RESPONSIBILITY: Philosopher, Smadar Bustan

Smadar Bustan, PhD , (FRANCE) ,  is a philosopher, ethicist and scientist at the University of Paris Diderot. In her research on human suffering and pain, she developed a tool for evaluating the suffering of chronic patients following experimental and clinical studies in Luxembourg and France. She co-founded at Harvard and heads the International Program on Suffering and Pain (www.suffering-pain.com).
The dilemma discussed here bears on responsibility, a Latin term from 1590 respōns(us ) or response, which became philosophically prominent rather late in the 18th century. Our question is, does responsibility, and more specifically medical responsibility, change during a global health crisis? Is responsibility limited in the avalanche of an infectious transcontinental disease, obliging us to relieve clinicians from the burden of decision-making process carried out in individual cases?
A broader conceptualization of the nature of responsibility is necessary in order to deal with this dilemma, by first asking: what does it mean to be responsible in times of pandemic? Responsible behavior during the coronavirus infection outbreak was very much present in every household and country around the globe. Yet the lack of adequate knowledge caused significant inconsistency leading to public panic and raised doubt about what it means to act in a responsible manner, both personally and collectively. The problem with a pandemic is that the personal and the social intermingle to the extent that the most casual individual acts, such as coughing, sneezing, going out of our homes, or walking around maskless, turns a person into a biological agent engaging into irresponsible behaviors that some would qualify as criminal or immoral. This Covid-19 Epidemic has been enhancing mutual accountability to such an extent that individual responsibility is transferred from an autonomous self to a self intrinsically bound to others. One can no longer exert free will to live carelessly and be prepared to risk contamination.
What we have learnt from this epidemic as a globalized society is that individual responsibility is no longer exclusively centered on what we are bound to undertake by duty, of a person being responsiblefor something or someone (a parent for their child, a doctor for their patient) since simply by being, breathing, existing, we are accountable, all of us together and every one of us individually.
Unfortunately, under such circumstances, our responsibility becomes as vulnerable as we are.
The fragility of a pandemic causing this involuntarilyresponsibility by existence , with its inevitable sharing of accountability, leads us back to our main ethical dilemma when asking what motivates us to make the right choice for a responsible act during a health crisis. For the overwhelmed practitioner inquiring how to fully know what the right act is, how to best choose in relation to the available resources and to whatever is in one’s power, the resignation to do ‘the best we can’ may provide protection from liability but not necessarily satisfaction or peace of mind. When the medical model of responsibility is guided by reasoned thought in regard to what we can do and the means that lead us to better ends, It is difficult not to notice the unrest when this intellect-based definition of being responsible entails a sense of feeling morally, medically or even humanly irresponsible. When reading Dr. Nacoti’s testimony, it becomes clear that even though a well-regarded thought led him and his colleagues to make decisions for saving lives, the strong remorse experienced following the death of their patients shows that a reason-based decision for acting responsibly with a negative end result may leave clinicians with a feeling that they are partially at fault for the failure.
The severity of the pandemic has exposed many of the medical workers, as those in the frontline in north Italy where Dr. Nacoti works, to face the toughest triage procedures in medical care with the prospect of having to ration equipment and care, sacrificing certain people for saving others and facing unthinkable choices regarding life and death. The lack of treatment led to the use of drugs on the basis of limited evidence concerning their effectiveness and therefore not without risk while trying to assure the highest rate of survival. In this respect, even when providing immunity against malpractice during the emergency of Covid-19 and hence excluding any legal responsibility, as Dr. Fischkoff recounts about the State of New York, the problem with ethical responsibility persists not only in regard to the possible damage caused by one’s own act, but also to the consequences of this act on the people to whom they must answer. We find here the two aspects of the modern idea of responsibility, associating legal and moral responsibilities. The interdependence of these two aspects may explain why, despite excluding any legal sanctions and therefore legal responsibility in a time of unprecedented crisis (facing scarce resources and exceptional emotional burden on healthcare personnel), the ethical dilemma persists because medical decisions remain attached to our moral obligations. Treating clinicians whose actions are based on well justified rational decisions may still carry blame, unable to wash away the guilt, because these fail to comply with their moral convictions.
