Ireland has gone into lockdown to try and minimise the number of deaths caused by Covid-19. In coming to this decision, the Government has decided that, for now anyway, the good of the lockdown outweighs any possible harms that might result.
Obviously, we do not shut down society each year to try and minimise the number of deaths caused by the latest winter flu. We decide then that the number of lives that might be saved is not worth the price of effectively shutting down society. Here, we have weighed things differently.
Every policy has costs, not simply in economic terms but also from the point of view of human relationships, mental health, civic liberties (including religious freedom), etc. We are hearing about an increase in domestic violence. How many marriages might end in divorce due to the lockdown? Will depression (and maybe suicide) eventually soar? Recessions and financial ruin are associated with an increase in the overall mortality rate. How many could die as a result of growing hospital waiting lists and people avoiding A&E at the present time?
Catholic social teaching requires us to try and find the common good at all times by keeping different goods in balance, weighing them against each other, and deciding which are most important and which less important, and how the different weight we attach to each can change as circumstances change.
We will be asking a number of Catholic moral theologians and philosophers in the coming days to weigh up the goods to be considered in arriving at a suitable public policy at a time like this. We will bring them to you as we receive them.
Ethical questions in a pandemic
By Dr Angelo Bottone
The current epidemic raises a number of profound ethical questions. We are facing unprecedented events under the pressure of time and of limited resources. In the name of urgency and necessity we are experiencing exceptional restrictions of fundamental liberties, and a significant alteration of our familiar ways of living.
After the initial shock, when energies are inevitably focused on emergency measures, it is now time to address more fundamental issues that this epidemic has highlighted.
In the next few weeks, The Iona Institute will host a number of contributions by philosophers and theologians. We will address four issues in particular: 1. The balance of goods in the lockdown; 2. The morality of triage and of priority in care; 3. The impact of the epidemic on freedom, including religious freedom; 4. National and international obligations.
Why do we need a debate about ethics now? In the current exceptional circumstances, it seems that many decisions are not free choices, but they are rather dictated by necessity. Nonetheless, practical deliberations are always inspired by values. Either consciously or unconsciously, we all operate within a moral framework. We decide to pursue a certain course of action, rather than another, because we deem certain principles more important than others. This is obvious when we face conflictual duties – for instance, saving lives and preserving freedom – and we ultimately follow a certain road because of our deep philosophical commitments.
Strategic decisions are now led more by the assessments of the experts than the democratic mandate which legitimizes our political representatives. National and international bureaucratic structures define our common tasks in terms of measurable effectiveness to the point that we feel we are living in a tyranny of the specialists, legitimated by their scientific expertise.
Nothing should be done against science, but the problem is that science is not about ends, it is about means. Medicine tell us how to save lives but doesn’t tell us which lives should or shouldn’t be saved, and why they should be saved at all. Experts disagree, not only on purely scientific grounds – for instance, which treatment works better – but also on what we ultimately want to achieve. Different policies are expression of different values and it would be foolish to move through an epoch-defining outbreak without having a debate about what we ultimately want and why.
We need a debate about ends. What are we here for? The good life in a community, says an old tradition that goes back to our Greek philosophical roots.
What clearly emerges in front of our eyes these days is that we can’t understand ourselves as individuals. We are members of a community. My life depends on what other people around me do. My best efforts will count nothing without everybody else’s best efforts. More than ever, this epidemic requires us to think and act in solidarity, which literally means being strong together. This solidarity is necessary not only in action but firstly in the way we frame and approach our problems.
We are operating in fear and isolation, under the pressure of unprecedented events. We hear that we are forced to trade different values against each other. But to think according to an ethics of solidarity means that conflicts and tensions should be framed not in terms of opposition but as if they all together threaten to the same end, which is the common good.
It would be wrong to present our dilemmas in terms of exclusive interests: for instance, should we care for the sick or for the one who might lose his job? If we address this problem through the prism of solidarity, we will realise that it is the same person who is at risk of getting sick and losing their job, it is the same family, it is the same community.
Roles are now swiftly exchangeable – a health carer becomes a patient – and the same person often embodies many roles – someone who works from home may also be a carer or a patient. There is no family or group that is not potentially impacted. Traditional categories such as social class, gender, ethnicity, are now insignificant. We are all one and should think in solidarity.
In a competitive struggle for scarce resources, we give priority to those we consider more valuable, overlooking the rest. In a solidaristic approach, we give precedence to those who are most in need.
As every epidemic, this one is significantly impairing what constitutes a community, such as the acting physically together. Everything that is communal is currently affected, from mourning our deaths to celebrating sports, from worshipping to travelling. However, the present epidemic is different when compared with the big ones of the past, think of the Black Death, because contemporary means of communication allows us to be united in spirit with those who are distant. Even if only virtually, certain expressions of solidarity are easier to perform.
As part of a community, we have a duty to limit some of our legitimate desires and demands if they put others at risk. And risk should be understood not simply in the sense of physical health. There is a risk of cutting meaningful relationships, of compromising the education of the younger generations, of impairing mental wellbeing, of destroying business and charitable work, of neglecting those who suffer for other reasons, etc.
