How Not to Make Trade-Offs Between Health and Other Goods Antti Kauppinen (antti.kauppinen@helsinki.fi) Draft (under review), June 6, 2020 As of this writing, the global SARS-CoV-2 pandemic has not only maimed and killed hundreds of thousands of people, but also resulted in immense economic and other harm on a global scale. Much of the economic damage is simply the result of people avoiding social interactions for their own protection. But some of it is the result of lockdowns and other restrictions on people's ordinary activities, imposed by many governments around the world in order to 'flatten the curve' of the highly contagious disease. Such restrictions also cause many other harms from loneliness to increased domestic violence. In situations like this, there thus appears to be some kind of trade-off between economic (and other kinds of) flourishing and protecting people's health, at least in the short term. The question is: how should we assess such trade-offs from an ethical perspective in the context of this or the next epidemic? The first answer that has suggested itself to many people, including politicians and health economists (such as van den Broek-Altenburg and Atherly 2020 and Vaillancourt 2020), is that we should simply commensurate the likely economic and other costs of behavioral restrictions against their likely health benefits in terms of money. There are, after all, standard valuation methods for lives in the context of health care and other policy areas, so, the thought goes, why not just use them? I will focus on the most promising contender, namely giving each quality-adjusted life year (QALY) gained or lost as a result of social distancing measures the same monetary value that is already used in cost-effectiveness calculations within health care systems. For example, in the UK, health interventions that cost more than £20,000-30,000 per QALY are considered too expensive (McCabe, Claxton, and Culyer 2008), which gives a neat baseline for assessing the cost-effectiveness of 2 pandemic restrictions, which are after all sometimes labeled "nonpharmaceutical interventions". Simplifying greatly, if, say, closing down restaurants would cost £10,000,000 a week in lost income, it must save at least 333.3 QALYs a week to be worth doing, using the higher value. Otherwise the economic costs outweigh the health benefits, and it's wrong to close down the restaurants, on this view. A newer alternative for assessing trade-offs appeals to well-being years or WELLBYs instead of QALYs (Frijters et al. 2020, Singer and Plant 2020, Frijters 2020). Instead of money, the WELLBY method weighs outcomes in terms of subjective well-being, in particular life satisfaction. Using WELLBYs to assess trade-offs that involve economic costs thus involves a hazardous conversion of money into well-being, but the principle is the same as above: if, post-conversion, closing down restaurants causes a net loss of WELLBYs, it should not be done. In this paper, I'm going to argue that in spite of their surface attraction, both the QALY approach to health-economy trade-offs – which I will call the generalized QALY approach or GQALY – and the WELLBY approach face deep problems, even if we ignore all the problems with using them in health care allocation (for which see e.g. Harris 1987 and Hausman 2010). If all we know of our options is how many QALYs or WELLBYs they involve, we remain ignorant of morally crucial information. While I use the 2019-2020 SARS-CoV-2 pandemic as my case study, the arguments naturally apply to weighing the benefits and costs of nonpharmaceutical health interventions in general. My first main point is that both by making use of the monetary value of QALYs or by maximizing WELLBYs, we end up including morally irrelevant benefits and harms in our deliberation. While in health care context, money saved from withholding ineffective treatments is spent on effective treatments, the money saved by not imposing economic restrictions can be used to satisfy any preference whatsoever. Similarly, the WELLBY 3 approach counts any decrease in life satisfaction against saving lives. Drawing on work by Frances Kamm (1996) and others, I argue that not all preference-satisfactions or decreases in life satisfaction are morally relevant in the context of a life-and-death decision. While avoiding homelessness does weigh against statistical loss of life, reduced consumption of chocolate cakes doesn't count here. Nor do benefits to people at different levels of well-being necessarily count equally. Any single currency that enables trade-offs between any of benefit or harm whatsoever makes them too easy from an ethical perspective. My second point is that contrary to the GQALY approach, however much we are required and willing to pay to save another's life for a year, be it £30,000 or more, we must be ready to sacrifice a lot more to avoid taking another's life. Or, to put it differently, while patients have a positive right to claim assistance from the rest of us, people at mortal risk from a virus have a stronger negative right against being infected by others, which would cause them to lose a good they would otherwise enjoy independent