Utilitarianism and the Pandemic PDF

Received: 31 March 2020 | Revised: 15 May 2020 | Accepted: 20 May 2020 DOI: 10.1111/bioe.12771 C OV I D -19 : O R I G I N A L A R T I C L E Utilitarianism and the pandemic Julian Savulescu1,2,3,4 | Ingmar Persson1,5 | Dominic Wilkinson1,2,6 1 Oxford Uehiro Cent...

Received: 31 March 2020 | Revised: 15 May 2020 | Accepted: 20 May 2020 DOI: 10.1111/bioe.12771 C OV I D -19 : O R I G I N A L A R T I C L E Utilitarianism and the pandemic Julian Savulescu1,2,3,4 | Ingmar Persson1,5 | Dominic Wilkinson1,2,6 1 Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Abstract Kingdom of Great Britain and Northern There are no egalitarians in a pandemic. The scale of the challenge for health systems Ireland 2 and public policy means that there is an ineluctable need to prioritize the needs of the Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, many. It is impossible to treat all citizens equally, and a failure to carefully consider the United Kingdom of Great Britain and consequences of actions could lead to massive preventable loss of life. In a pandemic Northern Ireland 3 Visiting Professorial Fellow in Biomedical there is a strong ethical need to consider how to do most good overall. Utilitarianism Ethics, Biomedical Ethics Research Group, is an influential moral theory that states that the right action is the action that is ex- Murdoch Children’s Research Institute, Melbourne, Australia pected to produce the greatest good. It offers clear operationalizable principles. In 4 Distinguished Visiting Professor in Law, this paper we provide a summary of how utilitarianism could inform two challenging Melbourne Law School, University of questions that have been important in the early phase of the pandemic: (a) Triage: Melbourne, Melbourne, Victoria, Australia 5 which patients should receive access to a ventilator if there is overwhelming demand Department of Philosophy, Linguistics and Theory of Science, Gothenburg University, outstripping supply? (b) Lockdown: how should countries decide when to implement Gothenburg, Sweden 6 stringent social restrictions, balancing preventing deaths from COVID-19 with caus- John Radcliffe Hospital, Oxford, United Kingdom of Great Britain and Northern ing deaths and reductions in well-being from other causes? Our aim is not to argue Ireland that utilitarianism is the only relevant ethical theory, or in favour of a purely utilitarian Correspondence approach. However, clearly considering which options will do the most good overall Julian Savulescu, Oxford Uehiro Centre for will help societies identify and consider the necessary cost of other values. Societies Practical Ethics, Suite 8, Littlegate House, 16/17 St Ebbe’s St, Oxford, OX1 1PT, UK. may choose either to embrace or not to embrace the utilitarian course, but with a Email: [email protected] clear understanding of the values involved and the price they are willing to pay. Funding information KEYWORDS Wellcome Trust, Grant/Award Number: WT203132 COVID-19, pandemic ethics, resource allocation, utilitarianism 1 | I NTRO D U C TI O N The civil rights office of the US Department of Health and Human Services stated that: The COVID-19 pandemic has posed a formidable and virtually un- precedented challenge to health professionals, health systems and persons with disabilities, with limited English skills, or to national governments. The potential threat to large numbers of needing religious accommodations should not be put patients has led to restrictions on movement, employment, and at the end of the line for health services during emer- everyday life that have impacted the lives of billions and come at gencies. Our civil rights laws protect the equal dignity massive economic cost. Health systems, facing existing or predicted of every human life from ruthless utilitarianism.1 demand overwhelming capacity, have generated guidelines indicat- ing which patients should receive treatment. 1 One ethical theory has been both cited and criticized in public Fink, S. (2020, March 28). U.S. Civil Rights Office rejects rationing medical care based on disability, age. The New York Times. Retrieved from https://www.nytim debate about pandemic response. es.com/2020/03/28/us/coronavirus-disabilities-rationing-ventilator s-triage.html This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. Bioethics published by John Wiley & Sons Ltd 620 | wileyonlinelibrary.com/journal/bioe Bioethics. 2020;34:620–632.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 621 After the New York Times reported that some state pandemic plans may be different from the outcome whose distribution of goodness instructed hospitals not to offer mechanical ventilation to people above comes closest to being just or fair. Then the principle of beneficence a certain age or with particular health conditions (e.g. ‘severe or pro- will have to be balanced against the principle of justice. This will found mental retardation’ as well as ‘moderate to severe dementia’), the most likely have to be done in an intuitive way. It is very controver- Office for Civil Rights (OCR) responded: ‘… persons with disabilities sial what a just or fair distribution consists in, e.g. whether it consists should not be denied medical care on the basis of stereotypes, assess- in getting what is deserved or in more equal shares. This is far too ments of quality of life, or judgments about a person’s relative “worth” controversial to be settled here. It follows that the issue of balancing based on the presence or absence of disabilities or age’.2 justice and beneficence against each other must also be left aside. Utilitarianism is now often used as a pejorative term, meaning Another moral principle is a principle of autonomy, which gives something like ‘using a person as a means to an end’, or even worse, akin weight to an individual’s freedom to choose and to determine, for to some kind of ethical dystopia.3 Yet utilitarianism was originally con- themselves, how to live their own life. Individual freedoms may ceived as a progressive liberating theory where everyone’s well-being conflict with overall good, for example, when individuals choose to counted equally. This was a powerful and radical political theory in the flout social distancing laws, or when individuals demand a scarce 19th century, when large sections of the population were completely resource for themselves or their family members. This also brings disenfranchised and suffered from institutional discrimination. The the- us to the issue of whether the principle of beneficence should be ory played a role in antislavery, women’s liberation and animal rights impartial and accord the same moral weight to the good of all other movements. Yet utilitarianism remains relevant in the 21st century. As individuals or whether it should allow greater weight to the good of we will discuss, it may be particularly salient and important to consider those who are close to us (and to human over non-human beings). in the face of global threats to health and well-being. For the purpose of discussing what policies societies should adopt In this paper, we will summarize what utilitarianism is and how to deal with pandemics, it is reasonable to assume impartiality. it would apply to the COVID-19 pandemic. Our aim is not to argue A further issue is what constitutes goodness and badness for in- that utilitarianism is the only relevant ethical theory, or that a purely dividuals. According to the most familiar theory, hedonism, what is utilitarian approach must be adopted. However, it is important to intrinsically good consists in various positive experiences, of plea- note that whenever a utilitarian solution to a dilemma is adopted, sure and happiness. What is intrinsically bad consists in negative there will be more well-being or happiness in the world. Typically, experiences of pain and unhappiness. Hedonism is, however, fre- some people will be better off. Of course, there may be good ethi- quently criticized for being too narrow in not recognizing that what cal reasons to deviate from a pure utilitarian approach, for example we are not aware of can be good or bad for us, e.g. that our partners in order to protect rights or promote equality. However, consider- deceive us, or that the state surveys our behaviour, so cleverly that ing the alternative will help societies to identify and consider the we never notice it. For such reasons a wider conception of what is necessary cost of these other ethical values. Utilitarianism is not intrinsically good or bad for us than hedonism will be assumed here, the end of ethical reflection, but it is a good place to start. though to determine its