In its guidance document Ethics and COVID-19: resource allocation and priority setting, the World Health Organization (WHO) warn ‘setting priorities and rationing resources in this [COVID-19] context means making tragic choices’ (WHO 2020, p.1).

Specifically, as resources become extremely scarce, tragic choices will have to be made about access to hospitals, ventilators, therapeutic medicines, vaccines (WHO 2020) and, as it has turned out, personal protective equipment (PPE).

Meanwhile, healthcare providers (nurses, doctors, etc.) have also had to make tragic choices about the personal risks – to themselves and their families – they are willing to take as they continue to provide frontline care to those infected.

It is not just those working in the healthcare sector, however, who must grapple with the problem of making tragic choices. Individuals, families, and communities have also had to make tough decisions encompassing tragic trade-offs, the consequences of which may be far-reaching and linger for years.

Complying with lockdown rules, for example, has resulted in many heart-breaking situations such as families being separated; people not being able to be at the bedside of an ill or dying loved one; the bereaved not being able to attend funerals to say a final goodbye; owners having to close down a valued business and lay off loyal staff.

A question of nursing ethics
In this context, several questions arise: What is a ‘tragic choice’? What are the moral costs of such choices? And what, if any processes, can be put in place to realistically help guide those faced with having to make such choices and reduce the moral harms that might result from them?

The nature of tragic choices
The origins of ‘tragedy’ are thought to date back to the ancient Greeks and the performance of open-air theatre addressing serious subjects such as moral rights and wrongs.

Today, the term refers to a shocking, intensely sad, or mournful event that typically ends in disaster and which occurs through no fault or failing of those involved. It underscores human vulnerability and encompasses the idea that people ‘cannot control life’ and that ‘things will always happen that we are powerless to change’ (Spronk et al. 2017, p. 322).

What ultimately makes choices ‘tragic’, however, is that in making them ‘there is no way to avoid degrading some of our most deeply held values, such as the pricelessness of life’ (Bobbitt 2020).

The moral costs of tragic choices
Tragic situations in healthcare are not new, with healthcare professionals being only too aware that the tough decisions they make can have lasting and far-reaching consequences.

The COVID-19 pandemic, however, has added a whole new dimension to the problem due to the sheer scale and dimension of the tragic choices that have had to be made. For example, triage criteria in Spain recommended controversially that persons over the age of 80 years and those aged 70-80 years with co-morbidities be triaged away from advance life support (Herreros et al. 2020).

Some protocols also used ‘social value of the person’ as a decision criterion (eg. a person with four children should be prioritised over a single person) (Herreros et al. 2020).

Being ethical in extreme situations can be particularly challenging because it may not be clear what the ‘right thing to do’ is. As Kirsch and Moon (2010) reflected, when considering the question of ‘unforgiving triage’ during the aftermath of the Haitian earthquake disaster: ‘We have no answers. There are no answers’ (p. 921). Moreover, there is no magic formula for calculating the lesser of two evils when trying to decide what really is the ‘best thing to do’ in the extreme situation at hand.

No matter what is done, someone will be left without. Meanwhile, as decision makers navigate the progressively more extreme levels of a situation, the decisions they have to make and execute will be ‘increasingly harsh’, ‘morally agonising’ and, in the end, ‘morally deadening’ (Campbell et al. 2007, p.77).

Guidelines and protocols
Regardless of the extreme situations that decision-makers may find themselves in, their tragic choices still need to be morally justified (WHO 2020). To this end, two processes have been used: (i) developing ethical triage protocols, and (ii) developing ethics guidelines. The problem facing both processes, however, is that there is no one perfect solution since ‘every option has fateful consequences’ (inevitably someone is going to be hurt) (Bobbitt 2020).

Attempts to develop and apply reliable triage protocols have not been successful. For example, in one US outcome study, it was found that 67% of H1N1 flu patients who survived would otherwise have been considered for exclusion from ICU support (Fink 2020, p.2).

Protocols have also had to be withdrawn due to public backlashes against the use of controversial criteria. These and other examples have served to raise serious doubts about the ability of triage protocols to promote their intended utilitarian goals (Fink 2020).

They have, however, also raised questions about whether problematic triage protocols are better or worse than no protocol at all since without protocols individuals are left to make idiosyncratic decisions based on random and possibly unethical criteria (Fink 2020).

Ethics guidelines have also been of dubious value. Although contemporary bioethics has been enormously influential in healthcare, it has not been up to the task of guiding and justifying the tragic moral choices that inevitably must be made in extreme situations.

This inadequacy relates to the pre-eminence that contemporary bioethics has given to individualism and the value of autonomy. This focus has been at the expense of considering the collective good and the value of solidarity otherwise foundational to a morally just public health response.

COVID-19 has not only exposed the many gaps and inequities in our social systems but in our systems of ethical reasoning as well – especially when dealing with ‘no-win’ situations.

The ancient Greeks recognised long ago that tragedy is a part of human life. In response to this insight, the ancient Greek tragedy playwrights posed awkward and unsettling questions aimed at provoking their audiences to think deeply about how to respond to such questions. Today, it is the real-life tragedy of COVID-19 that is provoking us to consider awkward and unsettling questions about our most cherished values and ways of being.

While we may not be able to control life, we can develop ways to help reduce the ‘tragedy’ of our tragic decisions and prevent them from degrading our most important moral values. There is much work to be done.

References
Bobbitt P. 2020. We have to decide who suffers most in a pandemic. That’s complicated. Time 5 May. Online https://time.com/5831643/tragic-moral-choices-coronavirus-pandemic/

Campbell KM, Gulledge J, McNeill J R et al. 2007. The age of consequences: the foreign policy and national security implications of global climate change. Center for Strategic and International Studies, Washington DC

Fink S. 2020. Ethical dilemmas in Covid-19 medical care: is a problematic triage protocol better or worse than no protocol at all? American Journal of Bioethics, 20(7): 1-5

Herreros B, Gella P & Real de Asua D. 2020. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. Journal of Medical Ethics, 46: 455-458

Kirsch T D & Moon M R. 2010. The line. JAMA, 303: 921-922
Spronk B, Stolper M & Widdershoven G. 2017. Tragedy in moral case deliberation. Medicine, Health Care and Philosophy, 20(3):321-333

World Health Organization (WHO). 2020. Ethics and COVID-19: resource allocation and priority-setting (WHO/RFH/20.2). WHO, Geneva.

Dr Megan-Jane Johnstone AO is a retired professor of nursing who writes as an independent scholar. She is the author of the landmark book Bioethics: a nursing perspective (Elsevier, Sydney).