of the assistance of others. For the same reason, morality requires a person to bear the cost of many WELLBYs to avoid depriving someone else of one WELLBY that they would otherwise enjoy, other things being equal. Since GQALY and WELLBY approaches count all harms and benefits equally, they can't capture the important moral asymmetry between doing harm and allowing harm. Since governments have a moral duty to ensure that the rights of their citizens are respected, they have a strong moral reason to impose measures that protect the stringent negative rights of those at risk in a pandemic situation, even if the burden they impose is so great it couldn't be demanded for the purpose of aiding others, and even if total well-being would be higher without them. But how much and what sorts of things must we sacrifice? I conclude that there is no simple answer. We should give up the project of trying to balance the benefits and costs of pandemic measures in terms of a common currency, be it money or 4 subjective well-being, and make do with heterogeneous and hard-to-aggregate reasons pro and con in a democratic deliberative process. 1 The Generalized QALY and WELLBY Approaches to Trade-Offs As I noted at the beginning, the various measures taken around the world to curb the spread of the SARS-CoV-2 virus have had clear health benefits, but also a variety of different kinds of cost. I'm going to set aside the issue of whether, say, restrictions on free movement violate people's rights.1 Whether there are such moral harms or not, it is very likely that lockdown measures have both readily quantifiable economic costs and hard-to-quantify adverse effects on many people's well-being. At present, estimates of these costs vary widely, and often fail to distinguish between the costs resulting from individuals' rational adaptation to the pandemic (which involves avoiding situations of physical proximity to others) and the costs resulting from social distancing measures imposed to contain the pandemic, thus significantly exaggerating the latter. In any case, stay-at-home orders, business closures, bans on public events and use of public spaces, and other similar measures will no doubt reduce economic activity on a scale of billions of dollars, which in turn reduces consumption and causes unemployment and poverty. They also contribute to increase in domestic violence, loneliness, and even suicides (Kawohl and Nordt 2020). Given that disease prevention measures thus have significant costs as well as benefits, there is a real need to find a way to weigh the two against each other in the case of each proposed measure. The natural thought is that "making trade-offs requires converting different outcomes into a single unit of value", as Peter Singer and Michael Plant (2020) put it. (I will call this assumption into question below, but let's hold onto it for the time being.) What, then, should be the 'single unit of value'? For the Generalized QALY approach the 1 In my view, many such objections are based on conflation of legal rights with moral rights, which do not include the right to impose risk of serious harm on innocent others. 5 answer is money, while for the WELLBY approach it is well-being. Each answer has a clear rationale – but both, I'll argue, lead to moral mistakes. Start with money. It is what we already use to commensurate the value of the bewildering variety of things and services for sale. And what's more, there already exist widely used methods for quantifying the values of saving lives and other health benefits in monetary terms. For simplicity, I will here focus simply on quality-adjusted life years or QALYs, setting aside competing models like DALYs (disability-adjusted life years) and VSLYs (value of a statistical life year). The idea of a QALY is simple: leading a full year in perfect health constitutes 1 QALY, while a health state no better than death gets you 0 QALYs. Based on population surveys, proponents of the approach have quantified values somewhere in between for many possible health states – for example, a year of life on dialysis is worth 0.75 QALYs. QALYs can be and have been put to many uses. The most obvious is comparing the cost-effectiveness of treatments. Suppose that cancer treatment A costs $3,000,000 and is expected to yield 40 QALYs total for six patients, while cancer treatment B costs $5,000,000 and is expected to yield 70 QALYs for the same number of different patients. Let's assume that we're dealing with a public system and each patient has an equal claim to treatment. Which treatment if either should the hospital provide? Well, with these figures, it's easy to calculate that treatment A produces a QALY for $75,000 and treatment B for around $71,428. Treatment B thus promises more bang for the buck, so that there is at least a prima facie case for choosing it. The second relevant use for QALYs is that they allow health care systems to set a limit to how much of their resources they will put into a particular use. Since health budgets are always limited, interventions that are costly but ineffective have significant opportunity costs. No public system should spend a million to prevent ten men from