The ethics (mis)used for filling the voids or harm of harm reduction ethics

The current COVID-19 pandemic context is characterized by unprecedented scaling-up and intensifying of previously debated issues in medical ethics.

On the level of public health ethics, old debates about the validity (evidence embeddedness and unintended non-health related consequences), proportionality (fundamental human rights' limitations), timeliness (delaying the pandemic peak effect and allocation of scarce resources) and cost effectiveness (long-term effects) of measures and just distribution of harms and benefits are profoundly deepened [1,2].

However, one previously widely and thoroughly debated ethical issue has been particularly addressed in this context – the issues emerging around end-of-life care. There are several reasons for intensification of this particular debate in ongoing pandemic context. The group particularly vulnerable to COVID-19 are older persons with pre-existing chronic somatic conditions [1,3]. Additionally, the lack of curative interventions, need for prolonged supportive intensive care, inadequate preparations of health care systems together with untimely implementation of public health measures, lead to the inevitable collapse of available health care resources and systems [1,3,4]. The ethical issue that emerged from pandemic context is a quite unique and previously incomprehensible one: is it justified to limit (withhold or withdraw) lifesaving treatment to one person, even without their (or surrogates') consent, in order to save someone else's life?

Different authors suggested different measures on how end-of-life issues in this context could be tackled [1,2,[5], [6], [7], [8]]. Most of them advocate, at one level or another, certain relaxation of ethical standards and justification processes of different end-of-life related procedures (especially withholding and withdrawing life-sustaining treatments). In that sense, comprehensive guidelines on fair allocation of scarce medical resources have been proposed [1,2,7]. Customized intensive care unit admission triage protocols including integration of triage officers/committees and various priority scoring systems have also been highlighted [2,6]. Previously well-established tools, such as advance care planning are being increasingly encouraged [1,2,5,6]. Tools of informed assent, instead of informed consent, regarding the use of possible life-sustaining treatments has been reintroduced [5]. The main aims of such approaches are to limit the use of treatment options that are not only unwanted (either by patients or their close ones) or not beneficial, but also to allow just and fair (re)allocation of scarce health care resources. Additional commonly stated aim of such approaches and corresponding guidelines is to protect (preferably legally, ethically, psychologically and physically) frontline caregivers from making such a devastating finite decisions.

Even though any approach that aims for care concordant with established patients' values and goals is praiseworthy, the currently uncertain pandemic context may be a “slippery slope” for end-of-life issues. As ethical issues and corresponding debates are extremely context dependent, it is unwise to use this unprecedented and highly inconsistent context as a valid place where general argument about long-standing issues should be resolved. This does not mean that there are not many things of concern for medical ethics going on, either that one should sit back and wait for a more stable circumstances and reliable evidences to express their concerns and/or propose possible solutions. This urgent pandemic context made it clearer than ever that the strategy of watchful waiting and/or honourable retreat may yet lead to the most tragic of consequences. However, if not being particularly careful, otherwise trustworthy intentions and approaches could become “ethics of filling the (decisional) void” or “harm of harm reduction ethics”.

In order to be justified, restrictive public health measures need to be informed by evidence, while trying to reliably distribute potential benefits and harms according to principles of justice, equity and equality [1,4]. Currently widely used, public health strategies include the combination of containment and mitigation measures with the aim of delaying a pandemic peak effect, levelling the demands for scarce (and vastly neglected) health care resources while protecting the most vulnerable populations [3]. These strategies also attempt to buy enough time to both expand health care resources and investigate the threat further and find more appropriate, preferably curative solutions. In order to meet these general aims, highly restrictive public health measures have been employed with a dramatic immediate and postponed adverse effects on the whole of humanity, including social, political, cultural and health (especially non-pandemic) related ones [1,3,4,8].

So, on the one hand, we are trying to protect those immediately most vulnerable, while on the other hand, we are relaxing the decision standards of when to “let go” the same vulnerable population. While doing so, previously unimaginable adverse effects are affecting literally everyone. So, the question is whether we are using ethical narrative as a pretext in easing our conscience or our resources?

The fundamental moral question regarding the current pandemic situation is: what is actually a stronger moral imperative; acting on substantial but known or fundamentally unknown, but more immediate threats? Is it justified to tolerate (or even neglect) harms inflicted by well-known threats in order to protect from still unknown harms caused by more pressing threats? We believe that this represents, in fact, the primordial ethical dilemma in the ongoing pandemic. As this dilemma is mostly resolved by the introduction of restrictive public health measures, the further issues that are emerging are primary matter of survival utilitarianism, especially in the setting where these measures were introduced to late. However, ethics and survival are rarely the same things. One could even argue that ethics is about exactly those issues that emerged after the humans managed to unbrace most of the worries related to bare existence/survival, so when humans reached the stage of development when they became the agents who can and do shape their future and future of their environment. The most one can expect from survival strategies is to be fair, consistent and preferably transparent. Ethics is about what should and/or ought to be done, while ought implies that something can be done, while recognizing that every voluntary and intentional act is inherently morally notable as it reflects agents' values. In ongoing pandemic setting, that is similarly tragically shaped by the infectious threat as well as by inevitable but untimely responses, ethics is fundamentally misplaced, used in order to justify necessary (re)actions in rapidly emerging, highly uncertain context. Such ethics may be a prime example of ethics misused for filling the decision void and of harm of harm reduction ethics, characterized by disproportional and passively reactive lowering of some of most important and valuable professional and ethical standards.

So, there are two most pressing aims that should be met:

• •Being “left out” from critical treatment by any allocation strategy should not mean that person in need should not be cared for [9]. At least, palliative care, in its broadest sense, should be guaranteed for everyone in need. Proactive, innovative approaches may be needed in order to provide widely available and easily accessible palliative care, as surge of palliative resources could also be anticipated. Here, as early experiences highlight, the use of novel and digital technologies may be of great help [9].
• •Frontline caregivers should be thoroughly exculpated from imposed ethical dilemmas with considerable and irreversible consequences they are currently facing, as they are merely actors in a drama where most of ethical judgements and decisions have already been made. The responsibility of such decisions should not be transferred to moral agents that are on the front lines which moral agency and responsibility is profoundly undermined and every effort should be made to provide them instrumental and emotional support, also by using innovative and new approaches, such as digital technologies.

Ethics has long been trapped in so-called “is-ought” problem, that is, problem of translation of ethical norms or rules into (desired) practice [10]. However, one should be careful when the necessary or inevitable practice is recklessly translated into ethics. Various guidelines are useful and may serve as a “shelter”, but their true ethical worth needs to be thoroughly weighted within the wider historical, social, cultural and medical context. One may just ask is it the right time to do so or should we cherish watchful waiting once again?

Authors contributions

MC conceived and drafted initial version of the manuscript. MC and AK edited, reviewed, and prepared the manuscript for submission. Both authors contributed to and approved final version of the manuscript.

Declaration of Competing Interest

MC has received lecture honoraria from Lundbeck, Sandoz, Janssen, Pliva (Teva) and Alkaloid that are not related to the content of this manuscript. AK declare no compeeting interests.