Thursday, April 30, 2020

COVID-19, rationing and the question of age

Discussions about the role that age should or should not play when allocating medical resources during the COVID-19 crisis have been deeply revealing. Probably no bioethicist would come out in favor of basing such decisions simply on (older) age, though there is no problem finding such opinions on Twitter. But many bioethicists heavily rely on likelihood of recovery and number of years of life expected post-treatment in their favored allocation schemes, which in the context of COVID-19 will frequently come down to the same thing. In addition, constructs like the 'life cycle' or the 'fair innings' view are often sprinkled into the decision-making recommendations, i.e. the idea that all other things being equal, resources like mechanical ventilation should be given to those who have not yet been able to enjoy all stages in life's course. It is probably safe to say that, in most influential bioethics allocation schemes, age is not your friend.

These ways of thinking about age and rationing have been defended by prominent bioethicists for years, pre-COVID. Some of their limitations have been pointed out over the years, and in the wake of COVID-19, they are being pointed out again. As Harald Schmidt writes in the New York Times, despite the appearance of impartiality and equity, the criteria of likelihood of recovery and number of years of life expected post-treatment in fact biases access to medical care against those in society whose infected bodies were already compromised by racial, class and other factors. In addition, the idea of making decisions that favor youth over the aged on the basis of 'fair innings' is problematic for similar reasons. Just because a person is old does not mean that they had a good time of it: this confuses quality and quantity. Those who have suffered from systemic discrimination throughout their lives have had 'unfair innings'. And now, on top of all that, they are accorded less priority for medical resources during a pandemic, because they had the audacity to stick around. The common thread here is that commonly promoted allocation criteria fail to acknowledge how their implementation could compound existing social injustice.

But there is also something else. These allocation criteria are commonly promoted as if they are obvious and universally accepted. But there are good reasons to question this, as Nancy Jecker points out in a recent article in The Hastings Center Report (#behindapaywallgoddammit). Moral standing associated with age differs in different cultural contexts. In some countries, youth are favored over those who are old for a number of reasons, including the idea that youth are or are potentially 'more productive' than those who are old. Such countries tend towards a 'hourglass' conception of the life course, i.e. that your moral status gradually diminishes over time, which is supposed to explain why the death of a child is more tragic than the death of an older person. But in other contexts have alternative conceptions of the life course and aging where, if anything, some societies tend to discriminate against the young, and understand the moral importance of a person as something that grows over time and in that person's relationships with others. From this perspective, an older person is not someone lacking in utility whose allotment of time is running out, but someone who has gradually accumulated worth ('become more human') in the community.

There is no way of determining which conception of aging and moral standing is 'correct'. The point here is rather that criteria commonly proposed for the allocation of scarce medical resources in prestigious journals by prominent bioethicists during the COVID-19 crisis carry with them a number of underlying cultural assumptions. Making life-altering decisions on their basis may appear perfectly appropriate in some contexts, but expecting one size to fit all is unreasonable. And this matters in a global pandemic.

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Thursday, April 23, 2020

COVID-19 and American exceptionalism

Like serious health emergencies tend to do, COVID-19 is magnifying pre-existing economic, social and political problems in countries around the world. The United States is a glaring example: having responded slowly to the pandemic threat, it finds itself approaching 50,000 confirmed COVID-19 related deaths, shortages of personal protective equipment and other medical necessities, and a massive economic meltdown in a society with a threadbare social safety net. Unemployment has skyrocketed. Businesses are going bankrupt. The general chaos is further stirred by a science-averse and business-friendly president, and protesters demanding the 'liberation' of citizens from the 'tyranny' of public health restrictions aimed at protecting them. Right-wing media channels call the pandemic a hoax while at the same time telling its own employees to work from home and follow public health guidelines. There is a lashing out at perceived enemies: the World Health Organization, China, whoever. Every day brings something mind-boggling. If the country was a person, you might prescribe cognitive-behavioral therapy, bedrest, and Zoloft. But it is not a person, it is a nation where people are dying en masse from COVID-19, with no end in sight, and nothing confidence-worthy at the wheel.

I guess it is predictable that, in this situation, discussions about 'American exceptionalism' are going to crop up. The positions usually fall into three camps: (1) America is still exceptional in terms of being a economic-moral-cultural leader of the world and beacon of democracy etc., as opposed to 'shithole countries', and it is just going through a bit of a rough patch now; (2) America was exceptional, but now it isn't, and it has been in decline since [fill in the blank]; (3) The whole idea of 'American exceptionalism' was always a myth built on amnesia and hype, given its foreign policy history and longstanding internal social pathologies, and now the myth is being busted in Technicolor 24/7 for all the world to see.