The wide scope of risk is what makes this epidemic difficult to manage and it is not the role of ethics to identify what is practically appropriate in each circumstance. Our task, instead, is to inquire what goods we want to achieve and what moral principles should guide us.
I will address in a separate article the moral dilemma of prioritizing access to scarce medical resources but the general principle I am proposing, inspired by an ethics of solidarity, is that everyone should be cared according to their needs, rather than ability or, more often, inability to contribute to society.
An ethics of solidarity involves sacrifice. However, the question should not be formulated in terms of who we are willing to sacrifice for the common good. It is rather, what should be sacrificed? No one should be discriminated because is less abled, has less prospect of life, or can’t pay.
Different approaches and strategies employed to tackle this pandemic reflect who we care most. In any assessment of a balance of goods we should remember the dignity of the most vulnerable. Solidarity means that it is precisely those who are weaker that we hold stronger.
Measures have to be proportionate but what is a fair proportion cannot be determined in advance. By definition, this depends on the circumstances. What, instead, can and should be discussed is what society we wish for when promoting public health.
We won’t be able to do all the good we would like to accomplish but have we established what this good is? Let’s have this conversation.
Weighing goods and bads?
By Dr John Murray
It seems obvious that in this current crisis, and indeed more generally in political, professional, and personal life, we need to weigh up the goods and bads involved in the options we face for choice. Isn’t such weighing up required if we are to be rational and scientific and fair?
However, it is impossible to know all the goods and bads in the diverse options that we face when we have to make a choice. You simply can’t work out accurately all the consequences. For example, it is impossible for us to know accurately just how many direct and indirect bad effects the current Covid19 lock down will cause into the future. It is even more difficult to work out what the effects would have been if we had adopted some other policy or set of policies. Even if we compare ourselves to other countries, we can never be sure that our situation in Ireland is exactly comparable in all variables.
Furthermore, if we could somehow work out the consequences of a lock down strategy, we still would not be able to rationally weigh them up. The goods and bads in choices are irreducibly diverse. That’s why we have to make a choice. If one is going to weigh things, one needs a standard of measurement. What standard of measurement is to be used in weighing up the diverse goods and bads in coping with the Covid19 crisis? If we use several diverse standards of measurement, we face the problem of how to weigh up the different standards against each other.
We can try to simplify matters. We could focus on numbers of lives saved versus number of lives lost in each option. Hard to predict, but at least it looks like we are weighing up similar goods and bads using a transparent and rational standard of measurement. However, although lives saved or lost are important, no doubt, they are not the only things that matter. And we will cause harms if we cut down direct risks to life so much that we prevent people from living, from socialising, from working, from creating wealth, and so forth.
Perhaps all we can do is ‘do our best’ to make an informed guess about the goods and bads, about consequences. But even if we do that, we need to be guided by moral standards that cannot be reduced to (supposedl) scientific calculations. One such standard is the Golden Rule: treat others in the way that you’d like to be treated (if the positions were reversed). Only if this ethical standard of judgment is followed, honestly and consistently, can we be sure that the choices we make, and the structures we create, are not based on merely apparent ‘rational’ weighings of consequences, but on really fair and just choices to respect each and every person’s dignity. Judgments of proportionality that are shaped by the Golden Rule are able to avoid selfishness, moral blindness, prejudice and selfish partiality. We must love our neighbours as we love ourselves.
Dr John Murray is a lecturer in theology at Dublin City University.
Proporionality and Pandemics – A Difficult Assessment
By David Mullins
In the current health crisis, many goods have to be balanced. The big question is whether the good done by the lockdown is proportionate to the harm caused by it. So far, a big majority of people think that it is.
The principle of proportionality is used within Catholic Just War theory, for example. We do not go to war to resolve minor diplomatic incidents.
If we did, then the chosen means of resolution would be grossly disproportionate to any good that might be achieved and would therefore contradict the principle of proportionality.
Can we apply the same thinking to the ‘war on Covid-19’?
At the time of writing the European Centre for Disease Control estimate that 2.35 million cases of COVID-19 (in accordance with the applied case definitions and testing strategies in the affected countries) have been reported, including 164,656 deaths.
However, the public health response to combatting Covid-19 has included measures that will ensure more than 117 million children are now at risk of missing out on measles vaccines. This is according to the United Nations International Children’s Emergency Fund (UNICEF).
In 2018, measles infected an estimated 10 million people and killed 140,000.
According to the World Health Organisation the measles virus, which is highly contagious, has a mortality rate of 3% to 6% with malnourished children especially at risk.
The Covid-19 mortality rate is difficult to be precise about but during a March 3rd media briefing, WHO Director-General Dr Tedros Adhanom Ghebreyesus stated: “Globally, about 3.4% of reported COVID-19 cases have died.” It is likely to be much lower than this, however.
The public health response to Covid-19 has also brought about the suspension by the Global Polio Eradication Initiative (GPEI) of all activities that cannot adhere to guidance on physical distancing, such as house-to-house or other immunization activities using oral or injectable vaccines.
Augustin Augier, executive director of the Alliance for International Medical Action was reported on April 9th as saying that programs with the capacity to train about 500,000 African mothers to diagnose acute, potentially fatal malnutrition in their children have also been suspended.
