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Ethics in the pandemic

Skepticism calls into question the validity of some or all of human knowledge. (The Free Dictionary 2020) It is a thread that goes through many philosophical discussions of epistemology. Moral skepticism holds that there is no knowledge of what is right and wrong, of good and evil. And the skepticism of the outside world is the thesis that there could be no knowledge of matters outside one’s mind. (Sfetcu 2020)

In fact, we are all skeptical of at least some of the senses, or knowledge. But skepticism is considered an evil among many philosophers, who have devised entire intellectual programs specifically to defeat the skeptics.

But there is a virtue of skepticism that is crucial to a healthy democracy. Ancient skeptical tradition says that intellectual humiliation is a virtue. It is not a weakness to admit that you do not know, that you have no answers.

Today, we live in a world that causes an almost instantaneous judgment. We are inundated with calls for outrage, support, indignation and sympathy. The explicit norm is that silence is a kind of complicity, and not expressing an opinion is itself an approval. (Messerly 2020)

We live in a world where information has become increasingly difficult to process. A world with sophisticated fake news and deep capabilities, combined with old manipulation techniques, as in George Orwell, a world where virtual life like the Matrix influences our decisions in the real world.

We suffer from confirmation prejudices. Moreover, our beliefs prevent us from detecting bad reasoning. According to a famous study, we are less likely to discover formal errors in arguments when we have conclusions that we consider agreeable. Our beliefs are not just things we consent to, but things that determine us. The stakes of beliefs are high, and once we have them, we tend to keep them. (Messerly 2020)

Content providers compete for our attention, delivering more or less manipulative images and messages. We are encouraged to focus on instantaneous judgment, on the basis of which a purposeful narrative can be constructed, with a diet of information that protects us from unforeseen turns.

All these aspects are terrible for democracy. They can make us feel involved in the politics of the day, but it’s just an increasingly elaborate issue or marketing. The real policy is of great commercial interests that are based only on our perceptions. When our judgmental capacities are outsourced in this way, we lose our real meaning.

The ancient skeptical tradition teaches us the importance of suspending judgment, even in the face of persistent appeals to the apparent reality. Aikin and Talisse, in The Democratic Virtues Of Skepticism, (Messerly 2020) urge us to step back immediately, not as a way to separate ourselves from the world, but as a strategy to appreciate it correctly. Suspension of judgment is a necessary precursor to the correct assessment of the appropriate degree of trust we should attach to a faith. In a democracy, the project of self-government between equal politicians urges us to intellectual humility. Judgments must depend on the evidence taken into account. We need to be open to new evidence, able to hear those we disagree with, to hear their reasons. This is true democracy; equality with those with whom we disagree. Skeptics believe that very few opinions deserve to be agreed, but they also believe that almost every point of view deserves to be taken seriously enough to be investigated. We must take the views of our fellow citizens seriously, because they are our equals. For this, we need to find a way to slow down our tendency to hastily form beliefs.

“Who decides what is best for an individual?” The principle of well-being may conflict with the individual interest of patients. Distributive justice considers fair access to care and resources. Remunerative justice is concerned with the sanctioning of crimes. (Riggs 2020)

In 2011, the U.S. Centers for Disease Control and Prevention (CDC) published a paper on the ethics of ventilator allocation during a pandemic, stating that

“The utilitarian rule of maximizing the number of lives saved is widely accepted during a public health emergency”. (Centers for Disease Control and Prevention 2011)

Utilitarianism can generate significant personal, ethical, and practical moral barriers for health care providers:

“Covid-19 critical interventions – testing, PPE [personal protective equipment], ATI beds, ventilators, therapists and vaccines – go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace”. (Emanuel et al. 2020)

“[In a public health emergency], healthcare institutions and public health officials also have a duty to keep resources low, reflecting the humanitarian goal of saving as many lives as possible.” (Institute of Medicine (US) 2009)

Immanuel Kant argued that individual, conscious choices and respect for other people are the foundations of moral life. But in the case of pandemics, doctors are being asked to give up these values and focus on the wider interests of society. (Kant 2017) (Riggs 2020)

Much of the applied ethics relates to three theories:

