Ethical gap to implement utilitarianism in healthcare policy: A hidden Pandemic Ethics Crisis

Correspondence: Gausul Azam Ranju, Department of Physiotherapy, BGC Trust Medical College & Hospital, Chittagong, Bangladesh. Founder of School of Ethics, Nasir Building, Chandanaish, Chittagong, Bangladesh. email: physioranju@gmail.com; ORCID: https://orcid.org/0000-0002-6261-8557 1. Gausul Azam Ranju, Department of Physiotherapy, BGC Trust Medical College & Hospital, Chittagong, Bangladesh. Founder of School of Ethics, Nasir Building, Chandanaish, Chittagong, Bangladesh. Mail: physioranju@gmail.com; ORCID: https://orcid.org/0000-0002-6261-8557 2. Tania Serice, Nursing Officer, Ministry of Health and Family Welfare, Bangladesh. email: taniaserice@gmail.com; Bangladesh Journal of Medical Science, Special Issue on COVID-19. 2021. Page : 178-182 DOI: https://doi.org/10.3329/bjms.v20i5.55413


Dear Editor,
Utilitarianism is a principle type of consequentialism that is now treated as a foundation of morals and legislation in the healthcare sector.From the three philosophical approaches (Utilitarianism, Liberalism & Communitarianism) utilitarianism is an important public health discourse 1 . A very common assumption among practitioners and the policymakers isutilitarianism is a standard in the public health 2 . Though utilitarianism can't ignore its critics like the question on balancing equity & justice and it is arguable 123 but our aim is not to investigate on that purpose. This debate we raised here -how do we do good for all or how can we provide just or fair distribution for all ? We are not talking about -is utilitarianism an ideal tool for healthcare development or not? And even we do not haveto propose for an in-depth discussion of different forms and accounts of utilitarianism in this paper. Just we work on its basic dictum "the greatest happiness of the greatest number" 4 . According to Jeremy Bentham (1748-1832) "Nature has placed mankind under the governance of two sovereign masters, pain and pleasure", where pleasure comes from happiness and this is the thing to make something good. The motto of any healthcare policy is how to make good policy and health for the people. As we know the COVID-19 pandemic explore the limitations of the total healthcare system in the world, despite a significant development into the medical sciences in the last 100 years 5 .This article makes the argument that a defensible application of utilitarianism during the COVID-19 pandemic must take into account the interests of, and impact on, the protection of caregivers treating persons affected by the COVID-19 virus.
Utilitarianism is one of the contemporary themesof public health discourse. According to utilitarianism, the greatest amount of good is preferable and wellbeing has a priority 6 . Bayer and Fairchild argue about the role of utilitarianism in public health 7 . In this COVID-19 pandemic time most of the media, news portals, governments, and authorities only try to promote and ensure the treatment of the COVID positive patients and influence how to flatten the curve 8 . Most of the time everywhere the highlighted thing is we have to do work for the greater public good or well-being. But the question that is slightly ignored is -are the health caregivers really included in this public or the citizen (are they equally assessed like the public's right, life, liberty, and property)? According to Mackay "When public health limits the behavior of some for the protection of the many, it is operating on the welfare-maximizing principles of utilitarianism" 2 .In this situation, the behavior that happens in the doctor's life is likely to follow the same policy. All frontline workers during this COVID-19 pandemic have faced threats or even firing if they raise their voice for protection 9 . So from hypothesis now it is a prediction that the health workers are being punished for speaking out but they only obliged to do their duty (patient care) 1011 . If they raise their voice for the PPE, they are suspended from their job and they are noticed or even they are fired 1012 . Death threat and death like cases is now a fact for this PPE issue 10 . So, it is like an effort to make the "greater good for the greater number" by accepting the way that we are debating here today and perhaps it is not fully detached from the political or the business scheme.
Medical health ethics have an importance in the doctor-patient relationship status compared to public-health ethics 1 . But coronavirus is today not only the doctor-patient related issue but it has a public health concern. Another reminder is nursepatient relationship as we know nurses also has a full of values like scientific knowledge, technical skill and professionalism 13 . In social media civic people also make a lot of comments and create a bunch of myths around the novel corona virus 14 . The stigma associated with caregiver's contribution for the patients with COVID-19also has a big deal 15 . In healthcare (especially for COVID-19) when both medical and public health issues have different significant importance, but for the utilitarianism, we need to give an identical ethical recognition for both of the cases. For the case of coronavirus, both professionals and practitioners have the risk of being affected by it. Health is now a fundamental issue which has greater importance for both individual and collective situation. In an individual case, it is most likely for wellbeing, and for the collective case, it has an importance on countries' productivity 3 . So, we ignore here the difference between medical healthcare and public health care but we discuss in general health care (for the overall wellbeing and the productivity) where all of the health-related issues are included remarkably.