Closer to home all cancer screening programmes related to routine cervical cancer screening, routine breast cancer screening, bowel cancer screening, abdominal aortic aneurysm (AAA) screening and surveillance monitoring, and routine diabetic eye screening and surveillance monitoring, have all been suspended in Northern Ireland.
Here in the Republic all test appointments and invitations to screening for cervical cancer are cancelled.
If we take proportionality to mean that our actions must not bring about a worse state of affairs than if we had done nothing-then I am not sure the test has been met. Our actions to combat one disease are allowing a whole host of others to flourish and usually among the poorer populations of the world.
You might argue that the methods employed are about gaining time for a vaccine to be developed and about ensuring that one infectious disease is not brought into environments where others already thrive.
The problem is that we have no way of knowing if this approach will ultimately prove correct. This is a difficulty we should not shy away from.
For now, all we have, is at best, a kind of speculative ethical proportionality.
Let us remember that there is still no vaccination against Middle East respiratory syndrome, which is now known to be caused by another form of the coronavirus and which was first reported on September 2012 in Saudi Arabia.
So, what looks proportional now in terms of our response, may soon degrade into brutality if the same approach is still being persisted within 8 years’ time.
David Mullins is a bioethics commentator. He holds a Masters Degree in Bioethics, with a dissertation on “Ethical Alternatives to Embryonic Stem Cell Research”.
Rationing healthcare mainly by age is unacceptable
By Dr Angelo Bottone
It has been reported that some hospitals in the west of Ireland have been told to employ a point system to determine who should be sent to ICU during the Covid-19 crisis, and one of the criteria is age. If you reach exceed eight on this scale, you are not being admitted to ICU. According to the reported, which appeared in The Sun, simply being over 80 means that the person has seven points to start with, just two shy of the cut-off point.
The document is not available to the public but, if the report is accurate, this point system is totally unacceptable from a moral point of view. The elderly shouldn’t be sacrificed just because of their age.
Let’s explore in more detail what is wrong with age-based restrictions.
Life is getting longer in our western societies. The allocation of resources is something that must be carefully weighed not only during emergency situations, such as the one we are experiencing at the moment, but also in ordinary time.
The debate is not whether often scarce resources are to be rationed, as this is inevitable, but how to ration them according to justice.
When the state determines the kind of resources to be available, this, in turn, has an impact on the nursing homes or the hospitals, and consequently on the carers (physicians, nurses, etc.). At all levels, decisions have to be made on who will be favoured and who will not.
Our values, and what type of society we want to promote, will determine the status of older people and their worth.
Favouring one demographic sector of the population inevitably has consequences on other age cohorts. Some could say that giving to the elderly means to take from the youngest. If we think merely in terms of costs and benefits, elderly health care represents an investment of scarce resources with few returns.
Waning productivity in the later years of life cannot be a sufficient reason to curtail resources for the elderly. Rationing our healthcare resources must not be done using age as the main criterion.
This utilitarian principle can be easily extended to other vulnerable groups, such as people with disabilities, as they are also perceived more as a burden than for their intrinsic dignity.
A more moderate version of this approach would claim that age-based rationing implies not the complete withholding of medical treatments from older persons. Instead, it is only when a conflict arises that age should come into consideration.
For instance, when there is only one ventilator available and two patients need it, it should be given to the person with more years of life ahead of them.
This conclusion is based on a more subtle argument that has been defended by some bioethicists. All things being equal, they say, a treatment should be offered to the person who has more potential of a longer life.
The common mistake in all these approaches is that patients are not assessed according to their medical needs but according to other characteristics.
Age is not necessarily an indication of a medical condition. There are 80 year-old marathon runners.
Obviously, age has to be taken into consideration in a clinical assessment as it is an element to evaluate the potential of recovering. But this is the only potential that matters, instead of the hypothetic “potential of longer years”.
Age matters, to a certain extent, in determining which life has more chances to be saved, but not in deciding what life is more or less worth saving.
Favouring those with more potential of recovering is based on medical principles, favouring the youngest simply because of their age is unjust discrimination.
Age is an unreliable clinical outcome predictor and to give it such a disproportionate role, as in the document reported by The Sun, is only a sign of prejudice.
Rather than give such weight to a person’s age as the reported system seems to do, it would seem to make more sense to give more weight to underlying conditions such as respiratory or heart problems. In this way, age is not such a big consideration.
The recurring theme in all of those who defend age-based rationing hangs on defining the value of an elderly person’s life in future terms. The Christian tradition tells us that all life is sacred and deserves protection from conception to the end, no less when the end is closer.
Deliberately denying treatment to some individuals who might benefit from, simply because of their age, is an unacceptable form of discrimination.
It is a terrible form of injustice that targets the most vulnerable sector of the population and it fosters the growing trend of disrespect towards them, which is also behind the push for euthanasia.
How Should We Approach Triage in the Crisis?
By Dr Catherine Kavanagh
The current crisis of care in nursing homes is explained by some as simply an exercise in triage, necessary because there are not enough resources to go around, and it is alarming how many people simply shrug it off as inevitable. However, before capitulating completely to the law of the jungle, it might be worth thinking about what triage is, and asking if this is truly inevitable.
