JBI Dialogues: Episode 1

JBI Dialogues: Episode 1

Social and ethical implications of the COVID-19 pandemic: symposium editors Michael Chapman, Paul Komesaroff, Ian Kerridge, and Ross Upshur

In this our first episode of JBI Dialogues we welcome the editors of the journal’s new symposium on social and ethical implications of the COVID-19 pandemic. In addition to their work in bioethics, Dr Michael Chapman and Professors Paul Komesaroff, Ian Kerridge, and Ross Upshur are all physicians working across palliative medicine, endocrinology, haematology, and clinical public health.  Here they talk about: 

  • the meaning and importance of bioethics,
  • their motivations for starting this project and what they’ve subsequently learnt,
  • the symposium themes and their significance,
  • the case for why someone should make the time to read papers in this symposium,
  • the paper/s they would suggest to start your symposium reading, and why, and 
  • what comes next. 
Links Transcript

Edwina: [00:00:00] Hello, and welcome to JBI Dialogues presented by the Journal of Bioethical Inquiry as a multidisciplinary space to connect academic professional and community voices in conversation. JBI Dialogues involves our contributors, readers and the editorial team extending the work of the journal with exchanges of ideas about its published research and up and coming bioethics issues and practices. My name is Edwina Light and I’m the digital content editor at the JBI.

In this first episode of JBI Dialogues, we welcome the editors of the journal’s new symposium on social and ethical implications of the COVID-19 pandemic, the second part of which has been published this week. In addition to their work in bioethics, Dr Michael Chapman and professors Paul Komesaroff, Ian Kerridge and Russ Upshur are all physicians working across palliative medicine, endocrinology, hematology, and clinical public health. Michael Paul Ian and Ross, welcome and congratulations on the symposium, which brings together a remarkable and diverse [00:01:00] set of 65 articles from 133 authors around from around the globe.

So just for those who don’t know much about bioethics, can you tell us what it means here and why it’s important, perhaps Ross, you could tell us a bit about that.

Ross: [00:01:16] Thanks Edwina and thanks the opportunity to speak about our symposium. I’m very excited about its completion. So many people will understand when we talk about the social and ethical implications as in the title, the social side, but what makes an infectious disease epidemic or pandemic like SARS COV 2, ethical, what are the ethical issues? So bioethics is largely the broad reflection on the relationship between humans and the biosphere, including all of the means in which technology interacts with that. And so, when you talk about bioethical issues, you’re talking about questions that [00:02:00] raise issues around what the right or wrong thing, you know, most basic way.  What’s the most appropriate? What’s the correct? What’s the right? What’s the virtuous? What’s the best way to act or respond and treat each other? And how you distinguish that from its contrary? What is suboptimal? What is unethical? What is harmful? So, you know, good versus evil, right versus wrong, appropriate versus inappropriate.

And I’ve been arguing for decades that infectious disease epidemics are quintessentially bioethical events because they really do open up all of the ways in which humans interact with the biosphere. So in the example SARS COV 2, how was it that a novel coronavirus emerged into the human population?  What were the behaviors and actions that made that possible? Were they, the, were humans, you know, appropriately interacting with the biosphere, with the ecology [00:03:00] in a way that actually permitted this event to occur. And then there’s a playbook. Right through all the steps and phases of a pandemic from now, we have a new infectious disease and people are becoming sick, and which people are becoming sick? Well, usually it’s those people who are providing care, healthcare providers, physicians, nurses, and family members. And then you have questions that arise about duty to care. What are the scope and limits of the appropriate care? Do physicians have the right, the ability, the justified means of refusing care because they themselves may become ill? And that topic dates back, you know, as far as we can go, even to, you know, I’m fond of quoting from Thucydides, Peloponnesians War, his account of the plague of Athens in which he very clearly describes the impact of the plague on physicians, it would kill all the caregivers.

And so then you start to say, well, how are we going to stop this this [00:04:00] terrible plague?  Maybe we’ll have to restrict people’s mobilities. Is that justified? We need new knowledge. We’re going to have to experiment on people. Is that, and how do we justify that? And as you look through all of the key events of a pandemic, each one of them is not defined by its extrinsic scientific nature about what we know, but by the very questions that we have to ask about what the correct way to proceed is, how we’re going to treat each other, how we’re going to act collectively, how physicians are going to engage with patients, with their colleagues, et cetera, et cetera.

