OK, this is gonna be a long one. And if the C19 situation is fraught for you, then consider this a content warning—I’m going to talk about mortality and our societal attitudes to such.
I’ve been wanting to write something like this for a good few weeks, but have frankly been too much of a coward to do so. I’m only now stepping into the arena because I can follow in the footsteps of Silvia Camporesi, an bioethicist currently under lockdown with her newborn child in Northern Italy. After setting the stage in the present, Camporesi returns us to the pivotal moment of serious outbreak, and to a well-intended attempt at medico-ethical transparency which ran afoul of the polarising morality-machine of media in an age of attention economics.
The document [that the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care] released in early March aimed to guarantee ventilators for patients with the highest probability of therapeutic success – that is, those with the ‘highest hope of survival’. The criteria adopted were utilitarian: age and pre-existing medical conditions were factors that pushed a patient down the line.
The document provoked an uproar. The media feasted on it, spreading the panic. The situation in Italy was certainly exceptional due to the sheer number of cases presenting themselves each day. It’s likely the first time that many of these doctors, especially the younger ones, were being faced with such harrowing choices. Yet, from an ethical point of view, the document was neither unprecedented nor revolutionary.
She goes on to compare the triage process to that used in deciding how to distribute organ transplants, while pointing out a significant difference, in that folk in need of transplants can conceivably sit in a holding pattern for some time before a suitable donor is found; a C19 patient may die very fast if they can’t be given a ventilator.
But here’s the important bit:
The fact that we Italians think that these decisions are exceptional reveals the ways that our privilege has concealed the reality of finite healthcare resources. One of my bioethics students, Caitlin Gardiner, is also an Accident and Emergency (A&E) doctor in the UK. She reminded me that, in her native South Africa, such balancing acts are the norm. There, as she told me, only the tiniest fraction of patients who are ‘not too sick’ – that is, not too old, not living with HIV/AIDS, not too ill or too premature, if they’re babies – get to receive intensive care. And death from tuberculosis (another infectious respiratory disease), after being denied access to intensive care, is entirely normal. There are lessons to be learnt from the Global South, such as how to have humane but open discussions about prioritising patients. It’s best to have this kind of conversation in a non-emergency situation, when the emotions of patients, relatives and clinicians aren’t running quite so high. Arguably, we should talk not just about whom to intubate, but also about when to withdraw ventilation if a patient with a better chance of survival were to arrive. Beyond the context of a pandemic, developed countries don’t typically face these quandaries, which explains the moral distress on the COVID-19 wards in northern Italy, where doctors and nurses have been reported weeping in the hallways.
Camporesi goes on to discuss the intergenerational dimensions of the lockdown responses, whereby (to simplify a great deal) the young and less-at-risk are being cooped up and, in many cases, put in a situation where their already precarious employment circumstances are totally hosed—this being the same generation that (unavoidably) will have to pay off the debt incurred by the lockdown response in taxes and (more likely than not) endure yet more years of austerity in state provision. She also points out that the evidence that any of this will be any more effective at dealing with the virus in the long term (by comparison to, say, the Swedish approach) is extremely thin, to the point of being almost entirely based on speculative models assembled quickly for an audience of policymakers—i.e. for people whose working notion of futurity is rigidly delimited by the current electoral cycle.
For the sake of clarity, this is not to endorse the UK government’s much-discussed early-phase “herd immunity” strategy; I’m not doing that, and I’m pretty sure that Camporesi isn’t, either. (Nor is it to side with the misinformed rent-a-mobs besieging statehouses in the US—though there is perhaps at least one level on which we should sympathise with them, even while believing their actions to have been purposefully misguided by manipulative hucksters and shills.) The point is to get beyond the prevailing moral binaries and start grappling with the really tricky shit… and we can start by reiterating a crucial distinction which is getting lost in the discourse. To re-quote Camporesi again:
The fact that we […] think that these decisions are exceptional reveals the ways that our privilege has concealed the reality of finite healthcare resources.
Over the last fifty or sixty years, those of us with the privilege to be among the middle class of the Global North have grown accustomed to the idea that no one has to die before their time. That idea is illusory on two levels.
Firstly, it relies on a quantitative metric whereby the goodness of a life is measured by its length. This contradiction has its ultimate expression in the absurd and tragic immortalist aspirations of the transhumanists, and is tied up with the logic of accumulation: if capitalism is the game of seeing who gets to die with the most stuff, then the longer you’re in the game, the better chance you have of placing high on the leader-board. But the contradiction at the heart of that morality is manifest in privatised and for-profit provision of social care, an oxymoronic project in which miserable conditions for workers and inmates alike do little to disguise the extractive logic of the underlying system. The fact that it is this same for-profit system of social care where so many of the C19 deaths are concentrated is perhaps the grimmest irony I’ve ever encountered in my life so far.
The second level of illusion was pointed out by Camporesi further up. It’s never been that “no one” should die before their time, it’s that no one like us should die before their time—nice white middle-class people with money. Outside of the Global North, people die “before their time” all the fucking time—indeed, increasing numbers of them die in the course of their trying to get into the Global North. But that doesn’t merit much of a response, save either fleeting feelings of pathos which can be alleviated by charitable donations, or a more callous (but in some respects more honest) dismissal of those lives as being less deserving of duration.
