What is heroism?

The term hero is widely used and has been applied to a range of fictional and real figures, and consequently it is difficult to reach a precise definition that adequately reflects its common usage. A number of elements have been proposed as necessary for actions to be considered heroic.3

Since Urmson’s 1958 seminal paper, most accounts consider heroic actions to be supererogatory.4 5 Supererogatory actions are morally excellent actions that go beyond the duty of the agent: they are actions which are good, but not strictly required.6 Supporters of the concept of supererogation have used a ‘two-tier’ model of ethical guidance for action to differentiate what one must do (the obligatory) and what one can only be encouraged to do (the supererogatory).5

Although all heroic actions are supererogatory, not all supererogatory actions are necessarily heroic. Other elements are generally required to make an action heroic, which help to set heroism apart from other prosocial activities, such as giving money to charity (which are altruistic, not heroic).3 Heroism typically involves a voluntary engagement with an acknowledged degree of personal risk to help others.3 The risk does not have to involve physical peril, but may involve ‘personal sacrifice in other dimensions of life’, such as serious financial consequences or loss of social status.3 Both having the choice to act in a certain way and recognising the possible risks/costs are important—someone who has been forced into acting, or acts blithely without any awareness of the hazard, does not act heroically.

A full discussion of the moral and ethical status of heroism, and indeed the philosophical debate surrounding supererogation, is beyond the scope of this paper. For now, let us consider heroic actions to be voluntary prosocial actions, associated with an acknowledged degree of personal risk, which transcend the duty of the agent.

Heroism in the current pandemic

Even outside of a pandemic, there are ways in which the normal actions of healthcare workers could fit the above description of heroism. Healthcare workers voluntarily act to help others in the face of recognised personal risk when they are routinely exposed to infectious diseases in a variety of settings. An accident and emergency nurse risks contracting hepatitis through a needlestick injury, while a physician might be exposed to multidrug-resistant tuberculosis as part of their work. These personal risks are an accepted part of working in certain healthcare roles, so are not encountered unknowingly. Healthcare workers doing their everyday jobs have not, however, been widely lauded as heroes in the media in recent years: these risks have largely been viewed as simply ‘part of the job’. What has changed in the current pandemic to prompt a sudden focus on heroism? Is there something substantially different about the act of working in the COVID-19 pandemic which justifies the change in narrative?

Several historical epidemics have given rise to work examining the duty of healthcare workers to treat patients in the face of personal risk. In particular, the HIV/AIDS epidemic in the 1980s resulted in robust debates regarding the grounding and extent of a physician’s duty of care to patients.7 8 Later, the 2003 severe acute respiratory syndrome (SARS) outbreak further demonstrated the need to explore conflicts between professional and personal obligations.9–12 Most of these discussions concerning risk and obligation focused on the concept of ‘duty of care’, or ‘duty to treat’, weighing up the risk to individual healthcare workers against their duty to their patients.

In the COVID-19 pandemic, the risks to healthcare workers are appreciably greater than those encountered in normal practice. In addition to risk of contracting the infection, other costs include ‘physical and mental exhaustion, the torment of difficult triage decisions, and the pain of losing patients and colleagues’.13 The emotional cost of having to live away from vulnerable family members for extended periods of time while working has also been acknowledged. We might thus argue that although some personal risk is inherent in working in healthcare, these risks are so amplified currently that descriptions of heroism are justified. Moreover, the advice for the public to stay at home to protect themselves contrasts sharply with the requirement for healthcare workers to continue attending work to care for patients, which has emphasised the concept of healthcare workers making a significant sacrifice by continuing to work. The widespread use of militaristic language in the coverage of the pandemic has further fostered the image of front-line staff acting heroically in the ‘battle’ against the virus.

It is thus not surprising that many have reached for the superlative ‘heroic’ in describing the actions of healthcare workers. Yet while these descriptions of ‘healthcare heroes’ may be superficially fitting, the continuing dominance of the hero narrative in the media is in several ways unhelpful.

Heroism stifles meaningful discussion about the duty of care and its limits

A significant problem with the dominant heroism narrative is that it stifles meaningful, and much needed, discussion about under what obligations healthcare workers have to work. The question of what can reasonably be expected of healthcare workers in a pandemic is best addressed through an examination of their duty of care, including what grounds it and what its limits are. Media focus on heroism does not afford sufficient examination of these questions.

