Emergency Ethics for a World Broken by Coronavirus

The title might seem melodramatic even though we are all on the edge right now. Humanity has survived many epidemics, two world wars, natural and technical disasters such as tsunamis or reactors exploding. The costs have been high though, and ethics has often shied away from providing answers for these tough times. In this post, I will argue that philosophers must be prepared to undertake a form of non-ideal emergency ethics to be able to help with the pressing moral questions, for instance in the medical sector.

Ethics for a Broken World

I have based the title of this post on a book called “Ethics for a broken world –Imagining Philosophy after Catastrophe” written by political philosopher Tim Mulgan. Mulgan imagines a future world irreparably damaged by climate change, which finds itself in permanent crisis: survival bottlenecks and a severe lack of resources are the norm. The book’s judgement about the current state of ethics and philosophy is not a kind one: Mulgan deems affluent philosophy (for instance libertarian or contractarian approaches or deliberative democracy) ill-equipped to deal with the ethical quandaries of a crisis and reasoning under scarcity. There is a lot to criticise in Mulgan’s approach, but it is hard to argue with his basic point: a lot of contemporary philosophy happens in the professor’s armchair offering little guidance for the “real world”.

Is current ethics up to deal with the hard decisions that need to be made, for instance by healthcare workers in Italy, the U.S. or Spain? In one of the first articles published on the tragic decisions Italian doctors face, Yascha Mounk strongly doubts that. He concedes that “Despite those years of theory, I must admit that I have no moral judgment to make about the extraordinary document published by those brave Italian doctors. I have not the first clue whether they are recommending the right or the wrong thing.“

Weyma Lübbe on Corona-triage

I find Mounk’s conclusion disheartening. More importantly, I disagree. For example, medical ethicists Julian Savulescu and Dominic Wilkinson and Weyma Lübbe have already provided constructive takes on the guidelines recently published by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). The guidelines provide criteria that doctors and nurses should follow if they have to make the tragic choice whose life to save if they do not have enough medical resources to save every patient. The authors base them on the principles of medical triage and Utilitarianism, which prescribes maximizing benefits for the largest number of people. They deduce that it might come to the tough decision of prioritizing patients who have more years ahead of them taking their overall health condition in account.

Weyma Lübbe points out that this deduction is problematic, because it corresponds neither to the principles of triage nor to its ethical underpinnings. The goal of triage is not to put age limits on distribution, but to save the maximum numbers of lives. Pointing out this misreading will not diminish the effort of the college, the purpose of which has been to ease the burden of health care workers. Quite to the contrary, it shows that ethicists should have done a better job in preparing for a world in crisis, as Mulgan has argued. Doing emergency ethics in a time of emergency does not seem to be a good idea.

At the same time, Lübbe’s thoughtful analysis shows where ethics and philosophy can contribute. If it engages with reality, ethics can – among other things – help other disciplines and people “in the field” to analyse the current problem thoroughly and from different perspectives. It can reflect on the concepts, reasons and arguments used and point out their consequences. It is also valuable in giving a broader perspective by drawing parallels with other contexts. However, ethicists must leave the armchair. All this must be done in an open deliberation with politicians, professionals and everyone affected (if possible) without presuming the outcome. This is what Jonathan Wolff calls engaged philosophy. Now, it needs to take the form of engaged emergency ethics, to borrow a term by Hugo Slim.

What would that look like? Its content will vary with the circumstances. I cannot provide a comprehensive account here, of course. At best, I can start with the first two steps that Wolff proposes for engagement: 1. identify the issue and current state of affairs and 2. identify the arguments of values. I will illustrate this by focussing on two issues: vulnerability and the tension between individualism versus collectivism.

Vulnerability

Now more than ever, vulnerability should take centre stage in moral responses. As we now know, Corona is a lethal threat to people who are vulnerable. But what does that mean? According to MacKenzie and her colleagues, we are all vulnerable beings “as a result of our finite, embodied existence.” The Corona crisis shows us this very clearly. However, some people are more vulnerable than others. MacKenzie and her colleagues distinguish between situational vulnerability (those that arise from context), and pathogenic vulnerability (i.e. situational vulnerabilities that arise from significant oppression or injustice).