precise import would take us too far afield. Some moral theories imply that there is a stronger or more strin- gent moral reason to omit doing harm than to benefit. Thus, they 1.1 | What is utilitarianism? imply that there is a stronger reason to avoid making things worse for somebody by killing them, causing them injury or pain, than to Most moral theories imply that there is a (moral) reason to do what is benefit them by preventing them from being killed, injured, etc. expected to maximize what is good for all, or more precisely, the net With respect to pandemics, considerable moral weight has been at- surplus of what is good for all over what is bad for them. This might be tached to harms such as death and disease that can be prevented by called a principle of beneficence. Utilitarians hold that maximizing what various constraints. Therefore, for the present discussion it is bet- is good for all is all there is to morality. It makes moral decisions simple ter to proceed on the assumption that there is no significant moral by supplying a single measure of rightness: maximization of utility. In difference between harming and omitting to benefit. many situations this may be enough, along with rules of thumb with Utilitarianism typically accepts that instances of goodness and the help of which it could be determined what maximizes utility. badness can be aggregated in a quantitative fashion. Thus, consider According to most moral theories there are, however, other a very mild pain that is caused by a physical stimulus of one unit moral reasons. For instance, utilitarianism has often been criticized and that lasts for 10 min. Now compare 100 instances of such a for ignoring the question of what is a just or fair distribution of what pain either spread out over 100 lives or over one life lasting many is good for all. The outcome that generates the greatest good overall decades with a single instance of excruciating pain caused by 75 units of the physical stimulus lasting for 10 min. According to a 2 HHS Office for Civil Rights in Action. (2020, March 28). Bulletin: Civil rights, HIPAA, standard utilitarian calculus the former outcome is worse than the and the coronavirus disease 2019 (COVID-19). Retrieved from https://www.hhs.gov/ latter, but this seems implausible. Most of us would prefer 100 sites/default/files/ocr-bulletin-3-28-20.pdf instances of mild pain dispersed over our lives than 10 min of 3 Smith, W. J. (2020, May 11). Bioethicist: Mandate COVID ‘contact tracing’ app, vaccinations. National Review. Retrieved from https://www.nationalreview.com/corner/ excruciating pain. It might be thought that this issue is crucial in bioethicis t-mandate-covid-contact-tracing-app-vaccinations/ the present context, since we will have to balance the deaths of a  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 622 | SAVULESCU Et AL. lower number of people against smaller burdens for a much higher it is important to have a way of reaching a decision quickly about number of people. We will, however, see that what is morally rel- which patient to attend to first. Triage rules are potentially justi- evant from a utilitarian perspective isn’t death in itself but rather fied by a form of rule utilitarianism that enables rapid intuitive the length and quality of life the deceased would have had if they decisions. hadn’t died. ‘Critical level’ utilitarianism requires choosing the action that will It might be said that what matters in the end is what action actually maximize the good when we are thinking in the ‘cool, calm hour’, maximizes what is good for all rather than what action is expected to with all the facts at hand. Hare imagined a decision-maker who had maximize what is good for all. But our best guide to what will actually perfect knowledge of the outcomes of all available options (he called happen is what is expected to happen on the best available evidence. them a ‘utilitarian archangel’). In complex situations, where there is So, when we decide what to do, we have to go by what is predicted to time to do so, we must try to rise to the more reflective and deliber- be best. This is true in most situations (although in some special cases ative critical level and ask what action we should endorse. What re- we know that what is expected to be best is not what will actually be ally is the right answer? Hare argues that in such situations we should best4). The expected utility of an action is the sum of the products of the employ act utilitarianism (this corresponds to system 1 and 2 think- probability and value of each of the possible outcomes of that action. ing in psychology6). 1.2 | Act and rule utilitarianism There are two broad schools of utilitarianism. According to act Box 1 Alessandro is a 68-year-old doctor. He has moderate utilitarianism, the right act is the act that produces the best con- chronic obstructive airways disease. He contracts COVID-19 sequences. According to rule utilitarianism, the right rule is the rule while caring for patients with the same disease. He develops that produces the best consequences. The law is often an instantia- respiratory failure. Jason is a 52-year-old businessman who tion of rule utilitarianism: laws are chosen because they bring about contracted COVID-19 while travelling for business reasons. the best consequences. He is otherwise well but develops respiratory failure. These versions of utilitarianism can come apart. Sometimes an The triage question: There is only one ventilator remaining. act will clearly have better consequences, or no adverse conse- Who should receive ventilation? quences but a rule proscribes that act. The UK government received modelling that predicted that Principles or laws around non-discrimination are examples of COVID-19 would lead to 500,000 deaths in the absence of this. Not considering a person’s advanced age or severe disability measures to reduce spread. This could be reduced to 20,000 (e.g. severe dementia) in the allocation of resources, including ven- by implementing major social distancing measures (lockdown). tilators, might mean that another person is unable to access those The economic effects arising from restriction of liberty will resources who would have gained greater benefit from it, against predictably result in large numbers of job losses, mental illness, act utilitarianism. Yet the rule might still overall have better conse- and increased medical risk (e.g. unemployment is associated 7 quences if the non-discrimination rule has over-riding benefits. with increased risk of coronary heart disease). Cancellation of elective operations and interventions will result in prolonga- tion of suffering and potentially death. Those suffering from 1.3 | Two level utilitarianism non-COVID illness may not be able to receive treatment in hospital because there are no beds available. The two different schools of utilitarianism can be combined. The The lockdown question: How should we balance prevent- father of modern utilitarianism, Richard Hare, argued that moral ing deaths from COVID-19 with causing deaths and reduc- thinking occurs at two levels: intuitive and critical, and that we tions in well-being from other causes? 5 should move between these depending on the circumstances. At the intuitive level, we have many rough rules of thumb that can be rapidly deployed without protracted and demanding reflection: don't kill, don't steal, be honest, etc. These enable us to act effi- ciently in everyday life. During a pandemic, doctors and other de- cision-makers require rules of thumb. For example, when faced 6 Kahneman, D. (2011). Thinking fast and slow. London, UK: Farrar, Straus and Giroux. with multiple simultaneous patients in the emergency department 7 Maani, M., & Galea, S. (2020, April 13). The true costs of the COVID-19 pandemic. Scientific American. Retrieved from https://blogs.scientific american.com/obser vations/ the-true-costs-of-the-covid-19-pandemic/; Clemens, T., Popham, F., & Boyle, P. (2015). What is the effect of unemployment on all-cause mortality? A cohort study using 4 See Jackson, F. (1991). Decision-theoretic consequentialism and the nearest and propensity score matching. European Journal of Public Health, 25(1), 115–121; Lundi, A., dearest objection. Ethics, 101, 461–482. Falkstedt, D., Lundberg, I., & Hemmingsson, T. (2014). Unemployment and coronary 5 Hare, R. M. (1981). Moral thinking: Its levels, method and point. Oxford, UK: Clarendon heart disease among middle-aged men in Sweden: 39 243 men followed for 8 years. Press. Occupational and Environmental Medicine, 71, 183–188.