losing their hair, 6 since it would mean smaller resources for more serious medical problems, resulting in more suffering. As noted, in the UK, NHS considers a treatment sufficiently cost-effective if it produces a QALY for less than £20,000 to 30,000. In the US, it has been calculated that Medicare is prepared to pay around $121,000 per QALY for dialysis (Conover 2020). With these numbers, neither of the two cancer treatments above would be offered in the UK, while Medicare would presumably pay for B. What I'm calling the Generalized QALY approach or GQALY says that we should assess the cost-effectiveness of nonpharmaceutical interventions such as business closures or movement restrictions by using the same (or similar) monetary value for each resulting QALY as in the health care context. This yields the following core claim: The Core Claim of GQALY If the opportunity cost of a QALY saved by a nonpharmaceutical intervention under consideration exceeds the maximal monetary cost per QALY considered acceptable for a health care intervention, the measure should not be adopted. The example I gave in the introduction illustrates this core claim. Suppose that closing down restaurants in some part of the UK costs £10,000,000 a week and is estimated to save (each week) the lives of 30 people, who would each live in perfect health for 10 years, thus resulting in 300 QALYs (the Restaurant Closure Case). The cost per QALY of this measure is thus £10,000,000/300= £33,000. This slightly exceeds the maximum that the NHS is willing to pay for a QALY, so GQALY says that under these assumptions, the restaurants should not be closed. (This calculation ignores other benefits from keeping the restaurants open, such as the pleasure people take in eating and conversing. But that wouldn't change the outcome here.) 7 GQALY has been at least implicit in many different commentaries on COVID-19 policy. Health care economists come closest to explicit statements. For example, Eline van den Broek-Altenburg and Adam Atherly (2020) estimate the costs of COVID-19 measures and total expected amount of QALYs gained in the US, and conclude as follows: We calculated the cost per QALY gained from the current approach to be somewhere between approximately $75,000 and $650,000. [...] This is somewhere between reasonably cost effective and clearly not a wise investment if we used the conventional standard cut-off point of $100,000 per life year gained. If the total investment was $4 trillion, the cost per QALY gained would rise to a range of $300,000 to $2.5 million per QALY gained - an expenditure far out of line from other healthcare investments. [...] In a world of finite resources, it's necessary to make choices. Why not use a framework that has been defended by governments and scientists for decades to justify treatment and health reimbursement systems' decisions to not pay for life saving treatments? Writing in the UK Institute of Economic Affairs blog, Richard Teather (2020) takes the same line: How does the coronavirus lockdown look on a QALY-based cost-benefit analysis? The overall cost of the government's actions is not known, but the Treasury's estimated direct cost of the aid package to deal with it is £350 billion. At that level, based on a mid-point of £25,000 per QALY, the government's actions would have to save 14 million life-years to meet the standard NHS cost-benefit criteria. [...] The headline direct cost of the lockdown is fifty times what would normally be considered reasonable, even based on the highest estimate of potential deaths, so the prima facie case [against the lockdown] is strong, even if we allow a huge margin for error. 8 Many more quotations could be found in online commentary on COVID-19 measures (e.g. Young 2020, Vaillancourt 2020), but in the interest of space, I trust the above will suffice. From QALYs to WELLBYs Because QALYs have well-established monetary values in a public policy context, they're an attractive tool for health-economy trade-offs. But as I noted, disease prevention measures have many non-economic costs as well, say increase in loneliness. Making trade-offs in terms of money requires also giving a monetary value to these other costs, too. Many find this an unnecessary detour, since there is an alternative currency available, namely well-being: loneliness and disease reduce well-being a certain amount, and money tends to increase it, whether directly or indirectly via consumption. But can well-being be given a precise value in any way analogous with money? Proponents of recently popular science of well-being think so. There is, after all, a burgeoning literature on subjective well-being (SWB), measured in various ways (see Diener et al. 1999). The simplest and most widely used is life satisfaction, measured in the UK by asking the question "'Overall, how satisfied are you with your life nowadays', where a 0 is 'not at all' and a 10 is 'completely'" (Frijters et al. 2020, 16) Among others, Paul Frijters and co-authors (2020) make use of life satisfaction measures to define a wellbeing-adjusted lifeyear, or WELLBY. A year lived at life satisfaction level 1 on a scale of 1 to 10 yields 1 WELLBY; thus, given