Ethics and the Coronavirus 'Very Existential Questions Arise in the Face of Scarce Resources'

The coronavirus pandemic poses a threat to our society, warns medical ethicist Christiane Woopen, the chair of the high-level European ethics body. In an interview, she explains how doctors decide which seriously ill patients to treat and the perils the disease creates for society as a whole.
Interview Conducted By Christiane Hoffmann
Christiane Woopen, chair of the European Group on Ethics in Science and New Technologies and professor of ethics and theory of medicine at the University of Cologne: "We're not in the process of introducing age limits for care."

Christiane Woopen, chair of the European Group on Ethics in Science and New Technologies and professor of ethics and theory of medicine at the University of Cologne: "We're not in the process of introducing age limits for care."

Foto: Marcus Simaitis / DER SPIEGEL

DER SPIEGEL: Ms. Woopen, you’re a professor of ethics and theory of medicine, having studied medicine and philosophy. We’re in an exceptional situation morally with the corona crisis. As an ethicist, what concerns you most these days?

Woopen: We are experiencing a breaking away of structures that normally would provide us with security, on many levels, for each individual in his or her daily life, as a whole society and also globally. We are experiencing the end of reliable planning, existential hardships, physical, emotional and economic, border closures and travel bans. This requires considerable creativity and resilience on the part of all people, but also on the part of social and political institutions.

DER SPIEGEL: As a medical ethicist, are more people turning to you for guidance now?

Woopen: If the number of infected people climbs too sharply, very concrete and existential questions arise in the face of scarce resources. It could be, for example, that we don’t have enough ventilators. This is already the case in Italy. What do you do if suddenly three patients are admitted who need ventilation, but there is only one device left? We should prepare ourselves for such situations, and a great deal is being done in the health care sector to ensure that this situation does not arise.

DER SPIEGEL: Who should decide in an emergency who will be treated and who will not?

Woopen: Ultimately, it is the doctors on site who must decide. But they must do so according to generally agreed upon ethical criteria. This kind of criteria has been developed in disaster medicine. But we as a society must not leave doctors and nurses alone with this.

DER SPIEGEL: In Italy, those with good chances of recovery are apparently more likely to be given a ventilator than the sickest people.

Woopen: In Italy, it seems that a utilitarian approach is now being adopted: the greatest possible benefit for the greatest possible number of patients. In the German health system, we have a different approach: equal access to medical care for all. But in an emergency situation in which we can no longer take care of everyone, we will have to decide according to certain criteria.


Woopen: The first question is: Can a patient who needs a ventilator be saved at all?

DER SPIEGEL: That means that if there is no chance of recovery, the sick person would be sent home …

Woopen: No, the patient would then receive palliative care, either at the hospital or at home.

DER SPIEGEL: And among those who could be saved, who would get the ventilator?

Woopen: At first, those who have the most urgent need for them. However, if two patients urgently need to be ventilated, but there is only one device, the one with the better chance of survival should get it -- a difficult decision.

DER SPIEGEL: How well are doctors and nurses prepared for these burdensome decisions?

Woopen: I assume that the teams in the hospitals are agreeing now on how they will proceed, should such a situation arise. But given that conflict situations can arise from one minute to the next, it is important that the entire team acts in unison. And every hospital should also provide psychological and pastoral care for its staff because those kinds of decisions cost energy. The personnel need people they can talk to.

DER SPIEGEL: Is every life valued equally in this difficult balancing act?

Woopen: Absolutely.

DER SPIEGEL: So, if the chancellor were admitted to a hospital, she wouldn’t receive preferential treatment?

Woopen: According to our constitution, the Basic Law, human dignity is inviolable. This applies equally to all. Nevertheless, it may be important for ethical reasons that we protect certain people first in an emergency, because they are indispensable to the functioning of the state or the health care of the population in the face of existential challenges.

