Covid-19 is posing ethical challenges for policymakers

April 2020

In France, to leave their houses, people must fill in a form that allows them to perform essential jobs, attend medical appointments or go shopping for daily needs, an errand for which people have one hour only and must stay within one kilometre of their homes. The certificates must be shown on demand. Breaching ‘confinement’ rules risks fines and jail.[1]

Such is life in France under the ‘lockdown’ imposed since March 17 to stop new infections from the severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, that causes a coronavirus illness known as covid-19.[2] This ‘suppression’ strategy is one of two broad options leaders in charge of democracies have adopted to fight the disease (discounting the option to do nothing, a policy no major democracy has followed). Countries such as Italy, New Zealand, Spain, the UK and some states such as California are in some degree of lockdown, a policy that mimics China’s authoritarian approach to combat covid-19.

These lockdowns dispense with liberty to halt the transmission of the virus. If that’s achieved (say, after two months), society can be reopened provided the borders stay shut and authorities can test, monitor and trace contacts of new infections to prevent a flareup. The suppression option has often been adopted when health facilities were swamped with cases. It comes with about as brutal an economic shock as can be self-inflicted because all physical businesses but essential services are shut down. But if the medical emergency were beaten and the public were confident about resuming normal life, the economy would be poised to recover. Risks of this approach include that lockdowns are never all encompassing so there is no guarantee the disease can be eradicated. Other problems include that lockdowns could be extended endlessly, the public might bristle against the restrictions, and it is unclear when an increase in a government’s exercise of power might be lifted. Most problematic of all is that the disease could resume its menace when the population is ‘unlocked’.

The other common approach to fight covid-19 is the ‘mitigation’ strategy, more commonly described as ‘flattening the curve’. These countries, after isolating the vulnerable, try to slow the spread of the virus through their populations in the hope of suppressing it enough for medical authorities to cope and for a vaccine to be developed (though none appears likely soon). Within this strategy, at the relaxed end of restrictions, sits the aim of allowing a population to develop a community, or ‘herd’, immunity or resistance to the disease a common way for most viruses to be contained. When pursuing mitigation, officials shut as little of society as possible until the spread of the virus is contained. (The northern hemisphere hopes warmer weather will slow the pandemic.) How much of the economy is closed varies across countries. Sweden,[3] where schools, restaurants and social gatherings are allowed, has a relaxed approach to mitigation, whereas Australia’s mix of social distancing, crowd controls and stay-at-home directives can perhaps be viewed as being at the harsher end of mitigation and blurring into suppression – Australia’s Chief Medical Officer Brendan Murphy describes Australia’s approach as “control and suppression” though people are much freer than in countries under lockdown.[4] The risks with the mitigation approach are that more lives might be lost, infections might spiral beyond the ability of medical facilities to cope and the economic shock, though initially milder than compared with the lockdown blow, persists longer and proves larger, especially if a spooked public voluntarily locks itself down.

How then to judge the ethics behind choosing suppression or mitigation? At a surface level, the decision appears an ethical choice between lives and livelihood, though, at a deeper level, the choice is between the lives taken by covid-19 versus the lives lost and ruined over the longer term by the steps taken to contain the pandemic. Given such unenviable choices and with no clear ‘right’ answer, one approach to answering this question might be to draw upon different forms of ethical traditions to install guidelines for policymakers. These are first that the cost of the decision must be spread fairly across society, and the disadvantaged, vulnerable and ill must be protected. Second, measures should be reasonable both in their intent and their consequences even amid extreme circumstances. Third, to do the least harm, policymakers should evaluate the unintended effects of their decisions and take steps to mitigate the damage. Fourth, extreme steps, such as army patrols and curtailments on freedom, should be relaxed as soon as possible.

Even within this framework, policymakers are in an unenviable situation because the scientific characteristics of covid-19 are unclear. The discrepancy in death rates across even neighbouring countries (about 0.8% for Germany but 11% for Italy as at March 30 compared with 0.1% for most flus) is just one source of confusion.[5] Scientists are still unsure of covid-19’s transmission rate, if it could mutate, whether or not it could turn on the young or come in waves as did the Spanish flu of 1918-1919 that killed 50 million people. Even allowing for the limited knowledge of the virus’s potency, however, it’s not unreasonable for governments to assume that the novel coronavirus is a highly infectious deadly virus that can leave survivors with life-long damage to key organs.

Ridden with angst about the worst-possible outcomes, policymakers had to make informed judgements about the best approach for their countries where, under utilitarian ethical principles, decisions should on balance favour the common good.[6] A country such as Italy, with an ageing population and a beleaguered health system, had little choice but to install a lockdown. Japan with high personal sanitation standards and an obedient, even if aged, population, and others with younger populations and sound health resources such as Australia sought to ‘flatten the curve’ albeit in an aggressive way. The conflict between the governments of Victoria and New South Wales and the federal government shows that even leaders atop the same populations can disagree on the approach taken.

In making their calls, policymakers had to judge what the death toll might be from either approach and think through the unintended consequences of each option. Flow-on effects of lockdowns might be a jump in family violence and mental-health issues. Leaders had to assess which option left their health systems better placed to deal with standard health emergencies, knowing that these too come with fatal and life-limiting consequences for sufferers. Officials needed to estimate the economic damage of each approach with no precedents to guide them. They needed to ask themselves which option might be less likely to ruin a generation’s job prospects and impoverish society for decades, which can lead over time to an increase in deaths of stress, despair, substance abuse, violence, civil unrest and poor health (care).