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 623 We will explore some of the implications of critical level utilitari- treatment, treatment that saves people’s lives for longer is to be pre- anism for the current COVID-19 pandemic. We will also describe ferred over treatments that save life for shorter periods. plausible rules of thumb that would tend to maximize utility and According to this criterion, priority should be given to the would be useful in emergency and urgent situations. Box 1 illus- younger Jason rather than the older Alessandro, because Alessandro trates two questions that have been prominent in the early phase is expected to live less long if successfully treated. If it were Jason of this pandemic. who was expected to die sooner, utilitarianism would support treat- ing Alessandro, even though he is older. Age is thus a de facto measure of length. Because older people 1.4 | Utilitarian rules of thumb tend to die sooner than younger people, utilitarianism tends to fa- vour saving the lives of the younger. However, age itself does not There are several rules of thumb that can guide rapid decision-mak- matter: it is the expected length of the benefit. This is why utilitar- ing about these kinds of cases. ianism is not unfairly discriminatory, and not ‘ageist’ in an ethically 1. Number problematic sense (we will discuss discrimination further below). One utilitarian rule of thumb is to save the greatest number Length of life is also relevant for the lockdown question. It is (other things being equal). This rule could be applied to the lock- the length of life extended that matters. This has implications for down question by assessing how many lives would be lost if lock- evaluation of current policy. In the UK, the decision to implement down is applied, or not applied. It could also be used for the triage national lockdown at the end of March was influenced by modelling question: in practice, this would mean considering the following produced by Imperial College (Figure 1). variables: The UK Government opted to try to reduce deaths to 20,000. A. Probability But it was not clear from the modelling figure of 500,000 how many If Jason has a 90% chance of recovery and Alessandro has a of these people would have died anyway from other causes,9 or rel- 10% chance, other things being equal, you should use your venti- atively soon after not contracting COVID-19. Every year more than lator for Jason. Indeed, if you treat people like Jason rather than 600,000 people die in the UK. For utilitarians, the number of lives people like Alessandro, you will save nine people instead of one saved is irrelevant—it is how long these lives would be prolonged by for every 10 treated. That is why probability is a relevant the intervention. 8 consideration. The average age of death of COVID-19 patients in Italy was 78.10 B. Duration of treatment This implies that many of those saved by implementing lockdown In a setting of scarcity, duration of time on a ventilator has im- would have short life expectancies. The average life expectancy at plications for the numbers of lives saved. The longer one person age 80 is 9 years, and overall, COVID-19 has been estimated to lead will be on a ventilator, the more people who potentially die because to a loss of 11 life years on average. According to utilitarianism, the they cannot get access to breathing support. If Alessandro needs a value of a year of full quality life is the same regardless of how old a ventilator for 4 weeks, and four others (including Jason) need it for patient is. However, if the pandemic largely affects patients with 1 week, the choice is between saving one person or four people. So short life expectancy, the benefit of a lockdown (preventing deaths) doctors should take duration of use into account. would be smaller than a different illness that affected younger pa- C. Resources tients. The cost of lockdown per year of life saved could be astro- When resources are limited, resources equate to numbers of nomical, when one considers all costs including economic and wider lives. The more resources a treatment or a person uses, the fewer social effects. are available for others. Imagine that Alessandro and Jason had iden- At the end of March, economists van den Broek-Altenburg and tical chances of survival, but Alessandro needed a treatment that Atherly, from the University of Vermont estimated the cost-effec- required three staff to administer the treatment (e.g. extracorporeal tiveness of implanting large scale protective measures to reduce the membrane oxygenation [ECMO]—essentially cardiac bypass) and spread of COVID-19. They calculated the cost per Quality Adjusted Jason needed a treatment that required only one staff member (e.g. Life Year (QALY) of a $US 1 trillion economic stimulus package mechanical ventilation). We can potentially save three people with against the number of lost life years potentially averted (up to 13 ventilation for every patient we save with ECMO. ECMO should be a million in the USA). They estimated that such a package would cost lower priority than ventilation. between $75,000–650,000 per QALY.11 (The US government subse- 2. Length of life According to utilitarianism, how long a benefit will be enjoyed 9 Triggle, N. (2020, March 21). Coronavirus deaths: What we don't know. BBC News Online. Retrieved from https://www.bbc.co.uk/news/health-51979654 matters—it affects the amount of good produced. Thus for life-saving 10 Hanlon, P., Chadwick, F., Shah, A., Wood, R., Minton, J., McCartney, G., … McAllister, D. A. (2020). COVID-19 – exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study [version 1; peer review: awaiting 8 peer review]. Wellcome Open Research 5, 75. Savulescu, J., & Wilkinson, D. (2020, March 17). Who gets the ventilator in the 11 coronavirus pandemic? These are the ethical approaches to allocating medical care. ABC Atherly, A. (2020, 24 March). Economic cost of flattening the curve. The Incidental News Online. Retrieved from https://www.abc.net.au/news/2020-03-18/ethic s-of-medic Economist. Retrieved from https://theincidentaleconomist.com/wordpress/econo al-care-ventilator-in-the-coronavirus-pandemic/12063536 mic-cost-of-flattening-the-curve/  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 624 | SAVULESCU Et AL. quently approved a $US 2 trillion stimulus package.) That suggests However, comparisons of overall well-being between individuals that such measures are unlikely to be cost-effective according to the are not straightforward. It is not necessarily the case that someone usual thresholds applied to the costs of medical interventions to with a disability would have lower well-being than someone without save lives. For example, the upper limit for cost-effectiveness of an a disability. Probably the most profound question in ethics is what intervention in the USA is often taken to be about $100,000 per year makes a person’s life good, or constitutes well-being. Philosophers 12 of life saved. have debated this question for thousands of years. Answers include There are two points to make about such an analysis. The first happiness, desire fulfilment or flourishing as human animals (which is that assessing the utilitarian answer to the lockdown question is includes having deep relationships with others and being autono- highly dependent on the specific factual answers—the harm averted mous, amongst other things).15 by acting, the harm caused by acting. It is exceedingly difficult to As a heuristic for triage, it may be that in developed countries a determine which course of action would be best from the point of threshold is set at a level where overall well-being is certain to be view of critical level utilitarianism, partly because of enormous un- low.16 One practical cut off would be unconsciousness or severe dis- certainty about the relevant facts. Secondly, even if lockdown were orders of consciousness, such as being in a minimally conscious cost-effective, it would not be as cost-effective as different inter- state. It is highly unlikely to be cost-effective to provide intensive ventions that save babies or young people. For example, if an inter- care for a patient who is permanently minimally conscious.17 Lines vention saved the life of a younger person with a different disease could be drawn where there is more uncertainty, and may need to be for 50 years, you would only have to save one-fifth as many to bring in countries with more limited resources, or if the demand were about as much benefit. It costs a few dollars to save the life of a child much greater. For example, the threshold might be set at the ability in a developing country. to recognize and respond meaningfully with other people. So, on this While interventions to prevent COVID-19 may be cost-effective approach, cognitive impairments that reduced the capacity to have (though this seems perhaps unlikely), they are unlikely to be the most minimal human relationships would reduce priority for treatment as cost-effective actions that we could take. There are likely to be bet- a proxy for believed reduced well-being.18 ter investments for utilitarians. As an example, The Gates Foundation Quality of life may also be relevant to the lockdown question. If has estimated that global eradication of malaria by the year 2040 the life years saved by lockdown were likely to be of reduced quality would cost up to $120 billion.13 Such an initiative (costing only that would influence how much benefit overall is gained, and there- 14 1/15th as much as the US pandemic stimulus package) would po- fore what economic cost would be worth incurring. tentially save 11 million lives. 