DER SPIEGEL: It’s reminiscent of a debate in Germany sparked by the former head of the youth wing of the conservatives, when he questioned whether society can really afford to be paying for hip operations for very elderly people. Is it possible that this question is now returning in a much more existential form, namely whether seriously ill people of a certain age should receive treatment at all in order to preserve resources for younger people?

Woopen: No, I don't see that. We're not in the process of introducing age limits for care. Also, from a medical perspective, we should not be making decisions based on age, but according to the individual condition of the patient.

DER SPIEGEL: In Germany, there is already a two-tier system of medical care with the private and statutory health insurance companies. Do patients with statutory health insurance have to fear that they will receive lesser care in an emergency?

Woopen: No, I don't think so. Everyone who needs intensive medical care will be treated equally.

DER SPIEGEL: Is society doing enough to protect doctors and hospital staffs from being overwhelmed and overworked?

Woopen: Everyone has to take care of themselves and their own energy levels, especially medical personnel. It doesn't make sense for people to exhaust themselves completely and then collapse. What we can do as a society is show them appreciation -- this can also provide them with strength. In addition, everyone can also behave in a responsible manner in order to prevent them from becoming overwhelmed. All those who are still inviting people to parties or who thoughtlessly fail to maintain sufficient personal distance are risking the lives of their fellow human beings and burdening those who are working day and night to save them.

DER SPIEGEL: You spoke of a collapse of structures. The French president has even said his country is in a "public health war.”

Woopen: I can see why Macron chose these drastic words: He wanted to wake up the public. Still, I think using war rhetoric is damaging. We are not at war. Wars are destructive, but action against corona is not. We are not fighting against other people -- we want to save people’s lives. We should avoid any kind of aggressive language. That just leads to panic and hopelessness.

DER SPIEGEL: The corona pandemic is a giant test for our society. On many levels, the individual is no longer deciding just for him or herself, but also for others. And much will depend on whether we look back and remember this time as an experience of selfishness and isolation or as an experience of solidarity.

Woopen: At the moment, I have the impression that we are writing a good story of solidarity, openness and coming together. We may be withdrawing more into our homes and our freedom of movement is getting smaller, but there is also a lot of positive and creative support and care. The restrictions outside have been accompanied by an inner opening.

DER SPIEGEL: After the terrible earthquake in Haiti, surveys showed that quite a few people were actually happier than before because they had experienced help and community.

Woopen: People in extreme crisis situations also have the feeling of being in touch with that which is existential. With that which makes life meaningful, that which matters. And to pre-empt critics who think this question is out of place at the moment, or that it is just glossing over things: I’m not referring those who are struggling to survive, whether physically or professionally. But we're all being somewhat brutally torn away from our everyday lives, which are often filled with superficiality, thoughtlessness and wasted time, and are being forced to focus on the essential: What distinguishes me as an individual? And what distinguishes us as a society? What kind of a society do we want to live in? What contribution can I and would I like to make now? Dealing with these questions is actually very beneficial.

DER SPIEGEL: Do you think fears of the virus are justified? We're reacting with measures that are far more drastic than during the last flu wave in 2017/18, which, after all, caused 25,000 deaths in Germany.

Woopen: This coronavirus is more contagious and the disease is more often fatal. This dynamic justifies the measures.

DER SPIEGEL: It's a matter of weighing the freedoms of the individual against the health of one's fellow humans.

Woopen: I am reassured that the politicians who are currently deciding on the incursions are aware of the importance of democracy and freedom. People in other countries have quite different concerns. In that sense, I think it’s justifiable that we are working to ensure that as few people as possible die in this pandemic -- with all the economic, social and personal consequences that come with this. But once we get through this crisis, we will have to think fundamentally about what restrictions we are prepared to accept at what point in time and for what exactly.

DER SPIEGEL: Would it perhaps be more justifiable to restrict the freedom of movement of at-risk people rather than society as a whole, meaning quarantining the elderly and people with pre-existing conditions?

