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Markkula Center for Applied Ethics

Coronavirus: Lessons from Italy

church pews covered with photos of members unable to attend services

church pews covered with photos of members unable to attend services

Margaret R. McLean, Ph.D.

(AP Photo/Luca Bruno)

Margaret McLean is the associate director and director of bioethics at the Markkula Center for Applied Ethics. Views are her own.

It’s official: novel coronavirus—SARS-CoV-2—has visited every continent except Antarctica and more than 100 countries. It is a pandemic. At the time of this writing, thousands of Americans have been infected, over 150 have died. Schools and colleges—including Santa Clara University—are shuttered; businesses locked down; restaurants and bars empty. It’s going to get worse before it gets better.

We stay home and keep six feet away from each other if we venture out. We wash our hands with the fanaticism of Lady Macbeth. All this to blunt the upward trending curve of infection and death. There is no soccer, basketball, hockey, or baseball; no London and Boston Marathons. We are running scared—mostly to the store to buy disinfectant, hand sanitizer, and—unexpectedly—toilet paper. Shelves stand empty.

We are likely to survive the panic-induced buying of toilet paper and, at my local grocery store, cupcakes. But the scarcity of adequate health care resources nationwide and globally paints a grim picture.

Consider the angst of a surgeon on the front line of the pandemic in Bergamo, Italy, as he waited—as we are doing now—for the tsunami of patients to hit:

“I myself looked with some amazement at the reorganization of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly ‘emptied,’ elective activities interrupted, intensive care unit freed to create as many beds as possible” leaving “an atmosphere of surreal silence and emptiness that we did not understand, waiting for a war that had yet to begin . . . Now, however, that need for beds in all its drama has arrived . . . The cases multiply, up to a rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing . . . ICU is full, and when ICUs are full, more are created. Each ventilator is like gold . . . Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted.”

Pandemic challenges our everyday ethical thinking as the unthinkable becomes thinkable and people die for want of a hospital bed or a ventilator. Everyday medical ethics in the United States rests on individual well-being and patient autonomy. Public health disasters refocus our ethics lens so that the everyday duty to care for individual patients is replaced by the duty to care for the community, and individual choice is supplanted by the common good. With a current prediction of thousands to millions of American deaths, we are coming to grips with the fact that not everyone needing an ICU bed or a ventilator will get one and that devastatingly painful, ethically defensible choices will need to be made.

Italy is now in triage mode. The number of patients needing intensive care beds exceeds capacity. The civil protection department of the Piedmont region, one of the hardest hit, is proposing to deny access to intensive care for those particularly vulnerable to COVID-19—anyone 80 or older and those in otherwise poor health. The unthinkable has become routine: the battle-tested principle to save those most likely to recover means that those who would have received care on a typical day are being sent home, likely to die.

Italy tells a cautionary tale, one that we must heed now. Here, as in Italy, there is a finite number of patients that can be treated all at once and the press of COVID-19 patients will surpass it. This nightmare has woken us up to the importance of social distancing, hand washing, and sheltering in place. We need to “flatten the curve” by slowing the speed at which the virus spreads in order to slow the rate of hospital admissions and ease the need for scarce resources—ventilators, hospital beds, and personal protective equipment for health care workers. Increasing supply will help some but only decreasing demand will save us from becoming Italy.

Put yourself in the shoes of an Italian physician deciding who gets the life-saving ICU bed—does life expectancy matter? Does having young children? Do those who can keep society functioning—health care workers, civic leaders, police, garbage collectors—go to the head of the line?

We have one shot to avoid these devastating choices. Now is the time to ditch ethics as usual, forgoing our individual choice, curtailing our freedom to move about in order to protect everybody, especially the most vulnerable. To quote an Italian journalist, “When everybody’s health is at stake, true freedom is to follow instructions”—shelter in place, keep your distance, wash your hands as if lives depend on it because they do.

Mar 20, 2020