Being prone to a severe or even fatal course of disease is certainly a situational vulnerability. However, vulnerability in the current context may also have other sources: social, economic, and environmental. Like rights, vulnerabilities may conflict. Right now, we have decided that biological vulnerability takes precedence, because of the severity of the consequences. However, other vulnerabilities, many of them pathogenic, must not be forgotten. In some cases, they will cluster with biological ones. To name only a few:

• Homeless people are at greater risk for Corona and cannot self-isolate, and only a few cities have addressed this issue.
• Many people with mental health issues are having huge trouble with being confined to their home.
• People (often women and children) are trapped in abusive homes. Domestic violence is already on the rise in all countries.
• Displaced and undocumented people are among the most vulnerable of all because they have no access to governmental protection as citizens. The conditions in refugee camps such as those of Moria, Syria or the camps on the Southern border of the U.S. are bad enough as they are. Now they become unbearable and dangerous as countries close borders. If we do not put efforts in finding suitable homes where they can wash their hands and self-isolate, we are failing the most vulnerable ones.

We thus find tensions between vulnerabilities: on the one hand, people need to stay at home to protect the vulnerable, on the other, the particularly vulnerable might be denied treatment if the resources of the collective are too scarce. What does this mean? It indicates that here are concerns of justice and public resources that will outweigh the concern for individual vulnerability. In the case of medical resource allocation under scarcity the concept of triage is a very important starting point, because it reflects principles that have been negotiated and tested in a long and reasoned debate between disciplines. If the main principle is to save the most numbers of lives, there will be a (tragic) tipping point when the chances of saving a life would be so slim that doctors should employ palliative care instead. When this tipping point occurs will vary with the circumstance and time. Sadly, Corona affects old people most severely these days. Many old people will have a low survival rate even with treatment. However, and this cannot be stressed enough, it would be a grave misunderstanding to deduce we should withhold treatment for old people altogether.

Individualism versus Collectivism

Individual freedom and autonomy have currently been curtailed severely because of concerns for others and to prevent the collapse of the health system. These steps have not been taken lightly in liberal societies that value individual freedom as one of their highest goods. Yet, the Corona crisis shows us that individualism has limits. Appeals to the common good and solidarity have trailed off until the government has enforced self-isolation. Some people and companies who have the financial or other means to help still do next to nothing or even try to profit from the crisis. We should thus examine the individualist arguments grounding our modern liberal political system to find out which kind of individualism can be reconciled with common good – and which forms are too atomistic. Ethicists working on climate change, such as Mulgan, have raised this concern before, and Corona highlights its urgency.

Feminists and some non-ideal theorists have introduced concepts like relational autonomy to highlight that none of us is a social atom: our relationships and society forms our identities in morally significant way. Annette Baier argues that there is very little that we actually do as individuals. Our reasoning and our intention-formation require commons of mind: shared reasonings, intentions and actions. This does not imply that domination or oppression of individuals is justified. It means that individual rights may not always trump the concern for relations or the collective, if the latter’s functioning or survival is at stake.

What does this mean for our moral response to Corona? Very minimally, that we need to curtail libertarian or individualist political reasoning. Concerns for public health and common goods should trump individual freedoms in situations where a large number of lives and the system’s capacity is at stake. Even though they have employed measures, countries such as the UK and the US still give too much freedom and responsibility for their health. Corona spreads at an alarming rate and hospitals are overburdened. What we need is a collective effort to reduce the spreading of the virus. In many countries, also in my own (Germany), collectivist and preventive reasoning came in too late and people had a hard time to comply with softer measures. Of course, hindsight is easier than foresight. We can learn for the future though. For instance, isolating hot-spots of an outbreak, nudging people to stay home, campaigning and a strong information policy are effective and less invasive tools. If all that fails, and it has, collective concerns justify a severe lockdown as we have now in many European countries. Shifting our perspective to alternative views like relational autonomy and common goods shows us how to reconcile these concerns for the collective with relational autonomy.

What do philosophy and ethics have to offer?

There are several other ethical concerns that should be discussed right now, e.g., the problem of paternalism towards people that are not high-risk, societal changes, economic ethics and the many issues arising out of globalised capitalism, and I hope they will be taken up soon. To conclude, does philosophy have anything to offer in these days of crisis? Engaged philosophers do and should. We need to seek an open debate with others to identify the different forms of vulnerabilities, collectivist and individualist concerns. These considerations need to be constantly re-evaluated in their significance against the background of the constantly changing circumstances. It also means we have to make hard choices, maybe even tragic ones. We need criteria to distinguish the acceptable from the worse and worst decisions.