Covid 19: Precautionary principle or « risk of blame »?

This text extends the debate on medical and health care decision making that was initiated around Evidence-based-medicine (EBM) with the white paper entitled:  » the role of physician training and medical epistemology in the Covid 19 crisis « . (1)

By:

  • Florence PARENT, physician, doctor of public health, coordinator of the thematic group « Ethics of health curricula » of the International Francophone Society of Medical Education (SIFEM).
  • Fabienne GOOSET, Doctor of Letters, certified in ethics of care.
  • Manoé REYNAERTS, philosopher, member of the thematic group « Ethics of health curricula » of the International Francophone Society of Medical Education (SIFEM).
  • Helyett WARDAVOIR, Master of Public Health, member of the thematic group « Ethics of health curricula » of the Société internationale francophone d’éducation médicale (SIFEM).
  • Dr. Isabelle François, physician and psychotherapist, member of the thematic group « Ethics of health curricula » of the Société internationale francophone d’éducation médicale (SIFEM).
  • Dr. Benoit NICOLAY, physician, anesthesiologist, micro-nutritionist.
  • Jean-Marie DEKETELE, professor emeritus of the UCL and of the UNESCO Chair in Education Sciences (Dakar).

A decision based on « reflective judgment(2)in reference to the German philosopher Emmanuel Kant(3)is a decision that takes into account the reality of the life, that is to say the particular situation, including the singularity of the Subject, of the Other (person or community) and, by this, the subjectivity of the real, what one would name the uncertainty.

In public health, the preferred criterion that best approaches such a decision is the anticipation of the « cost-benefit » of an action and therefore the risk taken in making the choice.

In fact, cost-benefit analysis values all the consequences of a program or intervention, making it possible to take into account the risks associated with the actions in order to choose between the various alternatives. The responsibility for the choice made, among multiple possibilities, is clearly announced.

This is a criterion to be differentiated from that of the precautionary principle (focused primarily on the risk for the object considered as vulnerable: person; community).

Finally, the statistical proof of the effectiveness of an action, based on a measurement, which is promoted by Evidence-based Medicine (EBM)(4)When it exists, it is only one of many pieces of information and parameters to be taken into account, depending on the degree of openness that the mobilized notions of health and person (in the sense of a Subject) will have fostered.

The precautionary principle

The precautionary principle radicalizes the EBM perspective by stating that, even if there is a demonstrated (or highly probable) benefit of an action to be taken, it should be refrained from if the absence of significant risk (non-maleficence) has not been established. It is an ethical position (and therefore debatable, since it is a question of values that are at stake), which privileges the principle of non-maleficence by considering that it must prevail over all others, for example over those of benevolence, autonomy or distributive justice, to take up the guiding principles set out in the principalistic perspective of Childress and Beauchamp(5).

Éric Chevet(6) points out that the precautionary principle has been the subject of many criticisms, including the criticism that the principle is a negative strategy because it  » [ne] would be, in fact, [qu’] a principle of suspicion and conjuration […], based on a progressive disqualification of science in the decision […] and on the desire to eliminate all uncertainty reinforced by the impossibility of achieving it. This criticism then highlights the paralyzing dimension of the precautionary principle, which degenerates into an aversion to risk-taking.  »

Initially laudable in its intentions, notably in terms of public health or environmental protection, this principle would then be a way of giving reason to the concerns of an opinion influenced by the media ready to be alarmed. This principle, ultimately paralyzing, would allow decision-makers to protect themselves legally (the « temptation of the umbrella » or blame avoidance strategy) to the detriment of the risk-taking that development presupposes.

With the precautionary principle, » says Michel Puech, « we are exposed to a drift, that of strategies giving priority to the absence of blame rather than to the absence of risk (blame-avoiding strategy), i.e. strategies that lead me to act in such a way that I cannot be blamed if things go wrong. This is how the solution turns into an aggravation of the problem. Precaution in the sense of blame-avoiding strategy comes down to a refusal to take responsibility in a situation which, precisely, requires the taking of responsibility, the capacity to assume, to decide because, in this situation, techno-scientific knowledge cannot « decide » by a simple optimization calculation. The precautionary principle is at the service of those who conceived it: politicians and technocrats who want to be responsible-but-not-guilty » (7).

