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  • BIOETHICS FORUM ESSAY

COVID-19 and the Global Ethics Freefall

Published on: March 19, 2020
Published in: Covid-19, Ethics, Global Health, Hastings Bioethics Forum, Pandemic Planning

Since the initial outbreak in Wuhan last December, the national and global responses to COVID-19 have been in ethics freefall. Chinese scholars wrote on this blog about the death of Dr. Li Wenliang, and how he was detained and reprimanded for raising the alarm about a novel infectious disease. As the Chinese government implemented drastic measures, including quarantining over 50 million people and other policies such as monitoring and regulating movements of hundreds of millions through smartphone apps, very few observers raised the issue of ethics or the now seemingly forgotten concept of human rights. There was also little talk about ethics when Japan quarantined passengers on a cruise ship without making significant efforts to stop infections among passengers. Or when it inexplicably released all the passengers who then dispersed worldwide. There has also been little talk about ethics regarding Iran’s ability to manage its epidemic with ongoing U.S. economic sanctions.

Following the WHO’s recommendations, most countries have been implementing widespread testing, contact tracing, isolation, and other social distancing polices to reduce physical interactions between individuals. The United Kingdom, however, has decided to pursue a different and controversial path. For the time being, the U.K. is not mandating strong physical distancing policies or making testing widely available. Instead, it is aiming to create herd immunity. Based on various models with diverse assumptions, the government is planning for 40 million people to become infected. With a 1% mortality rate (the estimated mortality rate in other countries), approximately 400,000 people will die.

It is classic and brutal utilitarian ethical calculation: creating herd immunity will potentially save lives in the long term and conserve other socially valuable goods which are greater than the costs of implementing socially disruptive policies and resource investments now to prevent as many deaths as possible of the 1% to 5% who are most vulnerable. The greatest risk is to older people and those with chronic diseases and conditions– and probably the most socially disadvantaged.

The U.K. government’s lack of transparency about the epidemiological models and reasoning behind the policies, and default to utilitarian calculations shows that past two decades of public health/global health ethics scholarship has had little impact. Of particular concern, at a time when hundreds of thousands of citizens’ lives are at stake, the British leadership is reverting to what Bernard Williams scathingly described as “Government House Utilitarianism.” That is, some of the great advocates of utilitarianism argued that secrecy may be necessary to achieve a utilitarian conclusion, as the uneducated might not understand the ambiguity or complexity, much less find it palatable.

Over the past four decades, I and other philosophers have argued that the distribution of health and disease reflects the way we organize our societies, and how we relate to each other. Living together allows us to create goods that help us pursue our life plans. And living together also exposes us to burdens, and harms. Public health ethics is not primarily or foremostly about the conflict between the interests of the few versus the greater good. It is about how we organize our society, how we relate to one another, to ensure that every individual is able to pursue a good life. From this perspective, the people who are currently infected with COVID-19, as well as older people and those with serious health conditions, are not the few whose rights need to be balanced against the greater good. Each of those individuals are equal members our society whose abilities to live good lives are at risk. If there are decisions to be made about whose lives are to be saved first, or what other socially valued goods need to be protected, justice demands that there be public deliberation, or as philosophers call it, the “publicity requirement.”

Indeed, this talk of ethics and public deliberation during a pandemic may seem superfluous to those who admire how the Chinese government acted boldly, and with unprecedented scale. It pursued actions for the greater good, and apparently gave a gift to the world by slowing infections down by weeks. But outbreaks and their progression into epidemics and pandemics reflect the way we organize our social institutions and relate to each other. There is much work here for those courageous enough to show how social inequities and injustice produced the outbreak and the way it is progressing. 

But more presently, our jobs now as health ethicists throughout the world is to help support national and global responses to think harder and better. Everyone is a global ethicist now.  

Sridhar Venkatapuram is an associate professor of global health and philosophy at King’s College London. He is on Twitter: @sridhartweet

For additional information and ethics resources on the Coronavirus, please visit our Ethics Resources page:
https://www.thehastingscenter.org/ethics-resources-on-the-coronavirus/

Read More Like This
  1. Hon-Lam Li on

    (This is a slightly revised version, hopefully free of typos.)

