RESPONSIBILITY: Clinician, Mirco Nacoti

Mirco Nacoti, MD,  (ITALY) , is an emergency, anesthesia and intensive care physician at Bergamo Hospital, Italy. An expert in international health and bioethics, he has extensive field experience in humanitarian crises and community approach to vulnerable people.
Two months after the beginning of the crisis I still have major problems sleeping.
I’ve dragged the corpse, from the bathroom to the bedroom, of a 50 years old man who had died at home.
I’ve seen dozens of people piled up in emergency rooms with severe dyspnoea and frightened eyes.
I’ve spoken on the phone to a friend of mine and said to her: you must choose between your father and your mother.
I’ve run at night to my hospital, taken a drug for sedation and come back to look after an old man dying, as my hospital was too crowded.
I’ve obeyed an order to transfer to Germany by flight an intubated man and he has died on his way. I’ve never spoken to his parents.
I know many young anaesthetists in my hospital who have decided alone who were to live and who were to die.
I feel a persistent smell of people suffering on my skin.
The pale light of an old humanitarian actor, with some studies in bioethics, is now a fire. 40 years later, the Alma Ata definition (2) of primary health care seems vital to me.
I’ve done and watched a lot over these past 2 months. But my night-time question is: have I thought enough? That’s why I’m very grateful to have this occasion to think.
Bergamo is a rich and populous city of northern Italy (1.000.000 people) and one of the epicentres of the worldwide COVID 19. Despite the generosity of health workers, we are undergoing a severe humanitarian crisis that is stressing every aspect of daily life.
From outside it is very hard to understand, because houses are closed for lockdown and are not destroyed as they would be in an earthquake. Furthermore, in regard to the dilemma of moral responsibility, the World Health Organisation figures do not represent the reality. WHO is doing a great job, as usual, but the figures provided are a dilemma, as usually occurs during an outbreak. Today WHO shows about 3.500.000 confirmed cases with 240.000 deaths (3) worldwide and in Bergamo 13.000 confirmed cases with about 2500 deaths (4). Unfortunately, the actual deaths reported by town halls are about 6.000-7.000 (nearly 1% of the population) (5). Considering that a fatality rate of 20% is a non-sense, because the Chinese experience (even in Hubei province) reports a rate between 1 and 3% (6), the number of people contaminated in Bergamo is likely to be between 250.000 and 500.000 (which means 25%-50% of the population). More than 2.000 people with mild-severe hypoxia, at the peak of the outbreak, stayed home because all the hospitals were overcrowded. These are the real figures. This is the picture of Bergamo’s disaster.
For this reason we wrote a paper which appeared in the New England Journal (7). In regard to the dilemma of moral responsibility, when the global medical community is called on to face a pandemic of unprecedented scale, with little scientific evidence and “crazy numbers” describing the situation, honest and forthcoming advocacy is an ethical duty, and that paper was a wake-up call for those involved in system preparedness and strategic planning.
An outbreak is neither a simple disaster casualty incident like an earthquake or a “simple” disease, but it’s a social phenomenon. Historical and social elements are key factors for development (for example, intensive promiscuity between animals and humans) and spread (for example health workers and ambulance rapidly become vector of the virus) of an epidemic (7).
A first consequence of this translation into a social horizon concerns the theme of responsibility. And in regard to the dilemma of moral responsibility, how much does the social narrative about the infection numbers weigh, for example, on the decisions to be taken and on the concepts that guide them (for example, that of proportionality)?
How do inaccurate narratives, from an epidemiological point of view, affect the ”judgment in situation”, that takes place in triage or in prevention strategies in other countries? How many shocking images are needed if figures are not reliable ?
Another aspect of the dilemma of moral responsibility concerns the care of decision-making process and the fragmentation of responsibility. Modern western medicine has centralized the care of patients in the hospitals (and our region does represent this process), preventing the community from being the main actor in the sphere of public health and putting into practice an “expropriation of health”, as Ivan Illich’ says in Medical Nemesis (8). Body has been progressively fragmented in small pieces by super-specialized doctors and responsibility has ended up being a question of legal responsibility, an economic matter, and not an ethical one. In this fragmentation, it has been acceptable for us to execute orders, even if epidemically dangerous or not ethical, because we were living an urgent situation, and during the fight against COVID 19 the mantra was “to do and not to think”. It seems, as Hannah Arendt writes in her ”Banality of evil”, that “nobody was responsible, or rather, nobody felt they were; they just did their job” (9). Would have been useful to have a mechanism of control of decision makers in close contact with territories? Only the awareness that the weight of a decision is to be shared can prevent us from turning the triage into a moment of irresponsible superhomism.
A further aspect of the dilemma of moral responsibility is the ethics of the research in urgent situation. As Derek C. Angus wrote in a JAMA view point (10), one stark example is the debate over prescribing available drugs, such as chloroquine, or testing these drugs in randomized clinical trials. At the heart of the problem is one of the oldest dilemmas in human organizations: the “exploitation-exploration” trade off. Exploitation refers to the “just do it” option. Exploration refers to the “must learn” option.
During his captivity in the 1940s, Archibald Cochrane treated many prisoners, often ill with tuberculosis, by observing how the disease benefited more from a good caloric intake than from drugs of uncertain or zero efficacy. The germs of Evidenced Based Medicine arose from those observations. 80 years later, in regard to the dilemma of moral responsibility, how many helmets to deliver respiratory assistance have been placed without any enteral feeding in Bergamo? Chloroquine, antiviral, anti IL6, anti-complement, steroids, antibiotics have been distributed without a real methodological approach, without monitoring, with people arriving at the hospital worn out after days of dyspnoea. What data, what ethical research can be produced in such a mess, what if you publish on an important indexed medical journal but the ”garbage in, garbage out” approach is still considered the right one (11)? Furthermore, in regard to the dilemma of moral responsibility, what about signatures extorted for consensus from a dyspneic patient with no family member nearby? Such a touchy a matter would require competence and experience, and yet it was often managed by residents instead of specialists. Not everything is lawful in urgency and there is an ethics of research even in urgency.
Derek C. Angus suggests at the end of Jama view point (10) that an integrated approach of “learning while doing” is essential in a crisis. Nevertheless, in our current context, it’s very important not to lose the capacity to think and probably we have to subtly shift from Angus’ suggestion to a “thinking/learning while doing”, as Hannan Arendth writes (12).
Goisis, a philosopher coauthor of the New England article, says that it is not true that nothing will be as it used to be before COVID 19. Millions of people in the world will be more vulnerable and isolated. But the economic, scientific, political and social mechanisms leading to this pandemic humanitarian disaster are still there. “Doctors have to give back to the community the capacity to promote health”, could have said Ivan Illich today.