The lived reality of the pandemic obliges us to go beyond the first form I named responsibility by existence to better examine the medically relevant form of responsibility by deliberation , introducing the idea of making a choice as a result of deliberation and of fully knowing what is the right thing to do. Two philosophers who represent this strand of thought with the traditional concept of responsibility as dependent on knowledge, striving to certainty and regulatively knowing everything or at least as much as possible, are Aristotle (4th century BC), in his account of Ethics, and John Stuart Mill almost two millennia later with his utilitarianism (13) (19th century). In the third book ofNicomachean Ethics (14), Aristotle examines what is good for the human being— what we need to undertake, aim at, and act upon, in order to do good. In our case, medicine aims at health, and physicians aim at healing. In this respect, what Aristotle also taught us is that when we deliberate, we always have some end in view. If I deliberate about whether to put a mask, I consider this in light of a future end in view, which is to avoid catching or spreading the COVID-19 virus. If I deliberate about whether to respect the extreme social distancing of the quarantine and stay at home, I consider this in light of a future end in view which is to slow down and eventually stop the epidemic’s spread.
Aristotle claims, however, that there are two things we cannot deliberate about: facts (which could only be examined) and end views, for the simple reason that we cannot change them. Hence our choice based on deliberation of doing good and acting responsibly are dependent on end purposes and on sticking to the facts, and basically on knowledge. At the same time, if during the Covid-19 pandemic we apply this philosophical recipe with reason-based choices regarding medical responsibilities, we soon realize that clinicians are being severely undermined, which only intensifies our dilemma. In reality, we have witnessed misinformation emanating from situation reports and official communications, including from public health authorities, through inaccurate or misguided information. For example, It was said that smokers are less likely to be contaminated, ibuprofen or aspirin can worsen the Coronavirus symptoms, or the virus is unstable at high temperatures and therefore will go away when the weather warms up. In the upheaval of the aggressively spreading epidemic, scientific facts continuously evolved so action based on facts had to adapt, inducing further confusion relative to our standard approach of evidence based-medicine that canceled out knowing beforehand and making a contingency plan accordingly. Furthermore, at the outbreak of the pandemic, the end view of medicine and its therapeutic goals, shifted from healing to prevention from dying, totally destabilizing the standard therapeutic goals.
Under a state of emergency and threatening rapid death, we could simply proclaim that without a solid foundation to rely upon for making choices, the entire undertaking of medical and social responsibility is bound to perplexities. Medical professionals must respond when facing flows of Covid patients with severe respiratory distress out of active commitment to vulnerable patients. De facto, they do respond. But do they need, in this unique scenario, to take responsibility for their medical response? In respecting their devotion and diligence, can we relieve clinicians from a part of the responsibility in the decision-making process as normally carried out in individual cases?
A comprehensive approach should be compatible with extant principles of responsibility under the given circumstances. A broad approach to analyze responsibility for pandemic diseases should consider both forms of responsibility, by existence and by deliberation. This would be better overall for society and healthcare, considering the disruption due to shifting facts and undermined medical ends, thus promoting more careful policies and actions.
At the same time, the outcome of the discussion so far has been to show us that a person or an act can be considered responsible so far as one is bound by it, or thinks it to be right. My first observation in examining “what is it to be responsible” in times of pandemic consists in introducing the idea of responsibility by existence for all , regrettably excluding the freedom to be able to do otherwise. And my second observation examining “what is it to act responsibly” consists in introducing the idea of responsibility by deliberation , of accountability for our actions and their consequences, and the praise and blame attributed to the moral agent. Deliberation is a reasoned thought about what we can change by our efforts and where we need to act differently in various occasions. And yet, in times of pandemic the foundation for well-reasoned and thoroughly discussed decisions, fostering a collegial consultation as standardly required, is damaged because neither the facts nor the end views are stable enough to serve as references for deliberately acting responsibly. Dr. Nacoti raised this point when he spoke about referring to the general qualification of the Covid pandemic as a war with a chain of command whereby clinicians were to simply obey, following the mantra of “do and do not think” and inexperienced doctors found themselves having to decide alone who will live and who will die. The resulting epistemological helplessness of the Coronavirus pandemic puts the idea of responsibility in a new light due to the conflict between the medical naturally learned profession and not knowing. This novel chaotic situation cancel’s Aristotle and Mill’s rationalist view of acting by virtue and for the benefit of good on the ground of knowledge, as clinicians who have an occupation requiring them to be well-informed in order to act responsibly lack in effect the necessary knowledge.
