The debate on Corona and the measures taken by governments is spinning out of control. We are concerned about how the increase of emotions – understandable as they are in the midst of this crisis – becomes a real barrier for the discussion that we really need right now.
The question about how one values life, and lives, seems to be the elephant in the room in our ways to cope with the pandemic. At the same time ethical decisions have to be taken that can no longer wait. They range from entry criteria to IC departments to a reconsideration of international relations. This sounds a little pathetic perhaps, but too often issues are labelled as too complex or too sensitive and then left alone – a luxury that I believe we have permitted ourselves far too long. We can no longer avoid tough choices by pointing at a ‘slippery slope’ that leads to the abyss – we are on the slope, and the abyss is in sight. But that is no reason to panic – which seems exactly what we are doing – in most of the high income countries.
Right at the beginning of the Covid-era we understood that this virus may be the first of a series of outbreaks that signal the underlying problems of climate change, loss of biodiversity, and globalization. We know that epidemics always deepen fault lines in inequity in the world. I am still trying to grasp why we then soon forgot all these syndemic complexities to fight ‘the last war’ once again: “let’s all unite to kill the virus”!
It is time to face ‘ethical values’ and be practical, because ethics is nothing if not practical. Part of this is to ask (and answer!) whose ethical values or which values need to be preserved – in other words, who are the people we care about most, and who are the we in this sentence? People who have had good lives? That may be those who have been so lucky to come closest to the four foundational requirements for health, summarized by Richard Horton in last weeks’ Lancet as peace and security; equality and equity; a balanced and sustainable ecosystem; and ‘just governance.
Let’s face that these four foundational requirements are aspirations towards a life without suffering (a fundamental ‘design’ error of our secular age – but this is not the place for philosophical musings about our human fate to understand why Sisyphus is, after all, a happy man.) Let’s then check the other end of aspiration, the ‘is’ rather than the ‘ought’, and realize the daily reality of obscene inequity and vulgar abuse of millions and millions of people around the globe.
Against this background we need to figure out how we (and again, who is we?) will chose between the interests within one group (e.g. people with access to high quality health care, divided by age, comorbidity, or number of quality life years expectations), and how we chose between different groups (e.g. the people in the first group compared with those living with life expectations so low that getting Covid is almost an indicator of success?).
Let’s then ask what would exactly be unethical (and from whose point of view), if we use the resources now used for implementing and controlling rigid measures, plus the substantial 'opportunity costs' of freezing education and culture and economy and so on, to provide tailor-made protection for the most vulnerable groups.
- To begin with the easiest part, the choices within privileged rich countries, we can start by granting the elderly who want a loving environment and refuse to be imprisoned and isolated for their own good, the freedom to do so and the offer them the needed help to realize that. Those that want protection should be served to the maximum to realize their choice.
- We give up enforcing behaviour change (for young people, but also to reboot the cultural sector) that is unrealistic, damaging and unsustainable for any prolonged time.
- We stop focusing on the IC-occupation as the determining factor. We accept that there is a maximum of IC capacity and a maximum budget. When these are reached, we will apply rules that we make as a society (not any subgroup) to decide who will be admitted (and therefore who will be not). A draft is made in Holland, where a triage system could control the patient flow by step-by-step considerations of priority, in this order: patients who are expected to require a relatively short ICU admission; patients who are active in care and have had risky contact with patients; patients from a younger generation (0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years); and if all these conditions are inconclusive, a draw will decide.
Much more difficult is moral behaviour towards all the people that have never had access to decent health care. Who may be the first to get caught by any new virus, because it will come from their threatened ecosystems. Who have never had the luxury of moral philosophy because they were too busy holding on to the slippery slope itself to avoid falling in the abyss.
I'm sure these decisions will hurt, and will hurt many of us. But we have seen them coming for a long time, and we now need to become moral philosophers fast.
Willem van de Put
Richard Horton, editor-in-chief of the prestigious medical journal The Lancet, reacted to the latest book of Bernard-Henry Lévy, The Virus in The Age of Madness. He takes issue with BHL’s idea of too powerful doctors in this pandemic. I usually like Richard Horton’s reflections – even though he is a powerful doctor. Bernard-Henri Lévy (AKA BHL) is slightly less interesting, as a now somewhat stale ‘Nouveau Philosophe’, known for meddling in international politics with remarkably little effect, which is why some people wonder “why everyone hates BHL”. His latest book has received mixed reviews (I like the one here), and there is indeed not much in it that has not been said better and earlier by the slightly less elegant but more effective Slavoj Žižek in his Pandemic!: COVID-19 Shakes the World. But BHL points his complains especially at the transformation of physicians into “supermen and superwomen”. Horton versus BHL? Who to love, who to hate?