The definition of triage is “the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of
survivors” (Merriam Webster) The original use is military, and in emergency civilian situations which present problems logistically akin to those of a battlefield, we also talk about triage.
All systems of triage presume an immediate emergency, needing quick decisions. The goal is to maximise the number of survivors, to ensure that those who need it most get treated first, and that those who can afford to wait, wait.
There are those who will not be treated: those who are already dying, and are unlikely to benefit from treatment, will give place to those who are seriously injured, but will benefit from treatment.
It is difficult to see how DNRs (do not resuscitate orders) feature here, since triage means applying certain principles in an ongoing situation, and one cannot say for certain that any given old person or disabled person will necessarily be in a situation where there is another patient who will benefit more from treatment, which then becomes unavailable to them as a result.
What seems to be the motivation behind DNR orders is rather “quality of life”. As F. J. Fitzpatrick points out, “quality of life” is a dangerously ambivalent term: “…the phrase ‘quality of life’ can be used to intimate that some people’s lives are worthless, and therefore that we should act with a view to bringing about their death”. Compulsory DNR orders for disabled and elderly people indicate an excessively narrow conception of “quality of life”: the thinking behind them can only be that these people do not have “quality of life” anyhow, and that death from Covid-19 would be a good thing for them. That does not look like triage, since that aims to save life as much as possible, is not concerned so much with broader “quality of life” issues as with immediate benefit given the resources available, and is not concerned with long-term disability or age. If the patient would benefit, and the resources are available, there is no reason not to treat a patient of 90 years of age, or a patient with Down Syndrome, and so on.
To sum up: we can all imagine tragic emergency situations where some people cannot be treated because they will not benefit from treatment, or because, given resources, they may have to yield to someone else who will benefit more: that is triage. We can all sympathise with medical personnel who have to make such judgements. However, we cannot assume in principle that some people’s quality of life does not merit access to treatment and therefore exclude the possibility of treatment absolutely for such people.
Catherine Kavanagh is Acting Head and Senior Lecturer in the Deparment of Philosophy, Mary Immaculate College. She taught medical ethics in the School of Nursing, University of Limerick, for six years, and was formerly the MIC member on the Committee for Philosophy and Ethics at the Royal Irish Academy, before it was absorbed into the current Ethical Lega, Political and Philosophical Studies Committee.
Who should get priority treatment in a pandemic?
By Dr Angelo Bottone
Philosopher Catherine Kavanagh has argued that the ambiguous expression “quality of life” can potentially be used to exclude those who are old or disabled from necessary treatments, especially at a time like this.
In Ireland, it is notable that fewer than 10pc of nursing home patients with Covid-19 have been moved to hospitals for treatment (see here), even though these homes account for a vastly disproportionate number of Covid-related deaths in Ireland.
What exact criteria are we using in deciding which elderly people get admitted to hospital in the current pandemic? It is not clear, but it is vital that we know.
An article that has been published in the prestigious New England Journal of Medicine discusses certain principles for allocating medical resources at a time like this. At first sight they seem to be sensible and agreeable but can also have harmful consequences if wrongly interpreted. In fact, and as we shall see below, it has prompted a critical response from a number of doctors and philosophers. We need a similar debate here.
The article in the NEJM is called “Fair Allocation of Scarce Medical Resources in the Time of Covid-19”.
The authors propose four main values that can be useful when there is a shortage of resources. They are: 1. Maximize the benefits; 2. Treat people equally; 3. Promote and reward instrumental value; and 4. Give priority to the worst off.
Based on a number of studies and documents produced through the years, those values can be interpreted differently and have to be translated into more definite guiding principles. The authors of the document propose six specific recommendations for allocating resources in the current pandemic, according to their own interpretation of those four values.
Without going into a detailed analysis of those recommendations, I will use the article to highlight how different interpretations give distinct outcomes that are not always ethically acceptable. The authors specify that no single value is sufficient to determine which patient should receive treatments.
I will deal with some of their principles here, and save the fourth value for a further article.
The authors say: “Fair allocation requires a multi-value ethical framework that can be adapted, depending on the resources and context in question”.
This is an important principle as abstract ethical considerations have to match with the circumstances. Ultimately, what is appropriate has to be decided by all of those involved, including the patients and their family. Nonetheless, a critical assessment of the ethical principles that guide those decisions is necessary beforehand.
I will begin with considering the fourth value, which is “give priority to the worst off”, as it is the one least discussed in the article but it is also the most ambiguous.
What does “worst off” mean? The article suggests two interpretations: the sickest or the youngest.
If the aim of medicine is to prevent, to cure and to take care, the worst off is someone who is in the poorest conditions from a clinical point of view. Someone who, using a clinical scoring system, is deemed able to recover but needs treatment more than others. (This would exclude futile treatments, when there is no prospect of recovery, and also non-necessary interventions, when someone can recover without treatment.)
However, other interpretations of the aim of medicine, focused more on well-being and quality of life, would claim that the worst off are those who “are at risk of dying young and not having a full life”, as the article explains, without endorsing this specific interpretation. The worst off could be “the younger people who will have lived the shortest lives if they die untreated”.
The difference between those two interpretations is not scientific but philosophical and it appears again in the discussion of the first value proposed by the NEJM article, which is the maximization of benefits.
