By Lachlan Dowling, JBI Intern
Amidst an era of turbulent change wherein the commitment of our prized institutions to the common good is doubted, a poem by the late-Russian Yevgeny Yevtushenko is particularly poignant. Entitled ‘Half Measures’, Yevtushenko criticises Russia during its 1990s democratisation over poorly implemented reforms:
“…[W]ith every half-effective half measure
Half the people remain half pleased.
The half sated are half hungry.
The half free are half enslaved.
We are half afraid, halfway on a rampage…
A bit of this, yet half of that…”
Time would vindicate Yevtushenko’s forewarnings of democratic backsliding in Russia. According to Baker and Glasser’s 2005 book Kremlin Rising,The separation of powers between the executive, legislative and judiciary branches of government from the 2000s onwards would become indiscernible as the Kremlin centralised authority. Elections too, have been managed farcically by the Kremlin, usually to ensure the Putin-centric ‘Unity’—later ‘United Russia’ movement prevails over carefully procured ‘opposition’ candidates.
Image: Term-limited, Putin endorsed Dmitry Medvedev for President at the 2008 election who in turn appointed him to be the Prime Minister of Russia, setting the stage for his eventual comeback as President in 2012 (left to right: Vladimir Putin, Yury Luzhkov, Dmitry Medvedev, Sergei Shoigu and Boris Gryzlov)
The poignancy of Yevtushenko’s poem lies, for the bioethics discipline, in the worldwide prevalence of inequality. Not just in terms of resource distribution, but in a broader and multifaceted sense for which it can be said, just as for bioethics, inequality touches upon every aspect of life that can be conceived of.
Despite their intersection, it is unusual for bioethics to be consciously observed as part of everyday human life. In consideration of this, and of the countervailing prevalence of inequality worldwide, a compelling case emerges for bioethicists to rely upon framing their work specifically around inequality so as to be most effective in their disseminations.
To return once again to Yevtushenko’s ‘Half Measures’, a clear spectrum may be observed between, one end ‘too little action’ or ‘inaction’ and on the other, ‘too much action’ on which to place political and legal decisions, here, with the attempted democratisation of Russia is what can be termed as an inequality of measure.
INEQUALITY OF MEASURE
Chapman and Komesaroff identified a capitulation by governments in response to COVID-19 from community cooperation and collaboration towards science and technology. The policy of using technology as the definitive instrument to ‘overcome all imaginable obstacles’ constituted a tacit inequality of measure. This inequality was manifested through policies which insisted upon the indomitable spirit of humanity, and which simultaneously refused to concede our inherent fragility. Accepting as a fact the deaths of millions of people across the globe due to the COVID-19 pandemic we see the limits too, not the futility of technology in solving our problems. Surveillance, public health restrictions, treatments and preventatives sure may have mitigated the total damage wrought on our communities but they were not, nor could they be the ultimate safeguards which our leaders represented them to be.
The pandemic ultimately exposed how woefully unprepared public healthcare systems were across the world. That these systems become overwhelmed was a serious concern and was the basis for then-Prime Minister of the United Kingdom, Boris Johnson, asserting that without stopping the spread of Coronavirus, there would come a moment ‘…when no health service in the world could possibly cope’.
Thus, was born the UK Government directive to stay at home, protect the NHS (national health service), and save lives. Similar messages which emphasised the vulnerability of national healthcare systems appeared throughout the west, and later, politicians would mythologise healthcare workers as ‘heroes’.
INEQUALITY OF MATERIAL
To once again invoke the ‘managed democracy’ of Russia where the practice of ‘pokazukha’ or ‘displays meant only for show’ is commonplace, a parallel with the aforementioned ‘heroes’ discourse can be observed. That dichotomy between propaganda and substance is an example of an inequality of material. One response by healthcare workers to this ‘hero’ narrative has been to view it as a tacit attempt by the public, and, by politicians to absolve themselves of their guilt. Specifically, relieving themselves of responsibility for spending decades undermining health services and failing to prepare for the pandemic. Such accusations are not without merit. Constant shortages of personal protective equipment (PPE) were but one issue which healthcare workers felt the public shows of gratitude were meant to distract from.
In a similar vein, Smith and Upshur found that issues identified to be unique to COVID-19 were not new; vulnerability in global healthcare systems, inept communication, and poor surge capacity were all ‘…recurrent and predictable…’. In fact, these issues had been identified by world leaders after the 2013-2016 West African Ebola outbreak which was labelled as a moment of great alarm. Yet, rhetoric rather than substance continued to lead global health policy. The COVID-19 pandemic was treated as a once-in-a-lifetime event, unpredictable, impossible to prepare for and rather than admitting that these ‘heroes’ were adapting to their failures, world leaders rendered the magnitude of their feats as an impressive response to the unpredictable course of nature.
Material inequality, when looked at in a more traditional sense, is perhaps at the forefront of the bioethics discipline. Manifesting itself in the most basic of ethical dilemmas such as whether to divert more resources towards the comfort of palliative care patients, and away from patients who may stand a chance at recovery with that additional assistance. Research in the JBI showed that, within the Australian context, the so-called conflicting duties of patient-care and of societal interest were wrought with conflicting advice that failed to touch upon the core dilemma; treating it as taboo and preferring only to be ambivalent in directing doctors how to allocate resources.
