Each affected country’s response to Covid-19 is based on what its government thinks is an acceptable cost to pay in responding to the virus.
This Covid-19 period is likely to offer numerous case studies of ethical decision-making at a time of humanitarian crises.
There has been contrast and diversity in the different approaches that countries have taken to tackle Covid-19 and mitigate its impact, especially with respect to the underlying ethical principles of decision-making.
At the end of March, different countries tried different approaches, with each one having a moral justification for pursuing their respective particular approach.
Some of them have been sticking to their original line of thought, while others made course corrections, succumbing to the pressure from critiques.
Some of these criticisms question the very assumptions behind the approach, while others question the morals/ethics behind it.
The purpose of this article is to present an overview of the ethics associated with the decision-making for each of these approaches.
1. Herd Immunity
The Herd Immunity approach seeks protection from a pandemic such, as Covid-19, in an indirect way.
When a large section of the population becomes immune to a particular strain (either by infection and recovery, or by vaccination), the contagious impact is disrupted; both from the perspective of spread and severity.
Among other countries, UK and Sweden followed this approach. They did not shut down their schools. They did not aggressively promote the ‘work from home’ option for working age adults. They only advised the elderly and the vulnerable people to stay at home.
They appeared to be very keen not to shut down their economy. They wanted business as usual to continue for the overall wellness of the society. Watch this video to understand the thinking behind this approach.
But due to various pressures, the UK discarded this approach in April, while Sweden has continued to practice the same.
Analysts determine that the thinking behind this approach is to expose the least vulnerable sections of the society, as early as possible, to this strain. It may sound crazy to think that the government wants the healthiest sections of the society to be infected first.
No doubt, some people will fall sick, some may even die. But a vast majority of the healthiest sections will recover, without requiring the support of scarce resources such as ICU beds and ventilators.
They will develop immunity to this strain quickly. This makes it easier for the rest of the society, because the herd immunity will kick in and mitigate the contagion impact. There is also a good chance of extracting the plasma of people who have recovered in order to transfuse and save other lives.
But, what are the criticism(s) against this approach?
One, leading public intellectual Nassim Nicholas Taleb questions here the science behind the assumptions made for herd immunity. For example, the UK assumed that those who have got infected, will not get re-infected. It also assumed the existing NHS system to have enough capacity to handle the demands of the sections exposed to this virus. It assumed that the vulnerable sections would remain shut-off in isolation. It assumed no vaccine coming in the foreseeable future.
Some of these assumptions fell apart in April. Consequently, the UK decided to discard this approach, while Sweden appears to be persisting with it.
Two, many simulation studies have shown that outbreaks of viruses such as the one causing Covid-19 will work over multiple waves (check here for more info). Herd immunity would be effective only if the period of herd immunity covers the onset of next wave. If this does not happen, then large scale loss of life is unavoidable during successive waves.
Three, this also leads to an ethical question: does the government have the moral right to use children and healthy adults as cannon fodder or first-level shield against such a deadly virus, in order to save older people?
2. Utilitarian approach
The utilitarian approach relies on achieving the greatest good for the greatest number of people, while creating the least amount of harm (or) preventing the greatest amount of suffering. It works on the basis of calculating the net social benefits and costs and deciding the best response.
Among other countries, Italy was following this approach. It was one of the worst affected countries and was suffering from a critical shortage of healthcare resources.
Authorities in Italy had issued guidelines to their healthcare departments that ‘first come, first serve’ could no longer be followed. Instead, healthcare administrators were empowered to determine that:
-(a) who had a better therapeutic probability of survival, and
-(b) who had a higher number of productive life years left.
Accordingly, healthcare administrators were asked to allocate scarce resources like ICU beds and ventilators to save those sections of the population that had the highest probability of contributing to society, post the treatment.
So, what are the criticism(s) against this approach?
One, are healthcare administrators equipped with adequate information, and are they in a rational frame of mind to determine the therapeutic probability of survival of a patient? What if they get it wrong?
Are they not susceptible to power imbalances such as an emotional relationship with the patient, the socio-political status of the patient, the physical might of the patient and their relatives, or even bribes offered by the patient?
If they succumb to any of these power imbalances, wouldn’t the social outcomes go haywire?
Two, this also leads to the ethical question that can the government and healthcare administrators be allowed to play God? What gives them the right to pick the winners in this crisis? Can they be allowed to engineer a social outcome according to their judgment of what constitutes the greatest good to the society?
3. The Lockdown-While-You-Still-Can approach
Among others, Indian government appears to be following this.
It identified the duties of the government and the public and implemented them. The government primarily relied on social distancing as a preventive mechanism to control the spread of the virus.
Cities have been under lockdown for a long period, including businesses and places of mass gatherings. Employers were urged to promote work-from-home and avoid all avoidable business travel. Restrictions were imposed on intra-district and intra-state level.
They virtually shut off international travel. They used all the powers at the disposal of the government to regulate public behaviour, and ensure availability of medicines and other scarce resources. Private healthcare providers, schools, and exhibition halls were directed to surrender their resources to public healthcare. They urged the public to be responsible citizens and do their duty to prevent the spread of the virus.
No one was under any illusion that these aggressive, precautionary measures will not have a devastating effect on the economy. The livelihood of many daily wage earners came under severe risk. But the government in India tried its best to use existing mechanisms (e.g. the JAM digital stack) to safeguard vulnerable sections of the population. The government reiterated that its priority was saving lives and the economic impact is a worry for another day.
The government is primarily relying on its limited public health system to put in its best efforts to serve all the needy.
The allocation of scarce healthcare resources is expected to be efficient, but highly insufficient. That said, the government is certainly not showing any willingness to take it on itself to engineer any kind of societal outcomes.
So, what is the criticism against this approach?
The economy has taken a hard hit, with cities and businesses gone in for a total shutdown. Livelihoods of daily wage earners and those in the informal economy have taken a big toll. Daily news items on the plight of migrant labourers are heart wrenching. Are these social costs acceptable, in order to save a few more thousand lives? Did the Indian government take a big political risk that many countries such as the UK were unwilling to take?
Hindsight is perhaps the only mechanism that will assess these alternate approaches.