2. A Disaster Medicine Situation Is Not a “Supreme Emergency”-However…
3. A Decision Based on Clinical Criteria Remains a Decision
4. From Scarcity to Duty: Strong Pushes and Option Luck
Conflicts of Interest
In ordinary language, we speak of a “disaster” also in a more restricted meaning, when an event causes significant damage or loss of life but not necessarily disruption effects on society as a whole.
Just and Unjust Wars was first published in 1977, the same year that the Additional Protocols to the Geneva Conventions were adopted. From the very beginning, it was discussed as a book devoted to supporting a rights-based approach, according to which some fundamental rights “cannot simply be set aside; nor can they be balanced, in utilitarian fashion, against this or that desirable outcome”  (p. 25). At the last moment, however, Walzer seems to put aside the need for an inescapable consistency between the means and the ends, and the reason is that what we are confronted with is a case of moral tragedy: “if one violates jus in bello, one commits murder and perhaps other crimes. On the other hand, if one does not violate jus in bello, one’s omissions may contribute causally to the death and devastation of one’s people at the hands of a brutal, rights-violative aggressor”  (p. 28). Alex Bellamy criticizes Walzer for contradicting his “deontological account of the just war tradition”  (p. 830) yet making clear that his position is not to be confused with some kind of realism of “dirty hands”. Even though a shift towards utilitarianism appears undeniable, Walzer “still holds that there are binding moral constraints on leaders which may be temporarily overridden in extreme cases but may never be ignored”  (p. 836).
The “strict conditions for legitimate defense by military force” entail a principle of proportionality openly: “the damage inflicted by the aggressor on the nation or community of nations must be lasting, grave, and certain; all other means of putting an end to it must have been shown to be impractical or ineffective; there must be serious prospects of success; the use of arms must not produce evils and disorders graver than the evil to be eliminated”  (2309).
According to Primoratz, the moral disaster position “is structurally similar to that of supreme emergency”. However, it includes “only extermination and ethnic cleansing of an entire people from its land” as a legitimate reason for the exception, thus preserving its “rarity value”  (p. 383).
“And when treasured principles of justice direct us in opposing directions, it is important to choose the course or goal that reasons support as being right under the circumstances. In those situations, we have to acknowledge that upholding some principle(s) of justice may be inappropriate for making the particular kind of decision at hand”  (p. 624).
The same argument was supported by the Italian Committee for Bioethics, which listed age together with “sex, condition and social role, ethnicity, disability, responsibility for behaviours contributing to the pathology, costs” as a criterion that should be deemed “ethically unacceptable”  (p. 3).
When a disaster determines different urgent health needs, it naturally also becomes important the ability of a team “to address the victim’s main problem (e.g., a team of orthopaedic surgeons may be unsuited to care for a child with second degree burns)”  (p. 59). Barilan et al. discuss the clinical and the utilitarian schemes of triage and propose a “hybrid” version, which they believe can “preserve (at least to a degree) the independence of medical care and the value of fiduciary duties in medical ethics (non-abandonment and continuity of care”  (p. 56).
“The Sequential Organ Failure Assessment (SOFA) score is a simple and objective score that allows for calculation of both the number and the severity of organ dysfunction in six organ systems (respiratory, coagulatory, liver, cardiovascular, renal, and neurologic)”. The score “can measure individual or aggregate organ dysfunction”  (p. 1649).
Daniel Callahan, approaching the issue of “setting limits”, assumes that our “common social obligation to the elderly” could be limited “only to help them live out a natural life span”. At the same time, he reaffirms “the inestimable value of individual human life, of the old as much as the young, and the value of old age as part of our individual and collective life”  (p. 116).
John Harris, for example, argues that the frustration of the wish to live out the rest of our life is an injustice “if we do not deserve to die”  (p. 406). I had the opportunity to ask him what exactly he meant by this expression. He mentioned as examples those who are murdered while attempting to murder an innocent person or a terrorist badly injured by the bomb he had planted in a hospital competing for first responder aid with his victims when scarce resources for rescue are available. It is worth underlining that such an extreme case may not only be an abstract hypothesis, especially in a war scenario. Gino Strada was a surgeon and the founder of Emergency. On the website of this humanitarian non-governmental organization, medical treatment is defined as a “fundamental human right”, which as such “must be available to everyone”. In a book in which he recounts his experience as a war surgeon, Strada recalls a difficult decision he made. In Kabul, when faced with a hundred wounded in a courtyard and forced to carry out triage, he had decided to prioritize the children and women without hesitation. He did not compare their clinical condition with that of the guerrillas, also in need of treatment, who had held him and his hospital at gunpoint for days, “without any respect for the other wounded and for those like us who were only there to provide care”. However, this decision left Strada with a heavy heart. In time, he could not avoid feeling the moral unease for a choice that was perhaps, after all, “just a kind of revenge” and had, in any case, nothing to do with his “job”  (pp. 56–58).
