Abstract

Dr José Ramón Acosta-Sariego is full professor of basic and preclinical sciences at the Medical University of Havana’s Victoria de Girón Institute, where he also chairs the Scientific Research Ethics Committee. He serves as vice-chair of the Board of Directors of UNESCO’s Latin American and Caribbean Bioethics Network (REDBioética) and in 2020, UNESCO’s Director-General appointed him to its 36-member International Bioethics Committee. Dr Acosta-Sariego has been academic coordinator for the bioethics master’s degree program at the University of Havana since its inception in 2006, is president of the Neuroethics Chapter of the Cuban Neurosciences Society and is a member of the Cuban National Bioethics Committee.

MEDICC Review: In several of your published works, you address the ethics involved in the process of formulating public policy. What ethical aspects should be considered as the world confronts the COVID-19 pandemic?

José R. Acosta: The effective exercise of human rights—including access to health care and education, as well as to the collective benefits of greater accumulated knowledge and technological advances—is only possible in the context of collective will built on ethical principles such as responsibility, solidarity, non-discrimination and protection of the most vulnerable.

In the Latin American and Caribbean region, the most unequal in the world, the neoliberal policies implemented by the military dictatorships during the 1970s and 1980s were continued by the representative democracies that followed. An ensuing more progressive decade was interrupted in several countries where the right has regained political power, restoring neoliberalism and its policies, and thus vastly deepening the gap between society’s haves and have-nots.

The COVID-19 pandemic swells in the current context of weak public health systems; a clear environmental crisis; intensified circulation of travelers, migrants and goods; concentration of human settlements; and unprotected populations besieged by deficiencies and conflicts of all kinds. In an interview published March 29 in the Argentinian newspaper La Nación,[¹1. Alconada Mon H. Frank Snowden: “Las epidemias son como para mirarse al espejo de la humanidad y puedo decir que no todo es bello”. La Nación [Internet]. Buenos Aires: La Nación; 2020 Mar 29. Available at: https://www.lanacion.com.ar/el-mundo/frank-snowden-las-epidemias-son-como-mirarse-al-espejo-de-la-humanidad-y-puedo-decir-que-no-todo-es-bello-nid2348455. Spanish.
https://www.lanacion.com.ar/el-mundo/fra... ] Yale University professor and historian of epidemics, Frank Snowden, observed that “coronavirus is the first great epidemic of globalization.” This is the first communicable event of a completely global scope, produced by a hitherto unknown causal agent, both highly infectious and highly lethal, and particularly aggressive within vulnerable population groups such as the elderly, the poor and the chronically ill. This “preferential” morbidity and mortality has become even more evident as the pandemic has progressed in the most impoverished communities within industrial societies, as well as in countries euphemistically described as “emerging economies.” COVID-19’s rapid spread and devastating effects have only been made possible by the favorable conditions created by neoliberal globalization.

If success is defined as corporate material gain at all costs, then it is exceedingly difficult to structure public policies to confront events with the power and magnitude of natural disasters or pandemics, which require enormous resource outlays that will not be returned in the form of profits, but rather in collective social benefit. This is why we see willful hesitation in some ruling government circles, placing the health of markets before the health of people, economic vitality before the lives of fellow human beings. This is the kind of ruthless utilitarian logic that is capable of admitting that a forecast of 100,000 deaths would be an indicator of having done “a very good job.”

The Global Health Security Index,[²2 The Global Health Security Index. Welcome to the 2019 Global Health Security Index [Internet]. Baltimore: GHS Index, John Hopkins University; 2019. Available at: https://www.ghsindex.org/
https://www.ghsindex.org/... ] a report published by Johns Hopkins University in October 2019, analyzed 6 categories, 34 indicators, and 140 items or questions to assess health security in 195 countries. This study warned that none of the surveyed countries were prepared to face a pandemic, including the United States, which scored highest on the index with 83.5 out of 100, compared to a global average of 40.

Despite the USA’s rank as the country best prepared to ensure the health of its population and the one best able to react to an epidemic, according to an April 1, 2020 Institute for Health Metrics and Evaluation projection,[³3 Institute for Health Metrics and Evaluation (IHME) [Internet]. Washington: Institute for Health Metrics and Evaluation (IHME); c2019. COVID-19 resources. Available at: http://www.healthdata.org/covid
http://www.healthdata.org/covid... ] April 15 was expected to be the day when COVID-19 would exert the greatest pressure on the country’s health services. It estimated the total need for hospital beds on that day would be 262,092, projecting only 87,674 beds available; in the same vein, the demand for beds in intensive care units was estimated at 39,727 with only 19,863 beds available. Additionally, it projected that 31,782 ventilators would be required at that time, in the context of the well-publicized controversy between federal and state governments on the acquisition of this life-saving equipment. Given these dire predictions, it is not surprising that the following day, April 16, 2020, was predicted as the day with the highest COVID-19 case fatality in the United States. The dates may differ depending on the pandemic’s behavior of course, but the general situation of insufficient health services’ response will inevitably occur when COVID-19 reaches its zenith in the United States.