So bioethics to me defines the scope of the human reality of epidemics. And one of the beautiful things about our symposium is that it covers the wide range of those experiences. So I hope I’ve persuaded people that this is really important, fundamentally important, to the very nature of what it means to be human.  And that’s where bioethics dwells.

Edwina: [00:04:59] Thank you, Ross. [00:05:00] I think that’s a really great way to set up our conversation and for anyone to sort of wade into the articles in the symposium. To step back to the beginning,  when you first put out the call for papers earlier this year, as all of this was starting to unfold, the first set of articles were then published in August and now the final part in October, what were the main motivations for starting this project? And what were you hoping to achieve? Maybe Michael, you could tell us a bit about that. 

Michael: [00:05:29] Yeah thanks, Edwina. And, I mean, thinking back to that time that, this was in March of this year 2020, and, obviously COVID-19 was, was something that we’re all grappling with. And it was, I think, clear to all of us at that stage that, that, you know, that it was having a huge impact on, on people, on communities, institutions, and countries, and, and that this was an illness, a virus that was having a global impact, you know, really challenging, all [00:06:00] these, these different countries on many different levels, you know, health, social, and all sorts of other ways. And so there was this very definite recognition. There was an impact and there were questions and problems associated with that. And many of these seemed novel and seemed to not have great answers available to us in this kind of emerging threats. But also there was a lot of deep fear and worry, and you know, that, that was really a prevalent sort of sense, that, that you know, that there were, that the world was kind of under threat from this virus.

And so conscious of all of that, you know, many people, you know, including ourselves obviously got together and, and felt that it would be, it’d be really great to be able to respond to that in a kind of a curious and positive way, to try and start to get some sense of what people were were thinking were the big problems that COVID-19, we’re rising beyond [00:07:00] just the incredibly obvious sense of this being a huge health problem that was raising kind of issues to do with health resourcing and other things that, we were conscious that there were the more subtle and, and yet still really important kind of problems that were being raised and, and responses that were being the being sort of turned towards this.

I think another thing is we’re also really conscious even at that early stage, and unfortunately this has become increasingly true over time, was that this was not even though this was a global problem, there was not a single homogenous sense of this experience. You know, that different communities, different countries were having a different experience of COVID-19 and, and that their responses were very different.

And so again, trying to collect some sense of what those responses were trying to do our best to learn from them and to try and share that learning as part of coming to some understanding of what it’s, what it was like to be inside the pandemic. [00:08:00] You know, in this, in this period of time in 2020, felt to us a really, really important step.

And, and that’s what we sought to do, by sort of reaching out far and wide, you know, across the world to many, many people, hoping that they would contribute to this, this shared work. And we were, you know, incredibly grateful to all the people who participated to make this symposium, you know, the, the, real, this amazing piece of work that it has become.

Edwina: [00:08:30] So it’s been six months since that call for papers, and the impact of and the responses to COVID-19 have continued to unfold. And at the same time, as you said, Michael, authors from across the world started to send in their work on the meanings associated with COVID-19 from the center of the pandemic.  Could you share some of your reflections on what we’ve subsequently learned in this time and through the symposium. Ian, did you want to talk to us about that?

Ian: [00:08:56] Absolutely. So I think the first thing to say is that [00:09:00] we’ve learned how little we knew the, is, is that it’s, in some ways, it’s not a very long time ago that, as Michael said, we put out the call for papers and we were talking about what our expectations are. And I think it’s fair to say that the submissions have vastly exceeded our expectations. Not that we had low expectations, we just were genuinely unclear what would come and, and what would come has, has sort of  illustrated, maybe four things.

I think the first thing is that is diversity, as Michael said, is that there there’s, there’s no single uniform experience of COVID-19. I mean, perhaps like all infectious diseases, it’s been very good at exposing fractures and inequities in each of the countries that it’s affected. So around the world it’s exposed inequities  in terms of particularly access to health resources, but education and health and poverty and food security and all of those [00:10:00] sorts of things. In the US it’s expose problems of race, and in Australia it’s exposed the ruin that is the aged care sector here. So it’s so it’s, so it’s exposed this extraordinary diversity of experience that people have been able to tell us about and write about.

The second thing is that it’s also exposed similarity. Is that, is that within this diversity of experience, it’s, what’s clear is that people all share this experience of threat, of social isolation, of disruption, of concern for vulnerability, and, and also as a positive, concern or a resilience perhaps, and a sense of, of community and solidarity.

