world. If we had paid more attention to the crisis in theater and had worked to develop effective strategies for prevention and treatment, the proportionality of resuscitation might now be different, changing my argument about the utility of the resuscitative act.

Reflections

It can be uncomfortable to raise questions about the limits of professionalism, the boundaries of heroism, and the obligations of healthcare workers when disasters and epidemics disrupt our daily norms. Although such a fluid situation can make it difficult to make an argument, contingency does not obviate a responsibility to voice a considered opinion when it is needed to catalyze an important discussion. I only hope my contributions have been both responsible and catalytic.