that the average life satisfaction level in rich countries tends to be around 7.5, their average citizens gain 7.5 WELLBYs each year. For proponents of the WELLBY approach, then, subjective well-being is the currency in terms of which trade-offs between different goods should be made. As Frijters et al. 2020 say, "Wellbeing-adjusted life-years (WELLBYs) expand the QALY idea to the whole of life, 9 not just health. It is hence a tool for judging the trade-offs between large government programmes" (4). In Layard et al. 2020, WELLBYs are applied to assessing lockdown measures in the UK, in particular addressing the question of what is the best date for lifting them in order to maximize WELLBYs. To convert various observed effects of lockdown and the virus, the authors make use of findings from the science of happiness. For example, when it comes to money, they report a robust finding that "a 1% gain in income increases wellbeing (measured 0-10) by around 0.002 points" (Layard et al. 2020, 5) The psychological cost of being unemployed for a year, in turn, is 0.7 WELLBYs. Estimating the well-being effect of changes of air quality and many other things, the authors conclude that the optimal date for lifting the lockdown measures in the UK is June 1. More radically, Frijters (2020a) calculates that even in the best case scenario for the UK, lockdown-produced unemployment alone will cause the loss of 50 million WELLBYs in 2020-2021, which, according to him, is equivalent to the harm caused by 1.7 million deaths of people with 5 good years left. Taking other wellbeing costs into account as well, he concludes that no restrictions should ever have been introduced, even if it resulted globally in 200 million deaths of people with three years left (Frijters 2020b)! 2 Counting Morally Irrelevant Benefits and Costs My first critical point is that whether we use money or subjective well-being as the currency for making trade-offs between health and other goods, we are bound to be led astray by morally irrelevant benefits and costs. Let's begin with money. As I say above, the attraction of using the QALY approach to assess trade-offs between health and other goods is that it converts health benefits to a familiar and handy measure of value, money. What I'll argue is that making trade-offs in terms of any such monetary value in the context of public decision-making in general will 10 result in giving weight to morally irrelevant benefits and costs, and must therefore be avoided. To see this point, return first to the kind of scenario where QALY monetization is useful, the comparison between cancer treatments A and B. The question we need to ask is this: how could the choice of treatment B be justified to the patients who thereby lose out on treatment A? Clearly, the justification must be that the limited resources are put to better use – more patients in equal need get more life-years as a result. We can say to patients in the A group: "We're sorry that we can't offer you treatment, but the alternative would have been a greater loss to an equal number of people – we couldn't have justified that choice to them." Let's then switch scenarios to the Restaurant Closure Case. Here, instead of taking action as a result of which 30 people a week would avoid getting sick and dying, the GQALY approach tells us that we should keep the restaurants open to avoid losses of £10,000,000 a week. How can we justify this choice to the 30 people who are about to lose their lives as a result? For the justification to be parallel to the cancer treatment case, we'd have to say that the money saved will be put to better use elsewhere. But that's precisely what we can't say here, when all we know is that the keeping the restaurants open will generate £10,000,000. Some of that money will be income that goes to the restaurant owners, managers, and workers, as well as the public purse via tax, and circulates back via consumption to feed further economic activity. Much of it could go in a safe, or be burned in an art performance, or buy another Bentley for a restaurant owner; some would pay for a dentist, some a birthday present to a child. All we can say for sure (more or less) is that it will be used to satisfy some people's preferences, whatever they may be. And this, I claim, is not a sufficient justification for the significant loss imposed by the continued economic activity in pandemic conditions. This is because some preferencesatisfactions are morally irrelevant utilities in the context of life-and-death choices. And 11 because the GQALY approach has no way to distinguish between relevant and irrelevant utilities, it can't be the guide we need to make ethical trade-offs among goods. By saying that some utilities are morally irrelevant I mean that they carry no weight in the context of the decision at hand, given the kind of reasons there are on the other side. Consequently, even if there are many such irrelevant benefits on one side, aggregating them together does not add up to a weighty moral reason to choose the option. Perhaps the best way to illustrate this is to start with Frances Kamm's Sore Throat Case (Kamm 1993, 165). As she originally puts it, we