Pandemic Ethics: From COVID-19 to Disease X

Description

The COVID-19 pandemic is a defining event of the 21st century. It has taken over eighteen million lives, closed national borders, put whole populations into quarantine and devastated economies. Yet while COVID-19 is catastrophic, it is not unique. Children who have been home-schooled during COVID-19 will almost certainly face another pandemic in their lifetime - one at least as bad-and potentially much worse-than this one. The WHO has referred to such a future (currently unknown) pathogen as “Disease X”. The defining feature of a pandemic is its scale-the simultaneous threat to millions or even billions of lives. That scale leads to unavoidable ethical dilemmas since the lives and livelihood of all cannot be protected. But since one of the most powerful ways of arresting the spread of a pandemic is to reduce contact between people, pandemic ethics also challenges some of our most widely accepted ethical beliefs about individual liberty and autonomy. Finally, pandemic ethics brings vividly to the foreground debates about the structure of society, inequalities, disadvantage and our global responsibilities. In this timely and vital collection, Dominic Wilkinson and Julian Savulescu bring together a global team of leading philosophers, lawyers, economists, and bioethicists. The book reviews the COVID-19 pandemic to ask not only 'did our societies make the right ethical choices?', but also 'what lessons must we learn before Disease X arrives?' Cover Pandemic Ethics: From COVID-19 to Disease X Copyright Contents Acknowledgement Foreword Preface List of Figures Notes on Contributors Introduction I.1 Choices I.2 Freedom I.3 Equality I.4 Pandemic X PART I. GLOBAL RESPONSE TO THE PANDEMIC 1. The Great Coronavirus Pandemic: An Unparalleled Collapse in Global Solidarity 1.1 Norms of Solidarity 1.2 The International Health Regulations: Fracturing of the Global Instrument to Govern Pandemic Response 1.2.1 Core Health System Capacities 1.2.2 China’s Delays in Reporting a Novel Coronavirus Outbreak 1.2.3 WHO’s Inability to Independently Verify State Reports 1.2.4 Declarations of a Public Health Emergency of International Concern and Global Pandemic 1.2.5 Travel Bans 1.3 SARS-CoV-2 Proximal Origin 1.4 Failures in Risk Communication and Lost Public Trust in WHO and Public Health Agencies 1.5 Failures in Scientific Cooperation 1.6 Nationalism, Isolationism, and Science Denial 1.7 WHO Caught in the Middle of Two Political Superpowers 1.8 Exacerbating the Global Narrative of Deep Inequities 1.8.1 Hoarding of Medical Equipment and Public Health Tools 1.8.2 Vaccine Nationalism 1.8.3 Failure to Back the ACT Accelerator and COVAX 1.8.4 Wealthy Countries Hoard Vaccine Supplies 1.8.5 Vaccine Diplomacy from the World’s Largest Dictatorships 1.9 A Failure of Imagination of Global Bodies 1.10 How to Solidify Global Cooperation and Equity 1.11 A Thought Experiment: Pandemic X Bibliography 2. Institutionalizing the Duty to Rescue in a Global Health Emergency 2.1 Extreme Nationalism 2.2 The Moral Necessity of Institutionalizing Duties of Justice, not Just Duties of Beneficence 2.3 A Dynamic Conception of Morality 2.4 Extreme Cosmopolitanism 2.5 A Positive Cosmopolitan Duty 2.6 Institutional Design 2.6.1 Creation or modification? 2.6.2 Key moral desiderata 2.6.3 Structural-Procedural Desiderata 2.6.4 Formal or Informal? 