    The idea of “herd immunity” sounds very dubious. We are supposed to let many of the old and the vulnerable get infected and die, whereas the young and the strong will become naturally immuned after coming into contact with the coronavirus. (I take it that the death rate of those infected with the virus is about 4 to 5%, rather than 1%.) Although various well-known British moral philosophers have embraced utilitarianism, this doctrine is highly implausible. Suppose we can save either someone’s life, or alternatively alleviate a huge number of headaches each suffered by a different person. Whom should we help? According to utilitarianism, we must alleviate the headaches if the number is sufficiently numerous. Yet this is very hard to believe. A more plausible approach is T. M. Scanlon’s contractualism. According to this theory, a policy is morally permissible if and only if it is reasonably justifiable to everyone affected by it. We cannot justify the “herd immunity” strategy to the old and the vulnerable, many of whom will die as a result. Consequently, such a strategy is not morally permissible.

    Hong Kong has been relatively successful in containing COVID-19 (despite a number of imported cases recently). This is partly because the memory of SARS in 2003 is still fresh, when Hong Kong was the epicenter. Since January 2020, Hongkongers have been ready to fight COVID-19 and not let the city become an epicenter this time. One important tool that Hongkongers use is masks (especially surgically masks). Unfortunately, the mention of masks has been conspicuously absent in the “social distancing” rhetoric either in the UK or in the USA. In Hong Kong, at least 90% of all pedestrians wear masks on any day (since late January 2020). I believe masks have helped contain the coronavirus in Macau, Taiwan, Singapore, Japan, South Korea, and probably Mainland China. It is a pity if the strategy being adopted in UK and USA does not include masks.

    Reply
  2. stefan topolski md on

    commonly good public health interventions are necessarily dictatorial interventions
    great ones, though nonexistent, (are) not
    and not everyone in any society is an equal member
    it will be hard to come to useful let alone realistic ethical discussions if working from this a priori fiction
    – from a dyed in the wool communal quaker libertarian –

    Reply
    • Hon-Lam Li on

      A healthcare intervention, whether it is dictatorial or not, had better be based on good grounds, i.e., grounds that are judiciously articulated and defended. Often, significant grounds are ethical ones. Ethical reasoning are typically made a priori. Ethical “thought experiments” are an indispensable tool in moral reflections. Even if these are fictional examples in the sense that the scenarios might not have happened, they provide important materials for deliberation as long as the scenarios (in the examples) are empirically possible because such examples might be “counter-examples” to the theory under consideration. If what you said were correct, it would follow that the whole field of bioethics is futile and a gigantic waste of energy since ethical discourse inevitably rely on such examples (or “thought experiments”). But bioethics is not futile.

      The point of the example regarding a life vs. numerous headaches is supposed to show that minor claims, no matter how numerous, cannot outweigh a very weighty claim, such as life. (Please see my earlier Comment echoing Prof. Venkatapuram’s essay.) This example undermines the utilitarian view (which is still widely accepted among bioethicists) on distribution of healthcare resources, and on policies about possible tradeoffs between public health and the economy in the current crisis of COVID-19. (Donald Trump’s idea that “the cure is worse than the disease,” if the economy is impacted too much for too long because of “social distancing” is a contentious issue for discourse.)