It is uncontroversial to state that healthcare professionals have a duty of care to their patients. This duty of care is a ‘special’ positive moral duty, which arises from the relationship between the healthcare worker and the patient.14 Special duties have two key characteristics: (1) typically they are role related, and are signified by an overt acceptance of the duty, and (2) they can obligate people to incur greater risk in performing the duty than we might expect others to.14 Yet the duty of care is neither limitless nor fixed.15 Sokol has been particularly critical of the concept of duty of care, noting that ‘in the medical context, is often invoked as a sort of quasi-biblical commandment, akin to “do not lie” or “do not murder”.’16 While it is intuitively appealing to rely on duty of care to justify what healthcare workers should be expected to do during pandemics, the phrase alone is too nebulous to be useful: relying on it can be ‘ethically dangerous by giving the illusion of legitimate moral justification’.16 If we accept that healthcare workers have a special positive duty to treat patients of emerging infectious disease, even at some personal risk—a ‘duty to treat’—we must critically examine both what grounds this duty and what its limits are.

Grounding the duty to treat has proved challenging: ‘a solid ethical basis for the health professional’s duty to treat victims of… infectious disease, even at some level of personal risk, has proved elusive’.17 A number of different accounts have attempted to describe the basis for the duty to treat, the most compelling of which are social contract models.14 According to these models, healthcare workers have a duty to treat which is grounded in a social contract, the result of a ‘negotiation between the medical profession and the community at large’.17 Healthcare workers have access to certain privileges as a result of their position in society (such as financial renumeration, relative self-regulation, trust and admiration from laypeople) and in return they have a duty to treat which may entail accepting a degree of personal risk.14 17–19 Clark argues that healthcare professionals who enjoy such benefits, but do not fulfil their duty to treat, are essentially ‘free riders’.18

Narrow social contract models, which focus exclusively on the contract between doctors and society (and thus exclude non-professional but essential health workers), have been criticised for being too limited to adequately address the response required by the healthcare sector as a whole to a pandemic.12 Reid argues that attempts to ground the duty to treat should address the broader question of what sort of society we want to live in, a question which cannot be viewed as a simple negotiation between any one professional group and a community.12 In asking, whether we would ‘prefer to live in a society that provides healthcare to people with infectious disease… or in a society that practices a form of quarantining of the ill without treatment, leaving them to die in isolation’, Reid recognises a broader social contract which is applicable to all those involved in healthcare, not just doctors.12

It is clear that the duty to treat is not limitless. Healthcare workers are not duty bound to do absolutely everything in their power to benefit their patients at any level of personal risk: for example, as Sokol points out, few would argue that doctors are morally obligated to donate their kidney to a patient.16 The idea that the duty to treat is limited, even in the current pandemic, is evidenced by the fact that healthcare workers with medical conditions which make them higher risk for suffering serious COVID-19-related disease have been advised to avoid patient-facing roles. For these healthcare workers, working with patients would thus represent an unacceptable level of personal risk, and would exceed what is required by the duty to treat.

Defining the limits of the duty to treat is a ‘daunting task, strewn with philosophical and logistical difficulties’.16 Indeed, one working group concluded that they ‘could not reach consensus on the issue… particularly regarding the extent to which healthcare workers are obligated to risk their lives’.11 If the duty to treat is most firmly grounded in a broad social contract between healthcare workers and society, consensus on what degree of personal risk should be undertaken in different circumstances must come from robust discussion between different stakeholders in society. A crude narrative which focuses on all healthcare workers as heroes stifles such discussion, as it does not properly recognise that the duty to treat is limited.