For our part, we consider that the use that has been made of the precautionary principle during this crisis leads to the criticism and the hypotheses proposed. However, we keep a neutral view on this principle. Indeed, the precautionary principle also has its strengths when it is mobilized in an appropriate and nuanced manner, as Éric Chevet has developed(8).

The issue of of blame and the question of values

Thus, in relation to the issue of blame that interests us here, it appears that values underlying the object of the decision emerge in a « radical » way without doubt, but at the same time, in a « masked » way, with this crisis of the Covid 19.

Indeed, it is very interesting to analyze the use of this precautionary principle (as a reminder, focused on the risk of an intervention rather than its effectiveness) depending on the object of the decision and the « risk of blame », testifying to the epistemological chaos(9) and, more fundamentally, ontological (i.e. our relation to reality) in which we find ourselves.

Let’s do the exercise

- Regarding the early treatment of the disease, the knowledge of the very low risk of the proposed molecules, especially hydroxy-chloroquine, widely documented by studies and experience, has not prevented the Order of Physicians from strongly advising general practitioners against prescribing them — by recommending the use of protocols considered formal, which did not include early treatment — by invoking wrongly the precautionary principle: What is the issue of blame here? Could it be the lack of certainty as to the efficacy of the treatment, thereby reinforcing the epistemological confusion previously discussed around EBM and at the same time signalling the value accorded to the latter, whereas the precautionary principle should be based primarily on the lack of certainty as to the absence of risk of an intervention, in this case of treatment?

- As far as containment is concerned, its various risks, psychological, social and economic, which were highly predictable while, at the same time, its benefits were only speculative, would have required the mobilization of the precautionary principle par excellence. However, this did not prevent the imposition of repeated confinements of historic proportions: What is the issue of blame here? One would be tempted to say « none » in relation to the propagation of the virus, because the decision implies that our psychological and social beings have no value (we would definitely have arrived in a biopower) in the face of the only vulnerability understood, that of our hospital health systems.

- With regard to vaccination, we are faced with a paradox in relation to the precautionary principle itself. The latter is reproached by its opponents for slowing down the evolution of techniques and progress. However, the risks (particularly deferred risks) associated with the vaccine, which are insufficiently documented given the time constraints (short lead time) of such technological developments and, consequently, relatively undetermined at the time of the vaccination campaign(10) have not prevented the mass launch of this one (all populations combined): What is the issue of blame here? The fear (self-generated because the lethality has always remained very low) of the risk itself (we are struggling, in a way, in a vicious circle), allowing to hide the object of vulnerability proper to the precautionary principle in public health, and to transfer it from the person (and the populations) to the only vision of eradication of an enemy that should become common: the virus

- Regarding prophylactic treatments (such as, among others, vitamin D and C, zinc or quercetin), despite their very likely benefit, inferable from numerous clinical research studies documenting their positive impact on the immune system, and their very low risk, no early and formal prescription action has been taken in favor of these treatments: What is the blame issue here? Could it be the fear of « medical experts » and other « decision scientists or politicians » of not being taken seriously ? And this, in the face of so-called « true » medicine, based on proof and technical prowess, such as that of vaccination?

In contradiction with the precautionary principle itself, which enjoins non-intervention in the face of risk uncertainty, our little exercise shows that only interventions with a risk assumption have been advocated.

One perceives then, simultaneously, the emergence of a « technical whole », which is self-justifying with regard to a scientism(11)on the one hand, by claiming that science has a monopoly on the elaboration of truth and, on the other hand, by denying to this science the legitimacy of organizing itself within the framework of a pluralism, at the same time methodological, postural and interpretative, thus disregarding the fecundity and the necessity of a plural and implicated science, which Léo Coutellec calls for, in connection with the requirement henceforth formulated that it should account for its social responsibility(12).

In the same movement, this « technical everything »(13) easily annihilates the notion of person, population or community. It thus evacuates the entire sector of ambulatory care and support, that of health promotion, or instrumentalizes them for its own ends by using them in a reductive way.

