Editorial. Published online 13 July 2020.
Michael A. Ashby
This editor cannot recall a time where you can hear something on the radio news in the morning and find that, not only does the news affect one’s own everyday life immediately, but also that there will be very few people on the planet who are not hearing similar news and facing similar impacts on the same day. In this time everybody and nobody is a Covid-19 expert. We have access to unparalleled quantities of information from multiple sources. It is striking that despite all the accumulating knowledge and experience, few virologists, infectious diseases doctors, or epidemiologists are willing to predict the outcome of the current pandemic. Nearly every publication is substantially devoted to the overwhelming topic of the time, and here at JBI we are no different in wanting to make our contribution. Being a quarterly publication, we are not in a position to respond quickly. However, our editorial group has already had over fifty manuscripts submitted in response to a limited call for papers to past contributors and editorial members of the JBI community. We are therefore planning for one or two subsequent issues to be largely devoted to Covid-19, recognizing that by the time they are published, much will have no doubt changed further. Our Associate Editor, Michael Chapman, who is curating these contributions, writes as follows:
This is a time of uncertainty, threat and upheaval. COVID-19 has already had a profound effect on individuals, communities, and entire nations. It has raised deep questions about how we allocate health resources in times of crisis and what it means to be a healthcare worker today. It has already challenged the ways we connect with each other, the nature of community, our concepts of home and value, and the relative privileging of economic and health associated welfare.
We will compile reflections on the meanings associated with COVID-19 that will offer insights into the global experience of COVID-19 in 2020, and also be useful in deeper consideration of this event after the crisis has passed. Due to this, the articles included range a gamut of issues including those of resource allocation, the implications of isolation, the development and use of technologies, changes in social and healthcare supports, examinations of community and political responses. It includes authors contributing from a variety of geographic and cultural backgrounds across our global North and South, from a wide variety of professional, academic, and philosophical traditions. Included responses range from scholarly to the more deeply personal. However, all contribute an analysis of the opportunities for learning that COVID-19 presents us, through understanding how we prepare and sustain ourselves within crisis and what meaning this should have for our “usual” lives.
For now, we already have a planned issue, and some time is needed to produce the Covid-19 issue(s), so in these pages, life goes on and we consider our usual range of bioethical topics, with a symposium theme of conflict of interest (COI). The scene is set in a lead essay by Wiersma and colleagues (2020), who point out, inter alia, that the subject has not progressed much in recent times, and a broader consideration is needed. Like first nations acknowledgements at gatherings and meetings, it is possible for COI reminders at meetings to risk becoming a ritual without substance unless we all have a deeper understanding of the underlying motives for our thoughts and actions, and real moral engagement with our dualities and conflicts.
A good example of this broader view comes in the paper by Giubilini and Savulsecu (2020), who point out that COI is mainly considered in financial terms but should also be understood to encompass moral and religious values, that, presented as conscientious objection (CO), can also generate interests for practitioners and may therefore influence advice and treatment decisions. COI and CO both operate in a secular space in a democratic jurisdiction whereby certain core values are accepted, rights laid down and observed, and disputes resolved through a combination of adherence to professional ethics, institutional policy, and, if need be, law. If a principle-based approach is adopted, the principles of respect for autonomy, justice, beneficence, and non-maleficence, being generally accepted, and if need be enforced, are independent of any one potentially interest-generating underpinning system, be it religious, or otherwise. In other words, their source of authority is not the issue. There is little dissent about the four principles approach to ethics (Beauchamp and Childress 2019), but the doing of ethics starts when these come in to conflict with one another, as they inevitably often will. It is not that the secular public space in which regulated professions operate can undergo purification rituals to get rid of interests, rather that they are there like kelp in the sea, swaying around naturally in the water for the diver to navigate. In ethics, the task is the navigation, not seek and destroy, as we do not live in a fantasy interest-free world nor can or should we. All professional practice is political, financial, and personal. For the diver, the first task is to see the danger, and so identification and transparency are needed. However, a politician can be forced to resign over the undisclosed gift of a bottle of wine but is not required to disclose a religious adherence that influences voting on social issues. Similarly, there are regions in many countries where access to abortion is blocked by groups of religious doctors, who have a strong interest in being seen to be exercising their beliefs, by their co-religionists in the secular public space because their beliefs are a matter personal conscience. So it is not that this is itself problematic, as freedom of conscience is indeed an agreed fundamental human right, but, per Mill, not when the exercise of CO infringes the rights of others in a democracy, who do not share the same beliefs. Giubilini and Savulescu (2020) shows us an expanded view of interests that deserves our attention and that CO is a key contributor to conflicts between them.