This can be understood as saving the most individual lives or as saving what they call “life-years”, which means saving the patients who will survive longest after treatment. It is a crucial distinction.
A utilitarian approach to medicine would claim that those who have more years ahead of them, because of age or health conditions, should be prioritised. (I have addressed this issue in my previous blog).
A personalist approach, instead, would say that all persons have incomparable worth, which cannot be measured or weighted against.
The NEJM article first suggests a balance of those two approaches, which I doubt to be possible. Then it claims that the life-year principle “becomes relevant only in comparing patients whose likelihood of survival is similar”, which means that only when two are in the same situation the youngest, or the most able, will be prioritised.
This is not ethically acceptable as it amplifies and perpetuates existing injustice against individuals with disabilities or older. Disability or nearness of death does not diminish the value of a life.
The NEJM article has prompted a reply from a group of philosophers and doctors who, in their joint statement, say: “we fear the practical effects of emphasising life-years, especially in a culture like ours.….in which youth is worshipped and the natural effects of age are despised. Sometimes we fall into a pattern of thinking of the elderly as a ‘burden’—on themselves and on us. We already have political movements, and in some places laws and policies, that would permit or encourage assisted suicide or euthanasia for those with lives judged to be no longer ‘worth living’ or ‘burdensome’ to society, including the frail elderly.
“In this milieu, a policy of almost always prioritising the young over the old could reflect and entrench a bigotry that is already widespread. It could lead to a further devaluation of the lives of the elderly, which could work severe and often lethal harms far beyond the triage scenarios imposed by public health emergencies. That is a possibility that gives us strong prudential reasons to oppose any principles that would advise doctors to maximise the number of life-years saved rather than to look to the number of lives saved—old or young.”
After having considered the first (maximise benefits) and the fourth (give priority to the worst off) value proposed by the New England Journal of Medicine article, let’s move to the second one, which is “treat people equally”.
This one is less controversial, at least in principle, but the meaning of “equally” can be interpreted in various ways.
The authors reject the first-come first-served allocation that it is used in other contexts, such as a waiting list for organ transplants. Treatments for Covid-19 are urgently needed and if equality is interpreted as a first-come first-served approach, this would favour those who are closer to the health facilities or it would encourage overcrowding, as happens each year in A&E.
When patients have similar prognoses, the article suggests random allocation, like in a lottery. This is a simple solution, it is not particularly problematic from an ethical point of view and it would spare us from considering other non-medical characteristics. But those circumstances are rare.
In any case, when patients have dissimilar prognoses it is crucial that everyone is entitled to equal respect and equal concern, according to their needs.
“Promote and reward instrumental value”, the last principle proposed by the journal, is the most complex one and I will address it in my next blog.
Who is giving ethical advice to NPHET?
By David Mullins
There has been much talk recently of the need for both government and the National Public Health Emergency Team (NPHET) to display greater levels of accountability and transparency.
This is particularly true with respect to the deliberative processes that are being engaged in prior to conclusions and recommendations being made.
Are the decisions of NPHET unanimous? Has anyone voiced strong opposition or put forward opposing ideas around the shape of the response that is going to be required should the economic and social restrictions remain in place?
What of the harms that are clearly accruing to non-Covid patients in terms of accessing continuity of care?
These are not immaterial concerns.
In fact, they refer to centrally important procedural and ethical values, which if ignored could risk de-legitimising the national effort.
The Department of Health agrees.
Here is how it framed the matter in its recent Ethical Framework for Decision- Making in a Pandemic:
“Good decision-making processes show respect for people and ensure procedural fairness, as well as confer legitimacy on the decisions made. Communicating decisions and the rationale behind them in an open and transparent way is one of the crucial factors in increasing the acceptance and cooperation of those who will be affected by these decisions, i.e. frontline healthcare professionals, patients and the general public.”
This approach is both laudable and welcome.
What we also need to know however is just who is actually behind the State’s ethical response. It is entirely inadequate just to say, ‘The Department of Health.’
For example, who specifically will offer ethical guidance to NPHET on the appropriateness or otherwise of Do Not Resuscitate Orders (DNR’s)?
Is there anyone in the State’s ethical response team who is pushing back against the permissibility of adopting criteria that de-prioritises eighty year olds for clinical intervention? Who is that and why?
Given that these are clearly issues of significant concern you might have thought that it would be the members of the National Advisory Committee on Bioethics.
But as the Iona Institute has shown previously, the National Advisory Committee on Bioethics last met on 24 September 2015.
There is no new available information which suggests that situation has changed.
This is despite the fact that the very reason for its existence is to “advise the Minister on the ethical and social implications of scientific developments in human medicine and healthcare. In particular, this includes: Providing advice in the form of expert reports on priority issues of national significance as requested by the Minister and providing recommendations and assistance towards the development of healthcare policy and associated legislation.”
We do know that Prof. Siobhán O’ Sullivan, who is the Chief Bioethics Officer at the Department of Health has been advising and has been present at Department of Health Covid-19 briefings.
Given the scale of the challenges and the ethical complexity involved in formulating a just response to this crisis, this seems like an extraordinary weight to place on one person’s shoulders.
There was a good reason to establish a bioethics advisory committee in 2012 and not just parcel the ethical deliberations out to one or even two or three people.