4. Equivalence of acts and omissions, withdrawing and 3. Quality of life withholding Utilitarians consider not just how long someone will live after treat- For utilitarians, how an outcome arises is morally irrelevant. It ment but how well they will live. They consider quality of life important. makes no difference if it is the result of an act, or an omission. This could be relevant to the triage question (as suggested in the Doctors, patients and families, however, hold that there is a moral quote from the Office for Civil Rights at the start of this paper). difference between acts and omissions. Many people hold a causal Consider an extreme example. The end point of dementia is un- account of responsibility: they tend to think that we are responsible consciousness. Imagine that of our two patients with respiratory for the consequences of our acts but not for our omissions. Thus failure Alessandro is still working, in possession of all of his faculties. people tend to believe that withdrawal of life-sustaining treatment is Jason, by contrast (in this version of the case) has end stage demen- morally worse than withholding life-sustaining treatment. tia. According to utilitarians, we should treat Alessandro if we cannot This folk commitment to a causal sense of responsibility and the treat both. Jason would derive zero benefit from being kept alive in acts/omission distinction has a number of bad consequences. an unconscious state. Indeed, this would apply potentially even if It means that there is considerable attention in pandemic Jason (with dementia) had a higher chance of survival, or were going guidelines to decisions about initiation of treatment. The ‘triage to survive for longer. question’ is largely or entirely focused on whether to start treat- What about lesser degrees of cognitive impairment or other ment. Withholding of treatment from patients with poorer disabilities? According to utilitarians, these would also be con- sidered in making allocation decisions if they affect the person’s 15 Parfit, D. (1984). Reasons and persons. UK: Oxford University Press; Griffin, J. (1988). well-being. Well-being: Its meaning, measurement and moral importance. Oxford, UK: Clarendon Press. 16 Wilkinson, D., & Savulescu, J. (2018). Prioritisation and parity: Which disabled infants should be candidates for scarce life-saving treatment. In A. Cureton & D. Wasserman 12 Institute for Clinical and Economic Review. (2020, 31 January). 2020-2023 value (Eds.), Oxford handbook of philosophy and disability (pp. 669–692). UK: Oxford University assessment framework. Retrieved from https://icer-review.org/wp-content/uploa Press. ds/2019/05/ICER_2020_2023_VAF_013120-4.pdf 17 Arora, C., Savulescu, J., Maslen, H., Selgelid, M., & Wilkinson, D. (2016). The intensive 13 Gates, B., & Chambers, R. (2015). From aspiration to action: What will it take to end care lifeboat: A survey of lay attitudes to rationing dilemmas in neonatal intensive care. malaria? Retrieved from http://endmalaria2040.org/asset s/Aspir ation-to-Action.pdf BMC Medical Ethics, 17, 69. 14 18 BBC News. (2020, 30 March). Coronavirus: Trump signs into law largest bailout in US Wilkinson, D., Brick, C., Kahane, G., & Savulescu, J. (2020). The relational threshold: A history. Retrieved from https://www.bbc.co.uk/news/world-us-canada-52070718 life that is valued, or a life of value? Journal of Medical Ethics, 46, 24–25.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 625 prognosis is often thought to be ethically acceptable. However, beyond prioritizing critical essential services workers (which is rela- some apparently poor prognosis patients will do well and a trial of tively clear cut and easy to enforce and has wide social acceptance). treatment might provide more accurate prognostic information. Utilitarianism is sensitive to the potential for abuse of its opera- Thus, under conditions of uncertainty, a trial of treatment with the tionalized principles. If there is a risk that a principle will be abused, possibility of withdrawal would be preferable to withholding this should be taken into account in deciding whether to operation- 19 treatment. alize it or not. For example, social worth is easily abused by the pow- Utilitarianism would reject the idea of employing any form of erful to claim privilege and priority. ‘first come, first served’ to decide about treatment. The timing of 6. Responsibility when a patient arrives needing treatment is morally irrelevant to For utilitarians, we are morally responsible to the extent that the whether or not they should receive treatment. This is a principle effects of our acts or omissions are foreseeable and we have control that we have elsewhere labelled the principle of temporal neutrality. over them. Intentions are irrelevant for utilitarians. It is not what we According to utilitarianism, doctors should be prepared to withdraw want to happen that matters: it is what we can foresee, and what treatment from poor prognosis patients in order to enable the treat- actually happens. So even if consequences are unintended, we are ment of better prognosis patients if they arrive later. still responsible if they are foreseeable and avoidable. Consideration of acts and omissions is also relevant to wider so- This implies that failing to take a course of action that would bring cial questions raised by the pandemic. Failing to implement a good about more good, or avert more harm, is equivalent to intentionally policy is equivalent to actively implementing a bad policy, when the causing that harm. The moral responsibility for choosing an inferior outcome of the two decisions is the same. So utilitarians hold policy policy is high for utilitarians and actions that result from this are sub- makers responsible not only for what they do, but for what they fail sequently blameworthy. to do. Failing to implement other policies, with the result of avoid- Utilitarianism is a very demanding theory in several ways. able, foreseeable deaths is equivalent to killing for utilitarians. (This Whenever we foreseeably and avoidably bring about a less good means that policy makers are just as blameworthy for failing to erad- state of affairs, we are morally responsible and blameworthy. If icate malaria as they would have been if they had failed to act in bringing about the best policy requires more research, we are re- response to coronavirus.) sponsible for the deaths that occur because that research was not 5. Social benefit done. According to utilitarianism, all the consequences of actions, both Another issue in resource allocation is responsibility for illness. short and long term, direct and indirect are relevant to decisions. Many people have the intuition that responsibility for illness should Thus it may be relevant to consider not only the benefit to the per- be taken into account in the allocation of limited resources. Smokers son directly affected by an action (for example, by being placed on should receive lower priority for lung transplants, drinkers for liver a ventilator), but also others. This can be called ‘social benefit’ or transplants. The UK government has also encouraged the public to social worth. take responsibility for their health. 21 In the case of COVID-19, peo- In pandemics, one rule of thumb likely to maximize utility would ple with various comorbidities have worse prognoses. For example, be to give priority to health care workers, those providing key ser- type II diabetes is one such comorbidity, and its risk factors include vices and others who are necessary to provide essential benefits to so-called 'lifestyle' factors such as diet and exercise. others. This has been applied in many countries, including the UK, to There are numerous problems with trying to use responsibility for testing for coronavirus. However, it might also apply to access to illness in the allocation of resources.22 Utilitarians eschew all direct ventilators or other medical treatments. A reason given for this is consideration of causal contribution to illness and, indeed, any ‘back- that it will potentially mean that they can also return to work ward looking’ considerations like desert. They are only concerned with sooner. 