Ethical road map through the COVID-19 pandemic

Zoe Fritz and others
BMJ 2020; 369
doi: https://doi.org/10.1136/bmj.m2033

The covid-19 pandemic has created profound ethical challenges in health and social care, not only for current decisions about individuals but also for longer term and population level policy decisions. Already covid-19 has generated ethical questions about the prioritisation of treatment, protective equipment, and testing; the impact of covid-19 strategies on patients with other health conditions; the approaches taken to advance care planning and resuscitation decisions; and the crisis in care homes.

Ethical questions continue to multiply as the pandemic progresses and new evidence emerges, including how best to distribute any new vaccines and treatments; how best to respond to evidence that disease severity and mortality are substantially greater in ethnic minority populations; how to prioritise patients for care as medical services re-open; how to manage assessment of immunity and its implications; and how the health system should be configured to manage any future peaks in cases.

Science and values

The UK government repeatedly states that it is “following the science” by heeding the advice provided through the Scientific Advisory Group for Emergencies (SAGE). However, this implies that the science alone will tell us what to do. Not only does this rhetoric shift the responsibility for difficult decisions on to “the science”, it is also wrong. Science may provide evidence on which to base decisions, but our values will determine what we do with that evidence and how we select the evidence to use. It is disingenuous and misleading to imply that value-free science leads the way. Both science and policy are value laden.

Values questions are being addressed primarily by professional organisations, although the UK government has independent advice, for example, from the Moral and Ethical Advisory Group. Despite such efforts to plot an ethical path, the current approach is piecemeal, confusing, and risks needless duplication of effort. Concerns are mounting about a lack of transparency around the ethical agenda underpinning decisions, a lack of coordination, and the absence of clear national leadership.

The info is here.

Global health without justice or ethics

S Venkatapuram
Journal of Public Health
https://doi.org/10.1093/pubmed/fdaa001

The great promise at the start of the twenty-first century that Anglo-American philosophers would produce transformative theories and practical guidance for realizing global health equity and justice has largely gone unfulfilled. The publication of The Law of Peoples by John Rawls in 1999 formally inaugurated the emerging academic field of global justice philosophy.1 After 2000, numerous monographs, journal articles and conferences discussed global justice. And new academic associations, journals and research centres were established.

One remarkable aspect of the new field was that the stark inequalities in health across societies were often the starting concern. Despite our diverse philosophical and ethical views, reasonable people are likely to be morally troubled about the large inequalities in life expectancies between some sub-Saharan country X and the USA or another rich country. This initially shared moral intuition or indignation, then, motivated diverse arguments about what precisely is morally bad about global health inequalities and global poverty and the possible demands of justice. Some philosophers described what ‘our’ duties are or, indeed, are not, to help ‘those people over there’. Others minimized the distinction between us and them by arguing for theories of radical global equality, the arbitrariness of political borders and duties that follow from our complicity in transnational harms experienced in other countries.

Progress in global justice philosophy seemingly promised real-world progress in global health equity and justice, because health inequality was the foremost issue in philosophical debates on global inequality, poverty and claims of the ‘global poor’. At the same time, largely driven by HIV research, bioethics went global as it was exported alongside medical research to resource poor settings. Bioethicists also began to go beyond clinical and research settings to examine public health ethics, social inequalities in health and social determinants—from local conditions all the way to global institutions and processes. Nevertheless, as of 2020, it is difficult to identify any compelling conceptions of global justice or global health justice or to identify any significant philosophical contributions to the practical improvement of global health and inequalities. What happened?

The rest of the article is linked above.

Trust in Medical Scientists Has Grown in U.S.

C. Funk, B. Kennedy, & C. Johnson
Pew Research Center
Originally published 21 May 20

Americans’ confidence in medical scientists has grown since the coronavirus outbreak first began to upend life in the United States, as have perceptions that medical doctors hold very high ethical standards. And in their own estimation, most U.S. adults think the outbreak raises the importance of scientific developments.

Scientists have played a prominent role in advising government leaders and informing the public about the course of the pandemic, with doctors such as Anthony Fauci and Deborah Birx, among others, appearing at press conferences alongside President Donald Trump and other government officials.

But there are growing partisan divisions over the risk the novel coronavirus poses to public health, as well as public confidence in the scientific and medical community and the role such experts are playing in public policy.

Still, most Americans believe social distancing measures are helping at least some to slow the spread of the coronavirus disease, known as COVID-19. People see a mix of reasons behind new cases of infection, including limited testing, people not following social distancing measures and the nature of the disease itself.

These are among the key findings from a new national survey by Pew Research Center, conducted April 29 to May 5 among 10,957 U.S. adults, and a new analysis of a national survey conducted April 20 to 26 among 10,139 U.S. adults, both using the Center’s American Trends Panel.

Public confidence in medical scientists to act in the best interests of the public has gone up from 35% with a great deal of confidence before the outbreak to 43% in the Center’s April survey. Similarly, there is a modest uptick in public confidence in scientists, from 35% in 2019 to 39% today. (A random half of survey respondents rated their confidence in one of the two groups.)

