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Let's imagine ourselves in the shoes of different people in our community to test whether our approaches are just
By Daniel Fleming | Australia
As we move through the pandemic and start to imagine life on the other side, it's appropriate that there will be a range of views about how we deal with the aftermath and how to prepare for similar events in the future.
We should encourage opinions that examine our response as a nation: what we did right, what we did wrong, and what could we do better.
That being the case, I've been left wondering at the amount of oxygen being given to a particular branch of 'pandemic analysis', one that sees cost-benefit analysis taking centre stage, with all the disturbing suggestions that follow.
Janet Albrechtsen's op-ed in The Australian, 'Old or young — every life has a different value and we accept that', is the most recent. While the article is more subtle than its headline suggests, I was left with a deeply uncomfortable question: do we really accept that?
Albrechtsen's article is pitched to overcome some of the tropes floating around in response to the COVID-19 pandemic. She refers to them as 'straw men': 'Some say we should put people ahead of economics' or 'Some say it is wrong to ignore the old.'
A straw man is a form of fallacy. It sets up a false idea of an argument, and attacks that idea rather than the argument itself. Albrechtsen suggests this is unhelpful in considering the ethical questions raised by COVID-19, and should be challenged. And I agree.
But so too is the straw man's close relation, the 'bait and switch', which arranges a set of statements that everyone knows is true, then follows quickly with a contested claim, in the hope that readers will accept this along with the others.
Let's start with some uncontested statements in relation to the allocation of health resources. Resources are limited in a pandemic. More so than in normal times.
Doctors sometimes need to make decisions about who will get access to a health care intervention and who won't. In a pandemic that happens with a greater frequency and intensity. No one I've spoken to in the past few months disagrees with these. These are the bait.
But the idea that in choosing 'who gets what', doctors are making judgments about the value or 'price' of individual lives, and that this somehow legitimises governments doing the same? There's the switch. That seems to be the view of Albrechtsen and others — that we should accept this as the basis for honest and pragmatic policymaking during a future crisis and get on with things.
Why is it that anything with a dollar factor or a cost-benefit analysis attached to it creeps into our reasoning so smoothly, as if it's some kind of neutral decision-making tool? I'm all for confronting the hard questions, but if this is the rubric we use to work out our collective future, then let's declare a day of mourning for our moral imaginations.
As the Harvard philosopher Michael Sandel points out: economic reasoning is never neutral: it always embeds preferences for some at the expense of others. It's harder to see this when times are good, because those at whose expense the economy functions smoothly are usually invisible, or at least at the peripheries, and often very far from those with decision-making power.
The harsh reality of this pandemic has meant that as the periphery has closed in, many of us, or our families, or our friends, have found ourselves on the outside. We tend to defend the economy when it suits us and ours, but that defence becomes lacklustre when suddenly we're not part of its chosen few.
This is a real-time exercise in John Rawls' thought experiment, the veil of ignorance, only now we don't have to imagine ourselves as someone else to test whether our society truly serves the good of all. Some of us have become that 'someone else' overnight.
The doctors I've been working with at St Vincent's Health's hospitals over the past two months — hospitals operating at the very heart of the pandemic — have thought deeply about how they would make decisions if a COVID-driven surge in demand meant there weren't enough resources for those who needed them.
They will consider a range of factors in making their decision, including the patient's wishes, along with possible alternative treatments, urgency of need, and likely therapeutic benefit. But is their decision ever based on a person's 'value' tied to some other feature of their identity like age? No. Nor should it be.
Their foundational ethical commitment is that all people have equal value. Which is why those doctors, when they do have to make these hard decisions, do so in good conscience, but also — as we've seen in places like New York City and London that have been hit much harder by the pandemic — with lament.
Some can't sleep at night out of recognition of the tragedy that more couldn't be done. And their tears spur creativity: what can we do differently? What others ways can we offer care when a ventilator isn't appropriate or is unavailable? This exact process led to St Vincent's Hospital Melbourne's recent, public, commitment that no patient would ever die alone in their care during the pandemic.
Instead of falling back on the idea that economic metrics like 'value of statistical life' are the way we solve our moral questions in the context of government policy and regulation, why don't we start with the foundations from which these doctors begin.
Every person has equal value. We have to make hard decisions about allocation of scarce resources. We won't do this by suggesting that some people are worth more than others. And then, let's see where our decision-making leads us.
Let's imagine ourselves in the shoes of different people in our community to test whether our approaches are just.
And if that means we lie awake at night wrestling with the realisation that we don't yet have a way of organising our economy in a way that truly serves us all, let's lament that fact, and let our tears be our motivation for addressing that lack of justice in the future.
Dr Daniel Fleming is Group Manager: Ethics and Formation for St Vincent's Health Australia, and a Fellow in the Law, Health and Justice Research Centre in the Faculty of Law at the University of Technology Sydney.
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