Trevor Stammersis Associate Professor of Bioethics, Director Centre for Bioethics and Emerging Technologies.
I always try to avoid analogies with war because in battle, the ethics that apply in peacetime are often suspended. However, with a worst-case scenario of 510 000 UK deaths from Covid-19 if nothing was done to control it, allusions to war are all too understandable. In just one recent news bulletin, there were references to a “field hospital” nearing completion at the Excel Centre to help fight the “unseen enemy” and “frontline” staff elsewhere reported as feeling like “cannon fodder” because of the lack of effective protection – a similar outcry to that about inadequate body-armour for soldiers in battle.
Much Christian comment on the pandemic to date has rightly focused on the importance of communities looking after each other and not succumbing to panic and fear but such appeals to ‘civil society’ will have no effect on those whose priorities are self and wealth rather than others’ health. The UK has been decreasingly civil for many years and that won’t change overnight.
Other writers have pointed to the underlying diagnosis of individualistic Millian autonomy. “Something like COVID-19 both strips away the illusion of control to reveal the vulnerability that always lurks beneath and confronts us with the anxious realization that we are frail and mortal. It also exposes the way we’ve been captured by an economics (and sociality) of scarcity and competition, rather than abundance and grace.”
Fewer so far however have so far mentioned that the crisis requires us to face the possibility of the ultimate sacrifice of laying down our lives, both literally and metaphorically, that others may live. One of our MA Bioethics graduates from St Mary’s refers to Luther’s letter to his friend, Johann Hess, during the Wittenberg plague of 1527, when the burghers of the town, like those of today, were fleeing to their holiday homes in the countryside. Luther wrote that although “examples in Holy Scripture abundantly prove that to flee from death is not wrong in itself” nevertheless “all those in public office such as mayors, judges, and the like are under obligation to remain…no one should dare leave his neighbour unless there are others who will take care of the sick in their stead and nurse them. In such cases we must respect the word of Christ, ‘I was sick and you did not visit me …’ [Matt. 25:41–46]. According to this passage we are bound to each other in such a way that no one may forsake the other in his distress but is obliged to assist and help him as he himself would like to be helped.” Luther himself decided to stay and made his home into a temporary hospital until the plague had passed. With headlines of a 36-year-old, previously-fit intensive care nurse critically ill in hospital with coronavirus, and three UK doctors now dead, Luther’s predicament has a curiously contemporary edge.
As the ‘coronacrisis’ develops, it will not be only health care workers however who should seriously reflect on the possibility of laying down their lives in a time of scarce resources. Reports are coming in that some elderly residents of care homes in Spain have been found dead, apparently being abandoned by the staff. Some cynical voices are indicating the higher mortality of the elderly from Covid-19 could well be a good thing. Ed Conway, economics editor of Sky News takes apparent comfort from the fact that “if you were a young, hardline environmentalist looking for the ultimate weapon against climate change, you could hardly design anything better than coronavirus. Unlike most other such diseases, it kills mostly the old who, let’s face it, are more likely to be climate sceptics. It spares the young. Most of all, it stymies the forces that have been generating greenhouse gases for decades.” Conway appears to forget that many older people such as Sir David Attenborough might also be lost to the green cause and that the young may perish in larger numbers than he thinks.
Though in peacetime, scarce resources should be apportioned based on immediate need, in time of war the ethics of triage comes increasingly into play: “This requires a switch from standard medical ethics with the primary focus on the individual autonomy of patients to an ethics of public health with a primary focus on the health of the community.” It may also require a switch at some point from medical utility alone to the much more controversial consideration of social utility. In the US, some are already being explicit about how older patients will be treated: “Consider a patient, 85 years old, on a ventilator, out of hospice care. Along comes a 45-year-old, with a family, and in fundamentally good health and a good prospect of full recovery from coronavirus if treated with the best available treatment. Is it not only acceptable but ethically necessary to take grandpa off the ventilator and switch him to palliative care, wipe away the tears, and switch the ventilator to the younger patient?” Should the ventilators eventually run out here, it is likely that things will go the same way. I am no utilitarian but I can see why this may be necessary.
The clinicians who have to take such decisions will inevitably suffer intense moral injury and distress. They will not be alone. To die alone in isolation is far from ideal and the complicated grief of those left behind can lead to mental scars that will long outlive the fear of the pandemic itself. This is why taking drastic measures now to try to limit the spread of the virus are so essential. Most of us just need to love each other enough to keep 2m apart but for some it will mean having to get close enough to risk sacrificing their own lives to save others. It is probably too late to prevent many such deaths now but every BBQ and homecoming from Thailand party held since the “Stay at home” advice was issued, is likely to increase them. Finally, if it will be bad for us, how much worse is going to be for those nations with minimal health infrastructure for whom the tsunami of Covid-19 death has yet to strike? They will need our financial and practical help long after we begin to recover. The next six months will show exactly how selfish or self-sacrificing a nation we are.