have some scarce medicine that could save either Jim or Joe, neither of whom has any special claim to it and both of whom have an equal claim to our assistance. The only right thing to do is randomize between the two potential beneficiaries. But now suppose that if and only if the medicine is given to Jim, there is enough left over to cure a sore throat that Nancy will otherwise have next week. Now, giving the medicine to Jim would result in an outcome that is strictly better than the outcome of giving it to Joe. Nevertheless, Kamm says, it would be morally wrong to give the medicine to Jim on this basis. Her grounds for saying this are, roughly, that from Joe's perspective, it would be as if something that would not be a contender in a pairwise comparison with saving his life (Nancy's sore throat) defeats saving his life, and an objective moral perspective should incorporate subjects' own perspectives. We would be "showing insufficient concern for what Joe's chance to live means to him" if we allowed the utility of curing the sore throat count against it (1993, 195-196). In other choice contexts, to be sure, Nancy's sore throat would be a morally relevant consideration (suppose the choice is between curing Nancy's sore throat and having a beer). For moral relevance, it matters what's on the other side of the scales. Importantly, then, if a curing a sore throat doesn't count in the lifesaving context, neither does curing a thousand 12 people's sore throats – we can't aggregate a bunch of morally irrelevant benefits together and weigh the total against a more serious benefit like that of saving a life. Kamm is not, to be sure, the only defender of irrelevant utilities and restricted aggregation of benefits. Recently, Alex Voorhoeve (2014) has argued for a similar view, according to which we must "aggregate relevant claims", where the standard for the relevance of a claim is, roughly, that an impartial spectator could sympathize with a subject who raises such a claim on their own behalf. The criterion for such ability to sympathize is that the person who makes the claim acts within the bounds of permissible self-regard. For example, it is intuitively not permissible for me to refuse to save a life, if the only cost to me is a feeling of nausea that lasts for an evening. If that is the case, then such states of nausea are not relevant in the context of saving a life, and it is not permissible to aggregate the disvalue of many different people's unpleasant evenings so that they together outweigh the benefit of saving a life. In contrast, I do have the prerogative of not saving a life in order to avoid sacrificing my limbs – a sympathetic observer can sympathize with such refusal, with pressing my claim "in the face of the strongest competing claim" (Voorhoeve 2017, 151). So losing a limb is a morally relevant cost in a life-and-death context, and there is some amount of lost limbs such that together they morally outweigh the loss of a life. Both Kamm and Voorhoeve openly acknowledge that such contextual principles of moral aggregation result in moral betterness (or at least moral choiceworthiness) not being transitive.2 I will not enter this debate here – suffice it to say that there are valid intuitions on both sides of the aggregation debate.3 But all things considered, the thought that not every harm counts against any harm from a moral perspective is very appealing. And that spells trouble for GQALY, because, as they say, a dollar is a dollar. Once we start making trade- 2 It plausibly follows from restricted aggregation that some number of saved limbs is better than some number of saved lives; some number of saved fingers is better than some number of saved limbs; but it's not the case that some number of saved fingers is better than some number of saved lives. 3 See especially Horton 2018 and Voorhoeve 2017. 13 offs between goods, say health and the economy, on the basis of any monetary value whatsoever for a QALY, we are counting any benefit that money can buy or harm that money can prevent against lost lives. While some of these harms – say, homelessness or loss of access to higher education – will indeed be relevant in comparison to deaths, we've lost the means to distinguish them from others. In this context, it is sometimes suggested that the amount of public revenue lost as a result of social distancing will result in increased amount of deaths (or lost life-years) in the future, for example by way of reduced healthcare funding in the future, so there is a like-forlike trade-off after all at least when it comes to some kinds of economic cost (e.g. Young 2020). Setting aside the asymmetry between preventing harm and aiding (discussed in the next section), the problem with this line of reasoning is that current choices in no way determine how the reduced public resources will be spent in the future. If country X now spends 10% of its budget on health care and its total revenue contracts a realistic 8% because of the combined effect of the pandemic and social distancing measures, it is still possible to maintain just the same level of health care spending without borrowing at the expense of future generations, if