Bioethics Forum Essay
Are Physicians Hypocrites for Supporting Black Lives Matter Protests and Opposing Anti-Lockdown Protests? An Ethical Analysis
The United States has seen a dramatic rise in social unrest drawing large gatherings of protesters at a time when public health officials and physicians are urging people to socially distance to limit the spread of a deadly pandemic. Two distinct protest movements, anti-lockdown and Black Lives Matter, have garnered remarkably different responses from physicians and their professional organizations. Physicians have been vocal in condemning the anti-lockdown protests, while endorsing and even participating in the Black Lives Matter protests. This has led to criticism of the medical community for being inconsistent and hypocritical. These allegations are serious as the perceived hypocrisy of physicians can erode trust in expert opinion at a time where decisive and coordinated action is necessary to minimize the death toll of Covid-19.
If the medical community expresses the opinion that mass gatherings during a pandemic endanger health, then it would seem that all mass gatherings should be equally condemned. Like most things in medicine however, there is a risk-benefit balance to be considered.
When faced with ethical principles in conflict, clinical ethicists often rely on a structured approach to identify important factors and weigh them against each other to illuminate a best way forward. We have chosen the four box method to help clarify the ethical issues around the Black Lives Matter and anti-lockdown protests during the pandemic. This method juxtaposes medical indications, patient preferences, quality of life, and contextual factors.
Medical Indications: What is the likely public health effect of the gathering? What would be the effect of achieving the outcome for which they are protesting?
Protester Preferences: What are the protesters values and beliefs? What is the outcome they hope to achieve?
Quality of Life: How will the quality of life of protesters (and of others) be affected by the protest? By achieving the desired outcome of the protest?
Contextual Factors: What are the historical and current socioeconomic issues motivating protesters?
For the protester preferences and quality of life, we limit our analysis to the points made by protesters from the respective movements. For medical indications, we bring in the viewpoints of medical and public health experts, and for the contextual factors, we include some of the historical and societal forces at play.
The coronavirus has caused a deadly pandemic. Social distancing and mask-wearing prevent the spread of this virus. Shelter-in-place orders can slow its spread, but can also lead to economic hardship and loss of jobs and health insurance and exacerbate domestic abuse. Lockdown of nonessential businesses protects workers against Covid-19. Mass gatherings can propagate the spread of the pandemic and should be avoided.
Black people die at the hands of law enforcement more than others and are disproportionately policed and incarcerated. The resulting mass incarcerations have significant health consequences for inmates and their families. The pandemic has also disproportionately affected Blacks, who are more likely to be essential workers and live in crowded conditions and thus are at increased risk of contracting and dying from the virus. Black people also experience discrimination in the health care system, contributing to worse medical outcomes. Historically, civil rights movements have led to progress with a positive impact on public health.
Therefore, the Black Lives Matter protests against police killings and mass incarceration and for equal treatment are aligned with public health recommendations, with the exception that they are taking place during a pandemic.
In contrast, the anti-lockdown protests are directed at the very public health and medical recommendations intended to protect the public and are taking place during a pandemic. However, they also make important claims about the importance of the economy: preservation of jobs and health insurance to prevent severe health consequences, including deterioration in mental health.
Both protest groups are exercising their First Amendment rights of freedom of assembly and speech.
At the forefront of the Black Lives Matter protests are demands for equal treatment by law enforcement. The pandemic has also laid bare the unequal access to health care and other societal resources, leading to a disproportionate death toll from Covid-19 among Blacks and other minorities. Still, some protesters believe they are more likely to die from police brutality than from Covid-19 and thus believe that the collective risk to minorities of the status quo outweighs the collective risk of protesting during a pandemic.
The anti-lockdown movement has made infringements on individual freedoms its rallying cry. Protesters demand freedom from the burdens of lockdown, social distancing, and masking, demanding a right to work and keep businesses open. Many perceive government intervention as tyranny despite the fact that, by law, governors and local governments are afforded significant public health powers during pandemics.
