From Thursday, around 200 medical ethicists will be meeting in Oldenburg to discuss medicine and time. Mark Schweda and Lena Stange from the division Ethics in Medicine at Oldenburg University Medicine explain why this connection is important, yet has so far received far too little attention.

The waiting room, where time seems to stand still, seems symbolic of the theme of medicine and time. Is this a topic that medical ethics addresses?

Mark Schweda: It is certainly a very good example of the importance of time in medicine. In the waiting room, we realise that medical care is not immediately available to all of us at all times. Resources are limited in terms of staff, funding and, indeed, time. Waiting times therefore frequently play a role even in day-to-day care. When someone who actually arrived later is seen before us, we find ourselves right in the middle of discussions about fairness. The same applies, for example, to waiting lists for organ transplants or the controversial debates we’ve had about triage regarding ventilator beds during the COVID-19 pandemic: who should receive potentially life-saving treatment first? How can we organise access to scarce resources in a sensible and fair way?

Lena Stange: Time can determine recovery, quality of life, costs and, ultimately, life and death. Anyone who wants to understand medical care must also understand the significance of time in this context. How much time each person is given is one of the central questions here. 

What about the time available to those working in the healthcare system – or rather, the time pressure they face?

Schweda: We, of course, repeatedly encounter the structurally driven time constraints faced by carers and medical staff. Studies show that patients are often interrupted for the first time within just a few seconds of a consultation. Conversations frequently take place under severe time pressure. And in nursing, there is the term ‘missed care’, which describes necessary nursing interventions that are not carried out, or not carried out in full, due to a lack of time. This not only has consequences for the quality of care, but also raises ethical questions regarding the well-being of patients.

Is there any area of medicine at all where time does not play a significant role?

Stange: Time is not a universal constant, but it is, in fact, always a relevant factor. This means, for example, that we make every medical decision with an eye to our own past and future. Time is not always a critical factor. Of course, there are also medical decisions that patients can make calmly and without time pressure because they are dealing with long-term prospects – for example, in the case of chronic conditions.

Schweda: The interesting thing is this: although time actually always plays an important role in medicine in one way or another, it has so far been scarcely mentioned in specialist discussions on medical ethics. In medical ethics, we often ask ourselves whether a particular course of action is, in principle and generally speaking, just or morally justifiable. But the extent to which this assessment depends on time receives little attention. Yet it is important, for example, to take into account the stage of life a person is at, or the impact our medical developments and decisions will have on future generations. This is another reason why we wish to address this long-neglected topic at the symposium organised by the Academy for Ethics in Medicine. 

Not least through the research carried out by the DFG research group ‘Medicine, Time, and the Good Life", you are examining this connection in depth in Oldenburg. What are you particularly looking forward to at the annual conference?

Schweda: In particular, questions regarding the significance of intergenerational relationships in healthcare. What role does it play in medicine or care that people, with their own limited lifespans, are at the same time embedded in cross-generational temporal contexts? What, for example, do we in medicine owe to the contribution of past generations to medical research, and to what extent does this itself impose a moral responsibility on us to contribute in our turn? How do we ensure that the medical and nursing care we are able to receive today will still be available to future generations? These are fundamental questions that are only gradually receiving attention.

How does an understanding of the influence of time help to improve medical care?

Schweda: It is important to take time more seriously as a crucial dimension in medical ethics. This improves medical ethics, and better medical ethics also means that we can better guide and support the medical profession itself – whether in the clinical ethics committees of local hospitals or in ethical policy advisory bodies, such as those at regional or federal level. We also play a part in the training of future doctors – for example, by encouraging them not to interrupt patients after just a few seconds, but to take more time and learn what they need to know to provide good care.

Stange: The perspective of time can also help us to identify inequalities in healthcare – for instance, where people have poorer access to healthcare services than others due to excessively long waiting times, time-consuming bureaucracy or age limits.

What role does one’s stage of life play in determining what is medically appropriate – and how might such perceptions change over the course of a lifetime?

Schweda: The great promise of modern medicine is to make time manageable or even to give us more of it. As a result, we are now discussing, for example in the field of reproductive medicine, at what age the use of new reproductive technologies is appropriate or not. Or take life-prolonging measures in intensive care: towards the end of their lives, many people today are overtreated. This means they receive treatments that are actually no longer beneficial or may even be harmful. When it comes to making a specific assessment, however, it makes a huge difference whether we are dealing with a young child, a teenager, someone in middle adulthood or a very elderly person. The stage of life at which a medical issue arises is of crucial importance. 

Stange: After all, many factors change over the course of a lifetime – not only one’s physical constitution, but also one’s own ideas about how one wishes to live. Take, for example, planning for the end of life: anyone who considers living wills reflects on what is important to them in a situation where they are unable to make decisions for themselves – and that can change time and again over the course of a lifetime.

Interview: Sonja Niemann