The first position is represented by those who think that the path forward is to wave more flags, carry more firearms, and use the word 'freedom' in sentences even more than usual. The second position is represented in a New York Times piece that ran today entitled: 'Sadness' and Disbelief from a World Missing American Leadership. In it, we are supposed to think that the United States had a glorious past (including apparently winning the Second World War without Soviet assistance) and the world now has heavy nostalgia for that made-in-the-USA dispensation of global goodness. But the reporter apparently did not interview anyone who takes position #3 seriously, which may in fact be in the ascendency during the COVID-19 crisis. Look at the reader responses to the New York Times article, for instance. Or look at articles coming in from the global south, such as this or this, where the unraveling of the United States' grip on the world is regarded as not entirely unwelcome.

Saturday, April 04, 2020

Bioethics blog as plague journal

I have not been active on this blog for quite some time. The causes are multiple, but one comes to my mind first: do people still read blogs, anyway? The doubt is de-motivational. Over the last years, it seems that more and more bloggers have switched over to Twitter, which is to say that they have stopped posting longer pieces beyond 'threads' on that platform. You can see Twitter's attraction: less of an investment in time and greater likelihood of immediate feedback or impact. It fits better in our life-work imbalence. This blog too has been associated with a Twitter account since 2012 (@BioethicsGlobal), but over the years I have found that the elements that make Twitter attractive can also make it repulsive. I think Twitter ought to be renamed 'Oversharing', or more to the point, 'Hostility'. I am there for the retweeted news items and pet videos, mostly.

So why back to the blog, if blogging has been culturally sidelined? The answer, like the (unhappy) answer to a lot of questions these days, is COVID-19. It is not a matter of getting likes or being retweeted, anymore than it was for Daniel Defoe when he wrote A Journal of a Plague Year in 1722. It is more a matter of trying to bear witness, in a medium somewhat more accommodating than Twitter, though without the detachment and hindsight that the coming tsunami of bioethics books on COVID-19 are likely to have. Right now, we really don't know where all this is going.

In the last two months, bioethics has been reacting to the COVID-19 epidemic in all sorts of different ways. One way to look at the bioethics response is by categorizing it (very roughly) in terms of medicine, science, politics and art.

Medicine: the speed at which recommendations have been formulated to guide the allocation of scarce medical resources has been amazing. It is almost an epidemic in itself. True, questions about fair allocation has always been in the American bioethics wheelhouse, even if talk of rationing health care there is also somehow taboo. It makes sense that bioethicists would want to be useful in this particular area, though you can wonder how much the schemes will really come into play in the terrible rough and tumble of ICU units.

Science: when a pandemic strikes the richer nations, there seems to be a rise in epidemiology talk in the general public. This could be a good thing, if it means entrenching a public health mindset. But sometimes it also means that a lot of people are talking out of their their hats. The more epistemological bioethicists find themselves combatting rumor and questioning the assumptions of mathematical models. And in addition, there is the question of what kinds of scientific studies should be conducted (and how) in pandemic circumstances, something much closer to home for European and American bioethicists this time around, when the mayhem is happening in Los Angeles and not just Liberia.

Politics: the virus is apolitical, but the responses to it by countries, communities and individuals are political through and through. As has been remarked before many times, and forgotten many times, an epidemic magnifies whatever problems were pre-existing in the body politic. And apparently we have a lot of problems, worldwide. Politicians may put re-election interests before scientific facts and public health imperatives. Instead of social distancing out of social solidarity, people may go out shopping for guns. In a horrible calculus, the value of the economy is weighed against massive numbers of the dead. Not to mention the geopolitics.

Art: there are a number of websites devoted to the COVID-19 pandemic from a statistical perspective. Deaths and confirmed infections per country are continuously updated. Like obscene things in general, the numbers are hard to look at and hard to look away from. But every death is terrible, for the person concerned and the fabric of relations from which they were torn. The human face of the pandemic, from the perspective of the infected, their families, health care workers, and others -- in this case to some extent literally everyone, even the billionaires -- also should inform how people in bioethics respond. This is a world of suffering and human drama, not a trolly problem, and bioethicists need to bring out their ethnologist, novelist, poet.

In the weeks (months?) that come, this blog will focus on the COVID-19 response in low- and middle-income countries, especially in sub-Saharan Africa. The pandemic is only just starting to pick up there. Different countries face different challenges, and context matters, but there are some overarching issues. The health care infrastructure in many places is weak. In most if not all countries, there is severe poverty. Social distancing or 'stay in place' may be unrealistic where people have challenges accessing running water, live in crowded townships, or rely on face-to-face contacts to survive. Unlike elsewhere, only a small minority have the luxury of continuing their livelihoods online. What ethical issues will this confluence of circumstances engender and expose? There is already concern that the global supply chain of medical resources is being diverted towards richer and more powerful northern countries, from whom Africa can seemingly expect little humanitarian aid this time around. What will 'allocation of scarce medical resources' look like when (as is feared) fragile health care systems are rapidly overwhelmed?