The Catholic Herald spoke to Michael Wee, a Catholic bioethicist based in Oxford, about some of the most widely discussed ethical dilemmas arising from the ongoing pandemic.
Let’s start with a question on many people’s minds. If a healthcare system runs out of ventilators, for example, due to the sheer number of Covid-19 patients, how should doctors decide who to treat first?
Even in ordinary circumstances, hospitals are always making choices about who to treat first because resources are never unlimited. Generally speaking, to save the most lives, you want to prioritise those whose conditions are the most serious and therefore need care most urgently.
But when the demand for critical care overwhelms the system, then you have to allocate healthcare resources in a different manner in order to maintain the goal of saving the most lives. So, among patients needing a ventilator, for example, you might have to prioritise those most likely to recover. Potential clinical benefit becomes the main criterion for allocation decisions.
In theory, many would accept this as a fair criterion. The challenge lies in putting it into practice. In relation to Covid-19, doctors would be looking at the presence of underlying conditions, as well as other risk factors like age, to assess the likelihood of treatment succeeding. However, it is easy to slip from making a clinical judgement about benefit into adopting a discriminatory attitude against certain patients. That is why the NHS has warned against “blanket policies” relating to age, disability or condition for access to treatment. Another danger is in adopting a tick-box approach to assessing patients – all too easy in a high-pressure situation, when holistic, individualised assessment might seem onerous. Evidence-based scoring systems are helpful but must not stand alone.
It is also important to note that the criterion of clinical benefit is not absolute and should not be applied in a cold, utilitarian manner. One does not need to constantly remove ventilators from patients just because there are new patients who are slightly more likely to recover. Starting a treatment is like starting a new relationship, which requires trust, and there is virtue in finishing what one begins.
Turning to a dilemma facing society more broadly, what are the ethics of continuing vs relaxing a lockdown? Is it possible to be saving lives at too great a cost?
The first thing to say is that saving lives is of the utmost importance, but it does not always override all other considerations. On the individual level, Catholic teaching is clear that no one is obliged to preserve their life at all costs. When treatment is overly burdensome, for example, and promises very little benefit in return, it is morally permissible to refuse or withdraw treatment. This is an application of the principle of double effect, where death is foreseen but not in any way intended. The intention, rather, is to prevent disproportionate suffering caused by the proposed treatment, and death comes about from the underlying condition. It is not the same as euthanasia where death is the intended outcome of an act or omission.
On a societal level, a similar prudential judgment has to be made about whether the means of saving lives is disproportionately burdensome to society. This means recognising the probable benefits that a lockdown brings, such as reducing community transmission of the virus and easing pressure on the healthcare system – and weighing these up against the cost of the measures.
But here it is essential that we do not think of the “cost” of the lockdown as merely economic. The economic cost itself should not be dismissed, but the narrative of choosing between lives and the economy is ultimately a false one. A lockdown itself can also lead to more deaths and poorer health. Mental health problems arising from the lockdown can increase suicide rates and self-harm incidents. Unemployment also increases the risk of suicide, or poorer health outcomes in the long term due to financial barriers to treatment. People are also putting off medical appointments and screenings that might have, say, detected cancer early.
Other factors to consider include the virus’s precise death rate, which is still difficult to ascertain. If mild and asymptomatic cases are much more widespread than originally thought, it could be that we are looking at a virus with a death rate of, say, 0.5% rather than 1% or 3%. This is crucial for weighing up the costs and benefits of any lockdown, as well as figuring out the best transitional means of easing a lockdown, which could be done by age group.
Lastly, when thinking about a potential end to the pandemic, many have raised concerns about vaccines developed using cell-lines made from foetal tissue. Does this pose a dilemma for Catholics and others who oppose abortion?
Certain vaccines are produced using cell-lines developed from the tissue of aborted foetuses. Some of these abortions took place decades ago, and the cell-lines are used regularly by labs around the world. It would seem that any complicity with such “historic” abortions in using these cell-lines is fairly remote and indirect.
Remote co-operation with distant evils is more commonplace than we might imagine: we might work in buildings built by slaves or live in countries that our ancestors once invaded and exploited. The further removed we are from the systems that produced such injustices, the less connected we are to the evils, and hence the less scandalous our association. But consider a scenario where vaccines were developed using cell-lines taken from a political prisoner executed by a totalitarian state. Surely we would feel uncomfortable, to say the least, about using such cell-lines for research, particularly if such executions and harvesting of tissue were still ongoing.
Similarly, scientists using foetal cell-lines need to consider the potential scandal involved in using such biological material. Does it not seem to suggest an acceptance of abortion and the idea that lives can be deliberately destroyed to benefit others? This is especially important given the present context, where abortions are still widely carried out and new cell-lines are still developed from aborted foetuses. There is a real value in scientists adopting a consistent, principled stance against using these cell-lines, whether old or new. This is necessary to reduce reliance on unethically sourced biological material and promote demand for ethically-sourced cell-lines.
This responsibility is morally demanding for scientists because of their direct involvement with such material. But in the document Dignitas Personae the Church also recognises that there are “differing degrees of responsibility” in relation to this problem, and teaches that “Grave reasons may be morally proportionate to justify the use of such ‘biological material’.” Hence, for ordinary members of the public who have serious reasons to be vaccinated – and particularly given that they have no say in how a vaccine is produced – it is morally permissible to accept a vaccine made using foetal cell-lines when there is no readily available alternative.
In relation to Covid-19, one must consider not just one’s individual circumstances but also the common good. Although the danger the virus poses to the average person is, statistically speaking, not huge, one must consider the danger it poses to the health of those we meet – elderly or vulnerable family members and friends – and its high degree of infectiousness. A successful vaccine would offer a viable route back to relative normality in society, but only when most people take it up. As such, all this taken together would certainly constitute a sufficient grave reason for an individual to make use of a Covid-19 vaccine which was developed with unethical cell-lines, unless one can reasonably access a better alternative.
Michael Wee is Education and Research Officer at the Anscombe Bioethics Centre, a Catholic research institute in Oxford, and a member of the Pontifical Academy for Life.
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