RESPONSIBILITY: Philosopher, Smadar Bustan
Smadar Bustan,
PhD , (FRANCE) , is a philosopher, ethicist and scientist at
the University of Paris Diderot. In her research on human suffering and
pain, she developed a tool for evaluating the suffering of chronic
patients following experimental and clinical studies in Luxembourg and
France. She co-founded at Harvard and heads the International Program
on Suffering and
Pain (www.suffering-pain.com).
The dilemma discussed here bears on responsibility, a Latin term from
1590 respōns(us ) or response, which became philosophically
prominent rather late in the 18th century. Our
question is, does responsibility, and more specifically medical
responsibility, change during a global health crisis? Is responsibility
limited in the avalanche of an infectious transcontinental disease,
obliging us to relieve clinicians from the burden of decision-making
process carried out in individual cases?
A broader conceptualization of the nature of responsibility is necessary
in order to deal with this dilemma, by first asking: what does it
mean to be responsible in times of pandemic? Responsible behavior
during the coronavirus infection outbreak was very much present in every
household and country around the globe. Yet the lack of adequate
knowledge caused significant inconsistency leading to public panic and
raised doubt about what it means to act in a responsible manner, both
personally and collectively. The problem with a pandemic is that the
personal and the social intermingle to the extent that the most casual
individual acts, such as coughing, sneezing, going out of our homes, or
walking around maskless, turns a person into a biological agent engaging
into irresponsible behaviors that some would qualify as criminal or
immoral. This Covid-19 Epidemic has been enhancing mutual
accountability to such an extent that individual responsibility is
transferred from an autonomous self to a self intrinsically bound to
others. One can no longer exert free will to live carelessly and be
prepared to risk contamination.
What we have learnt from this epidemic as a globalized society is that
individual responsibility is no longer exclusively centered on
what we are bound to undertake by duty, of a person being responsiblefor something or someone (a parent for their child, a doctor for
their patient) since simply by being, breathing, existing, we are
accountable, all of us together and every one of us individually.
Unfortunately, under such circumstances, our responsibility becomes as
vulnerable as we are.
The fragility of a pandemic causing this involuntarilyresponsibility by existence , with its inevitable sharing of
accountability, leads us back to our main ethical dilemma when asking
what motivates us to make the right choice for a responsible act during
a health crisis. For the overwhelmed practitioner inquiring how to fully
know what the right act is, how to best choose in relation to the
available resources and to whatever is in one’s power, the resignation
to do ‘the best we can’ may provide protection from liability but not
necessarily satisfaction or peace of mind. When the medical model of
responsibility is guided by reasoned thought in regard to what we can do
and the means that lead us to better ends, It is difficult not to notice
the unrest when this intellect-based definition of being responsible
entails a sense of feeling morally, medically or even humanly
irresponsible. When reading Dr. Nacoti’s testimony, it becomes clear
that even though a well-regarded thought led him and his colleagues to
make decisions for saving lives, the strong remorse experienced
following the death of their patients shows that a reason-based decision
for acting responsibly with a negative end result may leave clinicians
with a feeling that they are partially at fault for the failure.
The severity of the pandemic has exposed many of the medical workers, as
those in the frontline in north Italy where Dr. Nacoti works, to face
the toughest triage procedures in medical care with the prospect of
having to ration equipment and care, sacrificing certain people for
saving others and facing unthinkable choices regarding life and death.
The lack of treatment led to the use of drugs on the basis of limited
evidence concerning their effectiveness and therefore not without risk
while trying to assure the highest rate of survival. In this respect,
even when providing immunity against malpractice during the emergency of
Covid-19 and hence excluding any legal responsibility, as Dr. Fischkoff
recounts about the State of New York, the problem with ethical
responsibility persists not only in regard to the possible damage caused
by one’s own act, but also to the consequences of this act on the people
to whom they must answer. We find here the two aspects of the modern
idea of responsibility, associating legal and moral responsibilities.
The interdependence of these two aspects may explain why, despite
excluding any legal sanctions and therefore legal responsibility in a
time of unprecedented crisis (facing scarce resources and exceptional
emotional burden on healthcare personnel), the ethical dilemma persists
because medical decisions remain attached to our moral obligations.
Treating clinicians whose actions are based on well justified rational
decisions may still carry blame, unable to wash away the guilt, because
these fail to comply with their moral convictions.