The third thing is that it’s it, we’ve learned the true impact of dynamic experience and dynamic knowledge. The things that we thought we knew in March it [00:11:00] quickly became clear that we didn’t know what we were talking about. So we’ve gained a nonstop amount of dynamic information about the virus, about the threat, about how it’s controlled or how it shouldn’t be controlled, and arguably we’ve learnt an enormous amount about our own communities and about the global community as well.  It’s it’s really, I think, fomented  discussions abou things that you perhaps you wouldn’t think would be part of a discussion about a pandemic, so globalization and economic rituals, and the degree to which international travel is important, you know, a whole series of interesting discussions.

And so the last thing, and again, Michael touched on it that I think, as, as the organizers of this symposium and as the journal we’ve again been reminded of the value of community, because I think we’ve all been personally overwhelmed, and this is not about COVID, [00:12:00] it’s just about ourselves. I think we’ve been sort of touched by the strength of, in this case, this sort of scholarly community and, and, and the contributors, incredible generosity of spirits and, and willingness to engage in a task, you know, to people like, you know, perhaps they knew Ross, but they certainly didn’t know Michael or I, and they were and, and they, I’m sure they knew Paul as well, but they were willing to engage and share their ideas and, and that’s been really humbling, and wonderful.

Edwina: [00:12:32] In the editorial you comment on that diversity of papers from that community, and you describe a, sort of, a rich variety of substantive issues in which they deal, and the range of their theoretical cultural and geographical origins. You organized these into seven themes and with 65 articles and130-plus authors that must’ve been a task. Can you tell us a bit about those themes and their significance? Maybe Paul, you could tell us [00:13:00] a bit more about that.

Paul: [00:13:01] Yeah, look, thanks very much Edwina. This gets back really to Ross’s opening comment. When he commented on the ethical significance of the epidemic or pandemic. Traditionally or conventionally, an epidemic was thought of as a purely medical event, people get sick. But we, we’ve been able to see, certainly working through this project, how an epidemic is not just a purely biological event where people get infected with a virus or some other organism, but rather it has many different facets, many different components, and it’s really a sort of assemblage of different parts. There’s a medical component. There’s also a social and political one. There’s an economic aspect, and there are personal dimensions of experiences as well. And each of [00:14:00] these different components has ethical aspects to it.

And that’s what really, what our authors have been, have been, clarifying and working through in a very careful and rigorous way. And those different facets or components are reflected in the themes that we identified. And some of these really were, they came up in a very clear and repetitive way That there were many different areas that were common amongst the authors.

Certainly there were large scale views trying to understand the nature of the, of a pandemic in general, and how the pandemic, how this particular pandemic, was playing out in relation to those very large scale issues. There were global perspectives. The question of climate change, for example, [00:15:00] the impact on globalization as Ian mentioned, that the issues or divisions that came into focus and in many ways were magnified by the pandemic such as the racial issues in the United States that then propagated around the world. But there were also the personal experiences of individuals,  who were locked up in their homes, who were denied the opportunity to see loved ones and so on. And this evoked a very different sets of personal experiences of longing, of hope, of sadness, of fear and so on. There were issues of a fairly, of a more conventional and familiar bioethical kind, about how to allocate resources, how to make, make decisions, but there are also new issues about the nature of the clinical experience. How do you care for someone who’s dying, [00:16:00] when you can’t make physical contact with them, when you’re looking at them through a glass or through a television screen, when they can’t have contact with their own loved ones, you know, these are, these are some of these very, very new experiences that we’ve never had before.

And there was another category of papers that dealt with what we’ve called surveillance and the Panopticon, the sense that the political response to the pandemic required new relationships and maybe the eroding or compromise of political and human rights that we’ve previously really taken for granted.

So in all of these areas, we had a number of reflections. Often from different perspectives, often with contending, contending outcomes and conclusions. So,  as [00:17:00] Michael and Ross and Ian have all emphasized, what we came out of this with was an extraordinary richness of reflections, of ideas, of possibilities, and proposals for how we might move forward from here.

Edwina: [00:17:18] I mean with all the wonderful contributions, and I’m assuming people’s appetites have been whet to dive in, there is a lot of COVID news and analysis and commentary for people to digest. And that’s whether it’s in the mainstream and social media, as well as some academic and clinical  sources.  And I wonder if, maybe Ross, I know you touched on this at the beginning, but maybe you could just make the case of why someone should make the time to read some of the papers in this symposium.

