Scarcity as an Alibi: On the False Ethical Discussions about the War on COVID-19

Abstract

Occasionally, doctors and health providers have to choose whom they save from death and this is an extremely hard decision to take. Here, I work on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on medical doctors, nurses and other people who are at the front of the war against COVID-19. During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often have been), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, bring other good results to society? This discussion is of course important, but it leaves aside something more fundamental: the fact that resources are not simply scarce, they have been made scarce in the last years by a series of public policies nourished by an economic view that sacrificed social welfare on behalf of neoliberal beliefs.

A very good starting point to discuss ethical questions, and one which I have often employed as a tool in order to teach them, are dilemmas. A dilemma is a difficult choice between two or sometimes more courses of action, when all options have both good and bad consequences. It is rather useful to teach people how to deal with difficulties in the real world, where quite often you do not have the choice between what is absolutely good and fair and what is completely bad and unfair, but rather among dozens of shades of grey. Actually, you do not help ethics when you present people a list of right or wrong actions or when you let them believe they can follow the right path at no cost whatsoever. Ethics implies difficult choices and also losses.

The COVID-19 pandemic has made these choices important and much has been written about them both in the media and in specialized journals. Occasionally, doctors and health providers have to choose whom they would save from death, which is an extremely hard decision to take. I will work here on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on medical doctors, nurses and other people who have been at the front of the war against COVID-19.

During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often were), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, still bring many good results to society?

This discussion is of course important, but it leaves aside something more fundamental: the fact that resources are not simply scarce, but that they were made scarce in the last years by a series of public policies nourished by an economic view that sacrificed social welfare on behalf of neoliberal beliefs or superstitions. Let us not forget, for instance, that millions of masks were destroyed in France just before (and even at the beginning of) the pandemic.1 They had been stored for several years, after a previous important pandemic, but the State decided they were no longer necessary. Thus, when COVID-19 came, they were no longer available; a fact that accounted for many deaths of patients.

Obviously, we could say that several years ago there were no signs of an upcoming pandemic and the cost of storing those masks was high. At that time, a series of studies had been conducted, allegedly showing that hospital costs could be slashed if several services were suppressed. It is important to remember that this happened in France, an important country with a most serious concern about the need for a strong public sector able to deal with health or education problems.

I want to argue that, if on the one side ethical decisions are always difficult and often imply dilemmas—that is, a choice between two different but intensely bad outcomes—on the other side, we cannot ascribe to individuals or even to a whole profession the responsibility of a few options without considering who were first and mainly responsible for the final formula of choice.

A false ethical discussion such as this occurred in Brazil during the year 2020, when resources were quite scarce and the Federal Government engaged in a negationist attitude concerning COVID-19. Such a discussion was not really ethical because it ascribed the responsibility of choosing who would die and who would survive to health professionals, even though the Ministry of Health was, at that time, withholding oxygen from patients in the Amazonian city of Manaus, where many died because they lacked the conditions to be treated in the local hospitals. The same Minister of Health, even though he had been previously praised as an army general trained in logistics, had sent to the state of Amapá equipment originally intended for the state of Amazonas, with obviously severe effects for the victims of the pandemic.

To discuss the responsibility of doctors and nurses was a way of shifting the blame away from those who were in charge of public policies and who made bad or even wicked choices; an attitude that put Brazil on a level of deaths from COVID-19 much superior to the international average. If, until 15 October 2022, the total number of people who died from COVID-19 worldwide amounted to 6.57 million against a global population of 7.98 billion, in Brazil it was 687,000 from a population of 216 million.2 This means that more than 0.3% of Brazilians died from COVID-19; the global figures pointed to a death rate a little superior to 0.08%. Thus, deaths in Brazil were four times bigger than the world average. To put it sharply, almost half a million of the Brazilians who died from COVID-19 would still be alive if the country had matched the worldwide proportion of people who died from the pandemic; i.e., if the Federal Government had taken on board the sanitary measures suggested by the international medical community and adopted by most nations. This was mostly due to bad decisions from the Brazilian government; several of them made, it seems, on purpose.

A genuinely ethical discussion in such a case demands that we never disregard public policy decisions made by governments and those in power, either political or economic. We should not take the people at the front of the war on COVID-19 as the ones responsible for decisions regarding life or death, but understand that quite often they were limited by choices they did not make. The fault is not to be ascribed to those who have really fought death, but to those who, in the quiet of their bureaus, protected by silence and power, have decided to cut spending in areas that are strategic to human wellbeing.