LiPuma and Robichaud (2020) give a concise critique of the U.S. health system. Like all systems it has been under enormous strain, and its weaknesses have been graphically revealed in recent weeks. Linked to large pockets of poverty and marginal economic survival in that country, Covid-19 has had a terrible impact. The rest of the world is perhaps less generous about these failings because of the stature and wealth of the United States and its many political attempts to get universal coverage. Powerful lobby groups, an addiction to free market economics as the purification ritual for all ills, and successive political obstruction and failure, all contribute to some of the best care in the world and some of the most glaring gaps. Despite enormous expenditure, many pockets of the United States enjoy lower health outcome data than the much criticized and undermined former cold war enemy and neighbour, Cuba.
Dubljević (2020) uses Rawls’ method of wide reflective equilibrium to analyse the problems generated by fronto-temporal dementia, notably those that surround legal responsibility for anti-social behaviour, personhood, and autonomy. An unfortunate feature of this illness is the absence of insight and concern about inappropriate behaviour and its consequences. This can lead to legal difficulties, and presumptions in favour of autonomy and culpability can lead to unfair treatment, based on a failure to recognize that diminished responsibility is a feature of the underlying neuropathology.
Greason (2020) presents an empirical study of workers in long-term residential care facilities in Atlantic Canada. She reports significant dissonance between client-centred corporate policies and the actual experience of care in the facilities, resulting in staff moral distress. Risk management and protection of institutional interests and liabilities intrude and are often felt to influence care and ethical decision-making. Another significant finding was the influence of family, which was sometimes seen as overriding the autonomy of residents. Could it be that families, especially baby boomer children are displacing grief and guilt onto facilities and their staff, and at times privileging safety of their parents over resident freedom and quality of life, backed by institutions that are anxious to manage risk and avoid liability?
Saulnier (2020), also from Canada, in a critical analysis, champions narrative ethical methods but warns that it is important to be clear about whose story is told and from whose perspective. Critical theory places the question or situation in its broader cultural and historical context to generate a deeper understanding or power dynamics and prejudice, especially towards people who have stigmatized states such as, in this paper, those who are fat or non-cisgender.
Wareham (2020), writing from South Africa, draws our attention to gene editing techniques that have the potential for greater longevity. He points out that this could lead to issues of boredom and loneliness and have negative ecological consequences. He concludes that such concerns, including an absence of consent to the gene manipulation in the first place, should not deter this research, largely based on the notion that life is better than no life. Herein lies the present problem, namely that the longer lives that we are already experiencing on average, do lead to loneliness and poor quality of life that lead many people saying that there is indeed a point where death is preferable to life. So the perennial challenge to medicine, and science, is that life prolongation has its price, and many of our citizens are already questioning the narrow goals of medicine that struggle with letting people die. The genetic programming of people to live even longer will therefore receive mixed responses, there being more to life for many than longevity.
de Miguel Beriain and Sanz (2020) from Spain respond to an earlier paper in the journal by Raposo. They support this author in the assertion that germline modification is indeed permissible, and even desirable, by presenting four additional arguments against the notion that such interventions are contrary to human autonomy.
In the regular legal Recent Developments column, Di Nicol and Bernadette Richards (2020) reports on the evolution of regulations, in Australia, for mitochondrial transplant into embryos to prevent genetic conditions that are transmitted via mitochondrial DNA. She shows that these technical advances are unevenly regulated in Australia and elsewhere, which no doubt feeds anxiety about genetic engineering and “designer” babies. The United Kingdom has a clear legal framework after extensive consultation. There is much to be done as law and ethics catch up with science and events that are nearly always one step ahead.
This journal has long advocated for a global perspective in bioethics. Perhaps one positive result of the current pandemic, with its myriad bad consequences and anxieties, will be to make global perspectives necessary, for as we see, the virus sees no borders. These are man-made, and just as we have made them we can transcend and even dismantle them, although the reverse is also possible, namely that we wall off and feed nationalism. This choice is ours. Nowhere is this more clearly seen than in the present calls for an independent international enquiry into the origins of the Covid-19 pandemic. Science and global health unquestionably need to understand these origins, but such deep knowledge cannot be obtained if there is blame and intrusion of national interests into the process (see a recent post in the online publication The Conversation: https://theconversation.com/yes-we-need-a-global-coronavirus-inquiry-but-not-for-petty-political-point-scoring-138020).
To all our readers, we wish you well in navigating through a new age of unexpected uncertainty, wherever you are.
Published online: 13 July 2020. View references and other article details at the SpringerLink Journal of Bioethical Inquiry site.
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