The concept of utilitarianism in pandemic case:
What is utilitarianism and why do policymakers want to use it? And what is the relation to make a greater good by this concept? Utilitarianism is a consequential moral theory that we can define it as an "act in such a way as to generate the maximum quantum of well-being, happiness, or utility" 16 . Mostly it is well known by its famous dictum "the greatest happiness of the greatest number" which will help us to measure what the right thing we have to do? For example -Suppose Dr. Ranju is a practitioner who works in a hospital and Mr. A, B, C, D & E are the five sick people who come to this doctor's chamber with the sign-symptom of coronavirus, but it is not confirmed by the test yet. Mr. A comes from Wuhan city and that's why it is a high possibility for him to be treated as corona positive. The authority of the hospital can't provide enough PPE for the doctors and now the supplied PPE is finished. What does Dr. Ranju do? It is his duty to treat the patient but also it is his right to get the PPE to continue his duty.
According to the utilitarian theory, an action should be measured in terms of the consequences that it produces and by following this concept the authority ordered Dr. Ranju has to start his duty without the PPE (due to the lack of the PPE) to ensure healthcare facility for the five peoples (for the most good, even if the doctor has faced a risk). What does Dr. Ranju do? Imagine Mr. A is surely corona positive but others are not. If Dr. Ranju starts his duty without PPE and that's why there is a chance to be contaminated by the virus, and then he will contaminate the other four peoples. Then these four people spread it to the community and the doctor spread it to his family. So it is not the greater well-being to treat five people even if the doctor has faced a risk, but the greater good is ensured when the doctor's duty and right will be fulfilled at the same time.
This is the view of utilitarianism where the purpose is to maximize the total "utility", in this case, total welfare, of all the members of the society 3 . Due to the lack of proper ethical investigation here authority treats health workers as out of the members of the society and makes them vulnerable. And this is the gap we need to unveil here.

Marker of the Gap:
The bioethicists try to make ethical policy and help to rearrange legislations that can manage these situations peacefully and significantly. In the pandemic crisis, there is a non-visible enemy that we calla virus. If any visible enemy tries to attack us, the best protection protocol is operated by the police/cops. But what will happen for this nonvisible enemy? Or, is there any enemy between the doctor-patient relationships? In the normal situation, there is a 3 character one is the victim, one is the enemy and another is the cops/police. But in the pandemic situation, this is a little bit different. For better understanding, we bring here an example from the book of Physical Therapy Ethics, 2nd edition 17 . A story about Doctor Luis. She is a physical therapist working in a rehabilitation clinic, has a lady client who was injured in a family dispute. Suddenly, the irate spouse of the lady entered the chamber with intoxication mode and asked if his wife is in there, by pointing his finger to the treatment room. Now, what does Luis do? Does she tell the truth and make the lady's life risky again? Or, to save her client's life, she tells a lie to the lady's husband (e.g. -she has been discharged)? As a patient, the lady has a right to life and right not to be assaulted by others. On the other hand, the husband has a right to know about the truth (as a guardian). What does Luis do -if she tells a lie or if she ignores the husband's answer or if she avoids the protection of the patient's life, then all of them are morally and ethically wrong. In this situation as a doctor, Luis has to maintain the four basic ethical principles (autonomy, beneficence, nonmaleficence & justice) for the overall good. But if to tell the truth to her husband and to treat the patient at a time, has the possibility of violence by the husband and doctor's life also has a risk then what she has to do? Does the doctor willingly agree to keep her life in danger? Due to this critical situation, we can't claim against the patient or even the doctor. The husband was drunk, and this is the situation that makes this system ruthless. If any system or event like this is inappropriate, what is the logic to support only the patient and why do doctors have to suffer, when she is totally detached? Should we pressurize her to treat the patient without supplying protection or should we support him by sending a police force or cops? This is the point we try to rise.So, the thing is the enemy-doctor-patient-police relationship is a different thing than the concept we exercise in our regular society. This is the gap here and that is -the police are not enough to protect from this non-visible enemy (virus). So, to strengthen the health caregiverpatient relationship protection by the PPE is the point here. When there is a lacking of this protection,health caregivers are neglected and treated as a vulnerable group and the moral questions here is -

Why are patients getting the benefit but not the doctors? & is it utilitarianism?
2. Is it not a sign that the health workers are now a group of vulnerable people?
We will talk in detail in the argument section below.

