Pandemic Ethics—How We Ought to Respond
In this chapter, I plan to focus on four fundamental ethical questions that can apply not only to ethics during the COVID Era but also ethics that can be applied during other pandemics. These questions are as follows:
1. How ought nonmedical professionals respond?
2. How ought medical professionals respond?
3. How ought medical professionals and policymakers engage with the public?
4. How ought we strive to control the disease?
The chapter will also examine some public health questions that emerged during the pandemic, especially those that centered around masking and vaccinations. Though these topics are often presented as being strictly scientific, the reality is that they border on a fine line between medicine, ethics, law, and politics. This constant change in policy decisions regarding masking or vaccination is driven by the fact that it is largely based on data that evolve over time. While unsavory and the type of thing that is routinely questioned by pundits playing Monday morning quarterback, these decisions were often deemed preferable to the passive act of waiting for more data to become available while the virus was given free rein to spread. This is not to applaud every decision that was made; rather, it puts them into context. These are sensitive issues that each of us view through a different lens, and my approach is not to validate or defend any particular point of view but to be objective and present both sides of the coin for
the reader to understand how difficult it is for legislatures, clinicians, and scientists to make policies that consider how to balance saving lives with respecting individual freedoms.
the reader to understand how difficult it is for legislatures, clinicians, and scientists to make policies that consider how to balance saving lives with respecting individual freedoms.
The Foundations of Ethics
Ethics are foundational principles that guide decision-making processes and help individuals determine how to act. Within the world of public health, ethical systems are integral, especially when dealing with an emerging disease where there are significant gaps in knowledge among scientists. As Lawrence Gostin, a law professor at Georgetown University who specializes in public health law, wrote in 2004, “There is no way to avoid the dilemmas posed by acting without full scientific knowledge, so the only safeguard is the adoption of ethical values in formulating and implementing public health decisions.”1 These ethical systems help guide policymakers and experts to make calculated decisions about how to allocate resources, triage patients, and engage with the public.
There are multiple approaches to ethics, including deontology (or duty-based ethics), consequentialism (maximizing “the good” and/or minimizing harm), virtue ethics, and theories, that center on the concept of rights. While these approaches are distinct, they frequently overlap, and multiple systems may ultimately prescribe the same solutions when agents are faced with ethical decisions. Conversely, similar theoretical approaches may oftentimes lead to different conclusions about how one ought to act since definitions of core objectives may diverge.
For example, consequentialism, in its most rudimentary form, typically defines “the good” as life and would therefore dictate that one ought to save the most people in a scenario where there are two groups of people and one can only save one of those groups. For example, if a person is forced to make a choice between saving 5 people (and allowing 10 people to die), saving 10 people (and allowing 5 people to die), or failing to choose, in which case all 15 people die, then the moral choice would be to save the 10 people. Things, of course, get more difficult as one assigns moral values to things beyond life. For example, if a consequentialist ethic is combined with a chauvinistic form of nationalism, then one might claim that “the good” is not just saving the most people, but the most people of a certain type. Consequently, this would alter the calculus that is used to determine what is the moral response. In other words, how different individuals define “the good” can drastically alter our decisions, even if we are adhering to the same frameworks.
Consequentialism stands in contrast to other systems, particularly deontological ethics, which champion moral behavior that is less concerned
with consequences and more concerned with refusing to violate certain categorical imperatives. For example, if the scenario above were modified in a way so that the agent actively had to murder five to let ten live, the consequentialist might maintain that killing the five is the correct course of action. A deontological approach would likely refute that by claiming that killing five people would violate the categorical imperative to never murder anyone. In scenarios such as these, any attempt to find common ground (let alone synthesis) between the two schools of thought breaks down.
with consequences and more concerned with refusing to violate certain categorical imperatives. For example, if the scenario above were modified in a way so that the agent actively had to murder five to let ten live, the consequentialist might maintain that killing the five is the correct course of action. A deontological approach would likely refute that by claiming that killing five people would violate the categorical imperative to never murder anyone. In scenarios such as these, any attempt to find common ground (let alone synthesis) between the two schools of thought breaks down.
