Journal of Infection (2004) 49, 210–215

www.elsevierhealth.com/journals/jinf

Heroes of SARS: professional roles and ethics ofhealth care workers
Dena Hsin-Chen Hsina,b, Darryl R.J. Macerb,*aChina Medical University, 91 Hsueh-Shin Road, Taichung 40421, Taiwan, ROC
Doctoral Program in Life and Environmental Sciences, Institute in Biological Sciences, University ofTsukuba, Tsukuba Science City 305-8572, Japanb

Accepted 16 June 2004
Available online 27 July 2004

KEYWORDSSARS (severe acuterespiratory
syndrome);
Policy;Medical ethics;
Health care
professionals;
China;
TaiwanSummary Objectives. To examine the professional moral duty of health care
workers (HCWs) in the outbreak of severe acute respiratory syndrome (SARS) in 2003.
Methods. Descriptive discussion of media reports, analysis of ethical principles andpolitical decisions discussed in the outbreak, with particular emphasis on the eventsin mainland China and Taiwan.
Results. There were differences in the way that Taiwan and mainland China
responded to the SARS epidemic, however, both employed techniques of hospitalquarantine. After early policy mistakes in both countries HCWs were called heroes.
The label ‘hero’ may not be appropriate for the average HCW when faced with the
SARS epidemic, although a number of self-less acts can be found. The label was also
politically convenient.
Conclusions. A middle ground for reasonable expectations from HCW when treating
diseases that have serious risk of infection should be expected. While all should act
according to the ethic of beneficence not all persons should be expected to bemartyrs for society.
Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction
It was too heavy to be called as a hero; I just dowhat I should do.
—doctor facing SARS in Taiwan, May 2003.
* Corresponding author. Address: Institute in Biological
Sciences, University of Tsukuba, Tsukuba Science City 3058572, Japan. Tel.: C81-29-853-6614; fax: C81-29-853-4662.
E-mail address: macer@biol.tsukuba.ac.jp (D.R.J. Macer).

Severe acute respiratory syndrome (SARS) will go
into the medical records as the first new panic
disease that has swept international society in the
21st century. Although the number of persons whodied from the disease is currently less than athousand,1 it affected the lives of millions of
persons in 2003. We want to discuss the importantlessons that it raises for medical professionals—the‘heroes’ of SARS.
The focus on SARS was so high in the media thatnews of SARS overshadowed the outbreak ofanother panic disease, Ebola virus, that killed

0163-4453/$30.00 Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Heroes of SARS
more than 100 persons in March 2003 in Congo. The
attention paid on SARS meant less attention wasgiven to disease outbreaks like Ebola.2 SARS is thelatest of more than 35 new or reemerged infectious
diseases over the last 30 years. The difference wasthat most people in the world, especially in safe andsecure social settings felt protected from Ebola
virus of Africa, and even the global pandemic of HIV
seems distant from most people who donned masks
to avoid SARS. SARS infected and killed young andold, healthy and unhealthy, making everyone seemvulnerable.
In Taiwan, the SARS outbreak started from thetime a hospital was detected to have a widespread
hospital infection. The hospital was sealed as an
emergency and patients and staffs were all locked
up inside the hospital building to isolate them fromoutside, to spread the disease. The quarantine
order was announced without any warning andpreparation, which caused a massive panic.3 Similar
quarantine emergencies were reported in otherplaces also.4 HCWs who were placed in working
quarantine experienced fear, depression, anxiety,anger and frustration. There will be long-term
psychological consequences for some of these
persons. This paper discusses some of the ethicallessons of the first SARS outbreak in early 2003, witha hope that lessons will be learnt in time for the
next outbreak of SARS, or similar new diseases thatface those working in the field of infectious diseases
control.

Heroes and duties
During the international battle against SARS one of
the features was the proportion of frontline healthcare workers (HCW) who were infected and whodied. According to the data compiled from the WHO
until the 7 August 2003,1 20% of all persons affectedwith SARS were HCWs (1725/8422). The percentage
of HCW was highest in Canada (43% with 3/41
deaths), and Singapore (41%), higher than thatreported for mainland China (19%), Hong Kong (22%)
and Taiwan (13% with 6/180 deaths).
In the early stages of the outbreak, they had all
unknowingly treated patients with SARS. Even forthe latter stages in the outbreak in the first half of2003, there were several HCW who became ill withSARS in spite of ‘full’ precautions. When nurses anddoctors see their colleagues being critically ill
around them, dying or on ventilators, when justfew days ago they seemed so robust and well, theyrealized the dangers of being a professional.
Despite the rapid advancement of knowledge