This manifest blindness and abject lack of foresight are only possible when economic values predominate over moral ones. In this context, ethical principles of solidarity, responsibility, non-discrimination and protection of the most vulnerable cannot possibly guide public policies capable of articulating a coherent national response to address, counter and defeat disasters such as the COVID-19 pandemic. Thus, we see the devastating toll it has already taken in the United States and Europe, and the tragedy that is only just beginning in Africa, Latin America and the Caribbean.

MEDICC Review: Responses to the pandemic in some countries have pitted one approach against another, to the extreme of facing off epidemiological surveillance against individual empowerment and isolation against solidarity. How do you view this dilemma from an ethical-philosophical perspective?

José R. Acosta: These dichotomies are resolved in the moral debate between individualistic egotism and shared responsibility, expressed in solidarity. It is deplorable to witness traditional allies competing for resources in the face of the pandemic to address their own needs with no regard for the needs of others. We are also seeing significant defaulting on implementation of multinational mechanisms to confront COVID-19 collectively, even when parties are signatories to regional and international treaties that legally and morally obligate them to cooperate.

COVID-19 has confirmed the close and interdependent ties between the nature of life and the fabric of society itself. This pandemic—like all health problems, but particularly communicable diseases—highlights the underlying social determinants that decisively influence both the course and the outcome of the disease.

Protection of the most vulnerable, as well as sharing of risks and benefits in the application of knowledge and technology, are ethical principles enshrined in UNESCO’s Universal Declaration on Bioethics and Human Rights (2005).[⁴4 UNESCO [Internet]. Paris: UNESCO; c2020. Reseña. UNESCO’s Universal Declaration on Bioethics and Human Rights; 2006. 12 p. Available at: https://unesdoc.unesco.org/ark:/48223/pf0000146180
https://unesdoc.unesco.org/ark:/48223/pf... ] The isolation and surveillance measures necessitated by the pandemic in no way deny or prohibit cooperation and solidarity exercised with responsibility.

MEDICC Review: UN spokespersons maintain that all international sanctions should be lifted during the pandemic. From an ethical standpoint, how do you view the decision by the US administration to maintain its unilateral sanctions against Cuba now?

José R. Acosta: The sanctions imposed on Cuba are but an expression of what is known as “unconventional warfare,” escalated by the Trump administration to previously unimagined limits.

These practices are ethically unacceptable because they disrespect the rights to life, health, dignity and personal integrity; they increase human vulnerability; hinder access to economic, social and cultural rights; and they interfere both with freedom of choice and decision-making, by the way they wield objective and subjective mechanisms of power.

The systematic worldwide demand to lift these unilateral, immoral and illegal coercive measures as a practice in international relations has intensified in the COVID-19 context, because it is inconceivable to maintain sanctions and restrictions in the face of such a global emergency affecting everyone, instead of facilitating collaboration and exercising solidarity.

MEDICC Review: From an ethical perspective, how do you view Cuba’s decision to send emergency medical teams abroad in response to various government requests for help in confronting COVID-19?

José R. Acosta: As I mentioned, the accumulated health care needs are part of a systemic structural crisis of neoliberalism in many countries, associated with many other unfulfilled economic, cultural and social needs. Economic adjustment and austerity measures have greatly weakened the technical capacity and availability of human resources in these countries, although, since starting from a different baseline, poor countries have logically suffered the most. In these conditions, solidarity and international cooperation are quite necessary, and Cuba has forged a laudable tradition of providing this type of aid to those requiring it.

The practice of solidarity and global health cooperation has been an ethical principle of revolutionary medicine since the first international brigade was sent to recently liberated Algeria in 1963, a principle reconfirmed in the oath taken by the first cohort of physicians graduating after the revolution.

Collaboration in health became a vital part of the relations of friendship and cooperation Cuba established with African and Asian nations emerging from colonialism. US efforts to diplomatically isolate Cuba from the rest of Latin America and the Caribbean—part of the unconventional war—began to fail. As they did, friendly governments in the region began to request medical assistance in the form of long-term agreements as well as emergency aid in the case of natural disasters. Today, Cuba’s global health collaboration has been extended in different modalities to dozens of countries on virtually all continents.

Cuba’s solidarity in health has been reflected in sending health professionals, medicine, supplies and equipment, but also in training human resources in Cuba or in students’ home countries, and in scientific research and production of medications through joint development and technology transfer. Much of this collaboration has been offered free of charge, or else by mutually advantageous agreements with those countries that are in a position to assume costs. Through this solidarity, the principle of justice has been fulfilled by improving access to quality medical services for the most disadvantaged among us, both by Cuban personnel and professionals of the receiving nations who were trained through this cooperation.

