Margot Nicole I. Kuylen

In their discussion paper of November 2020, Cooket alpresent a draft protocol for navigating circumstances in which emergency services are overwhelmed. Their paper suggests that COVID-related triage decisions should be based on clinical assessment, patient and family consultation, and a range of ethical considerations. In this response, we note that the protocol exhibits an ambiguity that is likely to result in irresolvable dilemmas when put into practice. This ambiguity is exemplified in the paper’s prime ethical imperative (to ‘save more lives and more years of life’), which takes the form of an undefined conjunction whose practical implications are left unspecified. We see this ambiguity in the prime imperative as one manifestation of a broader set of tensions in the protocol. We show that the discipline of human rights provides an essential supplement to the ethical framework on which Cook and colleagues rely, providing a framework for understanding and working through triage dilemmas involving age, discrimination and equality.

The COVID-19 pandemic put a large burden on many healthcare systems, causing fears about resource scarcity and triage. Several COVID-19 guidelines included age as an explicit factor and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those in care homes. To ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions. Our study aimed to explore general public views in the UK on the role of age, and related factors like frailty and quality of life, in triage during the COVID-19 pandemic. We held online deliberative workshops with members of the general public. Participants were guided through a deliberative process to maximise eliciting informed and considered preferences. Participants generally accepted the need for triage but strongly rejected ‘fair innings’ and ‘life projects’ principles as justifications for age-based allocation. They were also wary of the ‘maximise life-years’ principle, preferring to maximise the number of lives rather than life years saved. Although they did not arrive at a unified recommendation of one principle, a concern for three core principles and values eventually emerged: equality, efficiency and vulnerability. While these remain difficult to fully respect at once, they captured a considered, multifaceted consensus: utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability. This ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage.

This thesis starts from the intuition that it is possible to oppress oneself. On an initial description, self-oppression is a form of agency in which the agent, though exercising self-control, compromises her own choices in doing so. But, as such, self-oppression seems paradoxical and thus impossible: how can an agent be both the oppressor and the oppressed? And how can she compromise her own choices? The headline aim of the thesis is to offer a conceptualisation of self-oppression, thus establishing it as a possible as well as a distinct form of agency. The strategy of the thesis is rather unusual. In the first chapter, drawing on Aristotle’s philosophy of action, I devise the category of hyperkrasia, designed to capture the phenomenon of self-oppression. I propose that, in hyperkrasia, an agent’s practical reason becomes authoritarian. This category is then further developed throughout the thesis, drawing on Augustine, Foucault, and Merleau-Ponty. Augustine’s notion of a corrupted will provides an account of how choice can be compromised without agency being bypassed: the agent with a corrupted will chooses to φ, but cannot but choose φ. Foucault’s notion of domination provides an explanation of how an agent’s will can be corrupted by factors influencing her perception of opportunities. Merleau-Ponty’s phenomenological account of action shows how our perception of opportunities can draw us toward action. Bringing these elements together, I propose that practical reason can influence an agent’s perception of certain opportunities, drawing her so strongly toward them that she cannot but act on them. As such, she makes a choice; but it is compromised, and this by her own practical reason. This resolves the paradox of self-oppression: it is practical reason which becomes the oppressor, and it compromises the agent’s choices by influencing the way she perceives certain opportunities.