This short incursion into the precautionary principle, which is necessary in order to articulate it more precisely with the use, on the one hand, of an EBM understood in a non-simplifying way and, on the other hand, of the « cost-benefit and risk » criterion in public health, allows us to better understand the profound epistemological confusion in which the scientific world, with the whole ship, captains and passengers, has found itself swallowed up!

It seems, indeed, that there is no suitable place on this boat, neither for science, nor, more seriously, for the (vulnerable) person, to the benefit, paradoxically to the precautionary principle itself, of the technique alone. However, the precautionary principle was initially developed to preserve what is defined as « vulnerable ». Is it an oversight of vulnerability except for the structural vulnerability of the hospital’s intensive care and emergency rooms? But what is vulnerability, and from there, what do health and the person represent in the decision-making field of public health?

Is it not urgent to toconcretely implement the definition of health « Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity », as conveyed by the WHO and public health discourses?

We can see to what extent, as for EBM in its reductive form, the use of of the precautionary principlealone, and all the more so when it is handled in such a contradictory way depending on the object it concerns (treatment, non-therapeutic intervention, vaccine, prophylaxis), allows us to escape, in the decision, from our responsibilities as human beings which are those of :

  • Acting, taking full responsibility for the inherentuncertainty of the world;
  • complexity, taking full responsibility for the global dimensions that inhabit us (anthropological, existential, spiritual, psychological, social and biological).

In echo with the mayor of Brussels Christos Doulkeridis on February 21, 2021, we believe that it is time to leave the aim of zero risk(especially in view of the amalgam that is made in the use of the precautionary principle). If it is not a question of starting from scratch (although…), at least, as he asks (and perhaps we could land on our feet in terms of the precautionary principle), it is advisable to « reverse the logic of risk »(14).

How to get out of it?

Nietzsche’s Zarathustra dares to sing « the joy of uncertainty », celebrating the spirit of adventure, the courage that leads to what has never been risked. By continuing to reread Nietzsche, we will discover how his tragic wisdom, less heroic, more durable, consists in continuously enduring uncertainty, in integrating it into our lives and thoughts. In connection with our epistemological thread(15), it will be important to incorporate it into our action-in-health by means of in-depth educational reforms based not on certainty but on uncertainty, i.e. on the praxis that of reflective judgment.

It is also about the « courage to be afraid » in reference to Eric Chevet’s book(16)  » A « biopolitics of disasters » is undoubtedly not without the risk of invading norms, of amplifying control and security procedures. Biopower, as we have seen, can drift towards « immunopolitics ».(17) diffusing a permanent anxiety and carrying its own risk of toxicity. The relationship to catastrophe can itself become catastrophic when it leads to the promotion of a bio-Leviathan dedicated primarily to the security and preservation of life.  »

« We give to Mrs. Ch. Dupont concludes this point of reflection at(18): « We must put a long-term vision in the balance, because we will always have fears, we are afraid, but we are adults and we must manage this society with a long-term vision.