it is decided to use about 10.9% of the new budget on health. Of course, this means that there will be fewer resources for other purposes, which means that more or less painful cuts have to be made somewhere, say the military or cultural investment. But that's just to say that prioritization becomes more important when resources shrink, and we can't have everything we want. Modern states can take quite a big economic hit and still provide for the basic needs of their citizens, if they decide to do so. That's why it's naïve to assume that loss of revenue automatically translates to future lives lost due to worse health care (for example). What about the WELLBY approach, then? Because WELLBYs use subjective wellbeing rather than money as currency, one might hope it doesn't face the irrelevant utilities 14 problem – surely well-being is always relevant! Alas, no. The WELLBY approach faces the classic aggregation challenges to utilitarianism, such as Scanlon's (1998) World Cup Case, in which we either have to interrupt a billion people's enjoyment of the year's most important sports event, or leave a poor worker to suffer immense agony inside a broadcasting tower for the duration of the match. It is a near certainty that we can gain more in WELLBYs by allowing the match to go on than by interrupting it. Yet this is a paradigm case of morally irrelevant utilities – while the joy of watching the final really is important to many, it is not something any one of them could reasonably offer as a justification to the person suffering immense agony as a result. This point isn't in any way restricted to outlandish fictional examples. Consider the claim by Paul Frijters (2020a) that 80 million people unemployed for five years is equivalent to at least 1.7 million deaths of people with five good years left in terms of WELLBYs lost. Let's accept these figures for the sake of argument. Dividing through, we get the result that if we have to choose between 17 currently healthy people dying now rather than in five years and any more than 80 people losing their job for the same number of years, we should choose the option that leads to the deaths of the old people now. While unemployment is no doubt a serious social ill – though just how serious depends on whether the unemployed have access to good housing, health care, and so on – it is difficult to see how such a choice could be defensible to those about to lose their lives. After all, each of them stands to lose much more individually than any of those who would otherwise lose their jobs. What's more, in this comparison, those who have only five years left anyway are in one important sense already worse off than those who face unemployment for the same duration, which may be morally significant. For prioritarians, it's more urgent to benefit those doing badly than those doing well, other things being equal (e.g. Nagel 1995, Adler 2012). Consider the following scenario: 15 A's well-being B's well-being Option X 1 10 Option Y 2 7 Prioritarians say that A's claim in favor of choosing Y is morally weightier than B's claim in favor of X, though B stands to lose much more (7 instead of 10) than A stands to gain (2 instead of 1). Prioritarians propose different functions for weighting the gains and losses of an individual depending on their level of well-being, but for my purposes, it suffices that on any plausible version, there will be realistic pairs of scenarios in which a smaller sum of gains for the worst-off morally outweighs a considerably greater sum of gains to the betteroff. Suppose that those with little life left are the worst-off. Then if, say, the gains and losses at the bottom get a 5x moral multiplier relative to those at the middle, the numbers calculated by Frijters (2020a) will end up favoring life-saving pandemic restrictions, even if we consider unemployment a morally relevant cost and aggregate the well-being losses of the many joblosers before weighing them against the loss of life of fewer people. While there's a significant net loss of WELLBYs involved, the extra weight given to the worst-off means their interests win out. So I conclude that the WELLBY approach does no better than GQALY, and for the same reason – using a single, unweighted currency to enable trade-offs between any goods and bads whatsoever makes trade-offs too easy, forcing us to make trades that we shouldn't make. 3 Ignoring the Asymmetry Between Doing and Allowing Harm 16 The second problem with using the GQALY and WELLBY approaches to evaluate pandemic control measures is that they fail to respect the fundamental moral distinction between doing and allowing harm, because the decision value that they give to harms does not depend on the agent's place in the causal sequence that leads to them. Like the previous problem I raised, this is not a minor detail that could be ironed out, but a core feature of the approaches – it follows from their very idea that we should give the same monetary value to a QALY (or WELLBY) produced by a health intervention and a QALY (or WELLBY) whose loss is avoided by measures that prevent harmful interference in people's lives. Let us start by outlining the distinction