FAUSTO GOMEZ OP
Bioethics is life ethics, or the ethics of human life from its beginning to its end. As a normative science, bioethics is concerned with the ethical problems connected with life, health, illness and death. It provides the ethical dimension to the life sciences.
In our globalized world, bioethical problems and dilemmas are to be addressed today – and the novel coronavirus is making it totally clear – globally and grounded on ethical universal principles and values.
We reflect first on the bioethical dimension of the novel coronavirus in general, and second on the dramatic dilemma posed by the scarcity of resources – of ICUs (Intensive Care Units), of mechanical ventilators or assisted respiration.
BIOETHICAL GUIDELINES
The human person is the center of all ethical and bioethical concerns. Every human person is an ethical being with unique and excellent dignity, which may be described as the possession of human rights that are inviolate: the right to life, to freedom, to the pursuit of happiness, etc. The human person is by nature an individual and a social being: humans depend on each other, and their health, too. Moreover, and as ecological beings by nature, as creatures of the universe their health depends also on a healthy environment.
Among the essential values that help us practice respect for every human being are: life, freedom, justice and solidarity, truth and the common good. We underline the importance of two ethical principles: solidarity and subsidiarity, which are always together in the social doctrine of the Church. These are particularly relevant concerning the novel coronavirus, civil authorities and professionals. The principle of solidarity (justice and love of neighbor)is practiced with all, principally with the most vulnerable in our societies and communities.The principle of subsidiarity states that “a community of a higher order should not interfere in the internal life of a community of a lower order” but help the latter if needed. (cf CCC, 1883, 1885). Situations of emergency, states of alarm or exception ought not to be prolonged more than necessary. Moreover, the pertinent norms on the Covid-19 of civil authorities ought to be based on the decisions and recommendations of independent professional experts, not politicians. The “political use” of Covid-19 is wholly unethical.
At times, there may be a conflict among ethical principles, for instance in the case of the new coronavirus and other pandemics there is the tension between the principles of personal human rights and the common good.
THE USE OF MECHANICAL VENTILATORS
The main ethical dilemma here, particularly for healthcare professionals, is selecting among patients who should use the insufficient number of intensive care units (ICUs), including ventilators. The dramatic decisions to be taken ought to be according to basic bioethical principles grounded on human dignity and rights and the common good. All human beings are equal in dignity and rights and therefore “equal cases deserve equal treatment.”
The main principles to guide us are respect for every human being, the common good, justice and solidarity. Justice implies equality: to give to each person what is due to him or her, radically his/her rights. Solidarity leads us to work for the common good. The common good is the object of justice and solidarity and means fundamentally respect for our rights and our duty to respect the rights of others.
Before applying the proper principles for a fair selection of patients, all other possible options should have been taken. What are the other possible options? Our experts mention the following: optimization of means available; caring for patients in serious condition cannot be provided by other means; the patient cannot wait until a ventilator is available; a ventilator cannot be used by two patients at the same time; the patient to be discarded cannot be taken to another hospital with the required ICUs; the relocation of other medical means destined to other patients who are not fighting for life is not possible, etc. We repeat: it is understood that the ICU is used in emergency situations and for patients that really need it and cannot be treated otherwise.
PAINFUL SELECTION OF PATIENTS
So the number of ventilators is not sufficient to cover the greater number of patients who need them. Among them, whom to give priority? This is not a new question. It was also the question in other pandemics and catastrophes from nature, and in wars. In wars: to choose among the many wounded whom to save, considering that not all could be treated by the few available doctors and nurses and facilities. It is also a problem regarding organ transplants: the demand is much higher than the supply. To whom may the kidney be given? In relation to the new coronavirus, PAV states: “The search for treatments that are equivalent to the extent possible, the sharing of resources, and the transfer of patients, are alternatives that must be carefully considered, within a framework of justice” (Pontifical Academy for Life [PAV], Global Pandemic and Universal Brotherhood. Note on the Covid-19 Emergency, March 2020).