2.6.5 The Big Question: Why Should Rich Countries Ratify such a Treaty? Bibliography 3 The Uneasy Relationship between Human Rights and Public Health: Lessons from COVID-19 3.1 Introduction 3.2 Scope 3.3 Content 3.4 Common Goods 3.5 Democracy 3.6 Conclusion Acknowledgements Bibliography PART II. LIBERTY 4. Bringing Nuance to Autonomy-Based Considerations in Vaccine Mandate Debates 4.1 The Standard Approach: Appeal to the Harm Principle 4.2 Application of the Harm Principle to Vaccine Mandate Debates 4.3 Mandates and Freedom of Occupation 4.4 Just a Prick? Bodily Autonomy, Trust, and Psychosocial Harm 4.5 Reasons for Refusal and Implications for Autonomy 4.6 A Word about the Least Restrictive Alternative—Mandates vs. Nudges and Incentives 4.7 Conclusion Bibliography 5. The Risks of Prohibition during Pandemics 5.1 Policing Pandemic Risks 5.2 Prohibition and Public Health Outcomes 5.3 Public Health Hypocrisy 5.4 General Principles for Prohibition and Pandemics 5.5 Conclusion Bibliography 6. Handling Future Pandemics: Harming, Not Aiding, and Liberty 6.1 Introduction 6.2 Distinguishing Not Harming from Aiding 6.3 How to Weigh Costs to Some against “Benefits” to Others Bibliography 7. Against Procrustean Public Health: Two Vignettes 7.1 Introduction 7.2 The Ethics of Considering Vaccination Status to Design Public Health Restrictions 7.2.1 Why Considering Vaccination Status Is Consistent with Freedom and Equality 7.2.2 Implementation, Ineligible Groups, and Vaccine Scarcity 7.2.3 Evaluating Discrimination and Related Objections 7.3 The Ethics of Using “Second-Best” Vaccines 7.4 Coda: Why Research Remains Imperative 7.5 Conclusion Bibliography 8. Ethics of Selective Restriction of Liberty in a Pandemic 8.1 Introduction 8.2 The Harm Principle and Liberty Restriction 8.3 Easy Rescue Consequentialism 8.4 Applying Easy Rescue Consequentialism to the Pandemic 8.5 Population-Level Consequentialist Assessment 8.6 Individual Costs 8.7 Resource Use and Indirect Harm 8.8 Consistency: Compare with Children 8.9 Objections 8.9.1 Discrimination and the Value of Equality 8.9.2 Relevant Differences 8.9.3 Reinforcing Structural Injustice and Further Disadvantaging the Worst-Off 8.9.4 Historically Wrong Discrimination and Symbolic Value of Equality 8.9.5 Proportionality 8.10 An Algorithm for Decision-Making 8.11 Conclusion Bibliography PART III. BALANCING ETHICAL VALUES 9. How to Balance Lives and Livelihoods in a Pandemic 9.1 Introduction 9.2 Benefit–Cost Analysis 9.3 Social Welfare Analysis 9.4 Evaluating Policies: a Numerical Illustration 9.5 Conclusion Acknowledgements Bibliography 10. Pluralism and Allocation of Limited Resources: Vaccines and Ventilators 10.1 Conflicting Values, Conflicting Choices 10.1.1 Problems 10.1.2 Choices 10.1.3 Public Values 10.2 Pluralism in Pandemics 10.3 Challenges to Developing Pluralistic Resource Allocation in a Pandemic 10.3.1 Epistemic Challenges 10.3.2 Normative Challenges 10.3.3 Political Challenges 10.4 Disease X 10.4.1 Preparation 10.4.2 Ethical Convergence 10.4.3 Collective Reflective Equilibrium 10.4.4 Dissensus and Parity 10.4.5 AI ethics 10.5 Conclusions Bibliography 11. Fairly and Pragmatically Prioritizing Global Allocation of Scarce Vaccines during a Pandemic 11.1 Background 11.1.1 The Proportional Allocation Scheme 11.1.2 The Fair Priority Model 11.2 Pragmatic Challenges 11.2.1 Uncertainty 11.2.2 Political Appeal 11.3 Flattening the Curve 11.4 Conclusion Acknowledgments Bibliography 12. Tragic Choices during the COVID-19 Pandemic: The Past and the Future 12.1 The Two Main Approaches for Resource Allocation: Ethical (USA) versus Medical (Europe) Framework 12.1.1 The USA: Anticipatory Guidelines, Ethical Debates, and Planning for Scarce Resource Allocation 12.1.1.1 Anticipatory Guidelines and Preparedness 12.1.1.2 Ethical Consensus 12.1.1.3 Guidelines Variations 12.1.1.4 Challenging Issues 12.1.1.5 Age? 12.1.2 Europe: Medically Drafted Guidelines 12.2 Outcomes 12.2.1 Western Europe: Covert Triage 12.2.1.1 Common Features 12.2.1.2 Formal/Informal Triage 12.2.2 The US: Informal Triage and Suboptimal Care 12.2.2.1 Lack of Formal