Two philosophers reflect on ethics and politics in corona times.
Each year, hundreds of thousands of first-year philosophy students are introduced to the finer points of moral philosophy through a famous nightmare scenario. They are asked to imagine a loose trolley racing over a train track to which five people are tied. They can divert the loose trolley to another track. To their horror, however, another unhappy person is tied to this alternative track. If they reroute the trolley, they save five people, but they kill one.
The Philosophy of Phase 3
In the Dutch context, philosophical reflections on the corona pandemic are reminiscent of this nightmare scenario. These considerations focus on the moral dilemma that physicians might face, namely, the need to refuse intensive care for older ICU patients to make way for younger patients. It includes scripts for emergency medical decisions under corona conditions, in particular the provisions for the so-called phase 3 or “code black.” This is the stage when ICU physicians must make life or death decisions based on “non-medical” criteria simply because they have more patients than beds, equipment, and staff. With every corona wave, code black and its ethical fallout — what is the criteria for letting someone die? — flare up again.
As various sources have reported an implicit code black, geared like the explicit one to let the vulnerable die, has already been in place since the onset of the pandemic under the auspices of advance care planning: older people have been discouraged by their treating physician from entering intensive care with COVID-19 infection. That the motives were not always purely medical can be inferred from the unprecedented fact that GPs took the initiative to call elderly patients with questions about their survivability if infected by corona. This happened around the time that the insufficient capacity of the Dutch ICUs became public.
Early on the pandemic, ethicists Marcel Verweij and Roland Pierik argued that, no matter how horrible this decision may be, doctors should bite the bullet and, given their limited resources, should act on the understanding that they will preserve “more” life if they are saving a younger person instead of an older one. Ethicist Fleur Jongepier rejects this line of thought because she considers subjecting human lives to a differential valuation to be inappropriate. She concluded that, given their limited resources, doctors should make the selection random. For the rest, we can only pull our hair and curse our fate.
COVID-19: Not a thought experiment
Undoubtedly, doctors are sometimes faced with tragic dilemmas. However, ethical reflection requires that we do not just fixate on the dilemma, but also think about its preconditions. It is precisely the image of tragic impotence around the decisions of doctors that obscures from view who and what is responsible for the fact that not everyone is saved from COVID-19 who could have been saved. When we consider the bigger picture, we see that doctors are forced to make tragic life-and-death choices based on decisions already made elsewhere.
So why is the situation in ICUs so bleak?
Manufactured Tragedy: Government Policy
When the so-called intelligent lockdown took effect in the Netherlands, Prime Minister Rutte announced, quite moving for many, that the young and fit must create a wall of immunity around the vulnerable (speech of 16 March 2020). Group immunity as a strategy against COVID-19 was always scientifically suspect. Nevertheless, we wonder what is left of Rutte’s idea that the majority would take a blow to ward her off the vulnerable.
The virus circulated freely through Dutch nursing homes. The circulation accelerated because, even at the height of the crisis and despite their urgent requests, nursing home staff were denied access to masks and disinfectants, so that nursing home residents became massively contaminated. The sudden influx of vulnerable elderly corona patients is one of the main reasons doctors in several ICU units in this country have had to brave the nightmare of tragic life or death decisions. The other important reason owing to venture capitalism is the stripped-down healthcare system in the Netherlands, in particular the limited number of ICU beds, the lack of ICU staff and the shortage of life-saving equipment on ICUs throughout the country.
With these two developments in view, it would be perverse to begin ethical assessments only where tragic life-and-death decisions loom, in the ICUs. Doctors find themselves in this situation because of government policies that claims to protect the vulnerable and in the same breath condemns them to death by negligence, as evidenced by mask-free or mask-averse hospital and care environments throughout the country.
While Prime Minister Rutte surrendered to the vision of a wall of immunity, the government was for too long reluctant, against international standards, to impose preventive measures that go beyond washing hands and keeping a distance of five feet. For a long time, the government refused to mandate the public wearing of facial masks, although scientific research suggests that masks can minimize the viral load and thereby minimize virus transmission. In view of these policy choices, the ever-looming tragedy on Dutch ICUs appears to be the result of decisions.
Prime Minister Rutte has been reticent with regard to more investment in the health sector even during the pandemic (“Rutte rejects extra investment with concern: ‘What will you achieve with that'”?). Years of this cavalier attitude has exhausted the health care system, led to the closure of fully operational hospitals, and shifted the financial burden to patients and paid little attention to nurses and doctors.
Societal Attitudes in the Netherlands
Even first-year philosophy students can find their way back from the trolley problem to their mundane moral intuitions and wonder: who tied up these people to the railway track? Why should I be responsible for the lever? Can’t we untie the victims? The COVID-19 pandemic is not a philosophical thought experiment anyway. So we have no excuse for excluding from moral criticism the policy-making that forces doctors to make tragic choices.
A critical ethical perspective on the corona crisis should not stop with demanding more responsibility from the government and healthcare officials. We must also demand more responsibility from ourselves: questions must be asked about the moral compass of a society that cannot understand the urgency of the pandemic but responds to all measures, whether reasonable or unreasonable, with childish frustration. Questions should also be asked about why the elderly and vulnerable people are marginalized to such an extent that we have no qualms about endangering their lives and, when the time comes, letting them die. It seems appropriate to say that COVID-19 exposes the deep sediment of moral values of Dutch society.
Perhaps these reflections help us see that the current is not a tragic fate. When doctors regularly find themselves in situations without life-saving resources, the moral problem lies elsewhere, namely with decision-makers whose policies cause a shortage of essential facilities, equipment, personnel and broader and better-designed pandemic policies. These policymakers have already determined that some can live, while others must die. The moral problem also lies with a society that, instead of protesting official disregard, becomes irritated about preventive health measures in their everyday life, especially when these measures mainly benefit others.
The fact may be that both policymakers and society at large have different priorities in corona times than saving lives, and in particular the lives of those in our society who are already vulnerable.
Featured image: John Franklin, Consigning bodies of the plague to a communal grave in the plague pit, Plague of London. 1841