      Reply
  3. Chalmers C. Clark on

    Andrew Cuomo Got it right . A response to Venkatapuram
    Chalmers. C. Clark
    In his article for the Hastings Center Forum, “COVID-19 and the Global Ethics Freefall.” Sridhar Venkatapuram describes what appears to be an ethical “freefall” surrounding the U.K. and the Covid -19 virus. But exactly what is this ethical free fall and what ethical guidelines might be introduced to arrest the fall? The issue seems to center on the possibility of Herd Immunity as a way of minimizing the bad effects of the Covid-19 virus. Herd Immunity functions in a population by inhibiting the spread of an illness by large immunization in a population. If person A doesn’t get the disease because A is immune then A won’t pass it to B, etc.. So how to induce the immunity? Two options to consider: (1) Vaccine or (2) natural immunity from allowing the progress of the illness. Since (1) is not available to us, (2) remains. The problem with (2) is that the option appears to suggest an ethics of allowing the illness to spread with little efforts to control it. There are; however, some benefits to such a plan: namely, A) similar mortality rates over the long run and B).reduced costs to those involved (i.e from schemes of social distancing that include lost work, failing businesses, inability to pay debts , etc.. ), and as Venkatapurum factors the point: “Based on various models with diverse assumptions, the government is planning for 40 million people to become infected. With a 1% mortality rate (the estimated mortality rate in other countries), approximately 400,000 people will die.”. The ethical free fall is now apparent: even if the mortality rates for option (2) are similar to other countries, to choose option (2 )would put the most heavy burden of illness and mortality upon society’s most vulnerable: the elderly and those already ill and immunocompromised. So the ugly utilitarian question Vebkatapuram considers thus obtrudes: Should the greater benefits to the greatest number -prevail over the rights of the vulnerable few? In an apparent response to the question N.Y. Governor Andrew Cuomo announced “Matilda’s Law” – named for the Governor’s mother – to protect New York’s most vulnerable populations, including individuals age 70 and older, those with compromised immune systems and those with underlying illnesses. “My mother is not expendable!”Cuomo said.
    As with Governor Cuomo, Venkatapuram appears to believe most of us would recoil in horror from option( 2), but why? What more exactly is the moral cost to option (2) that should override some clear utilitarian benefits to the greater good? Philosophically, Venkatapuram says “Each of those individuals are equal members our society whose abilities to live good lives are at risk.” OK, but isn’t it better to improve upon more of those equal lives rather than less? Are we thus back to the utilitarian calculus? Perhaps the strongest rejoinder to this question was articulated long ago by German Philosopher Immanuel Kant (1724-1804). Kant argued that all persons, as rational beings, have a special dignity such that each and every person has a value beyond price and should never be treated as a mere means to an end ( either of themselves or of others) but each and every person is always to be treated with the dignity of being ends in themselves. In crude form we all learned this as children when parents and teachers forcefully told us: ”Don’t use people!” But Kant’s point is more refined and focused than this common sense but blunt expression because we do and we must use persons all the time. We must treat persons as a means and frequently. I treat the check-out person in the market as a means to check-out my groceries and the garage mechanic as a means to fix my car, so what is Kant’s point here? To answer in one word: The emphasis is on: “mere” means. I.e., mere means as in Cuomo’s phase that his mother not “expendible.” I.e., a dispensible object for use without yielding to each a special dignity that warrants our unwavering respect.
    Perhaps this is the moral cost most would not pay in order to gain the greater good indicated by option 2. So perhaps along with the value of promoting the greater good, ethically we must always couch our efforts to do so, with a robust respect for all persons individually including the most vulnerable as human beings that all deserve respect for the inviolable dignity of being ends in ourselves and never as a mere means to what otherwise are important and worthwhile ends for the greater good.

    Chalmers C. Clark, Ph.D. Adjunct Associate Professor of Philosophy, The College of Staten island, City University of New York.

