“The duty to care”

“The duty to care” is the obligation of medical professionals to serve patients, including in emergencies, and a phrase the book tests against the conditions in which care becomes hardest to provide. During the Katrina crisis at Memorial Medical Center, staff had to act amid failing infrastructure, contested authority, and an overwhelmed evacuation system. The phrase consequently carries two demands at once: clinicians must not abandon patients, and institutions must prepare and allocate resources so that clinicians can meet that duty without treating scarcity as permission to lower standards.

The obligation under emergency conditions

The city’s evacuation order exposed how care depends on systems beyond the bedside. Residents without cars were directed toward the Superdome, while the city’s transport plans had serious gaps; ambulances from Acadian were immobilized in traffic, and some began taking patients to the Superdome rather than out of the city. Hospitals were exempted from the evacuation order because officials feared that injured people would otherwise be turned away, even as the hospitals themselves faced danger. The obligation to care was therefore not simply an individual professional virtue: it depended on whether transport, power, and coordinated plans made continued care possible. At Memorial, ICU nurse manager Karen Wynn recalled the command room’s shift from a hospital emergency to something resembling a military operation. With floodwaters approaching and power at risk, the immediate aim was to move patients quickly. On the helipad, a nurse who was also an Air Force captain took charge of flight-line organization after seeing doctors dispute a Coast Guard pilot’s assessment of how many patients his helicopter could carry. She cleared the helipad and moved people to a protected tunnel so pilots could land. When the last group of critically ill babies was assigned a flight plan to a hospital other than the one expecting them, the neonatal nursing director refused to release them unless the pilot could obtain approval to fly to Baton Rouge. The pilot received that approval within minutes. These scenes show care as practical judgment and coordination, as well as bedside treatment: professional responsibility could require staff to challenge hierarchy or redirect a rescue in order to protect patients.

Care, comfort, and the limits of certainty

The phrase also frames a disagreement about what care meant for patients whose condition was grave. In an interview, Susan Mulderick said that discussions about medicating patients concerned palliation and comfort, not hastening death. She offered Ativan as an example of a drug that might relax patients, but pharmacy records showed that Ativan and other ordinary comfort medications had already been prescribed by Anna Pou and other doctors during the disaster. The book sets Mulderick’s account beside the unresolved question of whether medication intended to ease suffering could also hasten dying. That distinction matters: naming an intervention comfort care does not, by itself, settle its purpose or effects. John Thiele’s later critical illness offers a different view of how clinicians assess a poor prognosis. He had advanced cancer and developed signs associated with a low chance of survival, but he maintained that his problems were potentially reversible. He said he would have continued treating a patient in his condition, despite warning a family that recovery was unlikely, because improvement remained possible. The contrast does not make prognosis simple; it shows why a bleak outlook and an irreversible condition are not interchangeable, and why decisions about continuing care require attention to the particular patient rather than a label alone.

A professional ideal under scrutiny

Anna Pou publicly challenged the American Medical Association’s directive that doctors serve during emergencies even when risks are greater than usual. In a lecture, she said, “The duty to care sounds easy, great. It’s not always so; it’s more romantic on paper.” Her criticism emphasizes the distance between a principle and the realities of disaster work. Yet the book also notes that in her public presentations about emergency medicine and immunity laws, she omitted the injections of patients at Memorial. The duty to care thus appears not only as an ideal debated in the abstract but as a standard against which contested actions and later explanations are measured. The 2012 Institute of Medicine report placed the obligation in a broader framework. It argued that crisis conditions may justify limiting access to scarce treatments, while providers remain responsible for caring for patients, treating them fairly, and stewarding resources. The report also cautioned against using do-not-resuscitate orders as triage criteria: those orders express advance preferences about end-of-life care, it said, more than they reliably estimate survival. When shortages require limits, the report called for decisions that are transparent, consistent, proportionate to the shortage, and accountable. This formulation resists two easy answers: that every intervention can always be provided, or that an emergency suspends the obligation to treat people fairly.

Preparation and the cost of care

The debate over the duty to care also turns on preparedness. Rear Adm. Ann Knebel argued that the goal should remain the highest standard of care possible under the circumstances, and that planning helps people reuse, reallocate, and maximize available resources. Without preparation, staff may face conditions they have never considered and be less able to respond. In this view, planning is not an administrative substitute for care; it is one of the means by which the duty can be fulfilled. The book warns that simply lowering standards can relieve governments and companies of pressure to improve disaster response, and that emergency standards might later be applied when resources are tight for reasons unrelated to catastrophe. The obligation also leaves a human cost among those who serve. Gina Isbell described poor sleep, nightmares involving her patients, guilt over the staff she had chosen for the storm, and grief for patients who died. She felt changed by the disaster, yet later said she would serve in another storm if asked: it was her job and her oath. Karen Wynn, meanwhile, found that preparing to speak about the events could make her feel as though she were reliving them; she suspected that she and colleagues would carry post-traumatic stress for life and no longer wanted the nursing responsibility she had once accepted. Their different responses keep the phrase from resolving into a simple tribute to professional devotion. The duty persists, but so do the losses, doubts, and consequences borne by the people expected to carry it.