211
with the intense research, and papers appearing in
all major medical journals,5 the threat of thedisease to HCW will remain for some time. Before
a vaccine is made, there will always be a threat ofbeing infected and killed on duty as a HCW. We
witnessed a number of HCW who started to think
about withdrawing from their post. It is ethicallyunacceptable to abandon patients. However,beyond the duty of a HCW, should we demand (oreven expect) that HCW should be ready to sacrifice
their lives for our society in severe pandemics, likethe outbreak of SARS. As one doctor in Taiwan said:‘It too heavy to be called as a hero; I just did what I
should’.
We understand that even a virtuous doctor or
nurse might not be willing to die for a patient. Does
the accepted norm of responsibility mean they must
put their own lives at risk? One important point isthat the social function of medical professionals
can not be replaced by others. Even in times ofpeace, we should always remember the reality thatbeing a helper of sickness will always present a
certain risk of being infected. Medical professions
have been well-rewarded by the society not only
because they are competent in operating medicine
but they chose the work of being a ‘life saver’.
In a number of countries in order to encourage
HCW, the government and the public started to givethe title of ‘hero’ to nurses and doctors who are
working in the frontline of SARS outbreak. On theother hand, some suggested to punish those who
were afraid of treating SARS patients. In Taiwan thisincluded threats of retracting their professional
license. There are memories of the AIDS scars in the
1980s when some hospitals in Asia refused to admit
patients with HIV. In a 1992 survey by the Japan
Hospital Association it was found that 40% of
hospitals refused HIV positive patients.6 Currently
refusals are not permitted.

Enforced heroes?
Can someone who makes an involuntary sacrifice becalled as a hero? Most nurses and doctors actually diedfrom taking care of SARS patients involuntarily.
Except for those on international teams who actively
sought out SARS patients, most did not choose to do
so. In large scale hospital quarantines in Beijing andTaiwan the hospitals were encircled and no one could
leave. Many HCW in Taiwan thus denied the title ofhero. Some said the more people call them in thisway, the more they fear they are in danger.
We could even imagine that the spiritual inspiration of being a ‘hero’ even lessens the212
implementation of good clinical precautions. In
Taiwan four nurses and two doctors sacrificed theirlife in taking care of SARS patients. The numbers forother countries are not clear, but one can expect it
to be higher for Hong Kong and mainland China,
based on the proportion of infected HCWs quoted
above. In Taiwan, a doctor died from giving airway
intubations to a terminal old woman even with theprotection of masks and glove; he was so young tograduate from medical school a few months ago andgot married only 4 months before. A nurse died withher 7 month old fetus just because of a shortcontact with an undiagnosed SARS patient in theemergency room. As those scary stories arerepeated numerous times among HCWs, can medical ethics overcome their emotions?
In facing the crisis of SARS, health professionals
may make efforts to combat the enemy like in thewar. However, could we regard the HCW as a soldier
in an army, as quoted in a China Daily report?7 Whenthe health staffs or soldiers decided to resign fromtheir job just in the moment of crisis/war, some
cultures attempt to remind the persons of theirsworn duties to contribute to national security bygiving the person a feather (sign of shame). Whilethe ethical ideal of self-less sacrifice of life forcuring disease is promoted in the public image andmedia, discussions with HCW in several countries
suggests that being a hero is not what modern
medical practice is for some HCWs.
Most HCWs in Taiwan are working in thecommercial hospital, where the hirer pushes
them to focus their effort of work on businesscompetition rather than the basic role of helpers
to human’s health. Beside academic achievement, the profit they can make for their
institute is the element to promote theirposition in their profession. It is easy to loss
the ideas of being heroes that is part of the
intrinsic nature of being doctors or nurses. Most
modern hospitals there are designed under theintention of attracting people to visit frequently. Besides for a commercial hospital, themost effective way to limit the budget is to
reduce labour costs. To use part time staffs
saves much money from less benefit and salary
pay. Could we expect nurses who were called
when they are needed and paid by working hourto devote themselves to the full professional
code and make all efforts when their life isthreatened? It is obvious that the feeling of
belonging and sense of nobility are essential fora professional worker, the problem is do wereally respect those health worker as healthprofession to supply the components to achieve
the sense of a professional.