    Andrew Cuomo Got it right . A response to Venkatapuram
    Chalmers. C. Clark
    In his article for the Hastings Center Forum, “COVID-19 and the Global Ethics Freefall.” Sridhar Venkatapuram describes what appears to be an ethical “freefall” surrounding the U.K. and the Covid -19 virus. But exactly what is this ethical free fall and what ethical guidelines might be introduced to arrest the fall? The issue seems to center on the possibility of Herd Immunity as a way of minimizing the bad effects of the Covid-19 virus. Herd Immunity functions in a population by inhibiting the spread of an illness by large immunization in a population. If person A doesn’t get the disease because A is immune then A won’t pass it to B, etc.. So how to induce the immunity? Two options to consider: (1) Vaccine or (2) natural immunity from allowing the progress of the illness. Since (1) is not available to us, (2) remains. The problem with (2) is that the option appears to suggest an ethics of allowing the illness to spread with little efforts to control it. There are; however, some benefits to such a plan: namely, A) similar mortality rates over the long run and B).reduced costs to those involved (i.e from schemes of social distancing that include lost work, failing businesses, inability to pay debts , etc.. ), and as Venkatapurum factors the point: “Based on various models with diverse assumptions, the government is planning for 40 million people to become infected. With a 1% mortality rate (the estimated mortality rate in other countries), approximately 400,000 people will die.”. The ethical free fall is now apparent: even if the mortality rates for option (2) are similar to other countries, to choose option (2 )would put the most heavy burden of illness and mortality upon society’s most vulnerable: the elderly and those already ill and immunocompromised. So the ugly utilitarian question Vebkatapuram considers thus obtrudes: Should the greater benefits to the greatest number -prevail over the rights of the vulnerable few? In an apparent response to the question N.Y. Governor Andrew Cuomo announced “Matilda’s Law” – named for the Governor’s mother – to protect New York’s most vulnerable populations, including individuals age 70 and older, those with compromised immune systems and those with underlying illnesses. “My mother is not expendable!”Cuomo said.
    As with Governor Cuomo, Venkatapuram appears to believe most of us would recoil in horror from option( 2), but why? What more exactly is the moral cost to option (2) that should override some clear utilitarian benefits to the greater good? Philosophically, Venkatapuram says “Each of those individuals are equal members our society whose abilities to live good lives are at risk.” OK, but isn’t it better to improve upon more of those equal lives rather than less? Are we thus back to the utilitarian calculus? Perhaps the strongest rejoinder to this question was articulated long ago by German Philosopher Immanuel Kant (1724-1804). Kant argued that all persons, as rational beings, have a special dignity such that each and every person has a value beyond price and should never be treated as a mere means to an end ( either of themselves or of others) but each and every person is always to be treated with the dignity of being ends in themselves. In crude form we all learned this as children when parents and teachers forcefully told us: ”Don’t use people!” But Kant’s point is more refined and focused than this common sense but blunt expression because we do and we must use persons all the time. We must treat persons as a means and frequently. I treat the check-out person in the market as a means to check-out my groceries and the garage mechanic as a means to fix my car, so what is Kant’s point here? To answer in one word: The emphasis is on: “mere” means. I.e., mere means as in Cuomo’s phase that his mother not “expendible.” I.e., a dispensible object for use without yielding to each a special dignity that warrants our unwavering respect.
    Perhaps this is the moral cost most would not pay in order to gain the greater good indicated by option 2. So perhaps along with the value of promoting the greater good, ethically we must always couch our efforts to do so, with a robust respect for all persons individually including the most vulnerable as human beings that all deserve respect for the inviolable dignity of being ends in ourselves and never as a mere means to what otherwise are important and worthwhile ends for the greater good.

    Chalmers C. Clark, Ph.D. Adjunct Associate Professor of Philosophy, The College of Staten island, City University of New York.

    Reply
    • Chalmers C. Clark on

      Some folks have been incredulous about whether the U.K. has actually considered Herd Immunity as a strategy bfor C0vid-19 bcontrol. Here is a segment of a NYT article speaking of the U.K.’s interest in allowing Herd Immunity for controlling the Covid-19 pandemic (link to full article follows below)

      Sir Patrick Vallance, England’s chief scientific adviser, said the government was looking “to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission.”
      Herd immunity, a term usually used to refer to the way mass vaccinations can stop the spread of disease and protect people who are not immune, is not seen by many scientists as a tool to be used against the coronavirus. Mr. Vallance has said that it would require roughly 60 percent of Britons to become infected, creating enough immunity in the population that a second surge in cases next winter would be less severe.
      … experts said that was an unusual and untested approach, and that it would be impossible to keep older and more vulnerable people from becoming infected too, putting them at a significant risk. They cautioned that the science was unsettled on how quickly people develop immunity to the coronavirus, and for how long. And experts urged the government to show more of the evidence behind its thinking.

      https://www.nytimes.com/2020/03/13/world/europe/coronavirus-britain-boris-johnson.html?action=click&module=RelatedLinks&pgtype=Article

      Reply

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