Notes et références
  1. Parent F, Gooset F, Reynaerts M, Wardavoir H, François I, Baudoux V, et al. Le rôle de la formation des médecins et de l’épistémologie médicale dans la crise de la Covid 19 – Kairos [Internet]. [cité 24 févr 2021]. Disponible sur : https://www.kairospresse.be/article/le-role-de-la-formation-des-medecins-et-de-lepistemologie-medicale-dans-la-crise-de-la-covid-19/
  2. Le jugement réfléchissant est énoncé sans disposer de catégories universelles contrairement au jugement déterminant. C’est la situation particulière qui fait émerger une loi, ou ce que Cornélius Castoriadis nomme la concrétude particulière. Par exemple, le choix d’hospitaliser ou non un patient avec le risque que cela engage, ou encore celui de confiner une population dans un contexte épidémique ou de mettre une personne en quarantaine. Le jugement déterminant est énoncé en disposant de catégories ou de concepts universels, ayant valeur de certitude. Le jugement déterminant ne tient quasi pas compte du particulier (contexte) ou du singulier (personne). Le degré de subjectivité dans la décision s’avère pour ainsi dire négligeable puisqu’on se fie à des lois générales fondées prioritairement sur des chiffres, des calculs et des statistiques, en proximité avec les principes des mathématiques cartésiennes (analyse de données d’études scientifiques, mais aussi projections sur des modélisations mathématiques, démarche ultime dans l’abstraction).
  3. Kant E. Critique de la faculté de juger. Paris: Flammarion; 2000. 540 p. 
  4. Parent F, Gooset F, Reynaerts M, Wardavoir H, François I, Baudoux V, et al. Le rôle de la formation des médecins et de l’épistémologie médicale dans la crise de la Covid 19 – Kairos [Internet]. [cité 24 févr 2021]. Disponible sur : https://www.kairospresse.be/article/le-role-de-la-formation-des-medecins-et-de-lepistemologie-medicale-dans-la-crise-de-la-covid-19/
  5. Beauchamp P of P and SRSTL, Childress UP& JAHP of EJF. Principles of Biomedical Ethics. 8e édition. New York: Oxford University Press, USA; 2019. 512 p.
  6. Chevet E. Le courage d’avoir peur : Réflexions sur le catastrophisme. Nice : Les éditions Ovadia ; 2016. 192 p.
  7. Puech M. Développement durable : un avenir à faire soi-même. Paris : Editions le Pommier ; 2010. 240 p.
  8. Chevet E. Le courage d’avoir peur : Réflexions sur le catastrophisme. Nice : Les éditions Ovadia ; 2016. 192 p.
  9. Parent F, Gooset F, Reynaerts M, Wardavoir H, François I, Baudoux V, et al. Le rôle de la formation des médecins et de l’épistémologie médicale dans la crise de la Covid 19 – Kairos [Internet]. [cité 24 févr 2021]. Disponible sur : https://www.kairospresse.be/article/le-role-de-la-formation-des-medecins-et-de-lepistemologie-medicale-dans-la-crise-de-la-covid-19/
  10. …allant même et de façon inédite dans cette crise jusqu’à permettre, par article de loi, de faire sauter le verrou de la responsabilité des firmes quant aux risques d’effets secondaires des vaccins.
  11. Delattre N. Scientisme et guerre des sciences. Psychotropes. 2010 ; Vol. 16(3) :7788.
  12. Coutellec L. La science au pluriel : Essai d’épistémologie pour des sciences impliquées. 1re éd. Versailles : Editions QUAE GIE ; 2015. 84 p.
  13. Nous attirons l’attention du lecteur sur un fait critique, celui de ne pas opposer la technique à l’humain, mais de considérer ces deux entités dans un continuum ontologique (cf. note 19). Cependant, ici, l’hégémonie techniciste ne laisse plus aucun espace à une liberté du Sujet.
  14. Lalibre.be L. Le bourgmestre ixellois Christos Doulkeridis en appelle au déconfinement : « Le risque d’explosion est là, un peu partout » [Internet]. LaLibre.be. 2021 [cité 24 févr 2021]. Disponible sur : https://www.lalibre.be/debats/opinions/l‑appel-d-un-bourgmestre-bruxellois-christos-doulkeridis-lance-le-debat-sur-le-deconfinement-603248a07b50a62acf2bd4ca
  15. Parent F, Gooset F, Reynaerts M, Wardavoir H, François I, Baudoux V, et al. Le rôle de la formation des médecins et de l’épistémologie médicale dans la crise de la Covid 19 – Kairos [Internet]. [cité 24 févr 2021]. Disponible sur : https://www.kairospresse.be/article/le-role-de-la-formation-des-medecins-et-de-lepistemologie-medicale-dans-la-crise-de-la-covid-19/
  16. Chevet E. Le courage d’avoir peur : Réflexions sur le catastrophisme. Nice : Les éditions Ovadia ; 2016. 192 p.
  17. Brossat A. La Démocratie immunitaire. Paris : La Dispute ; 2003. 128 p.
  18. Pour Info : quels sont les dangers des variants du covid ? [Internet]. LN24. [cité 25 févr 2021]. Disponible sur : https://www.ln24.be/2021–01-18/pour-info-quels-sont-les-dangers-des-variants-du-covid
  19. Steiner P. Philosophie, technologie et cognition. Etats des lieux et perspectives. Intellectica. 2010 ; 53(1) :740.
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