- BIOETHICS FORUM ESSAY
Covid-19 is making bioethics more relevant than ever. The ethical dilemmas raised by the pandemic are urgent and heart-wrenching. Who should get a ventilator if we do not have enough? How can we protect the most vulnerable (for example, disabled or elderly people) from discrimination in the face of difficult triage decisions? How should we balance our need for surveillance with considerations of privacy? How do we weigh individual liberty against the public interest of keeping people confined?
While such questions are not new for bioethicists, the need to answer them urgently, globally, and in very concrete settings, creates unprecedented circumstances. Is this an opportunity for bioethics to learn some important lessons? What should post-Covid bioethics look like?
Bioethics was born in the 1950s and 60s as a reaction to the atrocities of World War II and extreme violations of human rights in medical research. Consequently, it historically focused on combatting medical paternalism and on protecting and promoting individual rights in a Western– mostly American–context. It produced a tremendously impressive body of work on personal autonomy and the rights of patients and research participants to choose how they want to be treated and to give informed consent for any intervention.
But it was slower, some might say less successful, in building conceptual and policy frameworks for issues related to justice. It did not spend the same intellectual energy on coping with issues related to families and cultural communities. It started only later to develop tools for dealing with public health ethics.
Covid-19 emphasizes our connectedness. The virus threatens us all and requires a global response. It also shows that the actions of each of us have immediate and dramatic impacts on others. The legacy of Covid for bioethics may indeed be a dramatic shift towards areas that need growing recognition and faster implementation.
First, justice – and, in particular, distributive justice. Bioethics should recognize the urgent need to develop more nuanced conceptual tools for resource allocation, not just in the context of a pandemic, but more broadly. While Covid-19 emphasized the fact that our resources are limited, this is always true. We cannot meet all the health care needs of all citizens, but allocation is often done implicitly. Bioethics ought to show moral courage in making these aspects of health care explicit, in shining a light on the way we justify allocations decisions to ensure they are more equitable, coherent, and transparent.
Second, bioethics should also pay more attention to the broader context in which health care is embedded. It should promote the understanding that ethical challenges related to health do not begin when we are sick and in need of medical attention. They are always present, because our health outcomes depend on our socioeconomic status and on the ways in which we are embedded in families and communities. Post-Covid bioethics should step back, even more than it did until today, from conceptions of individuals as isolated autonomous decision-makers, and spend more energy understanding people as embedded within their social and cultural networks.
Third, bioethics should focus on exploring the global aspects of the bioethical dilemmas we face. It should recognize our connectedness not just as members of our local societies, but as members of a global community. This would mean recognizing what we owe each other across borders, not just within them. How our local decisions impact other regions, especially disadvantaged ones. The bioethical thinking about resource allocation and priority setting had painfully neglected the global perspective. Covid-19 should push us to change that.
The tasks ahead are colossal and conceptually daunting. They emerge from the teachable moment that is Covid-19. Coming from a history of emphasis on individual autonomy in local contexts, post-Covid bioethics should embrace the challenges raised by justice in a global context. It should put an emphasis on fairness, transparency, trust, solidarity, and compassion as leading values. This could be the positive legacy of these difficult times.
Vardit Ravitsky, PhD, is a professor at the School of Public Health at the University of Montreal and 2020 Fellow and Chair of the COVID 19 Impact Committee, Pierre Elliott Trudeau Foundation. A version of this article was first published in French as part of a La Presse Plus series edited by Jean-Philippe Warren -Concordia-and Guy Laforest-ENAP. The articles in French will also appear in ACFAS Magazine and are accompanied by a podcast on CRIDAQ balado. Twitter: @VarditRavitsky
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