It is the collision of these two illusions, and their simultaneous shattering by an Outside Context Problem which has demonstrated that a system over-optimised to the point that it has no slack is a system with no long-term resilience, that is causing the ongoing epistemic rupture. The grief over loved lives lost is real, and a significant part of the societal trauma, but there is another level of grief at play as well—namely the grieving of the shattered imaginary world in which this sort of thing wasn’t meant to be possible: the grief for deaths, but also the grief for the rediscovery of death in the abstract as an implacable and fundamentally unfair aspect of being alive. Death doesn’t care about your class, your education, about where you were born or how hard you worked. Death just ends you anyway. And our ability to assume otherwise is, to reiterate, a pretty recent (and unevenly distributed) thing, as Hugh Pennington’s memories of the all-but-forgotten flu pandemics of the late 1950s and early 1960s make clear.
I am a socialist. I believe that the entire point of a collectivised healthcare system is to minimise the inevitable suffering of our mortal existence, and to distribute what suffering cannot be done away with as fairly as possible, without regard to the privilege of circumstance. That neoliberalism has twisted that ideal into this lottery of misery is beyond tragic, and has made me very angry for a long time. The C19 situation has only amplified that anger. I am not for a moment suggesting that the UK government’s herd-immunity approach was ethically valid.
But I think it’s long overdue that the reasons for its ethical invalidity were discussed truthfully. Yes, to have followed that strategy would have resulted in far greater numbers of deaths than are even now currently occuring—but that scale of deadliness is in no small part a function of the socioeconomic structuring of UK society as currently constituted. As the experiences of Germany and other countries have shown very clearly, the rate of mortality could be much lower—and that’s nothing to do with the virus itself, but rather the systems in place to deal with such an eventuality.
And so you get the UK lockdown situation, where the vast majority of people accept the need to endure the restrictions so as to minimise the deaths and suffering that would result from a less draconian response—because contrary to the Hobbesean mythology at the heart of liberalism, people are for the most part decent and compassionate, and would hate to think that they’d caused someone else to suffer through their (in)actions. But you also get a very successful manipulation of the narrative by the government, whereby the real and genuine horror of the consequences is positioned in such a way as to obscure the cause of their scale—a cause which was always-already political.
It is entirely right, and entirely human, to grieve for the deaths and suffering of individuals who contract a symptomatic case of C19. It is also entirely right, and entirely human, to point out and decry the systematic and wilful mismanagement of the social contract that has resulted in the number of those deaths being so huge, and to question what might be the long-term consequences of the panicked yet still highly performative and politicised responses to that circumstance; it is not a question of either/or, but a question of and/also. By keeping the focus on the immediate catastrophe, those same people whose actions have made the scale of the catastrophe possible are laying a trail down which they will abscond from responsibility, not just for the catastrophe itself, but for the decades-long aftermath to follow.
(And if that sounds cynical, well, hey: I grew up in Thatcher’s Britain, and then came of age in the ideological vacuum of Blair’s. I’ve seen the successful adaptations that neoliberalism selects for, and the vast majority of the current crop—on both sides of the house—seem like some tiny Pacific island crowded with moral mutants, the halting state of a game to determine who can best compartmentalise their own humanity in order to secure and hold an abstract notion of power for its own sake. None of them ever saw a catastrophe they didn’t fancy themselves fit to manage, because you don’t even make it onto the island if you don’t turn up with that mindset already fully internalised. I know we’re supposed to hate the game rather than the player, but I’ve rather lost patience with that position of late.)
It is my hope that the C19 crisis might do something to dispel the illusion of immortality that capitalism confers upon the privileged. This is not because I somehow relish the thought of people dying, or consider it “necessary”; if you’re looking for the social Darwinists in this situation, you should be looking at the architects of the lockdown, who are quite willing to exploit our emotional response (and, it seems, doing a bang-up job of it, too) in order to get away with retaining their own grasp on power.
Rather, I hope we learn to become more accepting of the uncaring randomness of mortality for two reasons. On an individual level, I think it might serve to make us more appreciative of the time we get—and in a world where pandemics like this are likely to be an increasingly regular event, staged against the unfolding deep-time catastrophe of as-yet all-but-unadressed climate change, we’re going to need that ability to live for the moment.
But on the societal level, I believe that we need to get reacquainted with the randomness of mortality because it serves to remind us that, whether within privileged societies or more globally, the current distribution of death and suffering—and indeed of risk more generally—is mapped by class and race and gender.
We cannot defeat death. But we can seek to distribute it without making tacit decisions about who is more deserving of life—and the first step to doing that is accepting that we cannot expect to be kept alive forever, and that the quality of the time we get matters more than the quantity.
I don’t want older people to die in lonely agony for the sake of corporate profits and political advantage. Nor do I want younger people to live straitened lives of penury and panoptic sousveillance against a backdrop of ecological collapse.
Morality is easy. Ethics is hard.