There are even better reasons now given the impact that ethical frameworks can have on the shaping of genuinely compassionate and person-centred care.
For the sake of ethical transparency, and the maintenance of trust, it is high time we were told where the government is getting is ethical advice from.
Utilitarianism is no basis for allocating scarce medical resources
By Dr Tom Finegan
Decision-making in the context of scarce resources will tend to appeal to what sounds like utilitarianism, i.e., to the weighing of the “good” and “bad” involved in possible choices to see which choice will produce the highest amount of overall net good. For example, in the context of limited access to Intensive Care Units (ICUs) often the temptation is to adopt an approach which will result in the most life-years saved—so on this basis it may seem to make sense to exclude the elderly from accessing ICUs or adopting a presumption against allocating ICUs to the elderly. At the very least, it may seem that whatever the right approach is it will involve utilitarian calculations. It may seem that whatever we do we will have to weigh bad effects with good and see which course of action will produce an overall net good. Surely, it may be asked, this is the only rational and therefore moral way to proceed?
But many people hold that utilitarianism is a destructive moral theory. So are we in fact committed to adopting a utilitarian ethic in the sorts of moral decisions that emerge in times of crisis and scarce resources? I will provide an outline of an answer in four parts:
- What is utilitarianism?
- Why is utilitarianism a problematic moral theory?
- Is appeal to the utilitarian ethic unavoidable in the sorts of cases that tend to emerge in the current pandemic?
- Is there a moral way to make decisions concerning who stands to benefit from scarce resources?
(i) What is utilitarianism?
There are different branches of utilitarian theory so what I’ll do here is just sketch what I take to be the essence of utilitarianism. Very generally and very simply, utilitarianism refers to a moral theory that calculates how much good will result from a choice compared to how much bad will result from it, measures the overall good against the overall bad, and then judges whether sufficient overall net good will be produced by the choice to make it a moral choice.
Utilitarianism, then, needs to be able to add up different good effects together, add up different bad effects together, subtract one from the other, and provide a meaningful result that can guide moral choice.
The references to “good” and “bad” above refer to these concepts understood in a sort of pre-moral sense. It is not until the final judgment concerning whether or not sufficient overall net good would result from a choice that the concept of morally good or bad emerges.
(ii) Why is utilitarianism a problematic moral theory?
There are many reasons why utilitarianism is a problematic moral theory but here I will focus on just one or two reasons.
Utilitarianism proceeds by listing out a series of “good” effects and a series of “bad” effects that would likely result from a given choice. As indicated above, this listing of good and bad is blind to the particular moral significance of the goods and bads involved. So it lists out good effects in a way that an amoralist (someone who does not care about morality) might. This is hugely problematic because many goods concern moral principles and/or norms that simply should not be “weighed” against other considerations.
For example, the principle that every human life possesses equal dignity and should not be intentionally destroyed or neglected is not a principle that can be morally “outweighed”. There may be good reasons why this principle can be applied in certain cases to allow for the withdrawal of treatment so that death is allowed happen, for example, but in such cases the principle is not being “outweighed”. Rather, here the implications of the principle are being qualified or specified in light of other relevant principles and norms.
The above also goes for moral duties. Moral duties are basic. In principle they always apply in the relevant circumstances and so they are not outweighed by other considerations. Hence a medic always has a duty of care to her patients. It may happen that exceptions to the requirements entailed by duties can be made, or that legitimate excuses may arise for not fulfilling certain aspects of the duty. But what is happening here is not the pre-moral outweighing of the duty by other considerations. Rather, here the implications and scope of the duty are being qualified or specified in light of other relevant principles and norms.
Likewise, utilitarianism in listing out goods and bads as an amoralist would is blind to how certain justifications and motives should be excluded from any moral analysis.
Morally valid principles, norms, duties and rights are not the product of weighing up a list of pre-moral goods against a list of pre-moral bads to reach conclusions about an overall net good. Moral analysis goes in the opposite direction: judging what is morally good or bad proceeds by reasoning about morally valid principles, norms, duties and rights.
It follows that utilitarianism treats morally valid principles, norms, duties and rights in a way they should not be treated: as if they could be outweighed. This means the utilitarian can justify dismissing the following morally valid principles, norms, duties and rights in a way that (a) fails to see their moral significance and importance, and (b) fails to appreciate their moral relevance and applicability:
- The principle of the equal human dignity of all
- The norm against intentional killing
- The norm in favour of medical resource allocation based on need
- The duty of care medical professionals owe all their patients
- The rights patients have to equal care and concern, bodily integrity, a fair supply of medical resources, and life
(iii) Is appeal to the utilitarian ethic unavoidable in the sorts of cases that tend to emerge in the current pandemic?
In a word, “no”. It is true that we often talk in terms of “weighing” and “balancing” goods in order to arrive at a moral decision, but this use of language does not entail that we are committed to thinking like utilitarians.
If a hospital begins its moral decision making guided by the above principles, norms, duties and rights it has already rejected utilitarianism. None of these are justified by a consistent utilitarianism. If a hospital remains true to these moral guides (and others like them) then it remains anti-utilitarian.