CSC Declaration: Unclear Situation and Suboptimal Care 12.2.2.2 Excessive Emotional Toll on Frontline Healthcare Providers 12.3 Lessons for the Future 12.3.1 Strong Political Centralized Leadership Needed 12.3.2 Consistency and Transparency 12.3.3 Support for HCP: from Moral Distress to Moral Injury 12.3.4 The Role of Experts 12.3.5 Accountability, Transparency, and Ethics 12.3.6 Trust 12.4 Conclusion Bibliography PART IV. PANDEMIC EQUALITY AND INEQUALITY 13. Ethical Hotspots in Infectious Disease Surveillance for Global Health Security: Social Justice and Pandemic Preparedness 13.1 Requirements for Effective Pandemic Preparedness 13.1.1 The Central Role of Surveillance 13.1.2 What Does Surveillance Entail for Those who Are Surveilled? 13.1.3 A Global Focus on the Local: Where Will Surveillance Actually Happen? 13.2 Global Justice and Infectious Disease Surveillance 13.2.1 Pandemic Preparedness as a Collective Action Problem 13.2.2 Infectious Disease Surveillance as a Global Public Good 13.3 Surveillance and Social Justice 13.4 Three Tests of Ethical Commitment 13.4.1 Acceptable Sources of Surveillance Data 13.4.2 Data and Duties of Care 13.4.3 Prioritization Decisions between the Needs of Those in the Future and Those in the Present 13.5 Conclusion: Infectious Disease Hotspots Are also Ethical Hotspots Acknowledgements Bibliography 14. COVID-19: An Unequal and Disequalizing Pandemic 14.1 Introduction 14.2 COVID-19: An ‘Unequal’ Disease? 14.2.1 Communicable Diseases, Rich Countries, and Poor Countries 14.2.2 Lockdown 14.3 The Pandemic and the Policy Response to it 14.3.1 Introduction 14.3.2 The First Wave 14.3.3 The Second Wave 14.4 Policy and the Pandemic: Some Fallouts 14.4.1 Introduction 14.4.2 The Reach of Infections and Mortality 14.4.3 Economic Growth 14.4.4 Money-Metric Poverty 14.4.5 Livelihoods 14.4.6 Hunger 14.4.7 Education 14.4.8 Casualties of Caste, Religion, and Gender 14.5 Concluding Observations Bibliography 15. Pandemic and Structural Comorbidity: Lasting Social Injustices in Brazil 15.1 Introduction 15.2 COVID-19 in Brazil: Background and Pandemic 15.3 Making Visible the Intersection of Vulnerabilities: the Effects of COVID-19 in Brazil and its Colonial Entanglements 15.4 Poverty as a Risk Factor: the Case of the Pandemic in Slums 15.5 Racism and Sexism Aggravating Pandemic Risk: Unemployment, Hunger, and Domestic Violence 15.6 LGBTI+ People in the Pandemic: Isolation and Insecurity 15.7 Indigenous Peoples: Socio-environmental and Ethnic-racial Risk in the Pandemic 15.8 At-risk Groups: Colonial Vulnerability in Times of Pandemic 15.9 Adopting a Decolonial Moral Paradigm 15.10 The Colonial Past and the Post-pandemic Future Bibliography 16. Fair Distribution of Burdens and Vulnerable Groups with Physical Distancing during a Pandemic 16.1 Introduction 16.2 Overview of COVID-19 Control Policies in Japan 16.3 COVID-19: Older Individuals and Foreigners in Japan 16.3.1 Solitary Death and Social Isolation among Older People in Japan 16.3.2 International Students and Foreign Workers in Japan under the COVID-19 Pandemic 16.4 Three Policy Measures to Improve the Welfare of Vulnerable Populations 16.4.1 Minimize Restrictions 16.4.2 Provide Appropriate Information 16.4.3 Alternative Communication Tools 16.5 Adjusting the Public Health Policy for a Future Disease X 16.6 Conclusions Bibliography PART V. PANDEMIC X 17. Pondering the Next Pandemic: Liberty, Justice, and Democracy in the COVID-19 Pandemic 17.1 Liberty-Restricting Measures 17.1.1 The Debate 17.1.2 Selective Restrictions 17.1.3 Different Freedoms 17.1.4 Taking Harm Prevention Seriously 17.2 Global Justice 17.3 Going Forward 17.3.1 Democracy 17.3.2 Public Health and Government Overreach 17.3.3 Children 17.4 Conclusion Bibliography Index