Even though the battle against covid-19 is far from won, we can say that both approaches can be supported by sound ethical arguments even if the logic behind each judgement call is different. While only hindsight will prove which approach was the most effective, it would be hard to say any democratic government has acted unethically in its fight against the coronavirus, even allowing for mistakes. It can be said too that, given the economic and social damage covid-19 is likely to (and will) inflict, policymakers are bound to confront even harder ethical choices in coming years than those they faced during the emergency phase of the crisis.

To be sure, it won’t be much consolation to think that policymakers acted ethically if the social and economic consequences of their decisions prove immense. In some ways, the ethical choices surrounding covid-19 are no different from other weighty decisions governments make all the time when they implicitly put a price on life. Society places a hidden value on lives when, say, it settles on health budgets, sets maximum speed limits on highways or allows backyard pools. It’s just that covid-19 decisions are so consequential.

Perhaps, in time, covid-19’s greatest ethical lesson might be how it exposed the ethics of societies before the pandemic hit. The countries that might be judged to have failed the common good would be those with poor and patchy public healthcare systems, no contingency plans for a pandemic, few locally produced essential medical supplies, limited manufacturing to convert to factories of health equipment and, having stretched government finances, had scant ability to protect their populations without risking their prosperity. That would be many of them.

Opinions galore

Professor Neil Ferguson is a UK epidemiologist who is advising the UK government on how to respond to the novel coronavirus. He leads a team at the Imperial College in London that in March published modelling that concluded that if the pandemic were not immediately suppressed then 500,000 people in the UK would die (and more than two million in the US). The health system would be swamped, leading to other deaths.[7] The study prompted Prime Minister Boris Johnson, who is infected with coronavirus, to switch from flattening the curve to lockdown.

The government’s U-turn from mitigation to suppression was controversial. Mitigation through controlling the pace a virus spreads while building up community immunity is a common strategy to manage the spread of infectious diseases. Once a significant percentage of a population is immune to an illness due to vaccines or by gaining resistance through infection, a virus largely stops spreading. But no vaccine is coming soon for the coronavirus so community immunity can be built only through sickness for a significant (and unknown) percentage of the population. Plumping for this option, however, will lead to deaths and damaged survivors, even as many people, especially the young, show no symptoms.[8]

Fighting a disease by suppression is the opposite strategy. Most of the population are confined to their homes and never get the disease. While fewer deaths are likely than under the mitigation strategy, the population has no resistance to the illness if the virus resumes its spread once the lockdown is over unless a vaccine has been found or broader controls (such as closing borders) and a surveillance system act to limit the re-emergence of the disease. Not all countries are equipped to do this and a prolonged border closure would add to economic disruption. The most immediate reason why governments opted for lockdown was that medical facilities were overrun or modelling showed a coming deluge of cases. Once medical systems are coping again, the suppression orders should in theory be eased so such countries can unlock their societies and control the disease under testing, monitoring and tracing regimes – in essence, pursue a mitigation strategy.

To show how hard it was for authorities to make informed decisions, the Imperial College study that prompted Johnson to switch to lockdown was contradicted by one from Oxford University.[9] The Oxford modelling concluded that the majority of coronavirus infections are so mild as to pass unnoticed and unrecorded and that perhaps 40% of the UK’s population already had the disease. The study said that meant the lockdown in the UK serves no purpose because the number of cases to come could be handled by the country’s health system.[10] Claims that European countries were underestimating the true death rate of coronavirus because authorities only counted deaths in hospitals were among those used to discredit the study and reinforce the decision to adopt the suppression strategy.[11] 

Italy’s tragedy was heightened because it is an aged society and covid-19 has proven a deadlier disease for older people and for those with pre-existing conditions. This throws up another ethical dilemma for politicians. Many democratic leaders, from French President Emmanuel Macron to Johnson, likened the fight against covid-19 to a ‘war’. As armed conflict generally demands that young adults die to protect the rest of the community, covid-19’s similar twist is that both strategies come with an economic blow that will punish the young more than the saved older generations. The young are missing out on schooling, sport and socialising, face abhorrent job prospects and could bear the economic cost of covid-19 for decades to come in the form of higher taxes. Even before the crisis has eased, calls are mounting for retirees to pay higher taxes (which usually means reduced concessions). Few leaders expressed the ethical choice of lives versus lives more bluntly than US President Donald Trump, when on March 23 he tweeted that “we cannot let the cure be worse than the problem”.[12] The tweet came during a two-week stretch when virus deaths in the US spiralled and measures to arrest the pandemic forced 10 million Americans to seek unemployment relief.[13]

While governments have taken extraordinary fiscal steps to cushion the economic blow to society – as ethics demand – they still might not be enough to avoid a deep and prolonged recession. Many studies show that vast unemployment comes with hefty social costs including premature deaths. Philip Thomas, a professor of risk management at Bristol University, in March published a paper that concluded that a fall in the UK’s output of more than 6.4% could lead to a recession that would “cost more life” than would be saved through beating the virus through a lockdown.[14] The paper had its critics too.

Such is the conflicting information surrounding the ethical dilemmas policymakers face. Yet so far, amid all the murky data over the novel coronavirus’s characteristics and its economic impacts, the leaders of democracies across the world appear to have made decisions on combating covid-19 that, at the very least, don’t fail ethical considerations. If only their predecessors had thought as much about the common good before the virus introduced the world to steps such as lockdowns being imposed to control its damage.

By Michael Collins, Investment Specialist