Hanaamayer (usefully but, ultimately, inadequately) draws upon Weber’s (transcendental) ethics of responsibility to challenge EBM (Evidence Based medicine) principled conviction (rules-based) to determine good medical practice in terms of a supreme good that ‘maintains life’ on the basis of primarily empirical data and mortality outcomes. The ethics of responsibility places responsibility on individual clinicians to recognise that putative patients may not place the same value on mortality as the EBM guidance. For example, the evidence may suggest screening is a good thing because it reduces mortality, or that for example after a screen-diagnosed cancer that surgery is ‘evidence-based’ (on mortality grounds) and so desirable, if not demanded, but bearing the chance of overdiagnosis in mind and the thought of life after mastectomy might be grounds for an individual to decide against surgery.
As far as programmes of mass screening goes the very sending out of invitations and ‘offers’ to screen for life threatenting conditions or risk, already makes for a loaded invitation, invoking inevitable fear and a sense of moral duty to accept the invitation.
At the same time, in our contemporary capitalist cultures the ideal of maximising ‘life’ is endemic and normative, and part of our consumer culture, and so the offer of a test contains the promise of ‘more’, of everything, of happiness, life, health, meaning to life, and so on. It is in this sense seductive.
At a public health level, interventions are applied en-masse. The public health programmes, such as mass diagnostic testing demand an unconditional application, that is, the application is not conditional of the personal characteristics of any one individual beyond the population criteria for inclusion (for example age and gender). A question then arises, in the light of the first principle outlined in the previous blog that values maximizing individual autonomy over the body, when this principle is considered alongside a political welfarist societal principle: to try to maximise the potential for health of the most vulnerable and at risk in society – whether for reasons, for example, of age, co-morbidity, or poverty.
There are two scenarios we can consider:
First, an intervention may be primarily for personal individual potential benefit, even though it might carry a risk of personal harm (direct and empirical, such as the effects of treatments, for example, a mastectomy on self-image, or virtual and abstract such as overdiagnosis), and may well create false hopes for individuals and financial and efficiency opportunity costs for healthcare services. The individual’s consumption of, and participation in, the intervention does not have any added welfarist type value for others in society, and is only, in a social welfare context, selfish. [Unless, that is, one theorists that one person’s participation encourages others to participate as well, but even in this case it would be arguable whether this would of harm or beneficial for others in society at large.]
Second, a public healthcare intervention, such as a lockdown restricting social mixing to reduce viral transmission in a pandemic, is applied collectively in order to provide relatively greater benefit for those at higher risk. It is applied en-masse, affects all members of society, and for many at relatively low risk from the virus the intervention requires: a) personal sacrifice of autonomy; as well as b) sacrifice due to the direct harms of lockdown (for example, loss of income and social isolation, and emotional stresses).
In this second scenario, what is required is a collective welfarist valuation of the lives of those most at risk so that the majority are prepared to make individual sacrifices, even though the ultimate scale of benefit to those at risk is uncertain and the ultimate scale of harms to all are also uncertain and immeasureable. In effect the majority are being asked (or even commanded by diktat) to risk everything, even their lives ultimately, justified by the value they are asked to place on the lives of the weakest.
Sceptical voices argue that the risk from the virus are over-stated and that lockdowns cause more harm than good and are an unjustifiable and anti-democratic infringement of personal liberties.
Some argue that most older people are willing to sacrifice their lives so that younger people may have more freedoms, and that most older people are more harmed and upset by lockdowns than younger people and, in addition, would wish to be allowed their own ‘unlimited’ freedoms, of movement and social mixing, rather than be restricted by lockdowns. No doubt some of these views are held by some older people.
What is at stake here is political and ideological: a) whether individual practices that are felt as representing freedoms or individual liberty, are actually practices that are in effect self-exploiting and oppressive; b) whether capitalist culture incites a blinkered selfish approach to what are illusory freedoms, and incites an objectfication of the stranger-other, severing social bonds; and d) whether society as such becomes unimaginable and the concept of social-welfarism anathema.
Three issues need to be borne in mind: first, the pandemic, from a welfarist societal perspective is increasingly likely to require authoritarianism as trust in the honesty and competence in central government has been eroded over the last 12 months, and yet, second, authoritarianism incites xenophobia, and finally, third, the current greatest threat of authoritarian totalitarianism and its genocidal consequences, in the West, comes from ultra-libertarianism fuelled by capitalism and supremacist nationalism.