between doing and allowing harm and the rationale behind it. The best formulation of the asymmetry is that we need a stronger justification to do harm ourselves than to allow a corresponding harm to occur (e.g. Woollard 2015). Or, to put it equivalently but in different terms, our negative rights against being harmed by others are stronger than our positive rights to assistance with harm. So, for example, the fact that I'll otherwise lose a leg is not a strong enough justification for killing someone else, but it may suffice to justify not rescuing someone from a certain death, say drowning in shark-infested waters. In the first case, after all, I would deprive someone of a good that they have independently of me and my current activities and to which they thus have a stronger claim, while in the second I would deprive them of a good that they would only have in virtue of my assistance (Kamm 1996). So, importantly, I have to sacrifice more to avoid harming others than I have to sacrifice to help them. Why should this be the case? The best rationale for the asymmetry that I know of is provided by Fiona Woollard (2015). Woollard argues that just such a structure of normative demands is required for our lives and bodies to genuinely belong to us. Very briefly, as Warren Quinn (1989) pointed out, if it were permissible to use you or your possessions in whatever way was necessary to promote the overall good, your life and body and property 17 would not genuinely be yours. There must thus be a high bar for what Woollard calls causal imposition of harm on others. We causally impose harm on others, roughly, when our actions are part of a causal sequence that results in the harm in question.4 At the same time, for my life to genuinely belong to me, there must also be limitations on what I am required to do to prevent harm to others, protecting me against what Woollard calls normative imposition. If I must be ready to sacrifice my well-being whenever doing so would result in a net gain in total well-being, I have no space to shape a worthwhile life of my own, to echo Bernard Williams (1973). As Woollard rightly notes, the only way to guarantee that my life belongs to me in both of these ways is that others have a strong, hard-to-outweigh negative duty not to harm me (which I of course also have with respect to others), and that I have only a weaker positive duty to help others. Since directed duties correlate with rights, we can equivalently formulate this by saying that our negative right against being harmed by others is stronger than our positive right to demand others to help us. How does this asymmetry apply to the case of epidemic restrictions? To keep things clear, I'm going to simplify the reality of the disease, and distinguish between what I'll call the Safe population (say, basically healthy people under 60) and the At-Risk population (people over 70, diabetics etc.). In the case of At-Risk population, any restrictions on movement, business closings and so on can be partially justified on paternalistic grounds (or offered as advice, as is done in some countries). It follows from my stipulation that this kind of justification, whatever we make of it, is not available in the case of the Safe population. The only kind of justification for imposing restrictions on the activity of Safe people, whom I'll assume to be the majority of the population, is that doing so will protect the health of the At-Risk people. This justification is there also for restrictions targeting At-Risk people, of 4 Specifying exactly what it is to be part of a causal sequence turns out to be far from trivial, but I will ignore this complication here. 18 course, since they could also pass on the virus to other At-Risk people. (Relaxing these idealizations will not affect my argument but would complicate the presentation.) The key point here is that at least for the most part, social distancing measures are put in place in order to prevent people from engaging in activities that in the context of a highly contagious disease pose a significant risk of harm to others. In the absence of such measures, some people – and indeed an exponentially increasing number of people – would unwittingly or negligently infect others, thus bringing suffering and death to people who would otherwise have been fine and depriving them of goods that they would have had independently. To put the point in the language of rights, without the measures, some people would (typically unintentionally) violate important negative rights of At-Risk people. Assuming that a state should act to protect the rights of its citizens, it thus has a strong moral reason to impose measures that reduce the significant risk of some citizens violating the negative rights of others (in the same way a state has a strong moral reason to take measures to prevent citizens killing others or stealing from them). Naturally, such measures themselves must not cause more serious harm than they prevent and should be designed to minimize the lesser harms they will inevitably cause to some. One complication here is that many of the people burdened by the restrictions at a given time t will not be infected, and will