Schools of thought similarly opposed to one another emerged during the pandemic. At the most elemental, the question revolved around the degree to which one should amend their habits to prevent the spread of the virus. If one says that some amendments are necessary and ethical, while others claim that all amendments are supererogatory, then there is no possible way to harmonize the disagreement. This was further complicated by the fact that the power of the state was employed to discourage or prevent individuals from engaging in behavior deemed too risky as a means to promote public health. This does have legal precedent in the United States (see Jacobson v. Massachusettsi).2 However, given the political climate of 2020, it supercharged the initial argument about what changes to one’s routine are ethical in the time of a pandemic and became an issue of personal freedom versus state authority—a philosophical/political/legal debate rather than one about public health. The question ultimately became: Is it more important to take steps to mitigate risk and thereby save lives or is there a higher duty that precludes taking steps to mitigate loss of life? This leads to additional questions. Where is the threshold of acceptable risk? What can the state reasonably ask citizens to do in a time of crisis? What is the line between an assault on one’s personal freedom and an inconvenience that arises because one must share space with others during ordinary times compared to times of crisis? To say that no risk is acceptable is untenable or a straw man argument as is the position that we must never make concessions to others in shared public space. The former is the premise on which the ham-fisted of dystopian stories are based. The latter would be akin to a Hobbesian state of warfare involving all against all.
Still, exploring these premises can lead to profound questions that strike to the heart of political science and what people believe about the
relationship between the individual, the community, and the state, and an individuals’ position cannot be taken lightly or written off as just a tribalistic allegiance devoid of moral reasoning. Everyone must balance their willingness to accept restrictions on their actions and livelihood with the risk of being a link in a chain of transmission that could potentially make thousands of others sick and lead to dozens of deaths. In many cases, these are questions that require risk calculation, not just ethical considerations, and these are decisions that must be made by organizations, as well as individuals. As Spanish philosopher Jose Ortega y Gasset wrote in his 1939 essay, The Self and The Other, “Without a strategic retreat into the self, without vigilant thought, human life is impossible.”3
relationship between the individual, the community, and the state, and an individuals’ position cannot be taken lightly or written off as just a tribalistic allegiance devoid of moral reasoning. Everyone must balance their willingness to accept restrictions on their actions and livelihood with the risk of being a link in a chain of transmission that could potentially make thousands of others sick and lead to dozens of deaths. In many cases, these are questions that require risk calculation, not just ethical considerations, and these are decisions that must be made by organizations, as well as individuals. As Spanish philosopher Jose Ortega y Gasset wrote in his 1939 essay, The Self and The Other, “Without a strategic retreat into the self, without vigilant thought, human life is impossible.”3
I would add to Ortega y Gasset’s sentiment by saying that this retreat into the self, this act of vigilant thought (and, transitively, human life), is impossible without truth. Valorizing truth is fundamental to ethics since ethics is impossible without an earnest desire to search out the truth. More importantly, that search is impossible without trust. If we are to let ethics be our guide, we will need to emerge from this pandemic with the ability to trust one another again and promote more civil discourse rather than the kind of tribal bickering that masquerades as discussion. As Leonardo di Vinci long ago observed, “Dove si grida non è vera scienza” (where there is shouting there is no true knowledge).
Mitigation Strategies
For scientists and policymakers, one of the greatest difficulties of the pandemic has been the lack of information about the SARS-CoV-2 virus and the pathology of COVID-19. As outbreaks were occurring with increasing regularity throughout the United States in early 2020 (possibly even the very end of 20194), a lot of guesswork was involved in trying to implement regulations and processes to protect the public from widespread infection. Unfortunately, when the science of a disease is not clear because of its novelty, this can make consistent messaging difficult and, without a question, there was often dissonance in guidelines, as well as open disagreement among elected officials and public health officials about how to proceed.5
The ethical motivation of elected officials is understandable. While a cynical approach would be to claim that they are only after reelection, a more empathetic reading of their situation would recognize that they are bound by duty to protect their constituents’ life, liberty, economic interests, and social wellbeing. They did not want to incite a panic or take preventative measures that would ultimately cause more harm than good.
To what degree it was prudent to remain skeptical and risk-adverse was also difficult to ascertain since it depended upon the risks associated with inaction, which they could not have known.
To what degree it was prudent to remain skeptical and risk-adverse was also difficult to ascertain since it depended upon the risks associated with inaction, which they could not have known.
The motivation of public health officials, meanwhile, is often more straightforward and focuses solely on preventing deaths and illness.