20 bringing about the best outcome. If, for example, diabetes reduces the What about the social worth of others? Should criminals have chance of survival, it is relevant insofar as it reduces the chance of a lower priority in accessing limited resources? What about scien- survival, not because it was the result of any voluntary behaviour. tists working on a vaccine? Related to social benefits is the issue Responsibility (or the disposition to behaviour that led to ill of dependents. Should pregnant women and parents of dependent health) is only relevant for utilitarians insofar as it affects probability, children be given greater priority for health care? Developing rules length or quality of survival. This is in line with how responsibility is of thumb for assessing social worth is ethically and epistemically generally used in the NHS. 23 complex, liable to abuse and difficult to enforce fairly. Critical level utilitarianism would likely not endorse such priority rules, perhaps 21 Hancock, M. (2018, November 5). Prevention is better than cure – Matt Hancock’s speech to IANPHI. Retrieved from https://www.gov.uk/government /speeches/preve ntion-is-better-than-cure-matt-hancocks-speech-to-ianphi 22 Friesen, P. (2018). Personal responsibility within health policy: Unethical and 19 Wilkinson, D., & Savulescu, J. (2014). A costly separation between withdrawing and ineffective. Journal of Medical Ethics, 44, 53–58; Brown, R., & Savulescu, J. (2019). withholding treatment in intensive care. Bioethics, 28(3), 127–137. Responsibility in healthcare across time and agents. Journal of Medical Ethics, 45, 20 636–644. Glenza, J. (2020, 9 April). Who gets a ventilator? The 'gut-wrenching' choices facing US 23 health workers. The Guardian. Retrieved from https://www.theguardian.com/world Pillutla, V., Maslen, H., & Savulescu, J. (2018). Rationing elective surgery for smokers /2020/apr/09/us-healthcare-workers-make-gut-wrenching-decisions-coronavirus and obese patients: Responsibility or prognosis? BMC Medical Ethics, 19, 28.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 626 | SAVULESCU Et AL. 7. Avoid psychological biases, intuitions and heuristics 1.5 | The triage question Utilitarianism seeks to avoid biases, emotions, intuitions or heu- ristics that prevent the most good being realized. The above rules of thumb could be assembled into an algorithm for For example, humans are insensitive or numb to large numbers. 24 allocation of ventilators (Figure 2). Such an algorithm could be used They are also more moved by a single identifiable individual suffer- to inform rapid decisions if there were overwhelming numbers of pa- ing than by large numbers of anonymous individuals suffering each tients presenting in future surges relating to COVID-19. Alternatively, to the same extent (this is the so-called ‘rule of rescue’25). Thus they it might be used to inform decisions about highly scarce and expen- will be motivated to alleviate the suffering of a single highly publi- sive treatments such as ECMO. Because of the need for rapid deci- cized individual, rather than taking action that prevents suffering of sions, based on limited information, this represents an attempt to a larger amount of unknown or unidentifiable individuals. To some guide ‘intuitive level’ decisions in a way that would generate most extent, national responses to COVID-19 might represent a massive benefit overall. It is thus different from what act utilitarianism (or the form of the ‘rule of rescue’. critical level approach) would recommend. Probably most relevant to political decision-making is bias to- The algorithm divides decision-making into stages, and priori- wards the near future. The desire to avoid deaths now is stronger tizes on the basis of different criteria, depending on the availabil- than the desire to avoid deaths in the future. It is psychologically ity of resources. For example, it starts by giving highest priority to easier to impose severe lockdown now in the name of saving lives those with the highest chance of surviving and needing the lowest threatened now, even if the toll of loss of life would be greater in the duration of treatment. This would maximize the number of lives future. There is some evidence that the lockdown and related fac- saved. If there are sufficient ventilators to treat all patients with at tors such as reduced access to medical care are leading to additional least a moderate chance of surviving, there would be no need to deaths from causes other than coronavirus. 26 It might be anticipated invoke other criteria. Thus, for example, health care systems with that there will be large numbers of future deaths caused by the eco- ample pre-existing intensive care capacity, or who have been able to nomic downturn induced by the pandemic. After the 2008 financial expand their capacity acutely, might have no need to ration on the crash it is estimated that there were 250,000 excess cancer deaths basis of life expectancy or quality of life. just in Organisation for Economic Co-operation and Development If there are insufficient ventilators, additional principles might be countries. invoked. As noted, utilitarianism does not necessarily seek to save These future and non-identifiable deaths might be greater most lives, but would aim to achieve the most well-being overall, in- than or less than those prevented by lockdown. They are hard to cluding elements of both length of life and quality of life. At a second predict and even to confidently assign, which is one reason that level, triage might assess both of these factors for patients in need they are difficult to take into account. However, they are just as of treatment. In practice, however, estimation of predicted quality ethically relevant as the deaths caused by COVID-19. We should adjusted life years for individual patients is highly complex (and may not ignore them because they are less psychologically real and be uncertain). It would be quicker to set a threshold of length and motivating. quality of life worth saving. As an example, we have suggested that Utilitarianism aims to the maximize the good, impartially con- a health system under severe pressure might elect to only provide ceived. Statistical lives matter as much as identifiable lives. mechanical ventilation to patients predicted to survive for at least Another bias is to one’s family and friends. According to utilitar- 5 years with normal quality of life, but the specific threshold used ianism, we should give equal weight to the lives of strangers, even will depend on the level of resource availability and on the level of those in other countries. The effects on the pandemic in Africa are demand. yet to be documented or manifest. Given that there are fewer ad- vanced life support systems, the mortality is likely to be greater. Utilitarianism would favour diverting resources there if the effects 1.6 | The lockdown question would be greater. Much of ordinary decision-making is driven by emotion, biases While the triage question lends itself to heuristics, and the devel- and heuristics. Thus, much of utilitarianism will strike ordinary peo- opment of a rule that might generate the best outcome overall, it ple as counterintuitive. is difficult to know what intuitive-level response would be best for the lockdown question. Because of the scale of the impact of the pandemic, there is a danger that rapid rule-based responses might go badly wrong and lead to a much worse outcome overall. Instead, 24 this is a question that would be better answered by drawing on Savulescu, J., & Persson, I. (2012). Unfit for the future: The need for moral enhancement. UK: Oxford University Press. critical level utilitarianism. In large part because of uncertainty, 25 Jonsen, A. R. (1986). Bentham in a box: Technology assessment and health care there are different views about which strategy for entering or allocation. Law, Medicine and Health Care, 14, 172–174. leaving lockdown would generate the best outcome overall. For 26 Giles, C. (2020, May 12). Excess UK deaths in Covid-19 pandemic top 50,000. Financial example, there remains debate about whether the approach in Times. Retrieved from https://www.ft.com/content/40fc8904-febf-4a66-8d1c-ea3e4 8bbc034 Sweden (avoiding a national lockdown) is better or worse than the  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 627 approach of Sweden’s Scandinavian neighbour Norway, which im- 1.7 | Evidence sensitivity plemented a lockdown in early March. At the time of writing, Sweden has reported 2,769 deaths, (274 deaths/million popula- Utilitarianism is highly dependent on accurate information about the tion), compared with 214 deaths in Norway (39/million world. It requires good evidence. Without good evidence, it is less population). 