Ethicists, hold your horses (Part 1)

Fleur Jongepier                         Karin Jongsma

If intensive care beds or ventilators run out, who should be saved? And how should such decisions be morally justified? These are horrible, indeed impossible, decisions that clinicians currently face, or may be confronted with in the (near) future. In Italy, clinicians were “weeping in the hospital hallways because of the choices they were going to have to make”. These are also questions that ethicists have, for decades, thought long and hard about.

It seems natural – so natural it almost goes without saying – for ethicists to engage right now, and to start a public debate about the moral justifications of the possible triage options. And they have. Julian Savulescu and Dominic Wilkinson, for instance, recently wrote an article entitled ‘Who gets the ventilator in the coronavirus pandemic?’ They outline five different approaches, but really only take the utilitarian approach seriously; in other words, that a clinician should act such as to save the greatest number. On the utilitarian view, if “one person, Jim, has a 90 per cent chance and another, Jock, has a 10 per cent chance, you should use your ventilator for Jim.” We can call them Jim and Jock of course, but let’s not forget that Jock typically represents the elderly or people with illnesses or disabilities, whereas Jim represent the young and fit.

Similarly, in the Dutch context, colleagues Marcel Verweij and Roland Pierik recently stirred up debate on the opinion pages of the national newspaper. They proposed that in the event of extreme scarcity in the intensive care unit, priority should be given to younger corona patients. Verweij and Pierik are by no means the only ones defending this view. What’s the reasoning behind this view?

There are basically two arguments. First, young people generally recover faster, which means that giving priority to younger people will allow one to treat more people overall, thereby increasing the chance to save more lives. Verweij and Pierik provide a second, much more controversial, argument, namely, that the death of a young person involves a “much greater loss”. Why? Because an 80-year-old will have already “had the chance to live their life”.

This is not an unfamiliar standpoint within ethics – it’s known as the “fair innings principle” – but this doesn’t mean it’s uncontroversial. Here we are not principally concerned with the fair innings principle itself (though we have serious concerns on that front, too), but more fundamentally about whether now is the right time to have a public debate about whether it’s morally justifiable to sacrifice the elderly to save more lives whilst the pandemic is raging on.

An impossible burden

In response to alarmed reactions by some readers, Verweij and Pierik wrote a second article, motivating their reason for submitting their article to the national newspaper. They give two reasons: solidarity and democratic, public deliberation. We believe both arguments are insufficient reasons, in fact we think on the grounds of solidarity and democracy one can come to the opposite conclusion, that we shouldn’t have a public debate about the ethical foundations of triage decisions right now.

Let’s start with the argument from solidarity. We should have a public debate about the ethics of triage decisions because doing so is a way of expressing solidarity with clinicians. Verweij and Pierik write: “It’s an almost unbearable responsibility to have to decide who should and should not be offered a chance of survival. Solidarity means that we should collectively bear the burden of the crisis as much as possible.”

Some have recently suggested to introduce a “triage committee” to remove “the weight of these choices from any one individual, spreading the burden among all members of the committee”. Such a committee would also enable physicians and nurses to remain the primary caretaker and “fiduciary advocates” rather than simultaneously being the one having to decide whether their lives are to be saved at all, imposing on them an impossible double-role.

A need for moral reassurance?

But can ethicists — indeed, ethical theory — also help relieve the burden? In a sense, it feels right to stand firmly behind the clinicians, who are now making impossible decisions, and to tell them: You’re doing okay, your choices are ethically justifiable.

But it is not evident that clinicians are now actually helped by moral reassurances or for ethicists to ‘have their back’. It is also not necessarily a good idea to pull clinicians into a reflective, deliberative ethical mode right now. This could slow them down or result in confusion and might actually increase rather than reduce the burden on them. Clinicians already have had their training and learned the moral theory; now is the time to act.

A potential explanation for why ethicists are submitting op eds to the newspapers about triage decisions is that academic questions have become real life questions, plus academics are being told from every angle they need to get out of their ivory towers. As Verweij and Pierik write: “For us as ethicists, the question whose lives should be saved is obviously an interesting dilemma that we often discuss in our teaching and articles.”

