The Covid-19 outbreak has pushed European healthcare systems to their limits. Those at the frontlines have been forced to make grim decisions about which patients merit treatment and which will have to be turned away. Katerina Glyniadaki asks whether the moral challenges posed by the crisis may ultimately foster a greater sense of compassion and solidarity in European politics.

In the midst of the worst global pandemic in recent history, an increasing number of Covid-19 patients across the world do not have access to the critical care they need. Despite the rapid rise in demand, the available essential healthcare services remain finite. Even in countries with highly developed healthcare systems, such as Italy, Spain or the US, there have been dire shortages in intensive care beds, oxygen ventilators and personal protective equipment. Under these circumstances, and with limited relevant guidelines or feasible solutions, doctors are faced with grim daily dilemmas. Put bluntly, they have to choose who lives and who dies.

Dramatic as this sounds, decision-making under conditions of high uncertainty is not entirely new and unfamiliar to frontline workers. Especially in times of crisis, it is often those at the frontlines who have to make the hardest decisions, shaping directly human lives, as well as the outcomes of – not always perfectly-designed – policies.

Credit: Sam Saunders (CC BY-SA 2.0)

In the context of the so called ‘refugee crisis’, for example, moral challenges of critical significance for people’s lives have been part of the everyday reality of front-line workers. Asylum judges are meant to decide who deserves refugee protection and who should be deported, often in the face of limited available evidence. And, as housing is not always guaranteed for those in the waiting process, social workers have to decide who gets access to housing and who doesn’t, often based on a vague list of ‘vulnerability’ criteria. In a similar vein, as many applicants fall through the cracks of the system and can only make a living though irregular means, police officers have to decide whether or not to arrest the migrants who commit petty crimes.

Making such difficult decisions on a daily basis can put a heavy emotional toll on front-line workers, invoking equal amounts of stress and frustration. This is an important lesson I came to learn from my PhD fieldwork at the front lines of the ‘refugee crisis’ in Europe. Between 2015 and 2018, I conducted nearly 150 qualitative interviews with front-line workers from Athens and Berlin, including asylum judges, legal advisers, social workers, and healthcare professionals. Being almost always under strain, either due to an extremely heavy workload, a shortage of material resources, or a lack of available legal solutions, frontline workers constantly have to make decisions about who to help and who to leave behind.

Inadvertently, those beneficiaries who, in the eyes of front-line workers, appear more deserving of help are also the ones more likely to receive the help they need. In clear-cut cases, this means asylum applicants from war-torn countries are more likely to receive asylum, ‘vulnerable’ categories such as single mothers or physically disabled people are more likely to get housed, and juvenile delinquents are more likely to escape jail time.

In reality, however, very many cases are far from clear-cut, falling instead within a ‘grey zone’ of a given policy framework. Think of an asylum case of an 18-year-old boy who may be deported to Kabul, a city that may be neither entirely familiar to the young asylum applicant, nor entirely safe. What should the asylum judge decide for him? Alternatively, think of the case of a housing applicant with an invisible disability, such as a severe mental health condition, which she does not have the means to prove. What should the social worker decide for her housing situation? Or, think of the cases of ‘sans papiers’ who are caught breaking the law by selling fake sunglasses at a street corner. Should the police officer arrest them or not? Although frontline workers’ decisions may not immediately result in the literal death of these migrants, they are still critical for the migrants’ lives, while they are also shaping the outcomes of relevant policies.

In the case of the Covid-19 pandemic, the difficult dilemmas of frontline healthcare workers are undoubtedly more critical. Across different countries of the ‘developed West’, healthcare systems are now at a breaking point. And, as systems cannot support the sudden, sharp rise in demand for care, doctors and nurses continue to provide services under emotional and physical exhaustion, having to make life-or-death decisions about their patients, while simultaneously risking their own lives.

The severity and immediacy of these dilemmas notwithstanding, there is an additional reason the current situation seems so scary: these difficult frontline decisions could be about us. Although the economic impact is likely to affect some more than others, the virus is oblivious to physical borders and does not discriminate by social class, gender, ethnicity, race or religion. Especially in countries with nationalised healthcare systems, the patient a doctor may decide to leave behind could very well be us, or one of us: a family member, a beloved friend, a close neighbour. It’s no longer merely about the ‘other’: the migrant, the poor, the minority person. This time, the crisis has hit much closer to home.

Unfortunately for frontline workers, and for us, working to deliver services under highly pressing conditions is not entirely unprecedented. We now all wish there were more healthcare professionals able to respond at the front lines, more and better equipped hospitals, and some kind of protection for the most vulnerable among us. But as long as there continues to be a mismatch between the material and human resources needed and the ones dedicated to the cause, front-line workers will continue to carry a disproportionate weight of responsibility.

The question that arises, then, is whether these extraordinary circumstances will push us to rethink how we make decisions as citizens and as voters. Could the international shock of a rapidly increasing death toll manifest into a greater general sense of compassion and solidarity? Perhaps more importantly, could this unexpected experience show us the need to seek governments and policies that are more human-centric?

For the more optimistic among us, every crisis has a silver lining. In Macron’s words, “our welfare states are not costs or burdens but precious goods, indispensable assets when fate strikes”. At the EU level, politicians and bureaucrats have already begun to formulate a co-ordinated response strategy to mitigate the socio-economic impact this crisis is going to bring. In this crisis, we are all hoping that cooperation and solidarity do prevail.

Until that happens in a substantive and tangible manner, the clock is ticking painfully loud. As Giorgio Gori, the Mayor of Bergamo put it, “patients who cannot be treated are left to die”.

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Note: This article gives the views of the author, not the position of EUROPP – European Politics and Policy or the London School of Economics.


About the author

Katerina Glyniadaki – LSE
Katerina Glyniadaki is a Teaching Fellow at the LSE’s European Institute.

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