  1. Utilitarianism, where the right policy is the one that leads to the greatest happiness, (Bentham 1988) (Mill 1863) with the initial difference between an act and a utilitarian morality, later the idea of motive or intention into morality, (Sidgwick 1874) and Peter Singer with the preference into moral decision-making. (Singer 2011)
  2. Deontological ethics, based on “rules”, with an obligation to perform the “correct” action, regardless of the real consequences (represented by the notion of categorical imperative of Immanuel Kant), (Kant 2008and the natural law, developed by Thomas Aquinas. (Aquinas and Regan 2000)
  3. Ethics of virtue, derived from the notions of Aristotle (Aristotle 1566) and Confucius, (Confucius 2013) which states that the right action will be that chosen by a suitable virtuous agent. (Sfetcu 2020)

Consequentialism argues that the consequences of one’s behavior are the fundamental basis of any judgment on the correctness of such behavior. Thus, from a consistent point of view, an act of moral right (or omission to act) is one that will produce a good result or consequence. The moral value of an action is determined by its potential consequence, not by a set of rules. Consequentialism is usually in contrast to deontological ethics (where rules and moral duty are central), the ethics of virtue (which focuses on the character of the agent), and the pragmatic ethics (which treats morality as science). (Scheffler 1988) (Sfetcu 2020)

Utilitarianism states that the best action is the one that maximizes utility. Jeremy Bentham, the founder of utilitarianism, described utility as the sum of all the pleasures that result from an action, minus the suffering of anyone involved in the action. (Bentham 1988) There is currently disagreement about maximizing total utility (total utilitarianism) or average (average utilitarianism).

The largest medical institutions and various ethicists advocate a utilitarian approach in times of public health crises to maximize benefits for society, in direct conflict with our common (Kantian) view of respect for individuals. (Riggs 2020) A central problem with utilitarianism is that there is no clear way to evaluate moral choices, including in medical decisions. In general, Kantian medical ethics is respected in medicine. But in a pandemic, when resources are poor, deep choices of life and death must be made. In these situations, the principles of utilitarianism offer the best answer, with the transition from a patient-centered thinking model to a society-centered thinking model.

Savulescu et al. addresses the issue of pandemic priority in Utilitarianism and the pandemic, with a focus on two issues: patient triage, and quarantine. They believe that utilitarianism is the only relevant ethical theory to maximize what is good for all (the principle of beneficence). Individual freedoms may conflict with the general good, so the question of the impartiality of the principle of beneficence is raised. (Savulescu, Persson, and Wilkinson 2020)

To differentiate between what is good and bad for the individual, Savulescu highlights hedonism (which supports the pursuit of pleasure and the avoidance of suffering as the only components of well-being, and that what we should do depends exclusively on what affects the well-being of individuals), (Shaver 2019) but it would be too narrow to differentiate between good and evil.

Although some moral theories argue that it is more important not to do harm than to do good, Savulescu believes that there is no significant moral difference between doing evil and omitting good.

The main versions of utilitarianism are act utilitarianism (which argues that an action is correct if it maximizes utility), and rules utilitarianism (which argues that an action is correct if it conforms to a rule that maximizes utility). (Sfetcu 2020)

Richard Hare argued that moral thinking takes place on two levels, intuitive and critical, and that we should move between them depending on the circumstances. (Hare 1981) Triage rules can be justified by a form of rule utilitarianism that allows for quick intuitive decisions. “Critical level” utilitarianism involves choosing the action that maximizes the good when we think lucidly, with all the facts at hand. In complex and urgent situations, Hare argues that we should use act utilitarianism.

Savulescu explores the implications of utilitarianism at a critical level for the current COVID-19 pandemic, and describes ” plausible rules of thumb that would tend to maximize utility and would be useful in emergency and urgent situations.” (Savulescu, Persson, and Wilkinson 2020) As rules of thumb, consider the number, probability, duration of treatment, and resources.

An interesting approach to utilitarianism is the idea that, while preventing COVID-19 may be cost-effective, it is not the most effective action from a utilitarian point of view. The Gates Foundation estimated that global eradication of malaria would cost much less (Gates and Chambers 2015) and save many more lives.

