Building back better in bioethics

“Build Back Better” is not just a political slogan. It represents the feelings of bioethicists battered by the Covid-19 pandemic. According to an article in The Hastings Center Report by Susan D. Wolf, a bioethicist at the University of Minnesota, the crisis is a wake-up call to reassess what kind of a role bioethics can play in a post-Covid world.

“What shortcomings and misconceptions has Covid-19 exposed in bioethics?” she asks – and lists four of them.

Myth 1: We will know when crisis standards of care apply.” Bioethicists had ideas that a crisis would unfold according to a tidy plan. At the end of the falling row of dominoes, prefabricated standards would kick in to distribute scarce resources. In 2009 the Institute of Medicine set out a plan in Guidance for Establishing Crisis Standards of Care: A Letter Report. Unhappily, the politicians and administrators failed to take their call when the bioethics phones started ringing.

“The reality is that, in many places, no one has explicitly declared crisis standards of care. States vary in who has the authority to trigger CSC. Even when conditions were horrific, when patients were stuck in ambulances for hours awaiting admission, sharing ventilators, jammed in hallways, too often neither governments nor hospitals were willing to publicly announce the onset of crisis standards.”

Myth 2: We will be able to separate questions of clinical, research, and public health ethics.” But the pandemic erased the boundaries. People clamoured for promising remedies even though they had not been tested in randomised trials. There was no time for the trials. “The pandemic is schooling us that interdigitation is the norm. Bioethics started simple and needs to grow up fast.”

Myth 3: We will know when bioethics is succeeding.” Forests have been felled to publish articles, guidelines and frameworks. Which worked best? Dunno: dearth of data. “Bioethics cannot stop at journal articles and guidance posted on the websites of our health care systems and departments of public health,” says Wolf. “That rarefied world is far removed from the patients gasping for air, nursing home residents in panicked isolation, and ICU personnel at the end of their rope. Only research can illuminate what actually works. Without those data, we are flying blind.”

Myth 4: Bioethics has the means to succeed.” The pandemic has shown how unprepared bioethicists were to advise minority communities. “This pandemic has been a crash course in the lethal realities of health inequity as well as the failure of bioethics to learn from and genuinely partner with the communities affected,” she writes. “Customary bioethics approaches will not resolve this pandemic's debates over how to allocate resources in the face of long-standing health disparities and structural disadvantage.”

Michael Cook is editor of BioEdge   

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