16. okt, 2020

Ethics and Corona: whose values count?

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.

  1. 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.
  2. 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.
  3. 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