Such restrictions “must be in accordance with the law, including international human rights standards, compatible with the nature of the rights protected […], in the interest of legitimate aims pursued, and strictly necessary for the promotion of the general welfare in a democratic society”. Beyond that, they “must be proportional, i.e., the least restrictive alternative must be adopted where several types of limitations are available. Even where such limitations on grounds of protecting public health are basically permitted, they should be of limited duration and subject to review”. The reason for this clarification is that the limitation clause “is primarily in-tended to protect the rights of individuals rather than to permit the imposition of limitations by States”  (§§ 28 and 29).
The term “nudge” was first used in a book with the same title  to describe “any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives”. The appeal of nudging relies on the possibility of developing “a set of seemingly simple, low-cost solutions that do not require legislation and can be applied to a wide array of problems”  (p. 263). Of course, the parallel cannot be pushed beyond a certain point because it was precisely through legislative measures that restrictions and freedoms related to vaccination status were set.
“In the event that the seriousness of the health situation and the long-term unsustainability of the limitations on social and economic activities persist, the Committee also believes that–in the face of a vaccine that is validated and approved by the competent authorities–its being made mandatory should not be excluded, especially for professional groups that are at risk of infection and transmission of viruses”  (p. 11).
See, also for an introduction to this approach  (pp. 72–80 and 97–105).
This conclusion is not to be confused with a warrant for whatever kind of irresponsibility. Democratic equality “avoids bankruptcy at the hands of the imprudent by limiting the range of goods provided collectively and expecting individuals to take personal responsibility for the other goods in their possession”  (p. 289). For example, in the case of smoking, this approach provides that “a person who smokes would be entitled to treatment for resulting lung cancer, regardless of their degree of responsibility for smoking. But she would not be entitled to compensation for the loss of enjoyment of life brought about by her confinement in the hospital and reduced lung capacity, for the dread she feels upon contemplating her mortality, or for the reproach of her relatives who disapprove of her lifestyle”  (327).
Together with the dyadic perspective, Brown and Savulescu insist on the “diachronic responsibility”, which entails making a judgment on the agent’s behavior over time: some health behaviors, such as vaccination, are one shot; others, such as smoking, are to be repeated frequently to produce health consequences. Of course, this observation implies referring to the well-known debate on the notion of “identity” over time. They acknowledge they are “sympathetic to arguments that responsibility should not play a role in healthcare”, but also that “responsibility practices are a commonplace feature of almost all areas of human life and interpersonal relationships” and that such questions demand, therefore, “further interrogation”  (636).
The increase “may arise from altered access to healthcare services secondary to the profound reorganization of hospitals and the effects of lockdown on physical, psychological, and social wellbeing. Moreover, lockdown and the fear of contracting the infection in hospitals could have prevented patients from calling emergency medical services (EMS) or presenting to emergency departments”  (p. 242).
In Italy, for example, the death count doubled in March and April 2020 compared with the average of the same months from 2015 to 2019. According to the model proposed by Odone et al., “within excess mortality that was not captured by COVID-19 surveillance […] more than two-thirds of excess deaths might be due to causes other than COVID-19”  (p. 113). A study carried out in Paris and its suburbs in the same months showed a transient two-times increase in “out of hospitals cardiac arrest” incidence, coupled with a significant reduction in survival and only partially directly related to COVID-19, followed by a return to normal towards the end of the study period . Between March and May 2020, there was a significant decrease in new cancer diagnoses in Germany, with the subsequent risk of poorer outcomes because of many undiagnosed cases or cases diagnosed with some delay .
The idea of COVID-19 as an equality of opportunity disease has been contested as a myth to be dispelled: “It has killed unequally, been experienced unequally and will impoverish unequally […] We need to learn from COVID-19 quickly to prevent inequality growing and to reduce health inequalities in the future”  (p. xiv).
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