Dr. Smadar Bustan,
Philosopher
The novelty of the global outbreak of the highly contagious coronavirus
disease brought the entire world together as it shared a collective
experience, while at the same time, pulled us apart with closed borders,
home lockdowns, extreme social distancing and isolation. This
coronavirus threat presented a unique set of features: everyone had to
be treated as potentially positive as it is possible to be infectious
while being asymptomatic. The disease often became a death sentence
because there is no treatment or vaccine. Moreover, our contemporary
evidence-based medicine was challenged as the notion of knowledge becamein transitu , knocking the solid bottom of the entire healthcare
practice. Decisions need to be grounded in science but there was no
science to rely upon. Information has been confirmed and refuted on a
daily basis: face masks were publicly announced as protective measures
but then their viability was debated, medical protocols at hospitals
changed continually, confuse the frontline medical staff trying to save
lives while feeding substance back to the experiential knowledge of
medical care. Nations became indistinguishable by the worry and grief
that joined hands: the long lists of hospitalized people shared on
social media, the death tolls portrayed by endless lines of military
fleet transporting bodies of coronavirus fatalities for burial in North
Italy, the mass graves in Latin America or the extent of reported
cremations of the Covid-19 victims in China, as well as the alarming cry
of healthcare personnel worldwide.
The risk and prevention required to limit the coronavirus spread and
rapidly work out the most efficient containment measures, divided the
tasks between the political, medical-scientific, public and industrial
sectors. Despite their exceptional collaboration, we seem to have turned
back to population-oriented medicine after an accomplished era of
individualized medicine, looking at the mass instead of the ill human
being. In addition, when the whole world seemed to be coping as one,
differences emerged in regard to national or even regional
anti—Covid-19 management strategies, including sanitary and medical
interventions. Since the onset of the outbreak, while keeping people
alive has certainly been the immediate and primary imperative,
healthcare professionals have been overwhelmed by pressing ethical
challenges, having to make hard decisions for which they were
accountable and to provide reasons for their actions and omissions.
Clearly, clinicians are trained for ethical decision-making, but in view
of the pandemic chaos paired with the incredible shortage of medical
resources, ethics committees or advisory groups had to help by providing
specific guidelines such as those endorsed by the ‘Covid-19 ethical
decision-making tool’ (1).
The reality was and still is represented as being constituted in the
same fashion as that of decision-making in times of war where the
urgency, scarcity of medical supply or critical care beds, rapid
spreading of new cases, time sensitive procedures, and fighting the
unknown during a public health emergency continue to weigh efficiency
(Is it the most effective? What will be the end result?) over the
ethical (Is it the right thing to do ?). The dramatic phrasing
regarding “the war against Covid-19” announced by politicians and
health organization directors-general became integrated into the health
care system. It forced challenges that no longer strictly applied to
individual patient care (allocation of limited resources such as
ventilators, the sharing of patients’ confidential information with
relatives or even the media, denying opportunities for families to say
goodbye before a death) but also applied to the role of practitioners
who found themselves in a newly created chain of command.
The essential service of medical ethics and its decision making process,
as I see it, consists in allowing for one part of the decision to lean
upon another part of the decision in order to become unambiguous. In
this way, each one of the several aspects in which the ethical decision
may be considered, assures the values of the right and the good.
Obviously, dilemmas put us in a situation of conflict where a difficult
choice has to be made between different options. Medical ethics dilemmas
create even more conflict than most because they touch upon human lives.
The Covid-19 pandemic obliged us all to handle many dilemmas, some of
which we took upon ourselves as philosophers, ethicists, doctors and
nurses to discuss during the symposiumCovid-19:
Ethical Dilemmas in Human Lives held on May 7th 2020
and organized by the Paris Global Center of Columbia University and the
Columbia Global Centers. Humbly, we may not provide ready-made
solutions, especially as the epidemics storm still rages. This
discussion testifies to the ongoing pandemic emergency and its difficult
challenges while evaluating whether the ethical principles in the
recommendations were able to meet the lived reality. Looking at
accountability and consistency in regard to the context of this
emergency, it seemed equally important to examine, through an
international exchange, whether the contextuality of COVID-19 across
countries and cultures affected the ethical decision making processes.
The following collection of the symposium’s acts maintains the
discussion format whereby each dilemma is addressed by a Covid clinician
and then analyzed by a philosopher or an ethicist, who, at times, is
also a practicing physician. I organized the discussion around four
ethical key dilemmas with leading questions, even though others clearly
come up in the various discourses.