Print this case study here: The Case of Quarantine Ethics
The Case of Quarantine Ethics
The ethical dimensions of scarce resources is always a challenging topic, particularly now, with its forced relevance due to the outbreak of COVID-19. Ideally, this discussion would happen at a more stable time and not when realworld application is required. Who receives a ventilator and who does not is one of the most relevant resource constraint questions under discussion. Can an ethical framework or ethical system be developed that allows health providers to maximize benefit and be good stewards of resources, while also maintaining an accepted level of justice during these times?
Typically for emergency situations, the first instinct is to utilize a utilitarian perspective, i.e. maximizing the most amount of good for the most amount of people. Specific to ventilator distribution, the challenge with a utilitarian perspective is what is the factor that determines maximizing benefit? Would it be amount of life expectancy (days of life “saved” based on the average for all patients)? Or quality of life added? The likelihood that the patient will come off the ventilator? Which patients are offered ventilators can radically change depending on which of these elements the hospital or physicians choose to prioritize. The ethical framework developed by White et al. (2009) addresses these factors stating, “Principles guiding allocation decisions should include maximizing survival to hospital discharge, maximizing the number of life-years saved, and maximizing individuals’ chances to live through each of life’s stages” (p. 137).
In its, Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency (2011), The Task Force for Mass Critical Care suggested that the following conditions be present to initiate the triage process:
- Surge capacity fully employed within healthcare facility
- Attempts at conservation, reutilization, adaption, and substitution are performed maximally
- Identification of critically limited resources (e.g., ventilators, antibiotics)
- Identification of limited infrastructure (e.g., isolation, staff, electrical power)
- Request for resources and infrastructure made to local, regional, and state health officials
- Current attempt at regional, state, and federal level for resource or infrastructure allocation (p. 7-8).
The intention of these requirements being best provider for the most needing patient, delivering the most amount of good possible, and serving as a good steward for resource allocation. This is again a demonstration of utilitarianism, which is the underlying system for triage, which “refers to the methods used to assess patients’ severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment” (Christ et al., 2010, p. 892). Assessing patients and making determinations regarding treatment prioritizing is the attempt to promote the most amount of good while concerning resources properly, a fundamental responsibility of medical providers.
The limitations and challenges of the successful application of utilitarianism for emergency situations is that it a consequentialist approach, meaning the consequences of an action determine the ethical permissibility of said action. But we are not able to know the consequences in full when making a decision. Consequentialism is a retroactive perspective, so it is not effective in the moment in crisis situations. The counter to this argument would be that consequentialism looks at “expected” outcomes, not true knowledge of the future. But that assumes that expectations are easily available and known, and the fact is in a disaster or emergency situation, these expectations are unknown and standard protocols and methods are not practiced due to the nature of the emergency.
An effective system would be a combination of virtue ethics and principlism. A major perspective of virtue ethics is cultivating the moral character of the person, in this situation the provider, assuming that a person of high moral virtue will act in a virtuous manner, and thus perform virtuous acts. This is similarly applied with the framework by White et al. (2009) which state, “We propose an alternative, multiprinciple allocation strategy that better reflects the moral complexity of the issue and applies the same allocation criteria to all patients” (p. 137). Ultimately in crisis situations we need such principles and framework, as well as providers acting in a virtuous manner, to ensure ethical the delivery of scarce resources.
Bioethics in the News
Jane is 40-year old physician who is travelling back from providing free medical care oversees. She has been stationed in South America, where a new virus is spreading. Very little is known about the virus but is has been shown to be extremely contagious through the air. Jane arrives in the United States and is excited to be back after months away, particularly wanting to see her family. But at the airport, there is a mandatory quarantine of two weeks for all persons returning from the virus infected area.
Jane tries to explain that she has been travelling for over 24 hours now, and is completely asymptomatic. If she had the virus, she would have already started to show signs. Therefore, it is unnecessary for her to submit to the quarantine. The public health officials say it is a precaution, since not everything is known about the virus, and they cannot risk having her expose people here. Jane is extremely frustrated. While the public health officials discuss her situation, she sees an opportunity to sneak out an emergency exit and return to her family. What should she do?
The Limits of Ethical Systems
Suppose that you find yourself in a small town in the jungle. When you arrive, you find tied up against a wall twenty indigenous locals, and in front of them are armed men in uniforms. You just arrive and have no idea what is happening, who the people are, or any of the details. The captain of the men in uniform comes up to you and starts asking you questions, wanting to know why you are here. After some time, you prove to him that you are unaware of the details and are there by accident. The captain then informs you that the tied-up locals are random inhabitants who have been protesting against the government and are about to be killed as a deterrence to other protesters. But you, the captain says, are a special guest from an outside land, and you would have the honor of killing one of the locals yourself. If you accept, because of the special occasion, the other locals will be freed. If you refuse, there is no specialness about the day, and all twenty will be killed. The tied-up locals hear this and start to beg you to accept. What should you do?
Utilitarianism vs. Deontology
This is a thought experiment proposed by the British philosopher Bernard Williams. His goal for the thought experiment was to, primarily, critique utilitarianism, but also to critique all ethical theories. He argued that you should view this scenario in several different ways. Following utilitarianism, the answer is obvious that you should kill the one person, so as to save the life of nineteen others. If your intention is to promote the most amount of happiness for the most amount of people, it is a pretty clear decision. But Williams does not particularly like that solution, arguing that he does not want to uphold and support an ethical system that deems it ethically required for him to commit murder. Killing should always been seen as a wrong, maybe at the time being a necessary wrong, but wrong none-the-less. How can one follow a system when it does not just permit killing but requires it?
At the same time, he cannot fully support the alternative, which is not killing the local. He argues that since you happen upon the situation, it would have happened anyway, and thus you should view those twenty people as already dead. You did not cause it, but you were not involved and without your intervention they would be dead regardless. So, you are not killing one but rather saving nineteen. It would not be rational to refuse to save nineteen lives. Therefore, the deontological/Kantian arguments are incomplete.
The main point of Williams’ critique is to express the limitations of ethical systems. To put it in simple terms, moral situations in the real world are too complicated and exist in too much ‘grey’ to be easily solved by ethical systems. We can use ethical systems and work with them, but they are not machines with one end labeled “insert ethical situation” and the other “solution.” These systems are extremely helpful tools to be discussed, contemplated and used to help us figure out situations where one system may be helpful in a particular circumstance and another more useful in another. Essentially, there is no moral ‘Truth’.
I wanted to highlight this thought experiment when thinking about quarantine ethics. For the most part, utilitarianism is not an effective ethical system in the clinical setting. It could lead to the ethical permissibility of ending a single patient life so as to procure his/her organ for donation to save five others, a situation that goes without saying as not ethically acceptable in modern bioethics. But when applied to quarantine situation, it makes sense to limits the liberties of a single individual for the benefit of the larger population. You would likely argue that limiting a person’s right to movement is not comparable to killing a patient for organ procurement. And you would be right, but it still touches on the nature of the complexities of the real world. As we currently understand it, the world is too complicated to be neatly organized and understood by developed ethical systems. Such systems cannot account for all situations. Moreover, most people do not experience ethics and ethical situations systematically. There is something that does not sit well in the gut to consider killing people for other people’s benefit. You do not need an ethical system to explain that.
Ethics is human. Particularly bioethics. Ethics attempts to understand challenging situations in which humans find themselves. New ones are created, old ones lose their relevance, but the humans always remain. As long as there are humans and they interact with each other, there is will be a need for ethics.