The strength of the physician-patient bond is dependent, at least in part, on patients’ belief in their physicians’ altruism, ie, their willingness to do what is in the best interests of patients (ie, to fulfill their fiduciary obligation) and, historically, to occasionally do so at some risk. Indeed one of the cornerstones of professionalism is the primacy of patient welfare, a tenet that nurtures patients’ faith in that altruism. Altruism in turn provides patients with the confidence to trust their physicians, and to be open and honest, and thereby to establish a therapeutic relationship. When events transform medicine from the prosaic to the heroic (eg, early in the acquired immune deficiency syndrome [AIDS] epidemic, currently with the nascent US Ebola epidemic) patients’ admiration for the physician may become tinged with valorization. That valorization is grounded in the myth that at such times physicians will not merely commit their intellect and energies to the betterment of their patients, but will do so at personal peril. While it is not a myth that physicians have placed themselves at risk from entities as disparate as plague, human immunodeficiency virus, and Ebola, it is a myth to believe that all physicians have willingly done so.

During the plague years, many physicians chose not to do their duty, and did not don the plague doctors’ iconic costumes with their ankle-length coats and birdlike peaks to hold perfumed gauze to ward off the stench of death. More recently, in the 1980s, there were many publicized examples of providers distancing themselves from any obligation to care for AIDS patients, even those patients who presented with illnesses that would otherwise have fallen within their scope of practice. Indeed, there was enough “shunning” to lead the surgeon general to publically assail those who were refusing to provide care. Studies at the time reported that up to one quarter of physicians did not believe it was unethical to refuse to care for patients with AIDS. With the nation’s attention now focused on Ebola, and most particularly on 3 health care workers who contracted the illness while rendering care to infected individuals, the question we ask is what are physicians’ obligations to society to care for patients with Ebola virus disease, and, pari passu, what are society’s obligations to physicians.

Society invests heavily in their physicians. They partially underwrite their training. They donate their bodies to “science” in order help to train medical students. Despite contrarian beliefs, they continue to hold physicians in high regard (above scientists, engineers, artists, journalists, and clergy, among others) and recognize them as valued members of society. Most physicians are paid handsomely; physicians are more likely to be the upper 1% of earners than almost any other professional group. In exchange, physicians take an oath to serve–to avoid harming their patients, and to further their patients’ ends. The medical literature also demonstrates an evolution in medical ethics over the 2500 years since the time of Hippocrates, and speaks more precisely to the contemporary obligations of physicians. Physicians have historically played a high price for their revered status in society. Not only have they confronted infectious risks in the remote past–plague and tuberculosis–but they have continued to risk exposure in more recent times. As just one example, studies in the late 20th century clearly detailed the very high rates of hepatitis B (almost 30%) among surgeons. These risks and the obligations to assume them are seen as balancing all that society affords physicians whether supporting their training, offering respect, or providing significant monetary compensation for the care they render. At the height of the AIDS epidemic the American Medical Association espoused a view that we maintain succinctly articulates the role of physicians at times such as these, “A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is seropositive.”

If physicians are obligated to provide care than what are society’s responsibilities to physicians? In reviewing physician obligations to care for Ebola patients the Department of Public Health of Rhode Island said that fear of infection did not obviate physicians’ obligation to render care, “especially because the risk is understood and readily mitigated.” While it is unarguable that physicians’ risks should be mitigated, to date the nation’s track record in that regard has not been wholly reassuring. It is at the interface of physician responsibility and societal obligation that the boundary between obligatory and supererogatory (going beyond the requirements of duty) is defined.

With Ebola, society had the opportunity to confront the disease when it first arrived on our shores with optimal supplies and training given the relative wealth of the United States, and the murmurs of possible disaster that had emanated from East Africa for 40 years and that had become an insistent chorus over the preceding 4 months. Given the health system’s failure to prepare (regardless of whether and where the culpability should lie), the decision of health workers in Dallas, TX, to render care with improvised protective equipment, some exposed skin areas, and minimal training in donning and doffing could be seen as falling somewhere between supererogatory and foolhardy (or potentially misguided, or misled). However, even given a risk that has not been optimally “mitigated,” professionals will still feel a tug at their sense of obligation, much as a fireman coming home from a night out might still feel an urge to race into a burning building to rescue civilians, despite having no protective equipment at hand. Given the circumstances, the fact that professionals in Dallas, TX, did not turn away is to their lasting credit, and should never be dismissed as “people just doing their jobs.”

