Nuala P. Kenny details what we have learned from past pandemics and what we could learn from the current pandemic
The COVID-19 pandemic has created a universal experience of vulnerability. This new virus brings uncertainty regarding its rapid spread and duration. There is no definitive prevention or treatment yet. We share a visceral awareness that we are all embedded in global systems and practices. The presumed protective “bubble” of affluence and social advantage has been shattered as luxury cruise passengers are infected as well as the poorest among us.
Decisions made during the crisis will shape health care, the economy, politics, culture, and religion in the future. Clinical and policy decisions that ordinarily take years of research, deliberation and debate are now made with lightning speed. Fear, uncertainty, and personal risk can promote self-protection in stockpiling staples as well as discrimination. The “physical distancing,” necessary for infection control, carries the risk of emotional and spiritual distancing just at a time when human connection and solidarity are crucial.
There are also unique possibilities for good. Pandemic plans attentive to ethical and moral challenges can be instruments for building trust and solidarity in a deeply fractured world. We might finally learn the crucial importance of public health for health equity and the common good at all times, not just in crisis.
Canadian colleagues from public health, medicine, feminist ethics, and theology explored the ethical and moral issues experienced in the 2003 SARS epidemic. Among the issues we identified were:
- Balancing individual liberty, freedom, and privacy with protection of the common good. This issue includes isolation and quarantine; appropriate care for the sick; minimizing costs of care and quarantine with special funds and insurance; and avoidance of discrimination
- Conflicts between the duty to care for all the sick and personal and family safety, including issues of reciprocity in supporting those who bear a disproportionate burden; and the limits of professional duties.
- Accepting economic losses in the need to control deadly disease. We also identified related issues such as the impact on other patients in treatment, and investigation delays and support for the seriously ill, as well as hospital visitor restrictions, which demand attention to justice in the long term.
Society has faced and learned from five pandemics in the 20th century, including the Spanish, Asian, and Swine flus, and HIV AIDS. However, our research team concluded that renewing public health for modern challenges such as pandemics and global warming require deeper reflections on the nature of public health and public health ethics.
The foundation of public health is grounded in preventing illness and promoting health; building physically and socially healthy communities; and eliminating health inequities. The “heroic age” of public health in the 19th and early 20th centuries made its impact through attention to poverty, sanitation, pollution, epidemic disease, bioterrorism, and global warming through the activities of health protection, population health surveillance, disease and injury prevention, health promotion and, recently added, disaster response.
This focus has been regularly displaced by medical, scientific, and technological advances in health care for individuals, and a rapacious commercialization and commodification of health care.
A robust, coherent, and meaningful ethics of public health is distinct from the bioethics of clinical care and research dominated by liberal individualism with its treatment of persons as self-contained and self-directing. Françoise Baylis, Susan Sherwin and I have proposed that public health ethics must be built on foundational notions of relational autonomy, relational social justice and relational solidarity, and the common good.
Pandemic ethics must be rooted in public health in order to minimize serious illness and death and social disruption.
Prevention, the primary goal, requires vaccines, mitigation of the socio-economic factors facilitating spread, and privacy-challenging health surveillance.
Care of pandemic victims must be balanced with care of other seriously ill and dying patients and obstetrical care, mental illness, and addictions care. Triage in a time of scarcity based not on “who is sickest?” but on “who is likely to benefit most?” presents major ethical issues for trust in caregivers, equity, and solidarity, and is not understood by the public.
First responders and hospital staff have professional duties to care for the sick. They and previously unseen housekeeping, food services staff, and technicians assume risk for themselves and their families. Their protection must be a priority.
Today, we can only treat symptoms. Desperate doctors are developing innovative practices and procedures without rigorous science, such as sharing ventilators, plasma therapy, and off-label drug use such as anti-malarials. Policy makers and practitioners are tempted to use vaccines and anti-viral treatments prematurely.
Decisions and actions made in our turmoil and fear require careful, continual moral reflection.
I live in the hope that we can learn from the experience of COVID-19 and accept our human interdependence and the need for global solidarity.
Nuala P. Kenny is a physician and bioethicist, and an Emeritus Professor at Dalhousie University