D.H.-C. Hsin, D.R.J. Macer

Duties to patient versus family
Many HCW in modern times have only faced remote
fears of death, and it is a shock for many to realizethat their own lives are in danger. When they
considered that even with necessary precaution;
they still had to run a certain amount of risk, theirduties of being a wife/husband, mother/father ordaughter/son will call them home. Although SARS
was reported to have a relatively low mortality
rate, it attacks the young and healthy as well as theold and frail. Moreover, this is a totally new disease,
we know very little about it. The fear and worry of
being infected will always be a shadow to theircare. Will the public accept a health professional toexercise their right to remain off the job in thiscritical moment?
Every person of any profession has their personalrole in a family to be a father, mother, spouse andchild, in addition to their professional roles. The
constitution of most countries respect a person’s
human rights and ego (beyond the superego) i.e.
ego is the basic human nature which should behonored too. Part of the love of life that makes abioethics of an ethical person in ethical theories isself-love, not just love of others. Those medical
practitioners who stick to their post should be
respected; however, those who need to take abreak to recover themselves would also be acting
within their human rights and what is expected of areasonable citizen. There are cases recorded where
doctors spent weeks continuously battling thedisease, and there is need for a proper assessmentof how fatigue may have led to mistakes in care forpatients and mistakes in precautions of carers.
There is a human limit for everyone to cope with.
Those who battled self-lessly are called exceptions,for example, Ye Xin, 47, head nurse at the
Guangdong Hospital of Traditional Chinese Medicine, died in March after contracting SARS while
treating patients infected with the virus. Ye,
together with nine other nurses, was posthumously
awarded the Florence Nightingale Prize by theInternational Committee of the Red Cross in May
for ‘courage and dedication in the line of duty’.8

Media responsibility
In carrying out the responsibility of reporting thetruth, the media created the SARS panic. In most of
the infected areas, the government had no control
over the media. Under the pressure of commercial
competition, those narratives reported by media
could be exaggerated which cause mass panic andHeroes of SARS
changed the relationships between people. On thecontrary there was a lack of information in mainland China especially until 20 April, when thegovernment was attempting to limit panic bycontrolling the media. However, when the epidemic was revealed, the following month saw panic
there also. Everywhere society has to pay a price forliberty of the media, and to deal with the result oftransparent reporting. There were also rumours
spread through the Internet that generated fear.9
There are reports that in China 117 people werecharged with spreading ‘SARS-related rumours’,
though the exact nature of the types of Email they
were sending is doubted.10 However, without media
reporting as a way to educate society, the death toll
everywhere would have been higher.
The media generated fear, stigma and discrimination, but also showed the evil sides of the panics.
People who were subjects of discrimination
included those working in the hospital or enteringand coming back from infected areas, suspected
SARS patients and their family. Even those with very
common syndromes of cold (cough, fever, etc.)
were psychologically and socially isolated by theirfriends and relatives. From the narratives reported
by media, the mass panic caused by SARS haschanged the relationships between people.

Political convenience
In certain cases by calling health professionals‘heroes’ policy makers in government wanted toescape from their guilt of policy mistakes by giving
ambiguous honors. Governments had to face up to
the mass fear that SARS created, and any target
could be chosen. There were scapegoats in mainland China on the 20 April with the firing of the
Health Minister. In many countries affected by
SARS, and neighbours like Japan, one of the usual
targets for blame is foreigners. Persons from distantlands have always been blamed in cases of
disease.11
In early April, a Hong Kong resident came to
Taiwan to visit his younger brother despite being
supposed to be under home isolation in Hong Kong
due to the spread of the disease in his apartmentbuilding, Amoy Garden. His brother was infected byhim and it was the first fatal case of SARS in Taiwan.
One woman, who took the same train with him, washighly suspected to be the source of a major
hospital outbreak. At first, the doctors were notsensitive about her case since she had no contact
history to match the susceptive criteria for SARS.