Ross: [00:17:47] Well, I could be sort of flippant and say many people have a lot of time on their hands to when they’re kind of in lock down, and very risk to avail themselves of these papers as a means. But I think there’s [00:18:00] three reasons to read this. One is for a broader appreciation of the diversity of experiences related to bioethics that are represented in the papers. Two is that we had asked people to be relatively brief and non-academic so, even though this is an academic journal, each of the contributions is a very short, exceptionally readable. The quality of the writing in this volume is really quite remarkable. And three, it will help them, their understanding of all of the diverse impacts that this pandemic’s had, not just on the world around them, but many of them ask and many of the papers asking you to sort of reflect upon yourself, your views on, on how the world is constituted and put together and, and challenge you to sort of rethink how we are situated in the [00:19:00] world and how we’re going to think about that going forward.  So I think they’re quite inspiring. I think they’re quite enlightening and I think they’re exceptionally well done. And I am so pleased with our colleagues to, on short notice, come up with papers of such insight and quality on short notice. It was really quite remarkable. And I think really laudable.

Edwina: [00:19:23] It’s probably worth me noting too, that all, all the articles in the symposium are free to read. So whereas people may not have access to some of this sort of scholarship in other circumstances, they’re available to anyone and everyone.

Given all that you’ve said about these contributions in their symposium I know this is probably a difficult question, if not impossible, but if you had to highlight a paper that someone might begin with, could anyone say which one it would be and why?

Ian: [00:19:53] I’m happy to go first, Edwina, it’s Ian. For me that one of the beauties of this whole [00:20:00] symposium is their incredible richness and the fact that you can dip in and out of them as, as Ross says, they’re brief. So they’re, you get in, you read this wonderful idea and then you leave it.  And then you can reflect on it. So that’s great. For me, I’m gonna take a, one of the organizer’s prerogatives and give you two that, the two that I, that I just found wonderful.

One is a paper by Jing-Bao Nie and Carl Elliott on humiliating whistleblowers. This to me, this was just a staggering piece of writing. Jing-Bao Nie is an  extraordinary Chinese New Zealand bioethicist and Carl Elliot is a bioethicist well-known to many around the globe. Both of them write incredibly  eloquently, and they give a description of the very early phase where some Chinese physicians were trying to bring COVID-19 to the world’s attention.  It’s incredibly moving writing. [00:21:00] It’s a narrative description of the beginning of something that has become overwhelming to the world. And I strongly encourage people to read it.

The other is a paper by Chris Jordans, who’s as an academic bioethicist from Sydney, who in his paper, imagining and preparing for the aftermath of the COVID 19 pandemic, he pursues one really simple idea which is that when we think about prioritizing health professionals for vaccination and therapy and care and all of those sorts of things, and that’s been a pretty dominant theme around the world. He says, actually there might be others who are not health professionals who have a really important caring role. Mothers, people caring for, you know, multiple dependent individuals, in institutions or outside them. So he says that we shouldn’t take it for granted that we should privilege health professionals. And I found [00:22:00] that incredibly confronting and just wonderful.

Edwina: [00:22:02] Thank you, Ian. Michael?

Michael: [00:22:04] Thanks Edwina. A difficult task to pick just one paper, I do say, but yeah, I think, just reflecting on this for our discussion tonight, I’ve been thinking a lot about a paper by an American philosopher by the name of Alphonso Lingis, a paper entitled “The new fear of one another”. And for those that don’t know Alphonso’s work, and I do highly encourage anyone who’s interested to certainly read some, but Alphonso’s had a long career thinking a lot about you know, community and how people relate and the questions that raises and the meanings that poses for all of us. But for this paper, which is on one level, has quite a simple, simple kind of core message is, is that one of the challenges of COVID-19, is that it’s inspired [00:23:00] all of us to, to some degree, necessarily fear each other. And that at the same time, it’s also made it incredibly clear that we need each other now more than ever. And I think it’s that, that core dichotomy of the challenge of interconnection, the challenge of community, and the absolute necessity of it for me has been one of the, the real lessons of this year, this experience of COVID-19 for me personally, and within my interactions as a clinician and an academic. And so for me, this paper touches some very deep points and I’d really encourage it to anyone who wishes to read it.

