Lead Essay—Inside the Pandemic

Lead Essay—Inside the Pandemic

Editorial—COVID-19 Symposium. Published 26 August 2020.

Paul A. Komesaroff; Michael Chapman; Ian Kerridge; Ross E.G. Upshur

In the space of six months, the COVID-19 pandemic has transformed the world. Beginning with what seemed like a routine public health challenge in a single location, it quickly became a global health emergency, then a social and an economic catastrophe. While the full consequences of this momentous event may not become apparent for many years, it is inevitable that its effects will extend over generations to come.

The unfolding crisis has imposed a need on many people to make decisions with deep, sometimes unprecedented, ethical content. Those at the front line of clinical care have had to decide about their duties to their patients, their families, and to the broader community, sometimes with life or death consequences. However, the ethical perplexities have not been limited to those involved in clinical decision-making. Indeed, there are probably few people in the world who have been left untouched by questions of personal and social meaning and value that have been powerfully activated by the advent of SARS-CoV2.

It was in the context of the unfolding global reach of COVID-19 that this Journal of Bioethical Inquiry special collection was conceived. It was apparent from the outset that the range of ethical issues posed by the emerging crisis would be very extensive, as also was the fact that the nature and implications of the crisis itself would continue to evolve over time. The scientific and medical details required clarification. The social and economic impact, and how this varied across culture and geography, was yet to manifest itself. The large-scale questions about the factors that generate dangerous new infections, and the long-term implications for the future of global ecological systems, remained to be addressed.

The fluid and changing nature of the developing emergency clearly meant that neither definitive characterizations of ethical problems nor secure solutions to them were within our grasp. This very uncertainty, however, drew attention to some questions of potentially lasting and profound significance: How do responses form to novel ethical challenges? How, in the midst of rapidly changing circumstances, of ambiguity and disruption, is clarity gained about the nature of normality and of issues of value and how to react to them? How do individuals facing personal danger, sickness, privation, and distress grapple with decisions that may carry profound consequences for themselves and others? How do societies and political systems accommodate rapidly changing conditions that throw up demands and trials which had been anticipated but never previously encountered?

The project that formed the basis of this collection therefore took on a dual purpose: on the one hand it sought to document and classify some of the emerging ethical themes evoked by the novel pandemic, while on the other, it aimed to compile an archive of the dynamic process by which these themes emerged, how their meanings were discerned and how responses to them were constructed, against the background of changing knowledge and experiences. In other words, we set out to chronicle how ethical views are formed in the face of a real, urgent, and immediate set of challenges: not views from a single, given perspective, and not a “view from nowhere,” but the multiple views from the very centre of an unfolding disaster of catastrophic proportions, with all its unknown and unknowable entanglements and resonances and its potentially tragic endpoints.

Accounts of the ethical disquietude provoked by extreme urgency and frantic uncertainty abound in philosophy and literature, often with a focus on the existential dilemmas or the limitations of rational calculation. In daily life, in medicine and elsewhere, decisions of great moment often have to be made with incomplete information and under pressure of time. Crises of war, economic collapse, and civil unrest have undermined accepted ethical precepts and cultural and spiritual beliefs. Challenging new horizons have arisen from many past final days. However, the sudden advent of a global process that undermines and transforms individual and social experience and raises questions about the durability of the relationships between nation states, and between human society and nature, is a rare event. This collection seeks also to capture the momentousness and the novelty of this current cataclysmic experience.

The response to our call for contributions to the proposed archive was itself remarkable. The number and quality of the submissions was striking, and their diversity was extraordinary—in terms both of the rich variety of substantive issues with which they dealt and the range of their theoretical, cultural, and geographical origins. Together, they spoke of a fecund array of traditions, conceptual resources, belief systems, and personal experiences. To pursue further our own commitment to facilitating dialogues across disciplinary boundaries we encouraged the prospective authors to participate in the review process, to foster and enhance insights and understanding across the chasms of theory and weltanschauung. When we surveyed the results we were struck both by the wide-ranging nature of the materials and by the presence of recurring themes. Together, the submissions presented a picture of the complexity of the experiences formed in the crucible of the pandemic emergency, of the diverse effects on cultures, societies, and lifeworlds in transition, and of shared concerns, hopes, and fears.

Even over the few months it has taken to compile this collection significant changes in knowledge, attitudes, and understanding have occurred. This has led to a broadening and deepening of ethical questioning. The early preoccupation with protocols and guidelines contributed to organizational and policy responses to unfamiliar clinical circumstances. As the effects of the epidemic extended, attention was drawn to its differential impact on communities and individuals and how those already facing social inequities experienced the harshest consequences. Questions were asked about the factors contributing to the emergence of COVID-19 and of the increasing frequency of novel zoonotic infections in general, leading to a reflection on the inherent links between climate change, ecological crisis, and social injustice. For some, the global disaster has suggested the need for political renewal, which would generate consequences not only for the development and application of novel vaccines and medical treatments but also for the future ethical constitution of global society.

These themes have led naturally to a series of debates and reflections, which we have classified into seven categories, covering the range of issues and concerns: “Overviews and provocations,” “Society and the lifeworld,” “Global perspectives,” “Voices from different places,” “Bioethical debates,” “Clinical implications,” and “Threats of surveillance and the panopticon”. Each comprises reflections from multiple disciplines and perspectives, together demonstrating a shared, but multifaceted, sense of urgency and ferment.

Of course, where the debates will end up is not a question that can yet be answered. Nonetheless, their nature does highlight the intractability of the question with which we began. In the midst of an emergency we grapple as well as we can with the problems that present themselves. We formulate the issues to be decided on the basis of the extant knowledge and evidence, which are shaped by the theoretical and cultural frameworks within which they arise. We draw on the available resources, which are themselves marked by culture, politics, belief systems, and other factors. Our answers are partial and inchoate and often prove inadequate as the problems deepen and spread. But we keep trying, spurred on by our commitment to our history and traditions, our shifting value frameworks, and to each other.

The present collection may stand as a testament to such early efforts to act in the face of COVID-19. It may also provide a kind of guide not just to the challenges presented but also to the active, living process of struggling with uncertainty and danger, in the shifting, fragile contexts of fear, courage, and hope.

Published online: 26 July 2020. View full article details at the SpringerLink Journal of Bioethical Inquiry site.


Image: “This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses.” [CDC / Alissa Eckert, MSMI; Dan Higgins, MAMS (2020)]