Protesters believe that constitutionally guaranteed freedoms are more important than the collective benefit of a social lockdown in reducing the spread of the pandemic
Quality of Life
The Black Lives Matter movement demands equal opportunities and freedom from harassment and fear. Protesters ask for the ability to do normal everyday activities such as going for a walk or run without fearing for their lives or being falsely accused of criminal activity.
The anti-lockdown movement highlights the right to work and earn a living and the ability to enjoy such things as dining out, going to bars, and getting haircuts. They also want to be able to gather for funerals and weddings.
Unfortunately, Covid-19 public health interventions have been politicized in the U.S. to the point that at times policies and directives stem more from partisan politics than from sound public health evidence. Protests lead to more press coverage, which can effect positive change but also increase polarization.
The Black Lives Matter protests should be viewed through the legacy of slavery and systems that unfairly favor white people and disadvantage Black people and other minorities. The medical profession has historically failed to take a stand on racial justice issues, which has led to worse health outcomes for Black patients than for white patients. Black Lives Matter protests seek to dismantle these systems of structural racism. While most of these protests were intended to be peaceful, masked, and unarmed, some protests have devolved into unlawful riots, looting, and defacing and destruction of property.
The anti-lockdown protests should be viewed through the lens of the uniquely American culture of libertarianism that favors individual freedoms over solidarity and community welfare. Libertarian values still place limits on individual freedoms when they put others at risk. While sometimes peaceful, many anti-lockdown protesters have been armed, with the express intent to intimidate elected and public health officials. Taking up arms against the government and government officials is also unlawful.
We acknowledge that official statistics show that Black communities suffer higher rates of homicides and that a much-cited report from the Bureau of Justice Statistics showed Black people as the offenders in 52% of homicides between 1976 to 2005. But this figure and other statistics on Blacks arrested for homicide have been called into question, given that Blacks are more likely than other groups to be arrested. Nevertheless, the perception that Blacks are especially likely to commit homicides propagates fear and subconscious bias among law enforcement officers, which in turn can lead to disproportionate policing and use of deadly force. While there is a need for physical and legal protection for police while doing their duty, the contrast in law enforcement responses to the two protest movements striking.
Finally, it is important to acknowledge the potential severe economic consequences of the lockdown. However this must be weighed against the combined health and economic effects of the pandemic for both individuals and society. In addition to the loss of over 180,000 lives and growing, a recent estimate suggests that the societal costs of Covid-19 would end up being higher with inadequate containment measures than with lockdown measures because of a higher disease burden and a more prolonged recession.
While individual readers will weigh these arguments with their own values, there are legitimate reasons for viewing the anti-lockdown and Black Lives Matter protests differently both from a medical and a societal perspective. The most straightforward argument is that the purpose of the anti-lockdown protests is diametrically opposite to medical recommendations while the Black Lives Matter demands are consistent with public health imperatives.
Disclaimer: The authors are writing on behalf of the Society of General Internal Medicine (SGIM) Ethics Committee. The views presented here represent those of the authors and are not an official statement of SGIM or the SGIM Ethics Committee. We acknowledge the contributions of other members of the Ethics Committee.
Bjorg Thorsteinsdottir, MD, is an academic general internist and palliative care physician at Mayo Clinic in Rochester, Minn., and an assistant professor of medicine and bioethics at the Mayo Clinic College of Medicine. She does research on the ethics, economics, patient centered outcomes as well as shared decision making for end stage kidney disease, Twitter: @BjorgTh. P. Preston Reynolds, MD, PhD, MACP, is a professor of medicine and a general internist at the University of Virginia where she teaches and does research in ethics, professionalism, human rights, and the history of structural racism in American medicine. Lisa Rucker, MD, is a professor of medicine at the Einstein College of Medicine/Jacobi Medical Center in Bronx, N.Y., and has taught clinical medicine for more than 30 years. Elizabeth Dzeng, PhD, MD, MPH, is an assistant professor of medicine and sociology at the University of California, San Francisco. Her research focuses on the ethics, sociology, and human centered design in end-of-life care, Twitter: @lizdzeng. Randy Goldberg MD, MPH, FACP, is an academic hospitalist and chair of ethics at Westchester Medical Center in Valhalla, N.Y., and an assistant professor of medicine at New York Medical College, Twitter: @DrGaellon