Fleur Jongepier Karin Jongsma
In Part 1 we have argued that it’s better if ethicists do not publish their takes on triage at this moment.
A democratic discussion
One might rightly worry: isn’t what we are proposing here anti-democratic? Shouldn’t it be precisely part of a well-functioning democracy to discuss vital decisions, such as priority rules on intensive care units? Given the value of democracy and its connection to open debate, it seems discussing these matters with the general public is precisely what must be done. Even if people are startled, even harmed, as a result.
We agree that having societal debates is vital. We even agree that we need to have an open conversation about the possible moral justifications of triage decisions. However, the ‘argument from democracy’, as we might call it, is not an argument for having that conversation now.
Our worry about trying to aim for a ‘public debate’ where triage decisions are concerned, is that it will be neither a ‘debate’ nor strictly speaking ‘societal’. After all, only about 50% of the (Dutch) population reads the newspaper. In those percentages, men are generally overrepresented and migrants are underrepresented. So, the public reached through (online) articles may well be ill-representing society at large. As for having a ‘debate’: an (online) article does not constitute a debate (not the sort of debate we need to have, anyway). It’s one directional. This is particularly problematic when ethicists make it seem as if the theory or principle they defend (utilitarianism or the fair innings principle, say) is the moral principle.
It doesn’t need to be one-directional, and no doubt the ethicists who are engaging precisely hope and aim for readers to engage, too. And sure, readers could submit a two hundred-word reply, or say something in the comment section. But that’s not nearly enough. Also, let’s not forget these are likely to be individuals with time and energy on their hands, that is, probably not the ones ill or stressed out. That is: those affected most. If we want a genuinely public debate, we need to give the public a genuine voice. We need more than a handful of articles by ethicists to which citizens can respond in the comment sections. Having a proper public conversation is vital, but doing so now is, we fear, neither desirable nor possible.
A recent statement from the Nuffield Council on Bioethics deals explicitly with questions concerning democratic governance in relation to COVID-19. The authors express serious concerns about the situation in the UK – and situations elsewhere are probably not dissimilar – that, right now, decisions are being made that “go to the very heart of what governments are there to do: to protect the freedom and well-being of their people”. Yet public information is “limited and obscure” and no proper public discourse on any of the vital ethical-political questions has gotten off the ground. They plead for greater accountability and transparency, and ask the government to get public deliberation off the ground. We are “all in it together, we all need to know and all need to have a voice”.
The present article might be interpreted as being “against” initiatives like these. So we want to be clear: we very much share the overall pro-transparency and pro-democratic sentiment. But respecting and promoting transparency and democracy can be done in different ways. There’s a difference, to begin, between accountability and transparency (we all need to know) on the one hand and public discourse (we all need to have voice), on the other. We wholeheartedly agree with the first point. It’s crucial that governments make explicit the decisions they are making and make explicit their reasons (and empirical evidence, where available) for making those decisions.
As for the second point: yes, we do “all need to have a voice”. The question is: do we all have a voice? Are our voices at the same decibels? Do we all have a voice that will actually be heard? If we don’t, then it may not be the best idea to engage in public discourse now but rather do so later, once we’ve had more time to also think about and are actually able to guarantee the diversity and inclusivity of the debate we need to have. Public debates are difficult, slow, and complex and it is unlikely that a consensus or otherwise strong supported triage criterion will be the result from public consultation any time soon.
The alternative is a quasi-public debate, in which some members of the public are represented, and others (those most affected, we fear) aren’t. This is perhaps the worse of the two options. The combination of “public debate” and “now” form an unhappy couple. Doing it properly later may be better than doing it poorly and half-heartedly now. If only because three or four op-eds and a half-baked survey filled in by healthy, abled, and childless individuals might create the illusion that we’ve all had a say when in fact we haven’t at all.
Being realistic or a coward?
Our standpoint relates to an important distinction in political philosophy between ideal theory and non-ideal theory. Ideally, we agree: we need to have a public debate, we need to have it now, and we need to have it with all of us. But sometimes, pursuing the ideal can have counterproductive outcomes, and pursuing a non-ideal course of action (having the debate later), is to be preferred. Precisely because, paradoxically, the non-ideal course of action enables us to get closer to the ideal of all of us having a voice, and getting an actual chance of being heard.