This means that, first of all, we cannot frame public policies just by reckoning the chances that a tragedy might happen. Take a fire department. If we check the number of fires in the course of a decade in a big city and see they are decreasing, can we conclude that we should reduce the size of its fire department accordingly? How can we be reasonably sure a huge fire will not happen next year? Of course, the core of public policies has been and must continue to focus on causes and not only on effects. As we know dry weather increases the chances of numerous fires such as those that happened during the last summers in Europe and then across the Northern Hemisphere, we should try to ensure humidity remains above a level that will keep things safe for society. However, widespread fires, and also dry weather, do have multiple causes. The main one today is anthropogenic climatic change. How can we cope with it? Several measures need to be undertaken in order to contain, let alone reverse, it.

Let us come back to COVID-19 and add other recent pandemics that have come from the animal, non-human, world. It is widely accepted that COVID-19 came from the forests to the humans, as HIV previously did. Many scientists have been saying that the invasion of forests by humans may be the main cause of several pandemics past and yet to come. This implies we should undertake two orders of measures. First, in a defensive mood, it is necessary to ensure we have the means to contain and suppress such pandemics. So, we need masks, oxygen, hospitals and most of all doctors, nurses and all sorts of health professionals.

Secondly, we need a lot of science telling us how to interact with the wild world. We cannot simply invade it in order to seize exotic animals without nature exacting a huge toll on us. We need then to discard the Lockean way of perceiving nature as a reservoir given by God to “industrious” people—meaning most men of a European descent born into a capitalist society—so that the latter can add both a value and price to an inexhaustible quantity of animals and plants. Instead, we must consider the many costs humankind bears and will continue to bear due to its several irresponsible actions. In effect, Locke said that nature was given to us by God with no intrinsic value at all, but only the one labor added to it so that the fruit of an apple tree in the middle of savage America would belong to him (usually a White foreigner), who would pick it up [1].

The perception that apple trees, and many others, have grown due to the endeavors and labor of numerous indigenous people who took care of the prairies, forests and other native landscapes must never have occurred to Locke and his followers, or to the European explorers of the Americas. However, in the last few years scientific research has shown that the Amazonian rainforest, seen by most for a long time as something that involved no human planning or labor at all as a pure gift of Nature or of God, was actually the result of many efforts across the centuries by numerous indigenous populations [2]. There was not a huge gap between the American empires of the Aztecs, Mayas and Incas on one side and on the other side the “ignorant” Indians of, say, the Amazonian basin [3] or between the urban, sophisticated, traditional states and the people who lived in a rather nomadic way without the developments of urban life. Thus, the Lockean thesis that only European-modelled labor could improve what nature affords us and give it value can be proved to be false. More and more indigenous knowledge is being presently studied by scientists.

Coming back to COVID-19 and other recent as well as forthcoming pandemics, it is necessary to devise ways of keeping symptoms that bring no or just a few problems in the wild from becoming serious illnesses in an urban, human and densely populated world. This is the only path to avoid problems such as the one we recently witnessed, with millions of deaths and the closure of many economic and social activities for more than two years. We then need a lot of scientific research in order to prevent huge problems from getting out of hand. However, even if we manage this, we will still need to take care of the people who suffer. Hospitals will be necessary as well as health professionals and we cannot train enough lay-people to deal with serious health issues from one moment to another. Of course, we can establish emergency teams that could be brought from one geographical area to another or from one specialty to another, but all of this entails plans and costs.

This is why we cannot ascribe solely to individuals the responsibility of solving problems that have been created by policies, even though, of course, policies are adopted by individuals in power. If even the French system has been perverted so as to lose its ability to face serious big challenges after it has been adapted to obey the economic imperatives of short-term efficiency, the picture of what happened and will happen in countries with a feeble welfare state is frightening. We can take two examples of national states devoid of the features that made social democratic societies able to improve human life in many European countries: the United States and Brazil. Even if there was a huge distance between the income of an average American and his or her Brazilian counterpart, in both countries the welfare state is weak. In the United States, this comes from a conscious if misguided choice by the élite, approved by the electors due to political campaigns that constantly denounce the specter of European-style socialism. In Brazil, this arises from underdevelopment plus a political brainwashing of at least decades. In those two countries, the number of deaths due to COVID-19 was much higher than the world average. Societies with scarce protection for the vulnerable have suffered and will, in the near future, suffer much more than societies that have decided to take care of them; or rather, to build networks that both prevent health disasters from growing too much and help people affected by them.

We should then be very cautious before accepting the pseudo-ethical trap that consists of considering as a truly ethical dilemma put before an individual what is indeed the result of consistent, although problematic, political choices. Of course, political choices are made by individuals, but in order to gather power they must group themselves to further several common interests. We must then switch our attention from blaming individuals to ascribing responsibility to the powers that be. When we deal with individuals, we tend to emphasize their culpability. The Judeo-Christian tradition has been instrumental in creating what I would call blaming tools: if we are not able to solve a large-sized problem, we fragment it into small pieces and make many people suffer from what would be their fault. They are supposed to be the authors of the dramas and tragedies that had their impact on humankind.