The info is here.

'A coronavirus depression could be the great leveller'

Kyrill Hartog
The Guardian
Originally published 30 April 2020

Here is an excerpt:

So could the pandemic of our era, already considered the greatest global crisis since the second world war, turn out to be a great societal leveller?

Scheidel’s short answer is that the longer the pandemic wreaks havoc on the global economy, the greater the potential for radical equalising change. “It depends on how severe the crisis is going to be, how long it’s going to last and how much it’s ultimately going to interrupt supply chains.”

The pandemic has already exposed the limits of the market and highlighted the importance of effective state intervention and strong public healthcare provision. In the future this may well create a tolerance for higher and more progressive taxation. Governments have had to intervene to prop up businesses and jobs in ways that only months ago would have seemed unimaginable. The viability of a universal basic income — a dream for egalitarians worldwide — is once again part of the mainstream debate in many countries.

The response at EU level also shows a willingness for strong public intervention and an end to the fiscal restraint approach of the last decade — at least, temporarily.

As people start to believe in government intervention again, the post-corona political landscape may well provide fertile soil for reversing a situation where, since 1980, the richest 1% in the UK have tripled their share of household income and the wealth of the European top 1% grew twice as fast as the bottom 50%.

But Scheidel cautions that, while disasters are not uncommon, tectonic shifts are historical anomalies. In other words, it may take a disaster to usher in more equality, but not every disaster does.

The info is here.

Rebuilding the Economy Around Good Jobs

Zeynep Ton
Harvard Business Review
Originally posted 22 May 20

One thing we can predict: Customers who are struggling economically will be looking more than ever for good value. This will give the companies that start building a good jobs system a competitive advantage over those that don’t. After the financial crisis of 2008, Mercadona — Spain’s largest grocery chain and a model good jobs company — reduced prices for its hard-pressed customers by 10% while remaining profitable and gaining significant market share. Hard work and input from empowered front lines had a lot to do with it.

The pandemic is likely to accelerate the ongoing shakeup of U.S. retailing. The United States has 24.5 square feet of retail space per person versus 16.4 square feet in Canada and 4.5 square feet in Europe. This is almost certainly too much and the mediocre — the ones that don’t make their customers want to keep coming back — will not survive.

The pandemic is likely to speed up the adoption of new technologies. Although typically seen as a way to reduce headcount, adopting, scaling, and leveraging new technologies require a capable and motivated (even if smaller) workforce.

There is an alternative: A good jobs system that has already proven successful. Long before the pandemic, there were successful companies — including Costco and QuikTrip — that knew their frontline workers were essential personnel and treated and paid them as such. Even in very competitive, low-cost retail sectors, these companies adopted a good jobs system and used it to win.

There’s a strong financial case for good jobs. Offering good jobs lowers costs by reducing employee turnover, operational mistakes, and wasted time. It improves service, which increases sales both in the short term and — through customer loyalty — in the long term.

The info is here.

Four concepts to assess your personal risk as the U.S. reopens

Leana Wen
The Washington Post
Originally posted 21 May 20

Here is an excerpt:

So what does that mean in terms of choices each of us makes — what’s safe to do and what’s not?

Here are four concepts from other harm-reduction strategies that can help to guide our decisions:

Relative risk. Driving is an activity that carries risk, which can be reduced by following the speed limit and wearing a seat belt. For covid-19, we can think of risk through three key variables: proximity, activity and time.

The highest-risk scenario is if you are in close proximity with someone who is infected, in an indoor space, for an extended period of time. That’s why when one person in the household becomes ill, others are likely to get infected, too.

Also, certain activities, such as singing, expel more droplets; in one case, a single infected person in choir practice spread covid-19 to 52 people, two of whom died.

The same goes for gatherings where people hug one another — funerals and birthdays can be such “superspreader” events. Conversely, there are no documented cases of someone acquiring covid-19 by passing a stranger while walking outdoors.

You can decrease your risk by modifying one of these three variables. If you want to see friends, avoid crowded bars, and instead host in your backyard or a park, where everyone can keep their distance.

Use your own utensils and, to be even safer, bring your own food and drinks.

Skip the hugs, kisses and handshakes. If you go to the beach, find areas where you can stay at least six feet away from others who are not in your household. Takeout food is the safest. If you really want a meal out, eating outdoors with tables farther apart will be safer than dining in a crowded indoor restaurant.

Businesses should also heed this principle as they are reopening, by keeping up telecommuting and staggered shifts, reducing capacity in conference rooms, and closing communal dining areas. Museums can limit not only the number of people allowed in at once, but also the amount of time people are allowed to spend in each exhibit.

Pooled risk. If you engage in high-risk activity and are around others who do the same, you increase everyone’s risk. Think of the analogy with safe-sex practices: Those with multiple partners have higher risk than people in monogamous relationships. As applied to covid-19, this means those who have very low exposure are probably safe to associate with one another.