Of course, it may happen that a medical team in this hospital needs to decide who gets scarce medical resources. And it may decide against an elderly person obtaining the resource in a particular situation in favour of allocating the resource to a younger patient. This can be a moral decision (see below in the next section), and it doesn’t justify appeal to utilitarian calculations. In such a case the hospital can remain faithful to relevant principles, norms, rights and duties specified in light of each other, and can therefore avoiding listing out a series of pre-moral goods and bads as an amoralist would, and weighing them against each other.
The final decision, then, would be justified by reference to the relevant morally valid principles, norms, rights and duties, and not by reference to a pre-moral weighing of good and bad effects.
(iv) Is there a moral way to make decisions concerning who stands to benefit from scarce resources?
As indicated above, “yes”. I won’t get drawn into specific cases here, I will just outline ways in which a moral decision may be reached—ways which are not utilitarian.
For a start, there are non-utilitarian ways for moral analysis to take account of likely consequences. When consideration of likely consequences takes place in light of morally valid goods, principles, norms, duties and rights that are not generated by utilitarian analysis, then such consideration of consequences will be no concession to utilitarianism.
It would be immoral to simply exclude the elderly from the allocation of scarce resources or to presume they shouldn’t be allocated scarce resources. Those positions seem to be only justifiable on the basis of a utilitarian approach which seeks to maximise life-years saved, and which thus implicitly denies the equal value of elderly people. A primary moral consideration must involve the clinical question of whether a patient needs treatment and stands to medically benefit from treatment. There can be no exclusions or presumptions applied to deliberations over this matter. If it transpires that numerous patients fare equally as regards this clinical question and that there are not enough resources for all of them, it may be justifiable to allocate the resources to younger patients on the bases outlined below. (I am not suggesting that the only relevant considerations are the ones outlined below, or that they will apply in all cases, or that there are no considerations that will favour treating older over younger patients.) So in certain circumstances justice may requiring, or at least permit, allocating scarce resources to younger patients:
- Out of consideration for dependent, vulnerable persons (like children) who rely on the patient in question for their welfare. This consideration will tend to favour the allocation of resources to younger people in the context of resources scarcity
- Out of consideration for the likely proportionate benefit provided by the medical treatment. The idea here is that it may not be a fair, efficient use of medical resources to expend considerable medical energy only to effect very slight medical benefit (e.g., the allocation of very considerable medical resources to prolong the life-expectancy of a terminally ill patient by a matter of weeks). This consideration will tend to favour those with better overall health, and therefore, indirectly, will tend to favour younger patients
- Out of consideration for how certain patients may have already greatly benefitted from medical help over the course of their lifetime, and how fairness now requires that others receive some benefit from medical services. Again, this consideration will tend to favour younger patients.
Dr Tom Finegan, PhD, is a lecturer in theology and religious studies at Mary Immaculate College, Limerick; Vice-Chair of the Board of Governors of the Anscombe Bioethics Centre, Oxford; a member of the Working Group (religious education) of the Council for Catechetics of the Irish Catholic Bishops’ Conference; and a member of the Bioethics Consultative Group of the Irish Catholic Bishops’ Conference.
Should those in charge get priority treatment in a pandemic?
By Dr Angelo Bottone
The authors propose four main values that can be useful when there is a shortage of resources. They are: 1. Maximize the benefits; 2. Treat people equally; 3. Promote and reward instrumental value; and 4. Give priority to the worst off.
I have already discussed three of them and now I will concentrate on “promote and reward instrumental value”.
We value things intrinsically, for their own sake, or instrumentally, for the sake of something else. For instance, a banknote has little intrinsic value, it is just a piece of paper, but when it is a legal tender it also has an instrumental value because it can be used to pay for something. We employ it instrumentally for something else, to carry out a particular function.
Similarly, we can value human beings for what they are, in themselves, or for what they do, instrumentally. If I need a plumber, for instance, I will choose the one that suits me best. I treat him as an instrument for my purposes (do the job being paid for) and there is nothing wrong with it as this is the nature of a commercial transaction.
But when we need to evaluate who has priority in accessing medical resources, should we treat patients for their intrinsic value, simply as members of the human family, or also for some instrumental value, such as their utility to society?
In normal circumstances, we treat them according to their needs. Their past or their future, their role in society, their usefulness should not matter.
We give should give the opportunity to access the same treatment to an important doctor and to someone who has injured himself behaving recklessly, or to someone who is in prison. We value patients not from the point of view of society, but intrinsically, for what they are and not according to their history because even the worst human being deserves care.
Nonetheless, this general equality principle does not apply in exceptional circumstances.
For instance, if there is a health emergency on a ship with hundreds of people, it is morally acceptable to prioritise those who are in charge of the ship over the rest, because if they die, everyone else will also die. The instrumental value prevails in this case.
How this apply to our circumstances?
The NEJM article says: “Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past”.
I will call those “temporal criteria” as they associate value to time, to what someone did in the past or will do in the future.
I maintain that, in allocating medical resources, instrumental temporal value should not apply retrospectively. Obviously, those who have made relevant contributions should be recognised and rewarded but this should not count as a criterion to select who should have access to ICU beds, ventilators, etc. Nonetheless, treatments are not awards based on past merit but they are remedies offered according to actual needs. The focus in on the present.