The importance of acknowledging reciprocity

Reciprocity is of significant importance to social contract theories: in return for accepting personal risk in fulfilling their duty to treat, healthcare workers expect reciprocal social obligations. Healthcare institutions are obligated to support workers and acknowledge their work in difficult conditions. The need to provide personal protective equipment (PPE) to minimise risk of illness among healthcare workers has been highlighted by a number of authors.9–11 15 20 Other proposed reciprocal duties that healthcare institutions have to their employees include clear communication regarding expectations and risks involved; adequate support, training and resources to perform their duties; counselling and psychological support; support and compensation for their families if they die; and access to treatment or vaccination if it becomes available.15 17 20 21 The general public, who must play a role in supporting the healthcare system, ‘both during an epidemic and in times where there is no crisis’, also have reciprocal obligations.12 Reid notes that the public play a role in supporting a healthcare system when they pay taxes or vote for governments that support the healthcare system.12 In times of pandemic, the public also fulfil their obligations to healthcare workers by following public health guidance—for example, by adhering to social distancing measures, or by taking actions to minimise the spread of infection such as covering their mouth when coughing.

A public narrative that concentrates on individual heroism fundamentally fails to acknowledge the importance of reciprocity. Individual heroism does not provide a firm basis on which to build a systematic response to a pandemic: there must be recognition of the responsibilities of healthcare institutions and the general public. In the current pandemic, issues have been repeatedly raised regarding the availability of PPE for healthcare workers.22 The requirement for employers to provide PPE to minimise the risk to healthcare workers is reflected by the attitudes of workers themselves—97.2% of healthcare workers in one study agreed that their employer was responsible for offering PPE.23 Media coverage which praises heroism among healthcare workers diverts attention away from the critical importance of ensuring that reciprocal social obligations to healthcare workers are fulfilled; as Reid notes, ‘the obligation to noble self-sacrifice seems incompatible with insisting on proper protective equipment.’12 It has been noted that during the SARS epidemic, the hero narrative proved a politically convenient tool for deflecting attention away from governmental errors: ‘by calling health professionals “heroes”, policy makers in government wanted to escape from their guilt of policy mistakes.’9 Indeed, a response based on individual supererogatory action neglects the responsibility that the government and healthcare institutions have in supporting workers, and in creating and maintaining the systems required to deliver healthcare. The hero narrative fails to remind the public and healthcare institutions of their own moral duties, as in its focus on individual healthcare workers’ selfless sacrifice it does not recognise that their duty to treat is irrevocably tied to reciprocal societal obligations.

Negative impact on healthcare workers

The overuse of the concept of heroism in the media could also have a negative psychological impact on healthcare workers themselves, through the implication that all healthcare workers have to be heroic. We are, by definition, not obliged to perform supererogatory acts; as Singer et al 11 note, it seems ‘unreasonable to demand… heroism as the norm’.11 There is thus a fundamental problem in describing all healthcare workers as heroic. We cannot ask all healthcare workers who go to work to accept personal risk beyond what is reasonably expected of them, as it is simply too demanding; we cannot, in short, expect heroism.

It is important to acknowledge that some healthcare workers may feel that the level of personal risk that they are currently being expected to accept in working is beyond what they ‘signed up’ to. Empirical data on healthcare workers’ attitudes to personal risk and duty reflect the fact that not every worker feels comfortable with accepting such risk; an American study found that only 55% of physicians agreed that ‘physicians have an obligation to care for patients in epidemics even if doing so endangers the physician’s health’, while a British study reported that 26.0% of healthcare workers disagreed that ‘All HCWs have a duty to work, even if high risks involved’.23 24 In modern healthcare, the risk of exposure to infectious disease is not ubiquitous, and healthcare workers in certain roles may argue that significant occupational exposure to pathogens is not an integral part of their normal job.14 23 As ‘the risks of treating infectious diseases are simply not obvious in or central to some fields in the way that the risk of fighting fires is obvious in and central to the field of firefighting’, we cannot assume that all those working in healthcare were prepared for the high levels of personal risk that might be incurred through working in a pandemic.14 The heroism narrative leaves little room for acknowledgement of emotions such as fear or confliction regarding contradictory duties.

Fear and anxiety among healthcare workers who are facing personal risk must be acknowledged and addressed. This might be facilitated by moving away from labelling all healthcare workers as ‘heroes’—which places pressure on them to act in ways which are beyond reasonable expectation—and towards a discussion about what expectations are reasonable within a social contract model. The fact that healthcare professionals themselves have expressed discomfort with being labelled as ‘heroes’ further emphasises that the media’s use of the term can have a negative impact on those it is being bestowed on.25