27 likely that we would choose means that will bring about the most The important issue for utilitarians is not the number of good. deaths, but the QALYs lost. Because a large proportion of the Utilitarianism is thus complementary to science—it requires sci- deaths in Sweden are in care homes, there may be fewer QALYs ence. Thus utilitarianism will urge more research to get better esti- lost than a policy that caused a smaller number of avoidable deaths mates of consequences and probabilities from a wide range of of younger, healthier people. What is important is whether the possible courses of action. Utilitarianism invites scientific inquiry. QALYs lost in Sweden are greater or less than Norway, overall, as The Swedish approach to lockdown has been informed by epidemio- a result of the policy. It is far from clear at this point the answer logical models of the impact of coronavirus that were lower and less to that question. dramatic than some of the models used elsewhere (for example in Moreover, there can be difficulties in comparing countries, since the UK). 28 Any modelling or data that is used to inform decision-mak- they differ in more than just the policy applied. They may also differ ing should be openly available and subject to peer review. If the evi- in other characteristics. The mortality of Stockholm stands out in dence changes, or the modelling needs to be revised, policy should Sweden: half of Sweden's deaths were in Stockholm, yet its popu- also change. This means that countries might need to change their th lation is roughly 1/5 of Sweden’s: specifically, 1,428 out of 2,854 policy. That could mean relaxing lockdown, or implementing stricter deaths (May 5, 2020). The mortality rate of a region in the south of lockdown. The UK government changed tack in its response to coro- Sweden with a population of 1.4 million was half that of Oslo, the navirus in late March in response to revised modelling. 29 That does capital region of Norway (April 21, 2020), in spite of not having had necessarily mean that the previous policy was mistaken. As noted, a lockdown policy for 5 or 6 weeks. The number of deaths in this utilitarianism directs decisions on the basis of expected utility. southern region is 78 compared to 1,428 in Stockholm whose pop- Where our expectations change, decisions should change too. ulation is only a couple of hundred thousand greater (May 5, 2020). For example, in order to get better estimates of true mortality, One potential explanation for differences in mortality relates to utilitarianism would support random population testing to see the differences in population density. Another relates to the amount of incidence of COVID-19 in asymptomatic or minimally symptomatic circulating coronavirus prior to any change in community behaviour community members. (which may or may not have been imposed formally as a lockdown). A Sometimes the opportunity costs of gathering more information further factor may be whether the virus has had access to vulnerable or evidence will be prohibitive when urgent action is needed. In groups. The virus may have been more effectively kept out of aged these cases, it is important that beliefs are as rational as possible. care in the south of Sweden. That it isn’t simply due to a national They should result from wide expert dialogue, embracing the possi- lockdown is confirmed by the fact that this mortality figure is lower bility of dissensus.30 both than that of the neighbouring Danish capital, Copenhagen, 293, and the county surrounding it, 93 (May 5, 2020), despite that fact that shops, etc. have been locked down in Copenhagen since 1.8 | Global, impartial equality mid-March. It might be that conditions all over Sweden will soon be worse Critical level utilitarianism requires impartial and equal consideration than in Norway and Denmark because of the absence of a national of the well-being of all sentient creatures. In this case, it requires lockdown. However, it is possible that Norway and Denmark’s ap- consideration of people now and in the future, as well as people proach might lead to more deaths at a later stage because of further without coronavirus who might be affected by lockdown. It includes surges of the virus when lockdown is relaxed. More importantly, as the well-being of all people, old and young, sick and well, in one’s we have argued, the number of deaths from COVID-19 at a given own country and internationally. point in time is not decisive. The question is which strategy will pre- This means that it is critical to assess both the well-being costs of vent the most deaths from any cause (and more importantly preserve COVID-19, and the well-being costs of lockdown. There is currently the most years of life in full heath). We must keep in mind the pros- huge attention to quantifying the numbers of cases of COVID-19 pect of wider harms to the community as a result of lockdown and the economic consequences. 28 Savage, M. (2020, April 25). Coronavirus: Has Sweden got its science right? BBC News It is difficult to know what overall strategy would be best. There Online. Retrieved from https://www.bbc.co.uk/news/world-europe-52395866 are several clear points, though about how utilitarianism would in- 29 Stewart, H., Boseley, S., Walker, P., & Elliott, L. (2020, March 16). PM tells Britons to form a policy response to the lockdown question. avoid non-essential travel and contact. The Guardian. Retrieved from https://www.thegu ardian.com/world/2020/mar/16/pm-tells-britons-to-avoid-non-essential-conta ct-with-others 27 30 Worldometers. (2020, 6 May). COVID-19 Coronavirus Pandemic. Retrieved from https:// Wilkinson, D., & Savulescu, J. (2018). Ethics, conflict and medical treatment for children: www.worldometers.info/coronavirus/ From disagreement to dissensus. Elsevier.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 628 | SAVULESCU Et AL. infection and the number of consequent deaths. However, there is result, reported zero COVID-19 deaths at the end of April35). Policy much less attention to the possible consequences of lockdown mea- makers in LMIC may benefit from some of the modelling and scientific sures for people without coronavirus. Recent figures (at the end of expertise available in other countries to support their decision-making. April) suggest that the UK has had a large increase in all-cause mor- It has been questioned whether isolation will work in Africa or whether tality—the highest in Europe, and that this rate has not been decreas- it will kill more young people through its economic effects and subse- 31 ing even as reported deaths from COVID-19 have fallen. There is quent malnutrition.36 an urgent need to identify and quantify deaths (and more impor- For utilitarians, policy will need to be sensitive to context and tantly loss of years of well-being) from all causes in order to inform facts about individuals and local communities. The policy that is best decisions. Deaths or illness from COVID-19 might be greater in num- for one country may be worst for another. ber than other causes (or they might not), but they are not ethically Utilitarianism is a theory with no national boundaries. more important than those from other causes. Lockdown measures themselves will have direct morbidity and mortality (through denial or delay of medical treatment), as well as 1.9 | Well-being matters more than indirect effects through economic recession. One estimate is that 25 rights and liberty million jobs will be lost worldwide32 with associated loss of well-be- ing and death. For utilitarianism, well-being is all that matters. Liberty and rights are According to utilitarianism, the right policy is the one that max- only important insofar as they secure well-being. Thus a utilitarian imizes well-being overall, across all people across all countries. approach to the lockdown question may be prepared to override the Utilitarianism embraces radical impartial equality—all well-being right to privacy or liberty to protect well-being. and deaths are equal (other things being equal). The cause of loss of Vietnam, Singapore, Taiwan and China have used methods such well-being