EACME Newsletter 54

I am very glad to welcome you to a – noticeably slimmer than usual – EACME newsletter. The reason for its brevity will be obvious to all who read it, given many of us are at various stage of lockdown due to the COVID-19 pandemic. As I write the pandemic is fast approaching 1 000 000 confirmed infections. It is certainly a rare event that ethical issues are both so prominent in the news and so close to the lives of each of us. Clinical ethics is gaining rare attention in professional guidelines and national policy. Many medical ethicists are either taking up new roles in ethics consultation, or finding old ones making new demands, as clinicians try to avoid the overwhelming of health services by a tsunami of patients. Bioethicists and clinicians are therefore placed in the unenviable position of choosing which patients should access treatments for which too many patients have a pressing need. We must not be so naïve as to forget that, for much of the world outside of the global north, scarcity of healthcare is the norm. Yet for most medical ethicists working in EACME affiliated centres, the situation is highly abnormal.

If anything was to bring into stark relief the power of clinicians in exerting their values, it is this contrast between the power differential in the ostensibly “normal” (by which I mean pre-pandemic) clinical encounter, and that which occurs in the “abnormal” (intra-pandemic) clinical encounter. When considering the normal encounter, medical ethicists are used to advising clinicians, in many cases, to either defer to the patient’s values, or, in some circumstances where we feel the patient is not expressing an authentic choice, finding some middle ground between what is clinically good for the patient and what the patient believes. Under our current conditions, medical ethicists will find many situations where this customary approach simply does not make sense, because several patients will have equally rational desires for some scarce resource. Instead the question becomes how one decides between people, a question that demands the lens of (among others) fairness or desert. Indeed, when answering such questions in a liberal, pluralistic society (at least as cogently argued by Rawls), we must fall back upon a political, rather than a moral, theory. Such an observation implies that bioethics, and bioethicists, have been ejected from their accustomed sphere of the inter-personal to that of the extra-personal, in other words, the political. This, of course, is the realm in which Machiavelli suggested people should first learn “how not to be good”, so they might be good or not good as necessity demanded. Although this is a starting point that most moral philosophers would clearly reject, one thing is clear. This world based on necessity is, for bioethicists accustomed to working societies where resources are abundant, a brave new world indeed.