Rationing policies and the limit of their
rationality
Is a pandemic the appropriate moment to erase the plurality of
judgements and stop weighing each particular case in the name of
urgency? The risk of non-transparent rules of experts is to lose the
confidence of the public. Real time decisions are certainly harder than
applying efficiency rules. We should make room to moral intuition in
entering the framework of decision that leads to adapt the rules in
context. Should ethicists then help apply guidelines or assist with
rationalizing decisions? I doubt it. It would mean to transfer the
responsibility from the patient or his/her family to other efficiency
bodies. I would suggest avoiding these real and false dilemmas to
prevent the scarcity of medical resources by collaborating in solidarity
with those who are still handling the matters, the medical doctors
themselves.
Paradoxically, this pandemic has isolated half of humanity. It reminds
us first that we are all mortals, and that is what makes us equals.
Secondly, solidarity is the main ethical principle to escape from false
dilemmas. What is a false dilemma? It questions rational evidence in the
face of moral intuition. It is interesting to note that no regulation of
triage rules has been adopted internationally, which reinforces the
decision-making dimension associated with the survival and the
preservation of people’s abilities to survive. It could simply mean that
it is a matter of isolating patients at risk of dying or losing their
motor or cognitive abilities, if they are not treated, as an arbitrary
priority of these rules, or at least their relativity and adaptability.
These reflections force us to redefine the fairness models introduced in
this rationalizing, and to rethink a model of public health founded not
only on data driven medicine, but on deep and responsible democracy.
Can we really talk about scarcity, in our societies of abundance, or is
it more linked to ineffective management of priorities for the social
good, or to inadequate assets management?
The question will be why , and many speakers in the public debate
have stressed the unpreparedness of most states. It will also be
necessary to ask in what healthcare model this unpreparedness has been
possible, to clearly determine the responsibilities shared among the
different actors. We talk in peace time about the prioritization of
care, but some rulers preferred to talk about war, a term used to
justify all ethical transgressions. The wording of scarcity conditions
is not acceptable. It is necessary to give common reasons to all
caregivers as well as to the patients and their loved ones.
The procedural decision grids exist, but they do not free the medical
doctors from the difficult freedom of personal responsibility in the
heat of the moment. These tools are necessarily incomplete and therefore
do not exist, because a clinician will always have to use his ethical
imagination to practice a coherent care, adapted to any context and to a
diversity of needs in terms of gender, race, or class, having fairness
as its main horizon.
Indeed, if these decision-making grids are tools that have some
effectiveness in the emergency, we must not overlook the after-effect of
these decisions on the doctors and nurses in the aftermath of pandemics.
Prioritization is a societal choice that makes us all co-responsible.
The main issue remains prevention, which can avoid both lockdown and
tracking, and foster collective intelligence instead of infantilization.
Fairness is thus more than equality because it is sensible to plural
forms of vulnerability, while always aiming at the recovery of
capabilities for each person. Fairness is a plastic notion that implies
the articulation of care and justice.