However, if steps are taken to reduce risks–optimal personal protective equipment (PPE) and training–to what is essentially the lowest possible level then rendering care should be seen as obligatory. This assumes that in the first instance the lowest possible risk is not an excessive risk (eg, undertaking an intervention in which the nature of the exposure may be not be appropriately mitigated by PPE), and that the activities that put people at risk are not futile acts. In considering Ebola, many have already judged that the risk is not exorbitant and their judgment has been supported by experience: thousands have undertaken care of Ebola patients, and yet only a handful became infected. In the United States, with proper equipment and training the risks will undoubtedly be lower than those reported from Africa, where many health workers may have become infected in ways unrelated to their work in health care facilities. If providing care for infectious patients is not seen as an obligation–a shared responsibility of all physicians–then, as in the AIDS era when many avoided caring for infected patients, there will be an unfair distribution of risk, with some accepting more than their fair measure of exposure. Individual decisions not to care for Ebola patients would also potentially undermine patients’ faith in the altruism of physicians and thereby degrade the esteem in which our profession is held and the trust that underpins the therapeutic relationship. Finally, as argued above, these obligations to provide care even at the expense of some risk are part of an implicit contract with society. They give tremendously to us; we encumber a debt from all society does and offers, a debt for which recompense is rarely sought. That is not to say that physician obligations are merely transactional, ie, we receive recompense in turn we assume risks. Rather we are merely acknowledging our venerated place in society, a place ceded to physicians at least in part because of who we are. Emanuel described what he believed was the essence of our profession when he said, “The objective of the medical profession is devotion to a moral ideal–in particular healing the sick and rendering the ill healthy and well.” This quote was written early in the AIDS epidemic, a time when considerations of physicians obligations were litigated eloquently and at length, and when many thought leaders articulated the mosaic of moral, historical, and professional imperatives to render care to the infected. Arnold Relman perhaps put it most succinctly, “the risk of contracting the patient’s disease is one of the risks that is inherent in the profession of medicine. Physicians who are not willing to accept that risk…ought not be in the practice of medicine.” We would amend that message to note that physicians need to be stalwart, not suicidal. Caring for an Ebola patient with proper equipment and training is stalwart. Undertaking such care without PPE or facility in its use is foolish and even with both may be, in some cases and for many invasive procedures, prudently abjured if the expectation for benefit to the patient is limited.

How do obligations argued for here translate on a practical level? At the very least it means that when in the course of one’s ordinary assignments (turn in a given unit or on-service assignment) the need to care for Ebola infected patients arises, such assignments should not be shirked.

Society too must take a generous attitude toward protection of their health professionals. In exchange for their service they should not be subject to discrimination or unreasonable burdens, such as quarantine in the absence of symptoms. Providers in Dallas, TX, who rendered care not only risked disease acquisition, they also faced stigma and separation from families and friends. Steps must be taken to address those risks as well as the more obvious and more lethal infectious perils.

At the height of the AIDS panic among health care providers Arras wrote that if physicians stood by their oath and rendered care to the ill regardless of the risk entailed then those physicians could, “proceed to tell a story, to relate a history, of a profession that has incorporated a willingness to take risks for the benefit of patients as a constitutive element in physicians’ self-understanding…According to this story, physicians, if queried about their commitment to accept risk in the line of duty, would simply respond, ‘This is who we are; this is what we do.’”

At that time Arras lamented that such a selfless reply was not yet widespread, ie, this was a story not yet told. Since those years, at least with regard to the care of those infected with human immunodeficiency virus, it has become more so. Now, in the time of the Ebola panic, rather than bemoaning the understandable fear of physicians, and the reticence of many to “step up,” it might be more instructive to celebrate and appropriately valorize people like Nina Pham, Amber Vinson, and Craig Spencer who have assumed their assigned roles in hospitals and health centers or volunteered for such assignments in West Africa and in so doing have who have earned the right to tell that story of altruism that Arras imagined.