213
Thus, she spread SARS in the hospital before she wasdiagnosed.
Many hospital staff, patients and patients’families were infected at the same time. The
hospital was able to detect this spread and sealed
its premises entirely without good preparation.
Four thousand people were locked inside thebuilding to prevent further spread of the disease;and more than 30 000 people were isolated in theirhomes. This strong measure resulted in a mass
panic. But it was too late. The numbers of infectedcases increased exponentially.
Inside China, the people in Guangzhou province
are blamed. When one of us was in Beijing on 19
April, 2003, some experts said ‘The people in
Guangzhou eat anything that moves. It is theirfault.’ People in Hong Kong may have blamed theChinese. People in Taiwan or Canada blamed thosefrom Hong Kong. People in Japan in May blamed adoctor who traveled from Taiwan who later came
down with SARS. All the people they blamed were
just being human, but foreigners are convenient
targets. The Chinese government was so concerned
about the image of China that it is rumoured that
persons were threatened by death in case theytransmitted the disease to foreign countries.10
If we view the work of medicine a sacredvocation, an inner calling to dedicate and care forthe sick, it is contradictory to imagine somemedical doctors may be accused of giving rise to agreat loss of our society. Taiwanese society decided
to punish some of the head doctors who did notdetect and report the hospital infection in the earlystage. The final decision was to give the very toughpunishment of retracting their professional license.
Ethically a wrong decision should not be punished asa crime of that magnitude unless the healthprofession had a criminal intention (motivation).
Although the consequences were a great loss forsociety it is not a wise move for the future to punish
physicians for making mistaken decisions in emergency circumstances over public health if they were
not intending any cover-up. There seems to be athreat of political scapegoats in every health crisis.
We can expect future HCWs to move for greater
self-protection and hesitance in making decisions
that are necessary for public health crises likeemerging diseases.

Discussion: a middle ground
Between the Hero and the Coward, there must havesome space where people can be humane. It is
normal and proper for people to be scared to die yet214
fulfill their duty in the frontline. Except for special‘danger pay’ or another kind of reimbursement, acalling for increased emphasis on workplace safety
and a review of precautions is most important forthis critical situation. A well trained and equipped
health worker also needs to prepare for the frontline of possible bioterrorism, which may be similar
to what we saw with SARS. We need a well preparedexpert more than a hero. There were cases
reported where proper diagnosis of other diseases
was hindered by the infection prevention measures
being applied to treat all patients from SARS
infected areas as potential SARS victims.12 Spiritualmotivation should not slacken the implementationof sound precautionary measures.
As the WHO Director-General said ‘The containment of SARS required heroic efforts and extraordinary measures that are difficult to sustain overtime’.13 A Taiwanese study of nurses in May–June
2003 found that nurses’ agreement with thegovernment control measures was a predictor of
the extent to which they fulfilled their professionalcare obligation.14 This suggests that having the
support of the healthcare professions in policy isessential for everyone to work wholeheartedly.
Before the next outbreak, we need long-termplanning and humane intervention to prepare abetter response for the expected return of thedisease. In the future if some repressive regimes are
hit by SARS they might employ brutal tactics toquarantine and isolate people, possibly sowing
division among outside countries and multilateralorganizations over how to respond to apparent
human rights violations.15 Calls for development ofeffective Centers for Disease Control in otherregions of the world, including Europe, have been
made in response to the ways SARS was fought.16
The intention of calling for HCWs to above all dogood should not be blurred by wrong planning.
With SARS as with other severe infectious
diseases that are readily transmitted, the manner that home and work isolation is handled is a
key ethical issue. If people were diagnosed to besuspect or probable cases, all the people aroundthem may as well be suspected of having been
contaminated by them. Consequently, the persons they have been in close contact with, forexample, families, colleagues or schoolmates
may be isolated to avoid further possible spreadof the disease. Such home isolation has serious
social and psychological influences. In somecases, those who break home isolation may bepunished by imposing a fine. People who werevictims of SARS in 2003 were accused ofhindering the prevention or treatment of sudden
disease outbreaks if they broke such isolation. It

D.H.-C. Hsin, D.R.J. Macer
is normal to expect that quarantine will cause
fears, and people will lose their patience andself-restraint, but we should assume that all
people were originally infected by others with a
few recent exceptions infected by laboratory
medical research. Persons should be taken careof better than being totally restricted to avoid
them inflicting possible harm on others. With thepolicy of respecting human individuals complete
needs for physical and mental well being, more
people will be motivated not just to protect
themselves, but to contribute to the macro wellbeing of the society. There are still lessons for
all in society about the ethics of quarantine.
Modern society has forgotten the past risks ofinfectious disease outbreaks.
We would suggest to respect health worker’s
autonomy of making their own choice to take abreak from intensive physical or emotional loadingor to accomplish the historical mission of copingwith SARS. A well developed society that we live inshould have sufficient space to practice humanism
to everyone in any kind of situation including apublic health crisis. This is one of the lessons, weshould learn in preparation for the next crisis ofinfectious disease.

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