MEDICC Review: The COVID-19 pandemic poses old and new ethical dilemmas…how would you define these?

José R. Acosta: COVID-19 has catalyzed ethical debates on moral values and dilemmas at the micro- and macro-ethical levels that were already happening, but have now greatly intensified.

The fundamental macro-ethical issue is why the warnings were ignored: those from forecasting models about imminent catastrophic events, including epidemics, as well as warnings about the clear unpreparedness of existing health services to confront them, resulting in non-existent social services now being hastily assembled to address the challenges we knew were coming. Thus, we have the COVID-19 pandemic as the classic guerra avisada; a war we were warned was coming that has already claimed many lives.

MEDICC Review: There are other issues that present ethical dilemmas, from the individual to the global level: setting priorities in treatment when resources are insufficient, speeding up clinical trials for new treatment violating guidelines of established ethical standards, and taking care of one’s health in circumstances where it could conflict with the health of others. And these are just a few examples.

José R. Acosta: Of course. One of the epidemiological control measures that has shown great effectiveness in COVID-19 containment is voluntary and, if necessary, mandatory isolation. It should be borne in mind that the free movement of persons is an internationally recognized human right, and for some societies it carries a highly important symbolic value. The ability to convince or impose this type of restriction depends on more than the coercive exercise of authority; it requires persuasion about individual responsibility to care for one’s own health, as well as a discussion surrounding social responsibility for the health of others. In cases like this, individual autonomy is limited by its possible effect on the common good, for which the state is the ultimate guarantor, bearing maximum responsibility for the health of its population.

Today the right to freedom of conscience and expression can be exercised in a much broader, more public way through the technological support offered by social networks. Due to the social isolation that many people are experiencing as a result of the pandemic, they now have time to spend interacting online with others where they also seek information about their concerns and questions. The information they consume and spread takes on special connotation because it can be used to clarify doubts and offer security and confidence…but also to spread unverified news and even fake news, by disseminating unfounded rumors that can cause social destabilization, intentionally or unintentionally.

Decisions on use of scarce resources such as diagnostic tests, ICU beds, positive-pressure ventilators, or even the handling of corpses, have brought to the fore conflicts common to clinical practice, but under these pandemic conditions they multiply exponentially in both quantity and drama. Each country, region, or city has particular characteristics: not only the material conditions and resources available, but also the cultural underpinnings of their respective populations. There can be no general recipes to guide humanistic behavior in these cases; each place must establish its own protocols for action based on the underlying ethical principles of justice and equity. This is the best antidote to improvisation and shock.

Another revived debate has been the ethical conflict between the duty of health professionals to care for patients at the risk of their own safety and the utilitarian rationale of self-preservation when faced with overwhelmed organizational capacities for addressing the catastrophe. In practice, it seems that altruism has predominated, and this is confirmed by the daily applause in many countries by people grateful not only for the health professionals, but for all those who are putting their health at risk for the common good, under very difficult conditions.

So far, there is no cure or specific protection against SARS-CoV-2, the causal agent of COVID-19. Until we have these, the only effective measures are those of prevention and epidemiological control. Obtaining a vaccine and effective treatment require research protocols now being developed by several prestigious institutions, including WHO, which has convened an international collaborative project. Regardless of the worldwide interest in obtaining results in the shortest time possible, this does not preclude taking all steps necessary to ensure safety and efficacy, whether the product is a vaccine candidate, a medication or a treatment scheme. The immoral attempt to buy exclusivity of one of the vaccine projects is unacceptable, as is the proposal to conduct clinical trials in Africa, given the lack of protections for its populations and the weakness of regulations concerning norms of good, ethical clinical research practice.

COVID-19 has brought with it new ways of socially relating in conditions of isolation: novel artistic and communication expressions, different forms of working, remote teaching activities at all levels of education, solidarity business practices, e-government, and community health actions such as proactive screening in primary care services, among others.

Political leaders, scientists, intellectuals, artists and social commentators insist that the world will not be the same after this pandemic. But few dare to predict just how the world will be different. Voices already call for a broad international exchange to clarify what thinking will emerge to guide us after COVID-19.

In his article How the Pandemic Will End, published in The Atlantic in March,[⁵5 Yong E. How the Pandemic Will End. The Atlantic [Internet]. Boston: The Atlantic; 2020 Mar 25. Available at: https://www.theatlantic.com/health/archive/2020/03/how-will-coronavirus-end/608719/
https://www.theatlantic.com/health/archi... ] Ed Yong suggests that changes will be so profound, so radical, that children born during and shortly after this fateful year will be called “Generation C”, because they will have to deal with the negative and positive aftermaths of the bitter global experience that was COVID-19.

Are we witnessing the swan song of neoliberalism and the transition to a more responsible and supportive world, or are we staring at a dystopian future of unrelenting plunder?

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