does not matter. Thus, a utilitarian policy will only invest as tracing contacts and enforcing self-isolation using mobile phone in preventing loss of life from COVID-19 provided it is the most effi- data, with severe penalties for failure to comply (in Singapore, it is up cient way of saving all lives. to 6 months gaol).37 These countries have been highly effective at We have noted already that other global health priorities might be containing COVID-19, more so than liberal Western countries with considerably more cost-effective than the financial costs of respond- greater emphasis on rights and liberties. Utilitarians support the East ing to coronavirus. However, there are other important global consid- Asian approach of constraining liberty and privacy to promote secu- erations. The UK has banned the sale of 80 drugs to other countries in rity and well-being. This approach also appears cost-effective while a bid to prevent NHS shortages.33 From a utilitarian perspective, this delayed response may not be. may be the wrong course of action if the sale of the drugs would save One recent suggestion has been an app that facilitates contract more lives globally if exported. There may be a moral obligation to help tracing.38 However, participation in the programme is meant to be others that overrides the obligation to one’s own citizens. Many coun- voluntary: people would need to agree to share information about tries have sourced large numbers of ventilators in order to be able to their whereabouts and health status. Utilitarianism would favour a meet anticipated demand in their own country. However, the conse- more coercive approach if this is more effective. Those who favour quences of the pandemic may be much more severe in low and middle such voluntary programmes give greater weight to consent and pri- income countries (LMIC). Some of the investment that countries have vacy than to well-being and life. This is a value choice: it chooses in- made into their own (already well-resourced) health care systems dividual rights over overall reduction in the spread of disease. Of would yield much greater benefit for LMIC. That might include making course, countries are free to pursue individual freedom, but if the ventilators available (poor countries have been outbid by wealthy countries in the scramble to purchase ventilators).34 It might include support for LMIC policies that are less costly but potentially effective 35 Bui, T. (2020, May 1). Aggressive testing and pop songs: How Vietnam contained the ways of averting the crisis (for example, Vietnam employed mass test- coronavirus. The Guardian. Retrieved from https://www.theguardian.com/commentisf ing and contact tracing to prevent the spread of COVID-19, and as a ree/2020/may/01/testing-vietnam-contained-coronavirus 36 Broadbent, A., & Smart, B. J. H. (2020, March 23). Why a one-size-fits-all approach to COVID-19 could have lethal consequences. The Conversation. Retrieved from https:// theconvers ation.com/why-a-one-size-fits-all-approach-to-covid-19-could-have-letha 31 The EuroMOMO hub. (2020). Graphs and maps. EuroMOMO. Retrieved from https:// l-consequences-134252?utm_medium=email&utm_campaign=Lates t%20from%20The www.euromomo.eu, accessed May 5, 2020. %20Conversation%20for %20March%2024%202020%20-%2015724150 47&utm_conte 32 International Labour Organisation. (2020, March 18). Almost 25 million jobs could be nt=Lates t%20from%20The%20Conversation%20for %20March%2024%202020%20 lost worldwide as a result of COVID-19, says ILO. Retrieved from https://www.ilo.org/ -%2015724150 47+CID_5c42b122e0 0729810ed8 0b4b87906ccc&utm_source=campa global/about-the-ilo/newsroom/news/WCMS_738742/lang--en/index.htm ign_monitor_global&utm_term=argue 33 37 Department of Health and Social Care. (2020, March 20). Crucial medicines protected Vaswani, K. (2020, 19 March). Coronavirus: The detectives racing to contain the virus for coronavirus (COVID-19) patients. Retrieved from https://www.gov.uk/government / in Singapore. BBC News Online. Retrieved from https://www.bbc.co.uk/news/world news/crucial-medicines-protected-for-coronavirus-COVID -19-patients -asia-51866102 34 38 Forero, J., & Pérez, S. (2020, April 23). Coronavirus pandemic prompts race in Latin Valentino-DeVries, J. (2020, March 19). Translating a surveillance tool into a virus America to build cheaper ventilators. Wall Street Journal. Retrieved from https://www. tracker for democracies. The New York Times. Retrieved from https://www.nytim wsj.com/articles/coronavirus-pandemic-prompts-race-in-latin-america-to-build-cheap es.com/2020/03/19/us/coronavirus-location-tracking.html?referringSource=artic er-ventilator s-11587634202 leShare  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 629 liberty based approach is less effective, it will necessarily come at association is of sufficient strength, and the proposed policy is both the cost of additional cases of COVID-19 and additional deaths. necessary and effective, then assigning resources or burdens such as Importantly, the extent of the liberty restriction or rights vi- lockdown selectively is no more discriminatory than other policies, olation should be commensurate with the effect on well-being. such as the selective isolation of people on the basis of a proxy risk Utilitarianism would support isolating certain groups if the benefit factor for infection, such as travel history or contact with someone to them was greater or the benefit to others was greater. Thus a who has COVID-19 (this was the early strategy42). utilitarian approach to lockdown might favour selective isolation of Nevertheless, there would still be utilitarian reasons to reject the elderly and other vulnerable groups if that was the most cost-ef- policies that give lower priorities to these groups. In particular, these fective way to secure overall well-being. groups (with the exception of males) have already been disadvan- Likewise, the restriction of liberty of low risk groups may also be taged, and indeed this disadvantage may even be the direct cause necessary to secure large collective benefits. This justifies, for exam- of vulnerability to COVID-19. Justice requires that they not be fur- ple, in the case of influenza, vaccinating children, who are at low risk of ther disadvantaged. Accepting the validity of justice need not mean flu complications, in order to protect the elderly, who have less effec- rejecting utilitarianism. Utilitarians must consider all the effects of tive immune responses to vaccination and are at greater risk of flu their policies and actions. If some policy will perpetuate or exacer- complications.39 Although children have little expectation of benefit bate discrimination or injustice with concomitant effects on well-be- themselves from vaccination, vaccinating children is necessary to se- ing, these must be considered. Loss of short-term utility is justified cure benefits to overall well-being that cannot otherwise be achieved. by the larger long-term gains of a more just society. (It would also support challenge studies being performed [voluntarily] In any case, as we outlined at the beginning of this paper, utilitari- on low risk populations for a COVID-19 vaccine, e.g. young people.) anism is not necessarily a complete answer: one can sacrifice utility for It is often objected that utilitarianism leads to discrimination against other values. Thus, there might be straightforwardly utilitarian reasons those in ‘protected’ categories,40 such as the elderly, disabled, women, for treating different groups in the same way: the resulting fractures in 41 ethnic minority groups, etc. For example, in COVID-19, it appears that society arising from a policy that did not do so would ultimately cause elderly, male, obese, and BAME patients have a worse prognosis than a greater loss of well-being. Or there might be pure justice reasons: other groups (to varying degrees). Utilitarians, it is argued, will give lower upholding central values such as justice is more important than the net priority to some or all of these groups for access to limited resources and/ difference in expected health outcomes. or a higher priority to isolating these groups, which is discrimination. A key aspect of the law on discrimination is proportionality. In a The first issue at hand is the accuracy of the information. For ex- pandemic, very large numbers of lives are at stake. Equality, even for ample, apparent differences in mortality between groups may be mere those opposed to utilitarianism, is only one value amongst others. proxy correlations, that arise from unrelated factors such as faster Discrimination may be proportionate if the stakes are