Why is PPE reasonable?
In this coronavirus pandemic, why do we turn this PPE to give it an extra preference? According to the CDC "patients with confirmed or possible SARS-CoV-2 infection should wear a facemask when being evaluated medically" 18 . Without PPE it's like frontline Gpsareneglected. In Germany, due to the lack of PPE, the German GPs do a nude protest to understand how vulnerable they are without their protection. Ruben Bernau, a GP in that group stated that "The nudity is a symbol of how vulnerable we are without protection" 19 .
Not only the German but the other frontliner health caregivers protest is still ongoing 20 . Other places they are doing a silent movement for the same cases. We use silent movement here because every doctor wants and united for their rights, but they can't due to the fear of their suspension, unemployment, firing, death threat and so on that we stated in the upper section already. It looks like -Nobody knows the real solution for this problem. Doctors even sacrifice their lives for the sake of their duties, just they want protection not only for themselves, but for the overall good (like -patients, families, populations, and the globe). Not only that, but even doctors also buy their protection to save their lives and people's life 21 . These troubles make asenseof why PPE is reasonable for their life, right and just. We arise a couple of argument bellow on the argument section by raising these questions- Policymaking of public health is mostly a position based outcome that analyzes in relation to consequences which is known as utilitarianism 1 . It is one of the leading concepts of ideology for public health issues 22 . According to Beauchamp and Childress utilitarianism is one of several ethical theories that measures the value of actions by their ultimate ends and consequences. The method of this concept is perhaps the best known medical and nursing ethics text among the oft-used theories 23 . WHO also acknowledges it as a leading concept of ideology for public health issues 22 . We agree upon that but the gap we found here is the real greatest well-being will be truly possible when doctors' protection is appropriately maintained by themselves and by their authority. According to the Smith (2020) "Government and global health actors are currently working in a highly stressed environment…. securing PPE is a complex logistical challenge, I argue that we should bring about a shift in orientation from the provision of PPE as a supply chain issue, to seeing the distribution of PPE as a crucial issue. In the short term, this is essential in order to protect healthcare workers and prevent the health system overwhelm.
In the longer term, the equitable distribution of PPE has the potential to give the greater visibility to the risk and embodiedvulnerabilities that healthcare workers take in the course of their work, to deepen our understanding of the contributions that healthcare workers make to society and to the functioning of our health systems, and to bring deeper protection and empowerment to health care workers" 24 .
After the death of Dr. Li Wenliang in Wuhan, it is first to come to the media attention that the health workers themselves are a new group of vulnerable populations 25 . The upper example, nude protest, doctors movements, reports, and news also support that the health caregiver themselves is now a group of vulnerable people only for the PPE crisis. Now surely it is a catastrophe which makes them vulnerable. According to the Belmont Report 1979, to protect the vulnerable population from harm and exploitation has now greater importance 26 . Thevulnerability makes them unable to defend themselves as we see on the upper pieces of evidence. So it is hidden coercion to make our sense to understand that the overall moral more good is only the good of the population of the community (patients) and this is the best consequence that we justified. In ethics and health policy this concept is known as utilitarianism. But there is a gap when health workers are tagged as a vulnerable group.

[3] [4]
3 More overall good may be done for the population by the sacrifice of a minimal amount of health worker's life, but if it would be the theme then this will be done by having a rule that permits this practice thoroughly. And if it is validated, then there will be a crisis of the doctors which may lead to greater harm to the community. If health workers are neglected and having risk for their life how can they trust the government or the authority? And why do they come as health caregivers? Hence, the rule that allows one doctor dies to save five or more people, would not maximize utility 28 . So the crisis of PPE is the crisis of the health workers, the crisis of the health workers is the mismanagement of the treatment, mismanagement of the treatment increases the sufferings of the peoples which increases the pain of the greater number that leads to the oppositedirection of the utilitarianism concept.

Conclusion:
Health is now a fundamental issue for both individually and collectively 3 . But, in that case, today it is a fact that the healthcare workers are now involved in the group of vulnerable people. It is also a problem that they cannot speak up to justify themselves as vulnerable people due to the political and authoritativecoercion. "A particular principle of justice cannot easily supply any special moral obligations to care for certain segments of the population, even if they are so obviously suffering" 29 .Vulnerable people need special protections. In this pandemic crisis, it is a hidden gap to implement the healthcare policy for the greater/common/ public good. If the negligence procedure is done by having a rule that permits to continue it then it will be validated which tends the utilitarianism into the reverse way and we cannot find the greater good for the greater number but greater bad for the greater number instead.