What are the criteria for selecting some patients over others? The general ethical principle applied in these rationing situations is the so-called triage selection. Triage is usually defined as “the process of deciding which patients should be treated first based on degree of sickness or severity of injury.” Triage selection respects justice. “In such cases, after having done at an organization level everything possible to avoid rationing, it should always be borne in mind that decisions cannot be based on differences in the value of a human life and the dignity of every person, which are always equal and priceless. The decision concerns rather the use of treatments in the best possible way on the basis of the needs of the patient, that is, the severity of his or her disease and need for care, and the evaluation of the clinical benefits that treatment can produce, based on his or her prognosis” (PAV). Writes an expert of bioethics: “Careful assessment of the chances of survival of these patients and the magnitude of the sequelae they may suffer as a result of the progress of their disease is needed. Accordingly, those with the best prognosis for recovery and survival with the minimum of sequelae would be selected” (Julio Tudela, Instituto Ciencias de la Vida. Observatorio de Bioética, abril 11, 2020).
The application of the principle of social usefulness (utility) may be discriminatory: choosing the socially “useful” may imply discarding the socially “useless” (beggars, the incapacitated, the elderly), and this goes against the fundamental principle of the equal dignity and rights of every person. No one is useless. An unethical application of the principle of utility to the new coronavirus – unfortunately a reality in some places – is discrimination against some groups of affected patients such as the elderly and the disable. It is proper to help the majority of people but without discrimination. Social usefulness is ethical if it respects justice. In this case, experts speak of the painful application of the principle of catastrophic justice to decide who should be intubated and who cannot be.
Writes the Pontifical Academy for Life: “Technical and clinical means of containment must be integrated into a broad and deep search for the common good, which will have to resist a tendency to direct benefits toward privileged persons and a neglect of vulnerable persons according to citizenship, income, politics or age… Age cannot be considered the only, and automatic, criterion governing choice. Doing so could lead to a discriminatory attitude toward the elderly and the very weak.” Tudela comments: “The application of other criteria in a discriminatory manner, such as the age of the patient or other circumstances such as psychiatric disorders, dementia or any other forms of disability or dependency, would not be bio-ethically acceptable, because it would mean acting against respect for the dignity that every human being possesses.” Strong words: “The coronavirus is Darwinian: it eliminates the old, the sick and the poor” (Arthur Laffer, April 2020). For believers in Jesus and others, the most venerable persons are the preferred ones.
PALLIATIVE CARE
The medical/ethical decision to exclude some coronavirus infected patients from using the ICUs they need is not a form of euthanasia, but usually a painful decision, part of the only possible medical/ethical option. The infected patients excluded from the use of mechanical ventilators should continue hospitalized, when possible: a hospital offers much better care than a nursing home, especially the needed palliative or comfort care.
Palliative care includes medical, social and spiritual care: doctors and nurses address mainly the health problems, particularly pain; close relatives and significant others, provide “a warm heart” that fights the possible loneliness of patients, and pastors and chaplains care for the spiritual wellbeing and peace of the patients. In the context of the new coronavirus, the Spanish Bioethics Committee (April 2020) suggests that at least a close relative of the dying patient should accompany him or her. “This accompaniment and the spiritual and religious support constitute part of the rights of the patient.” Our Christian faith favors and practices as much as allowed, those suggestions based not only on our humanity but on the praxis of the Church throughout the ages. They are expressions of the merciful love lived and taught by Jesus Christ who had a special love for the vulnerable, in the case of Coid-19 the elderly, the disable and the poor.
May this tragic tsunami of the coronavirus Covid-19 aid us all to be more open to others, to help the most vulnerable and to practice solidarity and fraternity! As one family, we will get out of this pandemic and hopefully be thereafter more co-responsible, more humble, compassionate and wiser. (Photo: NBC News)
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