high enough spread amongst different groups in the community meaning there is and alternative measures are not available.43 uneven distribution of cases in the first place (we still do not know the true number of cases due to testing shortages in nearly all countries), the presence or absence of different groups in high-risk occupations 1.10 | Separateness of persons (in addition to uneven distribution of cases, there may be a ‘dose-de- pendent’ effect of the viral load on the severity of illness making some One prominent objection to utilitarianism is that it fails to respect workers more vulnerable), existing comorbidities that are correlated the separateness of persons.44 One instantiation of this problem with different groups, but unrelated to them and should be consid- that is relevant to pandemic management is that utilitarianism can ered separately, or poorer care due to bias or lack of access. Moreover, favour very small risk reductions spread over very large numbers of identification and analysis of these factors may lead to the ability to persons rather than the saving of one long life. Small goods can be apply effective focussed measures such as equipping care homes with summed to outweigh one large good. better testing and protective equipment, or focussed testing mea- Insofar as this is a problem, it can be avoided in practice by only com- sures. Utilitarianism fails if it is applied unscientifically, without fine- paring and summing comparable goods, for example lives. For example, grained information, or if it fails to consider the best policy responses. one could count only the saving of lives or the saving of a life for a suffi- If the evidence associating a group of people with higher mortality ciently long period of time (say 1 year) as a minimum good to be counted. is indeed both accurate and predictive of a higher mortality, and the This vice can also be a virtue. The significant misery that a large number of people experience during lockdown (unemploy- 39 Bambery, B., Douglas, T., Selgelid, M., Maslen, H., Giubilini, A., Pollard, A., & Savulescu, ment, depression, being victims of domestic violence, etc.) should J. (2018). Influenza vaccination strategies should target children. Public Health Ethics, 11(2), 221–234. 40 Savulescu, J., Cameron, J., & Wilkinson, D. (2020, in press). Equality or utility? Ethics 42 and law of rationing ventilators. British Journal of Anaesthesia. https://doi.org/10.1016/j. Cameron, J., & Savulescu, J. (2020). Why lock down of the elderly is not ageist and why bja.2020.04.011 levelling down equality is wrong. Under review. 43 41 Harris, J. (1987). QALYfying the value of life. Journal of Medical Ethics, 3, 1–18; Harris, J. Savulescu et al., op. cit. note 40. 44 (1995). Double jeopardy and the veil of ignorance – A reply. Journal of Medical Ethics, 21, Rawls, J. (1971). A theory of justice. Cambridge, MA: Belknap Press of Harvard 151–157. University Press.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 630 | SAVULESCU Et AL. F I G U R E 1 Estimated UK death toll in different scenarios. Figure retrieved from https://www.bbc.co.uk/news/healt h-51979654 but no longer available 46 [Colour figure can be viewed at wileyonlinelibrary.com] not be ignored and must be recognized as an ethical cost. If that bed to save the infant with a greater chance of survival, who would well-being loss is great enough for a large enough number of peo- have a longer life or less disability. They also supported saving the ple it could outweigh even the loss of some years of life for a rel- greater number. This suggests that there may be public support for ative few. the algorithm that we have proposed for the triage question. When people understand that there is an unavoidable need to choose be- tween patients, they appear to recognize that securing the most 1.11 | Conclusion benefit overall is both logical and ethical. One of the psychological biases that dominates decision-making Utilitarianism is a demanding and counterintuitive theory. Why should is loss aversion. Losses loom larger than gains. And when we evalu- we consider it? If the utilitarian course of action is not adopted, some- ate a policy we are liable to focus on the negatives, rather than the one (often many) people will suffer or die avoidably. There may be positives. Thus governments, such as East Asian governments, who good reasons (such as the preservation of liberty) to sacrifice well- radically curtail liberty and protect health and security are criticized being or lives. But such choices need to be made transparently and for being overly authoritarian. Liberal governments that protect lib- in full awareness of their ethical cost. One must have good reasons erty and incur greater infection risks (such as the UK and Australia) to deliberately choose a course of action that will be worst overall. are criticized for failing to protect the vulnerable and secure public Policy is often driven by politics or popular opinion, not ethics. This health. There is no win the in the court of public opinion. is morally wrong. Much of ethics in the public sphere involves social That is why we need, in the cool, calm hour, to set our policy signalling, moralism and sometimes wishful thinking (for example, try- objectives and priorities. Utilitarianism gives a clear framework for ing to wish away difficult ethical dilemmas). Careful consideration of that. And it gives criteria to judge success. the consequences of our actions requires us to face the facts and our The universal common ethical currency is well-being. What mat- values. A utilitarian approach is not simple, or easy. It requires that we ters to each of us is how well our lives go. This is the very heart and choose the course of action that will benefit most people to the great- basis of utilitarianism: it takes an impartial approach to everyone’s est degree, however difficult or counterintuitive that is. well-being. While people may argue other things matter (autonomy, There is some support for utilitarianism. In one survey investigat- privacy, dignity), everyone can agree that well-being matters. ing the public’s views on how to allocate intensive care beds amongst It is doubtful that any of the policies currently being adopted critically ill infants, we found the general public widely supported by any governments worldwide are purely or simply utilitarian. utilitarian allocations.45 They supported allocating the intensive care However, some are potentially reflecting more clearly and carefully about the costs and benefits of different courses of action and pol- icy. The fundamental difficulty facing all of us during this pandemic 45 Arora et al., op. cit. note 17. 46 is that we cannot know for certain which action will be best over- Data drawn from Ferguson, N. M., Laydon, D., Nedjati-Gilani, G., Imai, N., Ainslie, K., Baguelin, M., … Ghani, A. C. (2020, March 16). Report 9: Impact of non-pharmaceutical all. We do not know what a utilitarian ‘archangel’ would choose: it interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. https://doi. would require a detailed understanding of the science and facts, the org/10.25561/77482. Retrieved from https://www.imperial.ac.uk/media/imperial-colle ge/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-model nature of well-being and an exhaustive understanding of the conse- ling-16-03-2020.pdf quences of our choices. But that is what we should be aspiring to.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License SAVULESCU Et AL. | 631 FIGURE 2 An ethical algorithm for rationing life sustaining treatment [Colour figure can be viewed at wileyonlinelibrary.com] We must strive to get the facts straight on all the consequences of AC K N OW L E D G E M E N T S our choices. Our societies may then choose to embrace or choose JS and DW were supported by the Wellcome Trust (WT203132). not to embrace the utilitarian course. But at least we will then do so JS through his involvement with the Murdoch Children's Research with a clear understanding of our values and the price we are willing Institute was supported by the Victorian Government's Operational to pay for them. Infrastructure Support Program.  14678519, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/bioe.12771 by University Of Alberta, Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 632 | SAVULESCU Et AL. ORCID Dominic Wilkinson is Professor of Medical Ethics at the Oxford Julian Savulescu https://orcid.org/0000-0003-1691-6403 Uehiro Centre for Practical Ethics, University of Oxford. He is Dominic Wilkinson https://orcid.org/0000-0003-3958-8633 also a consultant in newborn intensive care at the John Radcliffe