Maybe we’re too pessimistic. When defending non-ideal solutions, one always risks slipping into cowardice. As the authors of the Nuffic statement acknowledge, maybe there is “no capacity now to open up a wider public discourse”, which is what we fear, but they also add, quite rightly, that “capacity should not be an excuse”. The solution must clearly then be not to accept the situation but to try and change the capacity. But can we? The real question is whether we can really get a public debate going that is legitimate and isn’t going to harm more than it helps. We need to think about the empirical chances of public deliberation actually being successful. Because if the public is not ready, or able, or willing to engage in public deliberation, or if it turns out only a privileged subset of the public is, then that might be a reason not to do it now, in spite of the fact that, ideally, we should all be deliberating about this together, right now.
Another obvious reason for not starting a societal debate now is that emotions are running high, there is a great deal of unrest, fear, misunderstanding and uncertainty. As far as we can see, there is now a need for articles about which specific action we should be taking in daily life (What are we supposed to do exactly when someone in our household becomes sick? Should we be making DIY masks or not?).
Let’s also not forget many members of the general public are currently being invaded by tent-building, pet-hunting offspring with Nutella-smeared faces. They may well have other things on their minds than the moral justification of implicit ethical principles for triage at the intensive care unit. They might well want to engage in public deliberation, but simply can’t, at this moment. These are not ideal circumstances for a complex societal debate about the principles of who should be saved in these extraordinary times. We believe a public discussion would be more effective, less aggressive, and more inclusive, if we have it when the worst of this is over. We contend therefore that, precisely for reasons of democratic legitimacy, now is not the time.
For the record: despite the title of this blog, there is plenty of constructive work that ethicists could do. For example, they could say something sensible about the currently emerging culture of ‘shaming’ and hostility; the difference between being alone and being lonely; how can we ensure ethically sound clinical research in times of crisis; how we should feel about the enormous influence of companies who sell ventilators and choose whom (not) to sell it to; how we should be dealing with digital social contact (and medical consultations) and how this differs or does not differ from face-to-face meetings. We are here specifically worried about whether ethicists can fulfil a constructive role when it comes to publicly defending certain moral theories or principles to justify ways of making triage decisions on intensive care units, or whether it’s better to place our trust in clinicians and/or triage committees.
The ethicist’s role in times of crisis
But isn’t this an ethicist’s job? Isn’t it their responsibility to publicly discuss uncomfortable moral principles and considerations, also in crisis situations? We realise that our standpoint is quite controversial, but we would say: no, not necessarily.
Indeed, it is the ethicist’s job to reflect on the ethical challenges and issues in society. Where possible, it is also their job to share their expertise with doctors when they undergo crisis training and learn about triage decision-making. At the moment, this is already going on. It’s not like ethicists are not consulted or asked for their views – the contrary. But it’s not enough for an ethicist to share their knowledge of how certain moral theories or principles are understood in ongoing debates in applied ethics. In their expert capacity, their responsibility also extends to taking into account what the articulation and defence of certain moral principles may lead to. This includes unintended messages. Especially utilitarians, who appear to have the loudest voice in current triage discussions, have every reason to include this factor in their calculations.
Isn’t it strange that we are engaging in public debate in order to say we shouldn’t be having this public debate? Yes, it’s strange, but these are strange times. For this reason, we ultimately decided that we would not send a (much) shorter version of this article to the newspaper, since that would be hypocritical. We decided it may be right to engage on a more reflective platform, without scarcity, and that allows for longreads. Though the irony of it all does not escape us.
We believe that now that there are actually real ethical dilemmas, this is, paradoxically perhaps, the time for ethicists to hold their horses. We should now be relying on the expertise – and by this we specifically also mean the moral expertise – of clinicians and their support teams, who face incredibly difficult decisions at the intensive care unit. We believe that this trust is more supportive towards clinicians than a reflectively substantiated ethical article that, no matter which way you look at it, raises questions about the decisions clinicians have to make. Applied ethicists are, ideally, good at ethically reflecting on ‘real life’ situations. Clinicians are good at acting in ‘real life’ situations.
To put it simply: fellow ethicists, now is not the time.
This article is loosely based on a Dutch article which previously appeared on the philosophy weblog Bij Nader Inzien. Translation by Radboud Recharge and the authors.