Woopen: Those kinds of scenarios are also being discussed, but they aren't sufficient. People who don’t belong to the risk group can also get seriously ill.

DER SPIEGEL: The lockdown doesn’t just limit individual freedom -- it also comes at an enormous cost. Is it acceptable to balance human lives against the economic costs of saving the community?

Woopen: That happens anyway. We have to decide, for example, how many emergency ambulances, rescue helicopters or hospital beds are to be set up for patients with serious burn injuries.

DER SPIEGEL: We are possibly only at the beginning -- there could be even more massive restrictions. To what extent can restrictions on freedom be imposed on a society?

Woopen: In any case, you have to carefully weigh how long a curfew could be reasonably imposed without the social climate changing or the threat of domestic and sexual violence becoming greater than the benefits. Underestimating the potential for aggression would be negligent no matter what.

DER SPIEGEL: You mean that we could again find ourselves in a situation in which people feel overwhelmed because too much solidarity is being demanded of them?

Woopen: We cannot assume that all the people in this country are good-natured, open-hearted and oriented toward the common good. The coronavirus is hitting Germany at a difficult time, and our society is not ideally positioned for this situation. Populism, extremism and xenophobia have intensified in recent years.

DER SPIEGEL: Could the corona crisis pose a threat to our democracy?

Woopen: We have already seen how the climate changed after the refugee crisis and what developments have resulted from it. It would be naive to not believe that there are also political dangers inherent to the coronavirus. We need to prevent forces that divide society from gaining further momentum after the crisis. In my view, the most important thing is that the support the government is promising is also implemented quickly and reliably. Otherwise, the government will lose its credibility, the people will lose confidence and the social consequences will be catastrophic.

DER SPIEGEL: Is there a measure for how much solidarity can be demanded of people? Have we arrived at the categorical imperative?

Woopen: Let’s stick to the golden rule. One can demand of everyone that they ask themselves how they themselves would like to be treated. And they should then treat others the same way. Everyone should put themselves in the position of those who are now in particular need of help.

DER SPIEGEL: Western societies, in particular, place a strong emphasis on individual liberties and the possibility of self-fulfillment, while Asian societies such as China or Taiwan traditionally focus more on the community. Are they better prepared for a pandemic?

Woopen: For thousands of years, the sense of community and the willingness to refrain from individual interests has been culturally anchored in countries like China in a completely different way than in Western countries, which have placed the individual at the center since the Renaissance or even before. Ultimately, however, community and individual can only be conceived together.

DER SPIEGEL: Meaning, you think the West should learn from the societies of the East?

Woopen: I wouldn’t polarize it that way. We should all remember that we are dependent on other people and the community.

DER SPIEGEL: Many are conflicted about how they should behave toward elderly relatives. Anyone who visits their parents or grandparents might also endanger them. But can we expect them to be lonely for weeks or months? Which is worse?

Woopen: It is particularly bad for people who live in nursing homes with advanced dementia, for example. They depend on regular visits, because otherwise they might not recognize their family after a few weeks. This can lead to very difficult situations. It would be best if digital contact could be maintained.

DER SPIEGEL: And if that’s not possible, who should decide whether to risk a visit?

Woopen: This is based on the trade-off between longevity and quality of life. It can only be decided individually, but in the event of a pandemic, other people also have to be taken into consideration. If, for example, an elderly person prefers to expose him or herself to the risk of becoming infected and dying earlier, then that is his or her personal decision. But that person also has to consider that they might then burden their children or grandchildren with the fact they caused the death of their father or grandmother. If people with severe dementia can no longer decide for themselves, those close to them must do so and also consider the consequences for the other residents and the staff of the nursing home.

DER SPIEGEL: The coronavirus will change our country and the world. What will be the most important change?

Woopen: The Greek word for "crisis” is the etymological source of the word "decision.” We all can and we all must decide: What kind of society do we want to be? How do we want to live together in this world?

DER SPIEGEL: Ms. Woopen, thank you for this interview.

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