Governments are facing mounting ethical challenges as the coronavirus continues to spread and the death rate continues to climb. These range from setting criteria that will determine who lives and who dies, to strategies to fight the virus, to choices between stopping or slowing the virus versus protecting a nation’s economic interests. The choices that are made could define cultures and nation-states for the 21st Century, just as World Wars I and II defined cultures and nation-states in the last century.
The ethical challenges are made more difficult by the newness of the coronavirus or Covid-19 as it has come to be known. The simple fact is that while modern science has made some lightning speed discoveries about the virus in the past three months, there is still much about it that we don’t yet know. Each day that goes by brings a new discovery about it or turns on its head something that scientists thought they knew about it.
For example, many scientists believed it only caused mild symptoms in normally healthy people in their 20s and 30s, and that it did not affect children, who remained asymptomatic. This view shaped decisions by some governments to keep schools and universities open even as they shut down other segments of their economies.
But some children and young adults have developed more serious symptoms. And, inexplicably some normally healthy young adults have even died from the virus.
To have and to have not
Usually in a hospital emergency room, patients are triaged and the most critical are treated first. That principle has only applied with coronavirus in the early stages of infection in a country. As numbers of infections have grown and state and national healthcare systems have come under increasing pressure it has become more difficult to make decisions along those lines.
With numbers of seriously ill admissions rising, doctors and hospital administrators are being placed in the difficult position of having to determine who lives and who dies. They might, for example, start to ask which patient has the better chance of success – a 70-year-old man or a 30-year-old woman? Or who has greater social or even economic value – a young mother of three or a single man in his 40s with no dependents?
Or, all other things being equal, how does a doctor choose between, say, a brain surgeon and a plumber?
These are not theoretical questions. Italy is already dealing with these dilemmas due to a shortage of respirators. In one case a Catholic priest, Fr Giuseppe Berardelli, who had been suffering for some years from a respiratory illness, reportedly gave up his respirator so a younger man with Covid-19 could be saved [later reports question this –Ed].
While Fr Berardelli may have chosen to sacrifice himself, what happens when two people are admitted in a serious condition to a hospital with only one available ventillator? Shortages of medical equipment, including protective gear for doctors and nurses, have led to questions about resuscitating coronavirus patients. A growing number of medical staff across the US are concerned about becoming infected while trying to resuscitate coronavirus patients when they don’t have Personal Protective Equipment due to PPE shortages as the crisis worsens.
Currently many are bound by medical codes and state laws to do everything possible to save a patient. But should that include placing their own lives at risk given the lack of equipment and knowledge about the virus? US doctors are seeking clarity around laws of individual states as they may need to consider a “do not resuscitate” policy regardless of the wishes of patients and family.
Governments make decisions about the allocation of scarce resources every day, including about a state’s health sector and hospital system. They now have to do so with respect to the unfolding Covid-19 pandemic.
Those decisions could determine who lives and who dies according to post codes. It could become a real case of the “haves and have nots”. Questions revolve around what criteria bureaucrats and politicians might use in allocating those scarce resources during this time of crisis.
In an interview with The New Yorker, Harvard Medical School bioethicist Christine Mitchell lamented the fact that many US jurisdictions lack bioethics bodies to advise politicians during this crisis. In particular, she criticised the Trump Administration’s decision not to have a National Bioethics Commission that could prove pivotal at this time.
However, it’s not clear that having a National Bioethics Commission would solve all the problems — the whole world is in uncharted waters with the coronavirus. Much would depend on the composition of the Commission and its philosophical starting point and decision-making criteria.
The ethical decisions that need to be made by front-line doctors almost pale into insignificance when compared with some of the broader strategic decisions politicians across the globe are facing in dealing with the disease itself. Those decisions could put many more lives at risk.
One such question is around building immunity to the coronavirus.