COVID-19 is for an important part an “epidemic of fear”. But that is not to be blamed on the doctors – although there are surely some virologists and epidemiologists who are celebrating their streaks of vanity ‘ad nauseam’. They are however eagerly offered the floor by the media – who in this time feed on fear even more than usual. The politicians who should be in control lose themselves in weakness and confusion – mostly brought about by the lack of vision, as Horton rightly writes.
Health has indeed become a public obsession, and I find it embarrassing to see how all other issues (from culture to climate) are wiped away to make room for the most basic individual survivor instinct. But again, it is not the doctors who wish to extend “an incestuous union of the political and medical powers”. Better arguments can be found in Barbara Ehrenreichs ‘Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer (2018), where she writes about the illusion of having agency over ‘our bodies, our minds, and even over the manner of our deaths.’
Doctors share, with all of us, the symptoms of a change in our societies that has been coming for a long time and is accelerated by an accumulation of crises: climate, inequity, and health. That change has more to do with a search for a new common ground that helps to unite people in trying to make sense of it all, now that religion and even neoliberalism have gone to waste. In this transition the truth that problems caused by a certain way of thinking will not be solved by the same way of thinking is, I think, obvious.
That openness for another way of thinking is what I miss in Hortons reply to the Philosopher. I like his call for including social and economic inequalities in the new policies and programmes needed, but a call for fairness between generations is nice, but will not do. The inequity that cuts across all the elements of the crisis is indeed accelerated and made more visible by the pandemic. But it is not the pandemic that dehumanised us, as Horton writes. The pandemic is the whistle blower, the canary in the coalmine, warning us for new and more effects of climate change. And yes, doctors and medical scientists have an important voice in shaping plans for a way of life that is less exclusive and more equal. But so does everybody else, from any walk of life.
Perhaps even some really ‘New Philosophers’?
Willem van de Put, 4/9/2020
Supporting women to overcome difficulties and PTSD related complaints
FGM (female genital mutilation) can cause immediate and long-term health problems for girls and women. FGM is a modification of girls’/women’s genital area, performed according to sociocultural logic in the absence of medical justification. The practice has the high potential of causing haemorrhage and infections and interfering with normal physiological processes which can lead to severe physical health complications (e.g., urinary problems, infections, difficult childbirth) and even death. This painful and often traumatizing procedure can also give rise to serious mental health predicaments (e.g., post-traumatic stress disorder, anxiety) . It is estimated that at least 200 million women and girls currently alive have undergone FGM, and that more than 3.6 million additional cases of genital cutting occur worldwide every year.
The Group for the Abolition of Female Genital Mutilation (GAMS) provides support to women concerned by FGM, forced marriages and other types of gender based violence that have come to Belgium (in- and outside asylum procedure, recognised refugees) through individual support, community support, awareness raising, training and advocacy. C4C has been invited to take part in these efforts. Together with GAMS we aim to develop cultural specific interventions for these vulnerable groups of people while restoring trust and confidence and building upon their strengths, interpersonal skills and cultural values.
 World Health Organization. Female genital mutilation (fact sheet). 2020. https://www.who.int/news-room/fact-sheets/detail/female-genitalmutilation. Accessed 4 Feb 2020.
 Andro A, Lesclingand M. Female genital mutilation. Overview and current knowledge. Institut National d’Études Démographiques. Population. 2016;71: 217–96.
 Institut National de la Statistique (INS) et ICF. Enquête démographique et de santé en Guinée 2018 : Indicateurs clés Conakry, Guinée, et Rockville, Maryland, États-Unis d’Amérique; 2018.
Mulongo P, Hollins Martin C, McAndrew S. The psychological impact of female genital mutilation/cutting (FGM/C) on girls/women’s mental health: a narrative literature review. J Reprod Infant Psychol. 2014;32(
 UNICEF. Female genital mutilation/cutting: A global concern. 2016. 6. UNICEF. Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change. New York: UNICEF; 2013. 186 pages