Quality of life may also be relevant: if the years of life saved by a pandemic lockdown were of low quality, it would negatively affect the overall benefits.

Triage generally focuses on whether or not treatment should be applied. According to utilitarianism, physicians should be prepared to refuse treatment to patients with a poor prognosis to allow treatment of patients with a better prognosis if they arrive later in the emergency department. Thus, for utilitarians the responsibility is not only of actions, but also of inactions.

Savuleascu emphasizes that the elaboration of rules for assessing the social value of people (who has priority) is complex from an ethically and epistemically point of view, susceptible to abuse and difficult to apply fairly. Utilitarianism at the critical level does not support such priority rules, being sensitive to potential abuse (social value can be easily abused by privileges and priorities).

Intentions are irrelevant to utilitarians; even if the consequences are unintended, we are still responsible for our actions, if the negative results are predictable and avoidable. Thus, the authorities have a moral responsibility for choosing the wrong policy. But those who do not take care of their own health are also responsible, as there is a tendency to take this into account when allocating resources. (Friesen 2018) ” Responsibility (or the disposition to behaviour that led to ill health) is only relevant for utilitarians insofar as it affects probability, length or quality of survival.” (Savulescu, Persson, and Wilkinson 2020)

Psychological bias, intuition and heuristics sometimes matter in triage. Utilitarianism seeks to maximize the good, designed impartially.

Savulescu states that all these rules can be assembled into an algorithm for allocating ventilators and other resources. The algorithm divides the decision-making process into stages and gives priority based on different criteria depending on the availability of resources. Utilitarianism depends very much on accurate information and requires good evidence, being complementary to science.

According to utilitarianism, the right policy is the one that maximizes the well-being in general, at the level of all people in all countries, through a radical impartial equality – it is a theory without national borders.

For utilitarianism, freedom and rights are important only insofar as they ensure well-being. Utilitarianism favors a more coercive approach if it is more effective. But it is important that “the extent of the liberty restriction or rights violation should be commensurate with the effect on well‐being.” (Savulescu, Persson, and Wilkinson 2020)

Savulescu concludes that utilitarianism is a demanding and counterintuitive theory. Health policy is often misguided by politics or popular opinion, not ethics. Utilitarianism provides a clear framework for setting goals and priorities, and provides criteria for measuring success.

Wim Vandekerckhove proposes an approach to the COVID-19 pandemic through the prism of disaster management, or existentialist philosophy. (Vandekerckhove 2020) Thus, Tanguay-Renaud talks about public emergencies by wondering what kind of emergency can justify the state of emergency in which the duties and promises made create new responsibilities and roles. (Tanguay-Renaud 2009)

Bernard Williams defines “the first question of politics” as “securing of order, protection, safety, trust, and the conditions of cooperation.” (Williams 2005)

Walzer discusses why, in a pandemic, the political community is put before family, friends, the religious or professional community. (Walzer 2006)

John argues that there are two ways in which actions are prohibited in emergencies: by adopting “threshold deontology” or rethinking the self-defense. (John 2009)

Melnick and Bernheim demonstrate how public health officials can use a code of ethics when making decisions about the allocation of ventilators, based on the principles of the code of ethics of public health, by building relationships to build biopreparedness. (Melnick and Bernheim 2009) This can create a consensus on resource allocation decisions. In this regard, in a paper on disaster management, Zack writes that

”… preparation and response require plans and both kinds of plans have ethical aspects. Is there an ethics of disaster preparation planning distinct from an ethics of disaster response planning?”, (Zack 2009, 55)

claiming that in previous pandemics there was inadequate disaster preparedness, only a disaster response. Zack discusses two models: Save the Greatest Number (SGN) and Save ALL that can be saved (SALL). While SALL has moral consensus, SGN is relative. SALL is the model we need to use in the preparation phase, and SGN will be used effectively in the pandemic, through medical triage. This can only be justified if there is a broad public debate, i.e. a political community. (Vandekerckhove 2020)

According to Wim Vandekerckhove, existentialism is another way of approaching the pandemic. In this regard, MacMillan et al. provides three key pieces of information: existentialism places a priority on the individual and the existential self, allows for a coherent examination of decision and ethics at the individual and organizational level, and is inherently “applied” and focused on the “process” by allowing an understanding of the meaning of work. (MacMillan, Yue, and Mills 2012, 27)