In some countries, these two groups butted heads. In others, the two recognized that there was far more overlap between their concerns than their differences, and so they managed to cooperate. They recognized that significant disruptions to daily life and the economy would undoubtedly occur but had the prescience to understand that these disruptions would be relatively minor if community transmission were to be squelched out quickly or prevented entirely. While rigid infection control procedures were enforced during periods of lockdown, the underlying principle was that they were warranted because they would allow the economy to quickly resume normal function and would mean more resources could be dedicated to containment, establishing a perimeter, and monitoring that perimeter. This was the model that Taiwan followed from the beginning of the pandemic. Australia and New Zealand eventually also followed the same model though the latter initially attempted to “flatten the curve.”6
A “flatten the curve” approach is more of a mitigation strategy. The goal is not merely to blunt the sharpest spike in cases and prevent the complete breakdown of national health care systems due to a tsunami of patients demanding emergency care but to buy researchers time to devise improved treatments.7 In the United States and many European countries, this strategy was preferred but imperfectly implemented.
As of September 14, 2021, Taiwan, which has a population of approximately 23.5 million, has had 16,093 confirmed cases of COVID-19 (67.5 per 100,000) and 839 total deaths (3.5 per 100,000).ii It should be noted that, as of May 1, 2020, there had only been 1132 reported cases and 12 confirmed deaths and that the numbers were inflated by an outbreak that occurred between early May 2021 and early July 2021 that has been responsible for the vast majority of all reported cases and deaths.8
As of September 14, 2021, Australia, which has a population of over 25 million, has reported 78,544 confirmed cases of COVID-19 (304.6 per 100,000) and 1116 total deaths (4.3 per 100,000).9 The biggest spike in 2020 occurred in late July and early August when daily new confirmed cases topped 700, and (though it may seem counterintuitive) approximately, 53% of infections have occurred in less vulnerable individuals, those
between the ages of 20 and 50 years, while just over 12% of cases were reported in individuals over the age of 70 years.10 It should be noted that Australia’s response has not been flawless. While lockdowns have kept many Australians safe, the country’s leaders started to receive a great deal of criticism in the middle of 2021 because of their failure to procure enough doses of vaccine, thus delaying a full reopening of the country. This failure has muted the applause for the nation’s initial response to the pandemic.11 Additionally, cases began rising in July 2021 due to the spread of the Delta variant. While this has led to more lockdowns and more complaints, vaccination efforts have progressed quickly and there is currently hope for a springtime reopening, even if it may not be complete.12
between the ages of 20 and 50 years, while just over 12% of cases were reported in individuals over the age of 70 years.10 It should be noted that Australia’s response has not been flawless. While lockdowns have kept many Australians safe, the country’s leaders started to receive a great deal of criticism in the middle of 2021 because of their failure to procure enough doses of vaccine, thus delaying a full reopening of the country. This failure has muted the applause for the nation’s initial response to the pandemic.11 Additionally, cases began rising in July 2021 due to the spread of the Delta variant. While this has led to more lockdowns and more complaints, vaccination efforts have progressed quickly and there is currently hope for a springtime reopening, even if it may not be complete.12
As of September 14, 2021, New Zealand, which has a population of just under 5 million, had reported 3982 confirmed cases of COVID-19 (81.9 per 100,000) and confirmed its highest spike in cases on April 5, 2020, when 75 new cases were reported. As of September 2021, 27 people (<1 per 100,000) in New Zealand have died due to COVID-19. Since the beginning of May 2020, only seven have died.13
As of September 14, 2021, the total number of confirmed cases in the United States is 41.37 million (12,425.1 per 100,000) and there have been 663,929 confirmed deaths (199.4 per 100,000).14
To challenge the efficacy of these three nations’ strategies and competencies is a difficult position to take, especially if the argument rests on the presumption that economic vitality needs to be considered in conjunction with the raw data point of number of lives lost. If our goal is to reduce death and illness, then there is no question that these are the countries that we should choose to emulate, even if no system was perfect.15 On the other hand, if our goal is to reduce death and illness and provide economic vitality, once again the Taiwanese, Australian, and Kiwi models are favorable. Taiwan’s economy grew by 3.11% in 2020 and was forecast to grow by 4.64% in 2021.16 While Australia had its first economic contraction in 30 years in 2020, the nation’s economy, as June 2021, is 1.1% bigger than at the beginning of the pandemic.17 The New Zealand economy shrank by 2.9% in 2020, but economic growth was estimated to be close to 0.8% above prepandemic levels.18, 19 Though GDP in the United States fell by 2.9% in 2020, it has since returned to nearly prepandemic levels and is expected to continue to grow for the foreseeable future.20 This is comparable to the other models, but the number of people who became sick and the number of people who died of COVID-19 are several orders of magnitude larger.