This principle is particularly relevant for separated families that want to see one another. I receive many questions from grandparents who miss their grandchildren and want to know when they can see them again. If two families have both been sheltering at home with virtually no outside interaction, there should be no concern with them being with one another. Families can come together for day care arrangements this way if all continue to abide by strict social distancing guidelines in other aspects of their lives. (The equation changes when any one individual resumes higher-risk activities — returning to work outside the home, for example.)

The info is here.

How Could the CDC Make That Mistake?

Alexis C. Madrigal & Robinson Meyer
The Atlantic
Originally posted 21 May 20

The Centers for Disease Control and Prevention is conflating the results of two different types of coronavirus tests, distorting several important metrics and providing the country with an inaccurate picture of the state of the pandemic. We’ve learned that the CDC is making, at best, a debilitating mistake: combining test results that diagnose current coronavirus infections with test results that measure whether someone has ever had the virus. The upshot is that the government’s disease-fighting agency is overstating the country’s ability to test people who are sick with COVID-19. The agency confirmed to The Atlantic on Wednesday that it is mixing the results of viral and antibody tests, even though the two tests reveal different information and are used for different reasons.

This is not merely a technical error. States have set quantitative guidelines for reopening their economies based on these flawed data points.

Several states—including Pennsylvania, the site of one of the country’s largest outbreaks, as well as Texas, Georgia, and Vermont—are blending the data in the same way. Virginia likewise mixed viral and antibody test results until last week, but it reversed course and the governor apologized for the practice after it was covered by the Richmond Times-Dispatch and The Atlantic. Maine similarly separated its data on Wednesday; Vermont authorities claimed they didn’t even know they were doing this.

The widespread use of the practice means that it remains difficult to know exactly how much the country’s ability to test people who are actively sick with COVID-19 has improved.

The info is here.

Suicides of two health care workers hint at the Covid-19 mental health crisis to come

Wendy Dean
statnews.com
Originally posted 30 April 2020

Here is an excerpt:

Denial, minimizing, and compartmentalizing are essential strategies for coping with a crisis. They are the psychological tools we reach for over and over to get through harrowing situations. Health care workers learn this through experience and by watching others. We learn how not to pass out in the trauma bay. We learn to flip into “rational mode” when a patient is hemorrhaging or in cardiac arrest, attending to the details of survival — their vital signs, lab results, imaging studies. We learn that if we grieve for the 17-year-old gunshot victim while we are doing chest compressions we will buckle and he will die. So we shut down feeling and just keep doing.

What few health care workers learn how to do is manage the abstractness of emotional recovery, when there is nothing to act on, no numbers to attend, no easily measurable markers of improvement. It is also hard to learn to resolve emotional experiences by watching others, because this kind of intense processing is a private undertaking. We rarely get to watch how someone else swims in the surf of traumatic experience.

Those on the frontlines of the Covid-19 pandemic, especially those in the hardest-hit areas, have seen conditions they never imagined possible in the country with the most expensive health care system in the world. Watching patients die alone is traumatic. Having to choose your own safety over offering comfort to the dying because your hospital or health care system doesn’t have enough personal protective equipment to go around inflicts moral injury. When facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients at great personal risk, the only way to get through each shift is to do what is immediately at hand.

The info is here.

Proximate Cause Explained: An Essay in Experimental Jurisprudence

Knobe, Joshua and Shapiro, Scott J.
University of Chicago Law Review,
Forthcoming.
https://ssrn.com/abstract=3544982

Abstract

Among the oldest debates in American jurisprudence concerns the concept of “proximate cause.” According to so-called formalists, the legal concept of “proximate cause” is the same as the ordinary concept of “cause.” The legal question of whether a cause is proximate for the purposes of establishing tort liability, therefore, is an objective matter about the external world determinable by familiar descriptive inquiry. By contrast, legal realists think that issues of proximate causation are disguised normative questions about responsibility. As the realists William Prosser and Robert Keeton put it, “Proximate cause is better called ‘responsible cause’.”

Recent work in cognitive science has afforded us new insights into the way people make causal judgments that were unavailable at the time of the original debate between formalists and realists. We now have access to the results of systematic experimental studies that examine the way people ordinarily think about causation and morality. This work opens up the possibility of a very different approach to understanding the role of causation in the law — one which combines the attractive features of both formalism and realism without accepting their implausible consequences.

In addition to providing a model for interpreting the case law of proximate cause, this paper also exemplifies a new way of doing legal theory — a method we call “experimental jurisprudence.” Experimental jurisprudence is the study of jurisprudential questions using empirical methods. Jurisprudential disputes about proximate cause are especially ripe for empirical analysis because the debate revolves around whether the legal concept of proximate cause is the same as the ordinary concept of causation. Interrogating the ordinary concept of causation, therefore, should shed light on this question.

The paper can be downloaded here.