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The UK Government’s public information campaign starkly tells us what we are to do – stay at home – and why – to save lives, and to protect the NHS. It’s fairly clear what it is to save a life, although it is not easy to measure how many lives will have been saved. But what is it to protect the NHS?
Clare Chambers is a member of the Nuffield Council on Bioethics and a Reader in Political Philosophy and a Fellow of Jesus College, University of Cambridge
The NHS is many things. It is buildings: hospitals, surgeries, clinics. It is equipment and technology: ventilators, beds, medicines. Above all else, though, it is people: doctors, nurses, cleaners, cooks, administrators, pharmacists, paramedics.
Many members of NHS staff have shared photos of themselves online, holding signs saying “We stay at work for you – please stay at home for us.” It’s the least we can do. But perhaps staying at home is not enough. NHS staff seem to deserve more, whether that’s better access to PPE and testing, priority access to services like childcare and food deliveries, or just better terms and conditions in general: higher pay, manageable shifts, less student debt.
From an ethical perspective there are a number of different ways to justify giving priority to NHS staff. There are things that NHS staff need just to be able to do their jobs properly. Masks may help us all to avoid infection, but there’s no doubt that a doctor about to intubate a patient has a greater need for proper protective equipment than someone visiting the supermarket. NHS staff must be able to make the best provision for treating patients while securing their own safety and limiting cross-contamination. Our absolute first priority in this pandemic must be to ensure that all NHS workers have the equipment they need to be able to operate safely and professionally.
Beyond the tools they need to do their job, priority for NHS staff is sometimes justified using consequentialist or utilitarian reasoning. If NHS staff are not protected from illness, so this logic goes, there will be fewer of them available to treat the rest of us. So, if we want to maximise the benefit that the NHS can bring to society as a whole we need to ensure that its staff, its greatest asset, are able to carry on working. This reasoning explains why NHS staff have priority for equipment over other workers whose jobs are less vital to the rest of us.
But consequentialist reasoning does less to explain why NHS workers should have priority over other essential services such as food supply. If there were no medical staff then those of us who become seriously ill may not survive; but if there is no food then none of us will survive. So should we prioritise the health of supermarket workers over the health of nurses? Consequentialism asks us to crunch the numbers: to work out how many lives are saved by giving a mask to a nurse versus giving it to a cashier.
Some calculations of this sort do have to be done, such as when comparing treatment protocols and resource allocation. For these high-level decisions comparing the numbers of lives saved can hardly be avoided. But as an ethical approach consequentialism is not enough. On its own, it falls short. It treats people as means to others’ ends: as tools for the greater good of society as a whole. It suggests that we can put a number on a nurse, a price on a doctor, a value on a cleaner. This way of thinking fails to respect the humanity and sacrifice of those we rely on to care for us in our times of greatest need.
Instead, or as well, we need to think seriously about our own duty of care. We must protect NHS staff not merely because we may need them (though of course we may), but because they need us. They need us because their work risks their own health, places them under immense emotional strain, and has subsequent costs for their families.
From an ethical perspective, we must recognise the interdependence of our social relationships. None of us can survive alone. None of us has succeeded alone. We all need each other.
This interdependence exists between us all, implicating many professions and persons beyond the medical. We need doctors and refuse collectors, teachers and vegetable pickers, police officers and social workers, scientists and actors, salespeople and politicians, journalists and novelists. We also need the large numbers of people, mostly women, whose work is invisible in traditional economic models; and we need people who cannot work due to age or disability, because they are interwoven in our lives and relationships. The social fabric as we know it relies on all of us, on our diversity and multiple strengths; and it makes us all vulnerable, too, because we are all reliant on constant cooperation and social provision.
In a global crisis we are all vulnerable. But some of us are made more vulnerable than others, and it is the most vulnerable who need the most help. In a pandemic, health service workers are often the best placed to provide help, but they are also, paradoxically, rendered extremely vulnerable. Their proximity to the virus renders them vulnerable both physically and emotionally: they are at greater risk of contracting the virus themselves, and they are constantly having to confront the devastation it can wreak.
We ask NHS workers to expose themselves to these risks for us. We ask them not to protect their lungs by staying safe at home, but to breathe the air of the emergency room. We ask them to remain focused on the virus and everything they can do for its victims, not to soothe themselves with daily distractions. We expect them to be constantly exposed to fragility, and that makes them fragile in turn.
We must take very seriously the obligations that we have to alleviate that fragility wherever we can. Just as collectively we shield the elderly and those with pre-existing conditions, so collectively we must shield our NHS workers.
The form of this shielding will, of course, be different. As the pandemic develops over the coming weeks and months the Government will repeatedly have to reassess the condition of the NHS: how it is coping with the changing situation, what it needs to survive and thrive. But this assessment should not be a mere numbers game: lives saved and lost, staff healthy and sick. It should take into account where vulnerability lies, and whether we are meeting our obligations to alleviate it. As a society, we will have to consider whether we are happy with the ways we are funding the NHS, the priority we are giving it, and the conditions its staff are facing. We will have to ask ourselves what we expect the NHS to do for us, and what we will need to do in return.
The expenditure time and effort on the establishment of the Nightingale hospitals instead of spending resources on the Social and Care sector; the announcement on the March 19 to discharge 15,000 patients into the community and care homes to free beds for coronavirus patients without mandatory requirements that they be tested for a virus and a government spokesman on May 23 "our strategy has been designed at all times to protect our NHS ....." all indicate the serious lack of judgement this effective but inappropriate strap line has caused.