A few months ago, a hot topic in Australian healthcare was VAD, Voluntary Assisted Dying. Why shouldn’t individuals have the right to bring their lives to a close when they find no pleasure or meaning as they experience terminal decline? One of the curious aspects of the debate is that it takes pretty much for granted the idea that death and dying are medically controlled: if doctors can keep us alive, doctors can help us to die. But that’s a story for another time.
Suddenly, however, the whole focus of healthcare has shifted. From discussing the importance of recognising an individual’s right to self-determination we’re now talking about how we should face the COVID-19 pandemic. As a society we’ve agreed – with various levels of willingness or reluctance – to limit individual autonomy, including through compulsion or coercion, ‘for the common good’. Of course, our response to enforcing strategies like social distancing depends on what we see as this ‘common good’. Does pursuing the common good mean extending restrictions in an attempt to extinguish, not merely contain, the virus? Does it mean giving priority to getting the economy going again? Behind these issues lurk more fundamental questions, including: “What sort of society do we want to live in?” and “What are our rights and responsibilities as citizens?”. There’s nothing quite like living in a State of Emergency to bring these issues into focus.
In the March 2018 Meaningful Ageing newsletter, I quoted the four convictions put forward eight years ago by veteran biomedical ethicist Daniel Callahan, co-founder of The Hastings Center. He was addressing the sharing of limited healthcare resources, but his ideas, which centre around intergenerational responsibility in a good society, come into sharper focus with the pandemic.
- It is the obligation of a good society to help the young to become old, but not to help old people become indefinitely older
- The young should support the old, and the old should not be an undue burden on the young
- Rationing of limited health resources is inevitable
- Rationing should be open, not covert; negotiated at the level of policy, not case-by-case in professional relationships
The pandemic gives specific content to each of these convictions. Tension between the needs of old and young is highlighted by the increased physical vulnerability of older members of society and the economic vulnerability of younger adults. With COVID-19, morbidity and mortality are higher for the old than for the young; the economic impact of social distancing strategies falls disproportionately on younger people; while both the ability to self-isolate and to work from home favour people of higher socio-economic status. Limits to the capacity of our health system are being made clear, so that rationing of life-sustaining technology is already happening in some places in Europe or being anticipated here in Australia. It’s an issue that has blown up so quickly there’s been little time for public debate, but at least attempts are being made to review this ethical decision-making in the public arena (Hellman 2020; Margo 2020, Savulescu and Wilkinson 2020).
The swift public health response to the pandemic in Australia, reflecting a refocusing from individual rights to an ethic of the common good, has illuminated as seldom before the inequalities embedded in our society, the inadequacy of some dominant ideologies, and the power of consensus. It has sparked conversation about the society to which we will return once the pandemic is over, and the different endings that could result from different re-entry strategies. Some see an opportunity to move toward new ways of social organisation, to renegotiate the intergenerational contract; others simply wish for a return to the status quo. The evidence from previous pandemics is that it is not possible to ‘snap back’ to the way things were – but that won’t stop many vested interests from attempting to do so. How can we ensure that we embrace the possibility of constructive change rather than fight a rearguard action defending a way of life that is no longer feasible, let alone justifiable in light of the inequity the pandemic has revealed?
As relaxation of strict social distancing requirements is commencing, the signs of what we will return to are ambiguous. A particular concern for those who wish for renewal is an emerging tendency of the federal government to apply the compulsions that were legitimately used to impose quarantine to moving out of quarantine. Thus, we see pronouncements that schools are safe, and that residents of aged care facilities are entitled to visitors, and that these pronouncements will be at least incentivised if not enforced. Viewed through the lens of the common good, the desire to have national, or at least state-wide, regulation comes unstuck as it limits decision-making appropriate to particular contexts. Some aged care facilities can readily and safely accommodate visitors; others are not in a position to do so. (They may be in a COVID hot-spot, they don’t have enough, or any, PPE available for the staff let alone visitors.) Some schools are safe – but others may not be safe. Local autonomy is needed to implement national guidelines safely and with as much local consensus as possible. An ethic of the common good draws our attention to the complexity of ethical action, which is not served by legislative action:
The diversity and complexity of ethics are its strengths. It unsettles our common-sense interpretations, upsets our tendency to pursue an automatic course of action, and forces us to clarify our own reasons for acting and give good reasons to others (Carter et al. 2012).
There’s a certain irony in the fact that the physical vulnerability of older people in Australian society is offset by our continuing economic power: we’re worth preserving on political, even if not social, grounds. But what are we to say to the younger people who have consented to arrangements that have preserved our lives at the risk of their livelihoods? How do we recognise that they are bearing the brunt of the social and economic cost? How are we to contribute to reforming a society that employs many of the young in insecure jobs in industries that serve (indulge?) older people – entertainment, hospitality, tourism? How are we to value care now that we have seen the importance of personal care attendants, healthcare personnel, delivery drivers, shelf-stackers, good neighbours, in keeping us safe? How can we, as older people, participate in public debate about the future and what we will contribute to it, when at present others presume to speak for us? The debate about visitors in residential care, for example, seems to feature predominantly political and business voices (Henriques-Gomez 2020).
Seeking such social re-evaluation and change involves a spiritual pilgrimage. It invites those of us who are older to accept our identities as ageing people, develop our connections with intergenerational communities, and to find purpose in what we have, and still can, contribute to a good society, rather than in what we can still consume and control. And in the coming years it will require generosity (of spirit, of resources) from those of us who have had opportunity in life in order that the generations that follow us will also have opportunity to build a new society where the common good stands in creative tension with the individualism that has flourished, excessively, in our time.
Bruce Rumbold
Associate Professor, Palliative Care Unit, La Trobe University
b.rumbold@latrobe.edu.au
REFERENCES
Callahan, D. (2012). Must we ration health care for the elderly? Journal of Law, Medicine & Ethics, 40:1 (14-15).
Carter, S., Kerridge, I., Sainsbury, P., Letts, J. (2012). Public health ethics: informing better public health practice. NSW Public Health Bulletin 23 (5-6).
Hellman, D, (2020). Doctors facing grim choice over ventilators. The Conversation, April 20
Henriques-Gomez, L. (2020). Australia’s aged care residents caught in stand-off over visits during coronavirus. The Guardian, April 27
Margo, J. (2020). How do hospitals decide who gets the available ventilator? Australian Financial Review April 3
Savulescu, J., Wilkinson, D. (2020). Who gets the ventilator in the coronavirus pandemic? https://www.abc.net.au/news/2020-03-18/ethics-of-medical-care-ventilator-in-the-coronavirus-pandemic/12063536