Don’t follow the herd
Until a week ago the British Government had been contemplating a strategy of “building herd immunity” to the coronavirus. The idea behind herd immunity is to let the virus pass through society so that the population acquires the antibodies to survive, much like a vaccine would do. It is generally thought that you need at least 60 to 70 percent of the population to be infected with the virus to provide protection for everyone. To its credit the British intended to protect the most vulnerable – such as the aged and people with underlying medical conditions – as it allowed the virus to pass through society.
The British Government pulled away from the idea at the last minute for several reasons.
First, medical professionals became concerned about the rate of severe illness caused by the disease – 19 percent. They believed this would overwhelm the UK’s National Health Service (NHS), which would lack the beds and emergency equipment to cope with the numbers that would require hospitalisation. Secondly there were concerns about a 2.3 percent mortality rate.
If you think about 60-70 percent of the UK population of 66 million needing to be infected to achieve herd immunity, the numbers that would need to be hospitalised and that would die are staggering. Even in a “best case” scenario the UK could have been looking at 236,000 deaths.
The human cost of achieving herd immunity appears too high. No doubt Prime Minister Boris Johnson was also concerned about the electoral backlash if the numbers of seriously ill and dying skyrocketed. He opted for a complete lockdown across the UK instead.
Not so Sweden.
By contrast with other countries, including other Scandinavian countries, Stockholm looks like it may be going for herd immunity. It has decided to keep schools open, although it has closed universities and other tertiary educational institutions, and suggested people work from home where possible. But public transport systems remain crowded and ski resorts continue to operate.
In the face of mounting criticism from some in its medical community, the Swedish Government has said it is not going for herd immunity. Rather, its strategy is based on protecting its economy. The head of Sweden’s public health agency said last week that Sweden “cannot take draconian measures that have a limited impact on the epidemic but knock out the functions of society.”
Is it the economy, stupid?
That is a growing concern in Western countries, not least the US. With numbers of those infected now approaching 70,000 across the country and with more than 42 percent of workers under “stay at home” orders, Wall Street has experienced a rollercoaster ride in the past few weeks, with some of the steepest share price falls since the Great Depression.
Congress passed a $2.2 trillion stimulus package to stem the economic damage as three million people registered as unemployed in the wake of the shutdown strategy.
The worsening economic situation caused President Donald Trump to state earlier in the week that he wanted the US “back open by Easter” on April 12. He went on to say the “cure” (referring to the shutdown and its economic impact) cannot be “worse than the problem”. He claimed that if the US went into a recession or depression the loss of lives would be far higher than that caused by Covid-19.
Public policy makers would obviously be concerned about a potential rise in violent crime and suicides if a depression were to occur. But the President did not elaborate or provide numbers of anticipated deaths from the coronavirus or as a result of an economic downturn.
Without data it is very difficult to make policy. Not surprisingly many in the medical community were alarmed that President Trump seemed to set a hard target date by which to lift the shutdown measures. Over the weekend, he changed his mind. Federal coronavirus guidelines such as social distancing will be extended across the US until at least the end of April.
Many have been arguing for a phased removal of the restrictions and targeting stricter restrictions at outbreak hotspots. (With things changing daily, Trump has hinted New York, the worst affected state in the US, might have to keep the strong restrictions longer than other parts of the country.)
The West should look more closely at the actions taken by several Asian countries in dealing with the virus.
China’s success came from totally shutting down hotspots like Hubei Province, with a population of 60 million, as well as the mega-cities of Shanghai and Beijing, for nearly two months. That had a significant impact on China’s economy, but it essentially succeeded in slowing down the rate of new coronavirus infections.
China is now more concerned about re-importing the virus from countries in Europe, the US and elsewhere and has put in place strict quarantine rules for people arriving from overseas. Last Friday it banned all foreigners from entering the country.
South Korea, Taiwan, Hong Kong and Singapore all had considerable success in slowing the rate of growth of new infections by taking some harsh lockdown and contact tracing actions early. That has bought them considerable time to prepare for the widely forecast second wave of the virus following the lifting of restrictions.
Rather than lift the shutdown Trump, and other national leaders, might be best advised to follow the lead of the UK.
