The virus and the virtues
Ethics and Covid-19
An 82-year-old patient receives physiotherapy at the NHS Seacole Centre, Headley Court, in Surrey - Photo: PA, Victoria Jones
It’s now six months since the lockdown began, and a second wave of the coronavirus may be upon us. We have learnt that in a crisis what makes the difference is not algorithms or protocols, but virtue and character
One of the things we have witnessed over the past months – clearer, perhaps, than for a generation – has been the virtues in full swing. At the start of the pandemic, when it became obvious that the excess deaths caused by Covid-19 were going to be alarmingly high, I was puzzled by the relative lack of comment in the popular media, or even in the academic press, about the virtues. Spinning around in my mind have been the words of Hillel the Elder: “If not now, when?”
Doctors and nurses and other healthcare professionals, suppressing their natural anxieties and fears, have been setting off each day to work under difficult conditions treating people who had the infection. To protect their families, some nurses left their homes and lived elsewhere. Many NHS workers have died from the virus, including a nursing colleague of mine: an expert in his field, a great friend to his colleagues and devoted to his family. And it wasn’t just the healthcare workers. Where would we all have been without the refuse collectors, the shop workers, the bus drivers and those who made deliveries to our doors? All of these people have shown courage, generosity, beneficence, kindness, to name just some of the virtues.
In the world of bioethics, however, the talk was largely of the dilemma that would face medical staff if people required artificial ventilation but ventilators or intensive care staff were lacking. Ethicists highlighted the tension between the doctor’s natural tendency to do his or her duty towards the patient in front of them (the deontological approach) and the demand that outcomes (in terms of patient welfare, absence of pain, health and wellbeing etc.) should be maximised on a population level (the consequentialist approach). It was presumed, by and large, that the consequentialist or utilitarian approach would win the day, but not without moral distress being caused to the individuals involved in making the sad but inevitable decisions. Hence, the priority for ethicists was to write protocols or guidelines for how such decisions should be made.
All of this was obviously worthy in one sense, but apart from the well-known problems with consequentialist thinking, for most of those involved in the coronavirus crisis (and actually for all of us) the intensive-care-bed dilemma was not the sort of issue we faced. The nursing sister who, at the end of a long shift, stayed on because she knew that a relative of a patient was going to ring in the hope of being able to speak with her, showed moral character. Her action could be analysed in terms of its likely consequences or her duty of care. But the reality is that she probably did not think about such things; she was simply disposed to act as she did.
The intensive-care-bed dilemma is not new. In George Bernard Shaw’s 1906 play, The Doctor’s Dilemma, Sir Colenso Ridgeon has to decide whether to treat a kind but poor medical colleague or a very talented but distinctly unpleasant man with whose wife Ridgeon has fallen in love. What strikes me is that in his preface to the play, Shaw saw the importance of the virtues. “Doctors,” he wrote, “if no better than other men [sic], are certainly no worse.” He recognised that many doctors, being people of good character, enter the profession for virtuous reasons.
These days the virtues hardly get a look-in. Yet in this crisis the need for virtuous practitioners became abundantly clear. In the real world, where decisions must be made on the hoof, sometimes with little space to consult colleagues or to discuss matters properly with the families of severely ill patients, following protocols, applying algorithms or whatever, might be desirable. But what is indispensable is that clinicians exhibit the virtues.
Quick or difficult or emotional decisions, subtle or nuanced distinctions, weighing up claims, interpreting results, putting decisions into effect, negotiating services for patients, communicating with stressed relatives, justifying actions, supporting colleagues and so on, all require particular dispositions if they are to be done well.
Think of care homes. Sometimes staff in private care homes were without personal protective equipment (PPE), whereas the NHS units just next door were fully equipped. What courage does it take to go to work in PPE? What courage does it take to go to work without it? Some agency workers, once they heard that a care home had the virus, would leave. Were they failing to show courage or was this great prudence? Perhaps they also had to care for someone who was vulnerable, or perhaps as sole breadwinner they could not take the risk of self-isolating. Meanwhile, there were managers going into infected care homes to keep up morale and to cover nightshifts. What virtues these people showed! And what virtues were required from the residents of care homes when they knew their neighbours were dying from the disease!
A common criticism of virtue ethics is that it does not tell us what to do: it is better at description than prescription. But virtue ethics is useful because of its descriptive properties. It shows us what living a virtuous life looks like. And virtue ethics is also prescriptive. To do the right thing, you should do what the virtuous person would do. To do well or flourish as a human being is to live in ways picked out by the virtue words: compassion, honesty, fidelity, steadfastness, justice, courage, hope, integrity and so forth. Perhaps above all, practical wisdom – the ability to know how to achieve the good aimed at – is what is required for decision-making in a crisis.
Our political leaders must demonstrate practical wisdom as they seek to discern how to navigate between the devastation that would be caused by any further lockdown and that attendant upon a resurgence of the virus. Head teachers have had to show practical wisdom in making preparations for their pupils to come back to school. Universities must also show prudence in the preparations they are making for their students.
At best, people are not automata simply following guidelines, protocols and algorithms. They are not just trying to maximise welfare or outcomes. They are not blindly doing their duty. They are real, feeling, empathic people of character, trying to be as good as they can be. If we are to do well, then all of us – young and old, students, scientists, business owners, citizens – facing a second wave of the virus must show a variety of virtues: charity, fortitude, fidelity and the like. Virtue ethics encourages us to recognise that our inner dispositions are important: thus, we can applaud each other for being good human beings, for demonstrating what it is to flourish humanly and for demonstrating moral character.
We are all in the business of trying to be virtuous – or should be. And in healthcare, the dilemmas are never solely to do with intensive care beds. I know someone who insisted on staying with her husband who was dying from Covid in hospital. Although it was against the rules, the staff allowed her to do so. She showed courage, self-control, fidelity and love; they showed wisdom, charity and respect.
The virtues invite us to be brave, compassionate, humble and to show integrity. Whether it is a decision about meeting friends or running a business, I can consider what the wise, virtuous person would do. How do I show honesty, fidelity, charity? We reflect and learn: this is how we get through, by being good, kind, thoughtful human beings. The virtues operate on a human scale and are concerned with what I become by what I do.
They are also about friendship. As Herbert McCabe OP wrote in The Good Life, “a study of the virtues must be a study of the manifold ways in which people interact in the community of friendship”. That community is very broad. It includes those in hospitals, shop workers, journalists and teachers (including those who work with children with intellectual and physical disabilities where the threat of being spat at necessitates PPE).
Solicitude for those who suffer from Covid-19, as well as the care we have for each other, is friendship. The virtues that underpin friendship are apparent throughout the world within and between communities. From small acts of kindness to the generosity shown by international cooperation in the search for a vaccine, the pandemic has revealed the virtuous side of humanity. We should recognise and laud it, for “if not now, when?”
Julian C. Hughes was an NHS consultant for over 20 years and professor in old age psychiatry. He remains honorary professor at the University of Bristol and visiting professor at Newcastle University.