The lived reality of the pandemic obliges us to go beyond the first form
I named responsibility by existence to better examine the
medically relevant form of responsibility by deliberation ,
introducing the idea of making a choice as a result of deliberation and
of fully knowing what is the right thing to do. Two philosophers
who represent this strand of thought with the traditional concept of
responsibility as dependent on knowledge, striving to certainty and
regulatively knowing everything or at least as much as possible, are
Aristotle (4th century BC), in his account of Ethics,
and John Stuart Mill almost two millennia later with his utilitarianism
(13) (19th century). In the third book ofNicomachean Ethics (14), Aristotle examines what is good for the
human being— what we need to undertake, aim at, and act upon, in order
to do good. In our case, medicine aims at health, and physicians aim at
healing. In this respect, what Aristotle also taught us is that when we
deliberate, we always have some end in view. If I deliberate about
whether to put a mask, I consider this in light of a future end in view,
which is to avoid catching or spreading the COVID-19 virus. If I
deliberate about whether to respect the extreme social distancing of the
quarantine and stay at home, I consider this in light of a future end in
view which is to slow down and eventually stop the epidemic’s spread.
Aristotle claims, however, that there are two things we cannot
deliberate about: facts (which could only be examined) and end views,
for the simple reason that we cannot change them. Hence our choice based
on deliberation of doing good and acting responsibly are dependent on
end purposes and on sticking to the facts, and basically on knowledge.
At the same time, if during the Covid-19 pandemic we apply this
philosophical recipe with reason-based choices regarding medical
responsibilities, we soon realize that clinicians are being severely
undermined, which only intensifies our dilemma. In reality, we have
witnessed misinformation emanating from situation reports and official
communications, including from public health authorities, through
inaccurate or misguided information. For example, It was said that
smokers are less likely to be contaminated, ibuprofen or aspirin can
worsen the Coronavirus symptoms, or the virus is unstable at high
temperatures and therefore will go away when the weather warms up. In
the upheaval of the aggressively spreading epidemic, scientific facts
continuously evolved so action based on facts had to adapt, inducing
further confusion relative to our standard approach of evidence
based-medicine that canceled out knowing beforehand and making a
contingency plan accordingly. Furthermore, at the outbreak of the
pandemic, the end view of medicine and its therapeutic goals, shifted
from healing to prevention from dying, totally destabilizing the
standard therapeutic goals.
Under a state of emergency and threatening rapid death, we could simply
proclaim that without a solid foundation to rely upon for making
choices, the entire undertaking of medical and social responsibility is
bound to perplexities. Medical professionals must respond when facing
flows of Covid patients with severe respiratory distress out of active
commitment to vulnerable patients. De facto, they do respond. But do
they need, in this unique scenario, to take responsibility for their
medical response? In respecting their devotion and diligence, can we
relieve clinicians from a part of the responsibility in the
decision-making process as normally carried out in individual cases?
A comprehensive approach should be compatible with extant principles of
responsibility under the given circumstances. A broad approach to
analyze responsibility for pandemic diseases should consider both forms
of responsibility, by existence and by deliberation. This would be
better overall for society and healthcare, considering the disruption
due to shifting facts and undermined medical ends, thus promoting more
careful policies and actions.
At the same time, the outcome of the discussion so far has been to show
us that a person or an act can be considered responsible so far as one
is bound by it, or thinks it to be right. My first observation in
examining “what is it to be responsible” in times of pandemic consists
in introducing the idea of responsibility by existence for all ,
regrettably excluding the freedom to be able to do otherwise. And my
second observation examining “what is it to act responsibly” consists
in introducing the idea of responsibility by deliberation , of
accountability for our actions and their consequences, and the praise
and blame attributed to the moral agent. Deliberation is a reasoned
thought about what we can change by our efforts and where we need to act
differently in various occasions. And yet, in times of pandemic the
foundation for well-reasoned and thoroughly discussed decisions,
fostering a collegial consultation as standardly required, is damaged
because neither the facts nor the end views are stable enough to serve
as references for deliberately acting responsibly. Dr. Nacoti raised
this point when he spoke about referring to the general qualification of
the Covid pandemic as a war with a chain of command whereby clinicians
were to simply obey, following the mantra of “do and do not think” and
inexperienced doctors found themselves having to decide alone who will
live and who will die. The resulting epistemological helplessness of the
Coronavirus pandemic puts the idea of responsibility in a new light due
to the conflict between the medical naturally learned profession and not
knowing. This novel chaotic situation cancel’s Aristotle and Mill’s
rationalist view of acting by virtue and for the benefit of good on the
ground of knowledge, as clinicians who have an occupation requiring them
to be well-informed in order to act responsibly lack in effect the
necessary knowledge.