Thus, we should not necessarily understand scarcity as something stemming from nature or from circumstances, but as something that can be and often is produced. The best example of this phenomenon, unfortunately, is the condition of many hospitals after neoliberal reforms subjected them to the criterion of productivity, leading to the closure of many facilities or the understaffing of health professionals. We should then think of health policies following a point that was made by Machiavelli at the end of his book The Prince:

I compare fortune to one of those great rivers, which when in flood covers the plains, sweeping away trees and buildings, bearing away the soil from place to place. Everything flies before it, all yield to its violence, without being able in any way to resist it. But although its nature is like that, it does not follow therefore that people, when the weather becomes fine, should not make preparations, both with canals and defenses, so that in the future the rising waters are directed away, and their force is not so unrestrained and dangerous.

[4]

There are two or three important ideas in this short passage. The first one can be considered to be a reframing of the conception of time. Several actions cannot be taken in the present. When we face a flood, we have almost nothing to do. We should have acted before, or we have to wait until the waters recede and we can build canals and dams that will prevent future floods from destroying our habitat. We could, maybe, say this idea is germane to the Greek concept of kairós, meaning there is a time propitious for action and times when it cannot be undertaken. The second idea is that time becomes a synonym of planning. The way to cope with future disasters is planning to build the aforementioned dams and canals. So, we need to understand the causes of floods (or fires and any other “acts of God”, to employ the English term for a big destruction not foreseen) in order to work on them and keep destruction far from us. A third idea is that action preventing massive destruction is a duty. We not only can prevent disasters, we also must do it.

With this complexity of ideas, we enter modernity. We need to do our best to preemptively avoid problems and evils that can be foreseen. If we suppose new pandemics can happen, we must take the necessary measures to keep them from arising or, at least, to minimize their impact. Machiavelli’s main point is that this must be done previously. Once a pandemic happens, we do not have much to do. This caution applies to both avoiding and minimizing the damage. We avoid the damage if we build the canals and dams before the floods, sometimes years before them. We reduce damage if we take the necessary measures as soon as we become aware of the impending disaster. In both cases, the essence of action is linked to time. The sooner, the better: this simple statement belongs to the kern of modernity.

This also implies that, as society becomes more democratic and inclusive, neoliberal policies show themselves to be inadequate for the framing of social policies. Let us dwell on this subject for a while. Neoliberalism can be understood as a capitalism without limits, as a complete faith in the power of the market. More than a century ago, Max Weber sustained that there is an ethic common to capitalism and to Protestantism, or should we say, to Calvinism [5]. However, historical experience has cast many doubts on this point. We could argue that it has shown us that capitalism is a very efficient system in order to produce goods, but it is rather amoral, meaning its efficiency is indifferent to morals. It is an excellent tool, a very good means to produce more, better and cheaper merchandise, but it falls short of defining the moral ends for human life. Ethics comes to capitalism from the outside: social movements, strikes and industrial action; environmental concerns have been necessary in order to pressure capitalism to give it an ethical facies that this mode of production would not devise by itself. Of course, capitalism has been more able than really existent socialism (or communist regimes) to consider these ethical worries, but we should not forget that they were not created by it. Neoliberalism, as a type of capitalism with no limits on the search for profit, has thus been at odds with ethics.

The rationale of capitalism, even though it is efficient for the production of goods, is not adequate for social areas such as public health, education and the sum of services a state needs to provide to its citizens. In the course of the last century, a type of capitalism with a human face has been a middle term between capitalism without borders and really existent socialism: social democracy or, should we say, the welfare state.

We have heard a lot about the demise of the welfare state, but one of the main lessons of the pandemic is that without it the human condition would only worsen. It will be, as Thomas Hobbes said, poor, nasty and short. If, on the one hand, the way we dealt with COVID-19—resulting in a rate of around 0.1% of deaths considering the world population as a whole against 5% just one century ago during the so-called Spanish Flu—is a strong testimony to the capacities of science to improve the world we live in, on the other hand hunger has come back in several countries, including Brazil, and hate is growing in many nations, making human relations more difficult. It is, therefore, an ethical imperative to address health problems such as the COVID-19 pandemic with public policies that ultraliberal policies cannot endorse.

To conclude, every time we shift the responsibility for bad or maybe perverse choices from politics to the actions of individuals devoid of political, economic or religious power, we risk not understanding what is really at hand and depriving ourselves of the means to face disasters that could have been avoided or at least seriously reduced if public policies had been undertaken in time. Not only it is unfair to put the blame on health professionals already stressed by the amount of work they have during a pandemic,3 it is also not productive. If we want to keep future pandemics from killing as many people as COVID-19, we need to have public policies strong and funded enough to face them.4