One of the reasons that these countries had low infection and mortality rates is that all three of them are island nations, which certainly makes it easier to screen and prevent infected individuals from entering the community and spreading the contagion. However, this misses the
larger point that especially New Zealand and Taiwan were able to launch a coordinated national response in the early stages of the pandemic that mandated the screening of airline passengers from high-risk areas and quarantining them for 14 days upon returning to their native country. In Taiwan, widespread masking, early delays to the start of the school year, and bans on large gatherings played a crucial role in preventing the early spread of the virus. On the other hand, in New Zealand, once the number of cumulative cases exceeded 100, a full lockdown was implemented on March 23, 2020.13
larger point that especially New Zealand and Taiwan were able to launch a coordinated national response in the early stages of the pandemic that mandated the screening of airline passengers from high-risk areas and quarantining them for 14 days upon returning to their native country. In Taiwan, widespread masking, early delays to the start of the school year, and bans on large gatherings played a crucial role in preventing the early spread of the virus. On the other hand, in New Zealand, once the number of cumulative cases exceeded 100, a full lockdown was implemented on March 23, 2020.13
While this is a very broad analysis that does not examine the nuances of each country or the myriad of specific factors, it does reveal that democratic nations where more stringent public health measures were quickly and effectively put into place fared better than the United States Flattening the curve may be an effective strategy for combatting infectious diseases that are less transmissible than SARS-CoV-2, but it was not an effective means of fighting COVID-19.
Individual Ethical Duties
Within the United States, literature about the ethics of pandemics created prior to 2020 focused on the potential challenges of operating with limited resources and questions about how to allocate medicines, ventilators, and personal protective equipment in an ethical or just manner. Writers also spent a great deal of time pondering about our ethical duties to other countries. To read older documents about pandemic ethics that date back well before SARS-CoV-2 can be a bit of a shock, since there seems to be an unspoken presumption that the United States would be able to manage its own affairs and that most policy discussions would center on the logistical challenges and moral imperatives of providing assistance to other countries or resource-starved parts of the United States.21
This debate has largely been coopted by the question about how one ought to behave with respect to social distancing protocols and mask wearing, and then about whether to get vaccinated. Frankly, most of the arguments revolving around social distancing protocols and masking in public do not represent ethical quandaries. No one should be losing sleep over these kinds of questions. If you have the option of preventing the spread of a deadly pathogen or not preventing the spread while out in public, you try to prevent it by making some concessions. To rule all voluntary concessions out because they are examples of “authoritarianism” is to brand basic civics as a form of tyranny. While there is a legitimate argument against the government mandating these kinds of measures,
this is a political question and not one of ethics. Furthermore, the claim that social distancing and mask wearing do not prevent the spread of the virus is simply incorrect, even if it is accurate to say that they are not 100% effective.
this is a political question and not one of ethics. Furthermore, the claim that social distancing and mask wearing do not prevent the spread of the virus is simply incorrect, even if it is accurate to say that they are not 100% effective.
The various protocols set in place to prevent the spread of the coronavirus helped to reduce the number of COVID-19 cases, and there is now evidence that they also prevented the spread of influenza. Due to decreases in mass gatherings and travel, on the one hand, and social distancing measures, mask wearing, and better hand sanitation, on the other, the 2020 to 2021 flu season more or less disappeared. There were fewer than 2000 laboratory-confirmed cases (down from around 200,000 in an average year).22 Deaths were significantly down, too. In the United States, where an estimated average of 38,750 individuals have died of the flu each season from 2012-2013 to 2019-2020, preliminary reports estimate that only 600iii died of the flu this past season.23, 24 That is about 1.55% of the deaths in an average year. Assuming that these same protocols reduced COVID-19 deaths by a comparable rate through the spring of 2021, one can argue that the approximately 600,000 deaths that occurred as of June 2021 due to COVID-19 represent 1.55% of the possible 38.75 million deaths that could have occurred without these measures. While this is not a valid argument for a variety of reasons, there is no doubt that there would have been a far greater number of fatal cases of COVID-19 without regular masking. Based on statistical data, continued skepticism on the matter of masking seems unfounded and has become more of a personal belief that is rooted in politics rather than science.