Indeed, examples of triage decisions are widely used in education as thought experiments. But real-life triage is a different matter altogether. We firmly believe triage decisions are in safe hands with clinical (support) teams, and, in fact, not broaching the issue of moral justifications of triage decisions could now actually express more solidarity and support with clinicians than defending a specific moral stance. A more practical point is that clinicians in all likelihood will neither have the time nor the energy to read the opinion pages. It is therefore questionable whether one could reach them with articles in the newspaper, even if one would want to.

You might say: in spite of the fact that clinicians indeed have had ‘the theory’ and in spite of the fact that we place great trust their decision-making capacities, actually having to make such decisions is another story. And this must indeed be acknowledged. The burden on clinicians is inconceivably heavy.

Given the current burden on clinicians, many clinicians would perhaps welcome, or even explicitly request, guidance from ethicists. So here we want to make clear that this is not what we are against. Ethicists can and do contribute to ongoing triage conversations with physicians, respiratory therapists, nurses, and critical care specialists. To an important extent, then, a public debate which includes ethicists is already ongoing. What’s less clear is just how ‘public’ a ‘public debate’ must be (more on this in part 2 of this blog post). In any case, ethicists can help out – and express solidarity with – clinicians in other ways – more fruitful ways, we think – than defending utilitarianism or the fair innings principle in the media.

Solidarity: a double-edged sword

As we’ve seen, one argument to have this public debate now is that this would express solidarity with clinicians. We’ve suggested that it is not evident that this would actually benefit them. Even if it did, though, an appeal to solidarity cuts both ways. After all, many members of the public were startled and hurt by the articles currently going around. That this has created unrest and real damage to some individuals was foreseeable. It was foreseeable that the message that the lives of some people would be considered less worthy than others’ would linger primarily in the minds of the elderly, the already ill or people with disabilities.

Obviously, the idea that some lives are more worthy than others is not the explicit or intended message of the articles which defend utilitarian or fair innings-based ways of making triage decisions. In the philosophy of language, however, a useful distinction is made between ‘saying’ and ‘conveying’. You can say something explicitly, but you can also implicitly convey a message, be it intentionally or not. It is understandable that some elderly, ill, or vulnerable readers interpreted utilitarian and fair innings-based articles in ways that had not been explicitly said. For instance, it’s understandable that many got the message that their lives were of lesser worth or that the elderly ‘have already had their chance’. These messages were, no doubt, not meant to be conveyed. But that they were conveyed all the same was foreseeable.

Here’s the thing: an ethicist should not only reflect on moral rules, norms, and principles, and how they (fail to) apply to the real world, but also on what communicating certain moral views can bring about in the lives and experiences of human beings. How and when to communicate and reflect on ethical principles is an important part of ethics itself.

Tragedy and the limits of ethics

Another possible unintentional message of the article was that the aforementioned priority principle that Verweij and Pierik defended could be interpreted as a bona fide or ‘sound’ ethical principle. It is crucial to emphasise that triages in intensive care in crisis situations are examples of tragedy. Tragedies pose a challenge to almost all moral theories and principles (see also this piece written by Schaubroeck on the BNI website (in Dutch) and this blog from John Danaher).

We generally consider moral theories, beliefs, and principles (such as justice, human dignity, non-discrimination, and so on) to be ‘admirable’ or the sorts of things we would proudly or wholeheartedly support. But this works differently in tragic situations. When a younger person is given priority and an older person dies as a result, we would not say that the underlying decision and principle was ‘admirable’. We would not proudly stand by the ethical justification for such a decision. The choice involves choosing the lesser of two unspeakable evils; it was a tragic decision.

Authors writing on triage decisions are well aware of this, of course. But the very act of defending, say, utilitarianism or the fair innings principle in public in times of crisis, and arguing what makes the approach justified, may have nevertheless convey a different message to some readers. It may convey that it is morally ‘okay’ to sacrifice the old or vulnerable in order to save the young. It’s not.

Given the likelihood that articles in which ethicists say how triage decisions ought to be made on the basis of moral theories and principles fails to reach or genuinely help its target audience (clinicians) and that another important audience (members of the general public) are likely to be harmed by its content, it’s better if ethicists would not publish their takes on triage at this moment. Precisely for reasons of solidarity.

(Photo source: ID 174419044 © Tommyandone | Dreamstime.com)

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.