This outcome for the practice of medicine and our philosophical inquiry
requires to rethink the notion of responsibility and moral obligation by
moving philosophical fields, going from Aristotle’s guiding but failing
rationality to Levinas’ field of ethical phenomenology. The reason is
that none of the perspectives that have been actually presented here has
paid full attention to a third form of responsibility, based on an
entirely different philosophical pattern and that provides a way out of
this dilemma regarding acceptable or unacceptable changes in medical
responsibility in times of pandemic. This alternative view
consists in arguing that responsibility is involuntary, not bound by
rational choice, certainly not a deliberate one and is totally
experiential. Becoming responsible for a sick person is imposed upon us
by his needy, vulnerable presence when calling for help, often withoutwords, in an appeal conveyed by the misery and helplessness of their
facial expressions. This sense of ethical responsibility goes beyond
that of a reflective commitment. And just like the first form of
responsibility by existence, it separates one from oneself by giving
precedence to the other person, while emphasizing here that this other
person is weaker and more at risk. Levinas considers the experience of
responsibility as what binds one person to another, as the foundation
for humanity and ethics which he demonstrates through the well-known
theme of the meeting face-to-face, when encountering the face of the
other person causes a phenomenological shock that makes one feel
inevitably responsible for their fellow human being (15).
I have to admit that in my writings on ethics and the sufferer and
especially in my review of what I call the “French School of the Ethics
of Suffering” (16), I always criticized this uncompromising level of
responsibility and priority Levinas claims we can grant another person,
even when we are ourselves sick, exhausted and emotionally strained
(17). But when I caught the Corona virus at the beginning of the
outburst here in France, the sense of responsibility and giving priority
for the well-being of another took over me. My symptoms were mild, but
sudden. I fell down on the floor without being able to get up again,
feeling the chill and honestly the fright of the unknown progression of
this aggressive virus that literally took control over my body within
minutes. While lying on the floor, what bothered me most was the
possible contamination of my children and particularly of my asthmatic
elder son who was designated as part of the Covid-19 risk group. I was
sick, not being able to give anything, let alone move my body, and yet,
just as Levinas claims, the disinterested sense of responsibility
towards another invaded me and my responsibility for not contaminating
them became my absolute priority. It was not a voluntary or deliberated
sense of responsibility and it very much obsessed me when I was most
helpless.
Obviously, one could contest this example by rightfully claiming that
children are an extension of the parent and do not represent a ‘real
Other’ in the full Levinasian sense. And as I demonstrate in my book on
Levinas’ ethics, the unreflective encounter with the other person rather
represents a situation that makes me surrender myself to them, often
against my own will and without being able to expect anything in return
(18). The Other could be a stranger one has to commit oneself to despite
wanting to walk away, a patient entering an already overbooked Covid
unit whom an overburdened doctor would rather put to wait or a
contaminated elderly person placed in the care of a scared nurse,
wearing a plastic bag due to lack of proper protective equipment
(reminding us of the institutional responsibility towards the caregivers
and the safety protocols). The other person may even constitute a threat
but since their urgent call for help precedes me and is imposed upon me
immediately, I am obligated to be there for them, unable «to get out
from under responsibility» (19). It is the lived experience and
encounter between human beings that make us responsible, not knowledge
or deliberation on the account of facts. Human responsibility is simply
being there for the other, claims Levinas (20). The activated sense of
responsibility towards the survival of others places them first, prior
to worrying about our own survival and prior to any conscientious
processing. One is compelled to worry and care for the other says
Levinas, since responsibility does not originate from within oneself,
but is rather an order or command that one receives. It precedes
us in the sense that it originates from a prior time and our ascendants
(ancestors or past generations), as Ezekiel Mkhwanazi beautifully
explains (21), it is pre-original (22)(23).
In transposing this view to our discussed dilemma of medical
responsibility, it soon becomes clear that what stems from this sense of
duty, of a caregiver or a medical worker, is not a Greek agency or
freedom to choose the good, but a fundamental archaic obligation of
oneself towards another, and that it “commands me and ordains me to the
other” (24). In this perspective, this amounts to saying that our
dilemma is cancelled since no judgement can be made about treatment or
availability of the medical caregivers during a pandemic. Their mere
presence beside a Covid patient’s bed is a celebration of being there
for the patient and of human responsibility at its best.