No doubt, public health guidelines have been a serious encumbrance throughout the pandemic. Masking is inconvenient and keeping a safe distance apart made it difficult and even impossible for some people to earn a living. Shutting down states and cities hurt people financially and psychologically. Not seeing family members for months at a time except through Zoom calls was emotionally harmful. If we were not still recovering from the difficulties of living through the pandemic, this book would not have been written. Despite all the hardship and tragedies, these actions saved countless lives and prevented the collapse of local hospital systems that, even years into the pandemic, continue to show signs of extreme
distress from being overburdened by patients with COVID-19, which has consequently led to the rationing of care and unnecessary deaths.
distress from being overburdened by patients with COVID-19, which has consequently led to the rationing of care and unnecessary deaths.
If we presume that saving lives is the primary objective of ethical behavior, then following proven health guidelines that prevent infection with SARS-CoV-2 and reduce the strain on health care systems would be ethical and shunning them would be unethical. As discussed before and mentioned in the media, the CDC at times did not effectively communicate about masking and social distancing measures and at times provided contradictory and confusing guidelines. However, if we are to constantly vindicate our criticism based on bad messaging by the CDC and overlook the scientific guidelines, then we are once again putting politics ahead of science. To throw out these live-saving guidelines because of bad messaging is like throwing out the baby with the bathwater.
The idea that the impermanence of protocols is evidence of voluntary caprice is unfounded, as well. As the French philosopher and scientist Blaise Pascal is purported to have said: “There is no such thing as the truth, we can only deliver the best available evidence and calculate a probability.”25 Information about the virus is constantly being updated based on new data and as more studies are conducted. It would be far more concerning if protocols did not evolve as more information was obtained about the transmission dynamics of the virus and other issues like vaccine efficacy. Medicine is a constantly evolving field, and questions about proper treatment and recommendations are dynamic and not static. This may be confusing and frustrating for the public, but this is not a failure of science. Rather, it is a failure of messaging and communication.
In the future, the CDC should consider coordinating their messaging with pillars of the community, including religious leaders, members of civic organizations, elected local officials, and the like. Many people are often skeptical of government officials as a rule and may be loath to respond to recommended guidelines that may be extremely inconvenient or harmful to their livelihood. Meanwhile, individuals are less likely to want to “shoot the messenger” if they have a long-standing relationship with them.
Vaccines
The case for getting vaccinated is slightly different than wearing a mask. There are risks associated with vaccination (specifically the Pfizer/BioNTech, Moderna, or Janssen [Johnson & Johnson] vaccines) that do not exist with mask wearing or social distancing. Common side effects include fever, chills, aches, injection-site soreness, nausea, and tiredness. Instances of Bell palsy have been reported, but the increased risk is small
(an estimated additional 2 people for every 100,000 people given the Pfizer/BioNTech vaccine), and the condition is usually temporary.26 Approximately 100 instances of Guillain-Barré syndrome (GBS) have occurred among the 12.5 million Americans who have received the Johnson & Johnson vaccine. Of those 100 cases, 95 were serious enough to require hospitalization. So far, one fatality has been reported as of September 2021.27 While an association appears to exist between the vaccine and GBS, the Food and Drug Administration (FDA) has not yet said that this is sufficient evidence to establish a causal relationship.28 Meanwhile, a study that examined the risk of relapse in patients with a previous history of GBS among those who received Comirnaty, the Pfizer/BioNTech vaccine, showed that only 1 individual out of the 702 patients required brief medical care for relapse of previous syndrome but quickly recovered.29
(an estimated additional 2 people for every 100,000 people given the Pfizer/BioNTech vaccine), and the condition is usually temporary.26 Approximately 100 instances of Guillain-Barré syndrome (GBS) have occurred among the 12.5 million Americans who have received the Johnson & Johnson vaccine. Of those 100 cases, 95 were serious enough to require hospitalization. So far, one fatality has been reported as of September 2021.27 While an association appears to exist between the vaccine and GBS, the Food and Drug Administration (FDA) has not yet said that this is sufficient evidence to establish a causal relationship.28 Meanwhile, a study that examined the risk of relapse in patients with a previous history of GBS among those who received Comirnaty, the Pfizer/BioNTech vaccine, showed that only 1 individual out of the 702 patients required brief medical care for relapse of previous syndrome but quickly recovered.29
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