Ethics in general, and medical ethics in particular, is about deciding what might be the right and just course of action in a particular situation.
What might be right for an individual might not be right for the population and vice versa. Hence ethical debate and discussion is common when new issues surface or old ones reappear. We have experienced this in the debate on assisted suicide and the ongoing debate on abortion and euthanasia.
These debates are lengthy, and legislative change may be glacial.
The ethical issues that have surfaced in regard to COVID-19 have not had time for debate, and in many ways such debate is now being examined after changes have been already been imposed.
Ethics is underpinned by certain principles, so it may be useful to examine these principles in the COVID-19 era. These include: rights and duties, autonomy and paternalism, allocation of limited resources and individualism versus collectivism.
Our democratic society is protected by legislation and the rule of law which enshrines certain freedoms. These include freedom of movement, freedom of assembly, freedom of religious observance, and freedom of expression.
As individuals, and as a community, we have a right to these freedoms and the government has a duty to protect them. In the presence of a pandemic, and in declaring a state of emergency, the government has the power to curtail or remove these freedoms and considers it its duty to do so when the health of the public is at risk.
The government might appear to be acting in a paternalistic manner by curbing our autonomy, but it would argue that protecting the health of the population at the expense of curtailing the rights of individuals is the right thing to do.
In philosophical terms this is the utilitarian approach, doing what is best for the greater majority at the expense of what might be best for an individual.
Clearly there are those who consciously or unconsciously disagree with this and gather in large numbers on beaches, conduct parties and travel during lockdowns. This is individualism at its worst and has no regard for the need of collectivism when it comes to managing a pandemic.
Should these individuals contract the virus they still have a right to be treated and the medical profession, governed by its ethical standards, has a duty to care for them.
When it comes to rights and duties as they relate to the medical profession, health workers, and others, including drivers who are at the frontline in treating and transporting patients, special rights may apply. Health workers have a right to work in safe and protected environment. We now have thousands of health workers around the world affected by COVID-19 and many are dying.
We have witnessed the impact of this in Tasmania where two hospitals have closed because staff tested positive for COVID-19. The flow on effects for local communities are unimaginable. When there is a shortage of personal protective equipment then health professionals are placed in an unsafe environment in breach of occupational health and safety legislation and legal action against their employer may ensue.
It has become apparent in the preparation for the optimal management of sick patients that ventilators to deliver higher concentrations of oxygen and intensive care beds are essential. In Australia, there is planning for up to 4500 ICU beds and we have access to 7500 ventilators.
This is based on mathematical modelling and takes into account a slow but progressive flattening of the curve through community-based strategies, including social distancing, social isolation, frequent hand washing, use of sanitisers and the wearing of masks in some instances.
As health professionals, we have a duty to offer patients the best available quality of care to ensure survival. However, if the demand for care is so great, as it is in the US and Europe and could be in Australia, that the supply of ventilators and ICU beds cannot meet demand, we have the ethical problem of “allocation of limited resources”. This then poses a nightmare ethical dilemma for medical professionals, almost always doctors.
Who gets the best available treatment and who does not? Who might live and who will almost certainly die? What are the criteria that will be applied to resolve this dilemma and make a decision that is right and just? Is the life of a 70-year-old virologist and Nobel prize laureate with diabetes and emphysema worth more or less than the life of a 40-year-old criminal serving a life sentence. What if the Nobel prize laureate also had dementia?
Ethical debate and discussion on these sort of issues is often conducted in the abstract with utilitarians taking one view and deontologists taking another view. But professional ethicists rarely have to make life-or-death decisions themselves. Fortunately, neither do most doctors. However, COVID-19 has changed all this especially for those doctors working on the frontline. These decisions are being made rapidly due to lack of available resources and quite possibly without much knowledge of whether the patient has had good life and in the absence of any advanced-care directive.
If we are experiencing shortages of life-saving equipment in wealthy western economies, imagine the plight of poor African countries, our Pacific island neighbours and India, and the decisions that doctors will be making in those places. Will we in Australia share our current excess stock of ventilators?
COVID-19 has raised the stakes on ethical debates to the here and now and away from the “what if?” Globalisation has made COVID-19 transmission possible. There is now no place for individualism.
We must seek global, collaborative and collective decisions to ethically manage this crisis as we go forward.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for 40 years