Edwina: [00:23:41] Ross, Paul.

Paul: [00:23:43] A paper that made a big impression on me was one by Claire Colebrook, an Australian cultural theorist now working at Pennsylvania State University in the United States. And Claire wrote about violence and the different [00:24:00] forms of violence that are bound up with the pandemic. And she talked about slow and fast violence, and the ways in which the pandemic has differentially affected, different components of society, especially in the United States. And she drew attention especially to the way in which poorer and especially Black people are particularly vulnerable in this setting.  And yet they’re called upon, again and again, to make sacrifices to save the society that has treated them in many, in many ways so brutally and so cruelly. And she ends with the question about which really was perhaps the question that stimulated many people to become involved in the Black Lives Matter movement, which is why should we [00:25:00] make the sacrifices that we’re being called upon to make, to defend a society against the onslaughts of this pandemic when the effects of the society on us have been so cruel and so devastating? What’s really ultimately, do we really want to make the sacrifices, to save a society that may not even be worth saving? Very potent, very challenging question that I think we, that I found very confronting when I read.

Ross: [00:25:39] Thanks. So as someone who’s been told his thinking makes Schopenhauer look cheerful, with a relatively dark worldview, the paper that I liked was “Hope and optimism: A Spinozist Perspective on COVID-19”. So when I was a graduate student I did a [00:26:00] whole course on Spinoza and as I went into my medical career, Spinoza’s thought, I think, kind of drifted into the background, though it’s always been a shadow. But this notion of hope, I think was really important. And Paul’s paper talks on hope. And the interview I have with Eunice Kamaara talks about hope as well. So I’ve been kind of, of the mind that extinguishing hope from my worldview, to face the world in its, you know, most essential characteristics, void of any sort of tainting by things that you, by a world of counterfactual might and maybes, that that may be misleading. I think helps me return to thinking through what hope may be and what role it could play in a bioethics in the aftermath of COVID, because I think we’re going to need some creative ideas that are leading us to normative spaces that currently don’t exist. And if hope is [00:27:00] the bridge to that new view of how we may be best deployed to work together and live together, not just as humans, but as beings in an ecosystem, then I think that was a real way for me to start to rethink and challenge my own pessimism about the way things have gone.  So I was really quite inspired by those papers that were pointing sort of green shoots of hope of a new way of thinking about humans’ interactions with the world.

Edwina: [00:27:32] Just to finish up. You’ve noted that in the present collection, may stand as a testament to early efforts to act in the face of COVID-19. So what comes next in bioethics or the JBI?

Paul: Maybe I’ll just make a brief comment and then let the others also add something. When we started off, as Michael said, our focus was on the immediate experience, [00:28:00] of an unfolding experience, that was, that was new to everyone. We had no idea where it was going.  And what we wanted to plot was the nature of that process of exploration and discovery. And I think we’ve achieved that to some extent, but what we’ve also come to understand ourselves is that this is going to be an ongoing, probably neverending process. It wasn’t a matter of starting one point now and then at a later time coming back and reflecting on it retrospectively because that isn’t going to happen. Rather we’re immersed in an ongoing process where these issues that we’ve identified will continue to mature and there’ll be new components to them, new aspects to them, that we hadn’t anticipated. So I think that what will happen next is that we’ll come back to these ideas that have been [00:29:00] germinating in this issue, and we’ll look to see where they went, where these themes, how these themes develop, what direction they went in. And whether in fact, the speculations that people made were borne out, whether the fears that people had actually came to fruition,  or whether, Ross’ pessimism or the possibility of hope actually was what came to dominate. We’ll find out ultimately, but maybe not for a long time.

Edwina: [00:29:33] Thank you, Paul, unless anyone else has anything else to add I think that’s actually a really lovely place to finish up our conversation. So, Michael Paul, Ian, and Ross, thank you for your time today.

And to our listeners, thank you for joining us for JBI Dialogues. A transcript of this audio resource is available on our website, bioethicalinquiry.com, where you’ll also find links to the symposium articles and other journal [00:30:00] issues. For JBI updates subscribe on the website to our email newsletter or follow us on Twitter @bioethicinquiry.

The Journal of Bioethical Inquiry is the official journal of the Australasian Association of Bioethics and Health Law and the University of Otago’s Bioethics Centre. It is published by Springer Nature.

ENDS

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