There the government has said it will cover 80 percent of the wage bills of employers up to £2,500 per week in order to keep layoffs and redundancies to a minimum. That could stall a recession by protecting jobs, ensuring families have money for essentials and, most importantly, ensuring a sense of confidence about the economic outlook of the country.
The move is significant given that it comes from Britain’s ruling Conservative Party, which was earlier considering a herd immunity strategy. Prime Minister Boris Johnson is to be commended for putting people ahead of his party’s usual adherence to strict fiscal policies.
But what of developing nations that cannot afford stimulus measures or a “basic social wage” while they try to get through the corona crisis?
Brazil’s President Jair Bolsonaro has been critical of the country’s largest state São Paulo since it commenced a state-wide two-week shutdown last week, calling it “hysteria”. São Paulo is home to 46 million people and is the engine of the country’s economy.
Bolsonaro is concerned that the shutdown could cripple the country economically. The shutdown is to be reviewed on April 7. Despite a rising number of infections and deaths, it is not inconceivable that São Paulo will lift the shutdown by Easter because of its economic impact on the state and the country.
India has also commenced a shutdown to slow the rate of infections that threatens to overwhelm its healthcare system. It too will have to make difficult choices between continuing a harsh shutdown and getting the country back to work.
Other countries, such as many in the Middle East, North Africa and Sub-Saharan Africa are not so fortunate.
Governments ruling over people living subsistence hand-to-mouth lives do not have the luxury of choice in responding to this virus. They cannot shut down their countries, provide stimulus packages or social wages to slow the progress of the epidemic. Coronavirus will ravage these countries and poses the threat of returning to other countries in a second wave even if developed nations succeed in stopping the virus in its tracks. It needs to be remembered that a second wave could be even more virulent, as occurred with the Spanish Flu in 1918.
The end of globalisation and the rise of nationalism
This possibility poses a new threat to the world and a new set of ethical choices for national governments. That threat is the rise of protectionism and, with it, the risk of nationalism.
The US had already been pushing to decouple its economy from China — a policy supported by both sides of the aisle in Washington. This has been given new impetus following the emergence and impact of the coronavirus on global supply chains. The current tit-for-tat rhetoric between Washington and Beijing over the coronavirus is not helpful.
While coronavirus might highlight the need for businesses around the world to return to more diversified markets and supply chains, it would be dangerous to move towards complete decoupling of economies. That could fragment the global economy and lend itself to nationalistic agendas that turn the world order into a winner-takes-all battle for limited natural resources. Consider that the Great Depression led to the rise of nationalistic governments and extremist political doctrines that culminated in World War II.
The world has been warned for decades of the risks of new pandemics and that they would likely rise in China, the Indian Subcontinent, Latin America, the Middle East or Africa. These countries are likely to be the source because of their rapid urbanisation with large populations living close to animals, including wild and exotic animals that they continue to eat. (Note that since the coronavirus outbreak China has outlawed and commenced a crackdown on markets selling wild and exotic animals.)
And the world has had plenty of warning signs of a coming pandemic in recent years, including the SARS outbreak (which originated in southern China in 2002), H5N1 Bird Flu (China, 2003), Swine Flu (US and Mexico, 2009), MERS (Saudi Arabia, 2012), H7N1 Bird Flu (China, 2013), and Ebola (West Africa, 2014). Yet, little was done in the way of preparation by national governments. That was a choice made by governments the world over. Was it an ethical choice?
Instead of pulling up the drawbridges, developed countries like the US, Canada, Britain, the EU countries, Australia and New Zealand, need to look at how they can work together with each other and with developing nations to better manage the next pandemic – and there certainly will be more of them.
In this sense the choice between globalisation and nationalism is also an ethical decision for national governments. Making the right choice will require true leadership that can resist populism. National leaders and governments need to choose to either work with other nations to mitigate the risks of future pandemics or lend themselves to political agendas that could lead the globe into a dog-eat-dog new world order. The latter could see the Doomsday Clock advanced yet another second.
The real threat to the future of humankind isn’t a pandemic so much as how we choose to respond to the threat of a pandemic.