This outcome for the practice of medicine and our philosophical inquiry requires to rethink the notion of responsibility and moral obligation by moving philosophical fields, going from Aristotle’s guiding but failing rationality to Levinas’ field of ethical phenomenology. The reason is that none of the perspectives that have been actually presented here has paid full attention to a third form of responsibility, based on an entirely different philosophical pattern and that provides a way out of this dilemma regarding acceptable or unacceptable changes in medical responsibility in times of pandemic. This alternative view consists in arguing that responsibility is involuntary, not bound by rational choice, certainly not a deliberate one and is totally experiential. Becoming responsible for a sick person is imposed upon us by his needy, vulnerable presence when calling for help, often withoutwords, in an appeal conveyed by the misery and helplessness of their facial expressions. This sense of ethical responsibility goes beyond that of a reflective commitment. And just like the first form of responsibility by existence, it separates one from oneself by giving precedence to the other person, while emphasizing here that this other person is weaker and more at risk. Levinas considers the experience of responsibility as what binds one person to another, as the foundation for humanity and ethics which he demonstrates through the well-known theme of the meeting face-to-face, when encountering the face of the other person causes a phenomenological shock that makes one feel inevitably responsible for their fellow human being (15).
I have to admit that in my writings on ethics and the sufferer and especially in my review of what I call the “French School of the Ethics of Suffering” (16), I always criticized this uncompromising level of responsibility and priority Levinas claims we can grant another person, even when we are ourselves sick, exhausted and emotionally strained (17). But when I caught the Corona virus at the beginning of the outburst here in France, the sense of responsibility and giving priority for the well-being of another took over me. My symptoms were mild, but sudden. I fell down on the floor without being able to get up again, feeling the chill and honestly the fright of the unknown progression of this aggressive virus that literally took control over my body within minutes. While lying on the floor, what bothered me most was the possible contamination of my children and particularly of my asthmatic elder son who was designated as part of the Covid-19 risk group. I was sick, not being able to give anything, let alone move my body, and yet, just as Levinas claims, the disinterested sense of responsibility towards another invaded me and my responsibility for not contaminating them became my absolute priority. It was not a voluntary or deliberated sense of responsibility and it very much obsessed me when I was most helpless.
Obviously, one could contest this example by rightfully claiming that children are an extension of the parent and do not represent a ‘real Other’ in the full Levinasian sense. And as I demonstrate in my book on Levinas’ ethics, the unreflective encounter with the other person rather represents a situation that makes me surrender myself to them, often against my own will and without being able to expect anything in return (18). The Other could be a stranger one has to commit oneself to despite wanting to walk away, a patient entering an already overbooked Covid unit whom an overburdened doctor would rather put to wait or a contaminated elderly person placed in the care of a scared nurse, wearing a plastic bag due to lack of proper protective equipment (reminding us of the institutional responsibility towards the caregivers and the safety protocols). The other person may even constitute a threat but since their urgent call for help precedes me and is imposed upon me immediately, I am obligated to be there for them, unable «to get out from under responsibility» (19). It is the lived experience and encounter between human beings that make us responsible, not knowledge or deliberation on the account of facts. Human responsibility is simply being there for the other, claims Levinas (20). The activated sense of responsibility towards the survival of others places them first, prior to worrying about our own survival and prior to any conscientious processing. One is compelled to worry and care for the other says Levinas, since responsibility does not originate from within oneself, but is rather an order or command that one receives. It precedes us in the sense that it originates from a prior time and our ascendants (ancestors or past generations), as Ezekiel Mkhwanazi beautifully explains (21), it is pre-original (22)(23).
In transposing this view to our discussed dilemma of medical responsibility, it soon becomes clear that what stems from this sense of duty, of a caregiver or a medical worker, is not a Greek agency or freedom to choose the good, but a fundamental archaic obligation of oneself towards another, and that it “commands me and ordains me to the other” (24). In this perspective, this amounts to saying that our dilemma is cancelled since no judgement can be made about treatment or availability of the medical caregivers during a pandemic. Their mere presence beside a Covid patient’s bed is a celebration of being there for the patient and of human responsibility at its best.