There are days for which the wise plan for and then, there are days nobody plans for. The days of the pandemic fit the description of the latter kind. The plethora of problems that the pandemic has made us come tête-à-tête with cuts across domains and goes from financial to environmental, political to social. It is common knowledge that a lot of countries, especially the developing ones, do not do great in terms of health infrastructure and times like these when the number of infected persons swell by thousands every day. The shortages and lacunae of the system stare at us with their mouths wide open. Surprisingly, the coronavirus pandemic gave even the most developed of countries a reality check vis-à-vis medical infrastructure and preparedness. The suddenness and the ensuing congestion were such that the Italians had to wait a full hour on the phone to get to ‘Emergency Services’. China created makeshift hospitals and India had to massively up its PPE production among other things. But among all of it, a rather peculiar problem appeared on the nontangible front.
When the numbers suddenly spiked in Lombardy, Italy, it was reported that some hospitals flatly denied admission to the elderly citing shortage of intensive care facilities. Similar situations appeared in Brussels, Belgium, where a number of elderly people succumbed to the virus in want of medical care. One of the reasons for the denial was that the survivability of the decrepit elderly people was less than that of young people mostly without comorbidities. Official guidance to doctors in Italy, as reported by The Independent, said that only patients “deemed worthy of intensive care” should get it (intensive care) and decisions based on a “distributive justice” approach balancing the demand for care versus available resources. This approach might have been practically viable and had saved more lives than lost but whether it was morally right or not, is a matter of discussion.
In this article, we attempt to delve into the dominant ethical principles of moral philosophy which shaped our thoughts and actions in the pre-corona world and how the same ethical principles play out in the peculiar situations which we find ourselves in, in the time of pandemic that is. The article however does not concern itself with medical ethics per se and only happens to incidentally use the case of hospital as the moral universe for showcasing the interplay of the ethical principles at work.
Moral righteousness of an act can be determined through normative ethical principles wherein either the actor is guided or assessed through the choices that he or she makes; or through the consequences of actions. Both these approaches have differing notions of underlying rationality that emphasise on parallel systems of moral justifications of any act or decision and are best understood in contrast to one another. These two prominent strands of approaches in ethical decision-making are deontology and utilitarianism.
In a world before pandemic, ethical decision making happened routinely with wonted moral implications wherein chronological advent of a patient prioritised the treatment to be received by them. For instance, a choice between an elderly and an adolescent (without comorbidity) is easier deontologically, where the first who came is prioritised, or preference of care is granted to the elderly/more needy. However, these priorities rapidly change in the pandemic-hit world, largely because of the magnitude of a multi-dimensional effect of decision making, and where the chronological age ceases to be a moral impediment and those most likely to survive are prioritised over those with remote chances of survival, making it a utilitarian approach. To put it simply, if an institution, under circumstances of making a choice employs a set of rules, like prioritising on the ground of age seniority, or chronology of arrival; without consideration of the consequence like chances of survival or immediate need of either party, it will be understood best in the light of a deontological approach. Whereas, if the same institution while making a choice treads the Utilitarian pathway and prioritises the consequences over means, it will in all likelihood treat the adolescent and not the elderly, since the former’s survival is more plausible than the latter.
With a two-dimensional understanding of whether means justify its end or its converse, it is easy to comprehend the ethical support of a philosophical approach guiding decision making. However, in complex circumstances it becomes difficult to identify the ethical righteousness of a decision through the classical approaches. It was perhaps easier to determine the course of action a medical institution would (should) take, if it faced a situation like the one discussed above, that is of a choice between an enfeebled elderly and an otherwise healthy adolescent, both infected with the coronavirus and requiring intensive care. However, the real world doesn’t present itself in white and black. Imagine with the other two candidates, there comes also a doctor who specializes in respiratory illnesses and works at the same facility which is faced with the current moral dilemma. Now in such a scenario, a third school of thought would seem to take the centre stage.
Contractarianism holds that actors are primarily self-interested, and that a rational assessment of the best strategy for attaining the maximisation of their self-interest will lead them to act morally (where the moral norms are determined by the maximisation of joint interest). If the medical facility takes the contractarian route, it would perhaps prioritise the doctor over the other two candidates, irrespective of doctor’s age, morbidities if any, or survivability. A plausible justification for it could be the first duty that the hospital owes to the doctor, who is an employee and also the general utility wherein the doctor if recovered can save more lives. With the three perspectives in the same line of sight, the contractarian approach seems to be reconciling with the utilitarian approach, given that the doctor has a utility not only for the medical facility where he works but also the society at large. Ironically, the deontological approach which enjoys the moral high ground otherwise comes a distant third in the race among the reconciling-conflicting philosophical pathways.
In the helter-skelter of the pandemic, the chaos has not remained just outside of us but has also shaped our conscience and actions. Our actions and their underlying moralities are undergoing change and all we can do is watch us becoming persons we probably never intended to become. For the conscientious beings it is difficult to stop at a traffic signal and shoo away the urchin who cleans their car’s windscreen in the hope of eliciting a penny or two. Of course, this is just one example but the divide is widening with each day passing. A crisis is an apt event to test the failings of popular norms and ideas. A crisis is also an apt event to find new ways of making the world a better place, proverbially.
Anurag Mishra is an independent researcher and an LLM from Tata Institute of Social Sciences. Sahiti Kachroo is a criminologist from Tata Institute of Social Sciences and practices law at the Supreme Court.
