Around the world, Covid-19 is raising profound questions about medical ethics. Julian Sheather FRSA argues that pandemics require us to think not just much more broadly and deeply about justice and fairness in health and health care, but also about how we treat animals.
I had an email from a GP colleague recently. He was responding to guidance on the ethics of resource allocation during Covid-19. The paragraphs I had drafted about general practice a fortnight ago were now out of date: general practice had been transformed more in the last three weeks than in all his 35 years as a GP.
For all the horrors of the pandemic there is something transfixing about watching the great and beloved (mostly) behemoth of the NHS respond to this once-in-a-generation seismic shock. For those who work in, or as in my case, near, the NHS it also offers an unusual opportunity to see it to some extent whole: as a single institution responding to an extraordinary challenge.
I work mostly in medical ethics. This has to do with identifying and responding to moral challenges that arise in medicine and allied practices. Probably fair to say that its focus has largely been on fine-grained problems. Defining moments include whether the withdrawal of life-sustaining treatment from a patient in a persistent vegetative state was lawful, or to what extent a competent child’s decision could override parental disagreement. Its domain has largely been the clinical, doctor-patient relationship; where scientific innovation and social change ignite, demanding frequently novel ethical challenges. It is where philosophy collides productively with scientific innovation and the urgent need for workable solutions to practical problems.
For all its urgency – not to mention intellectual fireworks – many people working in the area have felt the focus on these clinical issues, though critical, is only part of a broader picture. If we are serious about human health, if we hold it in high moral regard, then clinical ethical dilemmas only take us so far. Health is a collective as well as a private good. Although our health is an intensely personal matter, we hold the conditions for its flourishing in common. Colleagues working in public and global health have long argued that the intensely individualistic focus of much medical ethics is insufficient. Meaningful change in the conditions for good health requires collective effort. It has to do with politics.
Many a medical student will recount by rote the four (well-worn) principles of medical ethics: autonomy, beneficence, non-maleficence and justice. That last has always felt like an orphan principle, hanging in the background looking for a job of work.
But Covid-19 is about as potent a reminder as possible of the requirements of justice and fairness in health and health care. If the supply of ventilators is overwhelmed, among the most harrowing ethical questions is who we should try and save when we cannot save everybody. What would a fair or just distribution of live-saving treatment look like? These are goods we hold in common.
Consider as well the knowledge of interdependence that the pandemic brings. We isolate not for selfish private reasons but for the common good; we are but links in potential chains of lethal transmission. Private actions have enormous potential ramifications. We are not isolated monads pursuing private satisfactions but share a common human vulnerability, are exposed to a common potential fate.
Contrast the implications of Covid-19 for countries with universal, free at the point of care health services and those that rely on private payment. Look at how powerfully the pandemic is deepening already abyssal health inequalities in the US. Every week, in the UK, we step to our doorsteps to applaud the NHS, perhaps the finest example of mutual risk-sharing in the world. For sure it needs more than applause – proper protective equipment would be a great start – but the sentiments are genuine.
When we think of justice as an operative principle in medical ethics, the question often arises: justice for who? What is the scope of the principle? Who counts in the accounting that justice requires? In ordinary clinical ethics questions of justice usually involve, at most, a nod toward side-constraints arising from limited resources. In public health ethics, it is, usually, the population of a nation or state that counts. Public Health England focusses on, well, England. But Covid-19 reveals the limits of public health’s nationalism.
We knew there would be another pandemic. The timing and place of origin were uncertain. But another pandemic was as close to inevitable as makes no difference. The fervent hope was containment but to be effective, this requires extensive global collaboration. It requires the ability, if required, to shift significant resources to impoverished settings. It requires a rapid, joined up, properly global response. It asks us to think deeply about global justice.
Finally, permit me one last move. Covid-19 jumped the species barrier, probably in a wet market in Wuhan, China. Most pandemics follow a similar path – swine flu, bird flu, SARS, MERS – they leap from animal hosts, and spread like wildfire among humans with no immunity. And there is little doubt that intensive – frankly abusive – farming practices are a huge contributor. Pandemics – their awful destructive power – must therefore ask us to widen the ecosystem of justice to include the animals, wild or farmed, on which we so depend.
This transformative shock offers us opportunities not just to re-think how we provide our health services. It also opens up a fresh view on how we understand justice; to look not just to the people we share our countries with, not just to others who dwell in the world, but also out beyond the species barrier.
Julian Sheather is a writer and ethicist. He works for a number of leading national and international medical organisations.