One further example of material inequality can be identified in the availability of organs. For Reese and Pies it is clear that across the world there exists a disparity between the overwhelming demand for and limited circulation of kidneys. A shortage which they argue has not been reliably ameliorated by what has been a multi-decade campaign of altruistic policy, thus necessitating at least a consideration of market-based solutions. Research by Albertsen goes further to identify that not just for kidneys, but for all organs there are chronic shortages and that patients are dying on transplant waiting lists. Yet resolving this inequality is not easy, it requires choosing between what is ethical and what efficiently procures as well as distributes organs to those in need. The more care that is exerted to prevent either harm to or exploitation of prospective organ sellers, the less of those approximately 95,000 U.S. patients waiting on the kidney transplant list, for example, can be saved from premature death (Albertsen 2020; Reese and Pies 2023).
INEQUALITY OF MENTALITY
A lens starts to become apparent, through which it is easiest to view and understand the basics of the bioethics discipline; the lens of inequality. Afterall, it was not for nought that reference was made to the current era as being one of ‘turbulent change’. Such times are not appropriate for inaction, nor for wallowing in despair. To once again look to the past, a lesson can be drawn from U.S. President John F Kennedy’s inaugural address on January 20 1961 wherein he apprised the public of the ‘trumpet’ which summoned them:
“…a call to bear the burden of a long twilight struggle, year in and year out, ‘rejoicing in hope; patient in tribulation’, a struggle against the common enemies of man: tyranny, poverty, disease, and war itself.”
Today, the trumpet sounds once again, and an obligation falls upon every person to refrain from carrying an inequality of mentality. Consequently, it is imperative that an appropriate balance be struck between ‘rejoicing in hope’ and remaining ‘patient in tribulation’. Pervasive fears of nuclear annihilation in the 1960s have since been remedied through long-term diplomacy, however, in its place the existential threat of climate change has since emerged. This is a universal challenge necessitating high-level cooperation between all governments, international organisations, and private bodies. Often, the uncertainty of whether humanity can overcome this profound challenge is used as an excuse for communities to cultivate an attitude of indifference and apathy towards positive action. Ashby invoking not JFK, but instead former Greek finance minister Yanis Varoufakis calls for politics to be governed according not just through a ‘despair of the intellect, but hope of the heart’. Under such an arrangement, the inadequacy of historical efforts to combat the climate change crisis should be noted but the pessimistic thrall, the false equivalence between failing to expend all material, to execute all measures and failing to act in the slightest, must be thoroughly denounced.
Though bioethics is often taken to include environmental concerns, such as climate change, the JBI does not regularly discuss them. Bioethics is intimately related to the value placed on life, especially focusing on the question of how the value of human life can be both respected and actively promoted. Whereas environmental science can be full of technical jargon which may make it appear utterly irrelevant to the lives of ordinary people, and, quite impersonal. Yet, the two are not unrelated by any means. Butler identified a persistent failure by western society to recognise the link between the environment, the economy and both the security and wellbeing of humanity.
To hearken back to JFK’s inaugural speech, chaos is implicitly framed as a looming threat to humanity, comprised of the ‘common enemies of man’; tyranny, poverty, disease and war. By dividing the larger threat into smaller and more tangible challenges, a seemingly impossible task is made more manageable and in doing so, society can rejoice in hope while remaining patient in tribulation. And all of it; poverty, disease and war are exacerbated by the effects of climate change (Butler 2008). Recognising the flow-on effects of climate change reveals how it stands to disturb the sanctity of life and the provision of basic human rights, chief among those being economic and social liberty.
Image: John F. Kennedy gives his inaugural address as President of the United States; 20 January 1961
INEQUALITY OF MORALITY
Defending liberty, specifically defending the right to choose how one lives their own life, is a recurring, in fact, a principal concern of the bioethical discipline. In the context of the physician-patient relationship the question of whose values are more important often leads to an inequality of morality between doctors and their patients. Reichlin noted that as a matter of public policy it would be appropriate to discern ways in which both doctors and patients would be free to act according to their own morals.
Failure to observe such a fine balance risks an affront to the medical profession which willingly adopts a duty of care precisely because of the moral values held by its members. To require without exception that doctors acquiesce to the wishes of their patients because of their right to bodily autonomy would result in experimental treatment regimens and even worse, grievous harm to patients. Which of course is why doctors have their own professional standards to uphold alongside their patients’ rights. It would therefore be unreasonable to require doctors to perform treatments which contradict their own conception of their profession’s purposes. This is often referred to as the doctor’s right to conscientiously object. Reichlin’s research also approaches the dilemma from the other side, where conscientious objection is treated as an absolute right vested in physicians; one which overrides the patient’s claim to have agency over their treatment.
Absolutist jeering is not only unproductive, but it fails to accommodate reality. Take for example, a woman whose access to abortion services is limited because she cannot find a doctor who does not object. The potential for harm would be untold, as women resort to medically unsafe practices such as self-inflicted abortions with household instruments. Reasonableness must be an inseparable part of conscientious objection in such a way that should a doctor refuse to carry out treatment based on morality alone, they should refer their patient elsewhere and not prevent the treatment being sought by the patient altogether.
CONCLUSION
Inequality is far too often looked upon as an oversimplistic reason behind all of humanity’s woes. However, the idea of inequality is far more evolved than it is given credit for; encompassing not just an imbalance between the rich and the poor despite society’s preoccupation with economic inequality. Expanding inequality to consider themes such as measure, material, mentality and morality begins to shape a lens through which it is much easier for those uninitiated in the bioethics discipline to engage with its core teachings and dilemmas. Further, an elusive concept becomes far easier to explain as the limits of bioethics can be more readily conceived. The truth is, that if the human condition is impacted upon by a form of inequality, it is most likely a point of discussion in the bioethical sphere.
Lachlan Dowling is an intern at the Journal of Bioethical Inquiry and third-year Bachelor of Arts/Laws student at Deakin University, majoring in politics and policy studies.