And what about future usefulness or utility? Does it matter? It does but as an ultimate measure and only for the limited time of the in exceptional circumstances. (Think of the previous example of the ship).
The NEJM article says: “Critical Covid-19 interventions – testing, PPE, ICU beds, ventilators, therapeutics, and vaccines – should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response”.
They have a higher instrumental value because saving them we will also save other lives. Special considerations will be beneficial to them directly and to others indirectly. So, all things being equal, it is morally acceptable to favour them because of their indispensable role for society.
This kind of thinking seemed to be dominant in March when hospitals were outbidding care homes for PPE and staff leaving them in very short supply at great cost. Almost two-thirds of Covid-related deaths have occurred in care homes and, in the end, the hospitals were never overwhelmed with Covid-patients or anything close to it.
I don’t believe we have anywhere reached such an exceptional level of emergency that the survival of large part of the population depends on few health professionals, but this is an evaluation that has to be performed locally.
In any case, the main point is that “promote and reward instrumental value” should not be interpreted retrospectively. Instrumental criteria are valid only exceptionally, for a limited period of time, and for the actual benefit of others.
Safety above all things is not a Christian virtue
By Dr Angelo Bottone
Too much or too little are two ways of doing something wrong. A well-meant action can go bad because of an excess of it or a lack of it. Courageous gestures, for instance, lie between excessive fear and recklessness.
If we consider risk, which is a common and inevitable element of life, what is too much or too little risk? The answer depends on the circumstances, it is not something fixed that can established in theory but only in practice.
For instance, public worship is not permitted in Ireland at the moment, because there is some risk of spreading the Corona virus. Proper measures could be established to limit the risk we can afford but a total ban, which is an extreme approach, has been enforced instead. At what point does this become unbalanced, especially in view of the fact that all European countries – bar the UK – have already restored public worship, albeit with limits on number attending? Ireland does not propose to do this until July 20th.
We haven’t seen cases of reckless imprudence, where dozens of worshippers have crammed into a church currently open for private prayer, thereby defying the rules of social distance. This wrecked behavior has happened at some recent political rallies.
What we have seen in Ireland, instead, is probably an excess of fear when compared to other European countries, where the Christians – lay and cleric – have often lobbied, successfully, for a restoration of a full celebrations, with the due precautions. Ireland is an exception.
The Christian world view never equates the good life with self-preservation and excessive risk aversion. Obviously, in the face of a real threat, we have to respond with prudence and respect the gift of life but, on the other hand, the accomplishment of the good requires a certain inevitable risk taking.
We would have no Christianity if those living under persecution, from the first centuries until now, put their own health and safety before preaching the Gospel.
If we let fear lead us to narrow the scope of our vision, ignoring what is normally happening in other countries, and assume a posture of self-preservation, we would betray our Christian call.
“Normal fear protects us; abnormal fear paralyzes us. Normal fear is a friend that motivates us to improve our individual and collective welfare; abnormal fear is an enemy that constantly poisons and distorts our inner lives. So, our problem is not to get rid of fear but to harness and master it”, wrote Rev. Martin Luther King in one of his most famous sermons.
An ethics of security that trumps other goods has never inspired saints.
During this epidemic we have seen many acts of heroism, particularly by those who were taking care of others. In Italy, for instance, many of the priests and nuns who have died, were infected while ministering the sick.
Clearly, not everyone is required such an extraordinary level of self-sacrifice and, more important, there is no heroism in putting other people’s life in danger.
While we appreciate self-sacrifice, we also have a duty to protect others. Nonetheless, there is no Christian life, or life in general, without risk and all personal decisions have unavoidable consequences on others. Those who professed the faith during the persecutions also exposed their own families or communities to a certain level of hazard. The concern of hostile consequences should never stop us from doing good.
It might also be said that it is one thing for a person to take a risk for themselves by attending church in a pandemic, but then they risk others if they become infected. Nonetheless, again, this calculation will have been made by the Church in every other part of Europe, and they have decided the risk of catching the virus at a public Mass which has limited numbers and has proper hygiene measures is very small and is worth taking.
Someone might distinguish between moral and natural evil, where moral evil is the one voluntarily produced by human beings, while the natural one follows from the events of nature outside human control, such as diseases, calamities, etc.
They could claim that risks taken in defiance of a moral evil might be virtuous – think of the martyrs – while risks taken in defiance of a natural evil are mere foolishness.
I honestly don’t find this distinction between moral and natural evil significant when we consider those who suffer from these evils. Enduring the most difficult circumstances, including natural evils, is a form of strength not less praiseworthy than suffering from human misdemeanours.
“Not the injury but the cause makes martyrs”, says St Augustine. Similarly, not the origin of evil but our resistance to its many manifestations, makes us virtuous.
Courage stands between excessive fear and insensitive fearlessness. Following St Augustine, St Thomas Aquinas teaches that “fear is born of love, since man fears the loss of what he loves.” Courage takes fear into account and surmounts it, avoiding both excess and defect.
Sacramental grace is currently denied in Ireland, when we need it most. “‘Twas grace that taught my heart to fear and grace my fears relieved”, we sing. Sooner than July 20th we should return to public worship and let grace relieve our fears so that we can safely worship God.