For Albert Camus, the absurd is caused by the conflict between our expectation of a rational and just world and the disappointment caused by the real world. This conflict can be overcome by a “leap of faith”, accepting the irrationality of our choices. (Camus 1971) (Camus 1985)

It should be noted that such an approach, in which the protagonists accept what comes by playing their role, is also found in the most famous Romanian folk ballad, Miorița. (Baladă populară 2020)

Albert Camus emphasizes the importance of role-playing, and Vandekerckhove states that this acceptance of the role is not an excuse, but rather the basis for making exceptions and becoming authentic. This is what pandemic doctors do, they only fulfill their role by adopting the utilitarian approach. Despite the applause, says Vandekerckhove, they are not heroes. It just “plays their role.” They cannot do more than that. (Vandekerckhove 2020)

Anthony B. Pinn, in Humanism’s Vulnerable Human, (Pinn 2020) refers to Albert Camus’s La Peste (Camus 1972) to compare the existential circumstances of particular times of anxiety and trauma, similar from there to the current pandemic period COVID-19. Pinn believes that we need to look for ways to absorb and process this reality of our lives, trying to understand the circumstances. Humanists try to understand this phenomenon in relation to a great unity of life: “Camus reminds readers of the interconnected nature of all life—the manner in which human existence is tied to other modes of life, seen and unseen.” (Pinn 2020)

Sisif, de Franz Stuck, Galeria Ritthaler, München, GermaniaThe end of Camus’s book emphasizes the idea that life is subject to the movement and activity of material forces that humans cannot control. According to Camus, the end of the plague is not a victory over death, but rather a pause in action. There are threats we cannot conquer. In this sense, the “plague” thus generates a feeling of perpetual rebellion; an understanding of the fact that we struggle to improve circumstances all our lives, “because we can, not because we will be successful,” a clear reference to the myth of Sisyphus. If the fight is permanent, why fight again, if we don’t win once and for all? Le Mythe De Sisyphe Essai Sur Labsurde, of Camus, ends with these words:

“I leave Sisyphus at the foot of the mountain. One always finds one’s burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night-filled mountain, in itself, forms a world. The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.”(Camus 1985)

Personally, I have always considered this idea to be perhaps the most important in life: the result is much less important than the way to get it.

Like Sisyphus, we will have to fight this virus all the time, just because we can. COVID-19 will be defeated at some point, but will not disappear. The threat will remain.

“Things impact us, inform us, shape us—in a sense determine the nature and meaning of human life… we’re not only part of the world, we’re dependent upon a world that doesn’t bend to our will and doesn’t prioritize the criteria for our well-being.” (Pinn 2020)

For individuals in a pandemic, Hiram Crespo proposes the Epicurean philosophy as a tool to manage their own lifestyle. (Crespo 2020) Like Aristippus of Cyrene, (Internet Encyclopedia of Philosophy 2020) who invented the ethics of pleasure, we should be adaptable and flexible, seeing opportunities for pleasure in any situation.

Epicurus advises us not to postpone our happiness. The moments of isolation spent in the pandemic are moments to make the most of intimate pleasures. We must take into account what is in our power to control.

In Epicurus’ short Letter to Menoeceus about the fear of death and the fear of disease and pain, he says that nature sets the limits of all our pain and that since death is ignorance, the only way it makes us suffer it is waiting for something that we will not actually be there to experience. (Epicurus 2016)

The ancient Greek philosophers used the word ataraxia for the moral ideal of a quiet, pleasant, unperturbed feeling. Epicurus taught us that death is nothing to us. As long as we live, we should be concerned about the quality of our lives and the lives of those we love. (Crespo 2020)

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Sfetcu, Nicolae, “Ethics in the pandemic”, SetThings (October 29, 2020), DOI: 10.13140/RG.2.2.36811.82728, URL = https://www.setthings.com/en/ethics-in-the-pandemic/

Email: nicolae@sfetcu.com

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International. To view a copy of this license, visit http://creativecommons.org/licenses/by-nd/4.0/.

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