therefore as a matter of fact pose no risk of transmitting the virus at t. However, here it is important to bear in mind the dynamics of contagious diseases. Suppose that there are no restrictions on large gatherings, and an uninfected person goes to a large choir practice session at t. It turns out that precisely such situations are conducive to the spread of SARS-CoV2 in particular, so if even one infected person attends the practice, there is a better than even chance that the uninfected person will 19 be infected at t+1, and will subsequently pose a risk to others.5 This dynamic justifies burdening even currently uninfected people with the right kind of restrictions. A further justification is provided by the fact that given asymptomatic transmission, we are typically not in a position to know whether we are currently carriers of the virus. If in such circumstances we, say, go to a crowded restaurant, we know or should know that we're at least taking a risk of imposing a significant risk on others, which is itself morally objectionable.6 (Of course, if we knew exactly who is infected and capable of transmitting the virus – supposed it turned a person's face bright blue – it would be possible and morally required to quarantine only the blue people.) So, to simplify things even further, the measures are there to prevent Safe people from imposing a significant risk of serious harm to At-Risk people. With this in mind, let's return once again to Restaurant Closure. Recall that the stipulation was that closing restaurants would save the lives – or, more accurately, prevent the deaths – of 30 people for 10 years at the cost of £33,000 per life year. Compare this to a situation in which there's cancer treatment C, which would produce the same number of healthy life years that the patients wouldn't otherwise have, for the same cost per life year. As before, by NHS criteria, treatment C would not be funded, but the money would be used for some more cost-effective treatment. The proponents of GQALY say that by the same reasoning, the restaurants shouldn't be closed either. But this rides roughshod over the significant asymmetry between the cases. As I said above, we must sacrifice more, indeed significantly more, to avoid harming others than we have to sacrifice to aid them. So even if we accept that we (collectively) are not morally obligated to sacrifice more than £30,000 per QALY to provide 5 See 'Illness Ravaged Choir, but Quick Action Kept Community Safer, a Study Says.' (The New York Times, May 14, 2020, A11) 6 I discuss related issues in [Author redacted]. 20 aid for the sick7, it does not follow that we are not obligated to sacrifice a lot more than £30,000 per QALY to avoid harming the not-yet-sick members of the At-Risk population. Insofar Safe people can't be counted on to voluntarily make sacrifices that the At-Risk people have a right to demand of them, a government whose job it is to protect the rights of its citizens has a moral reason to step in and see to it that the Safe people live up to their obligation by, say, ordering the restaurants closed. To make this point more vivid, consider the kinds of conversation we as members of the Safe population might have with people who miss out on cancer treatment C, on the one hand, and At-Risk people who are infected as a result of keeping the restaurants open, in both cases as they're on their deathbed. The first conversation is a lot easier to imagine in the context of a well-funded state-run health care system, so I will do so. We might say to the patients "Look, we're really sorry that there's just palliative treatment for you. But we already pay so much tax to support all the important functions of the government that adding so much more that the system could treat your illness without an unreasonable opportunity cost would significantly impact on our ability to realize our own ground projects". If, indeed, such a speech were true, the patients couldn't argue that we're not giving them what we owe them, or demand the government to tax us more. But what about the restaurant case? We couldn't appeal to the cost of providing aid to the At-Risk population, since they don't need our aid in the first place. Unlike a medical intervention, staying at home or carefully maintaining a sufficient distance from others while shopping does not cause or produce a benefit like extending their lives for x number of years for members of the At-Risk group – after all, since they enjoy the good of health independently of our present activity, they would live for x number of years even if we ceased to exist before engaging in the activity. So instead of helping, all we'd be doing would 7 Of course the current levels of taxpayer funding for health care might be too low, but let that pass here. 21 be paying the opportunity cost of not posing a risk of harm of losing x number of years. The At-Risk people, however, could say "Look, I don't need your money or your help with anything. I just want to keep what's mine – my very life, my body, my health – and in these sad circumstances, your enjoying yourself in a restaurant takes these things away from me." And there would be little to say in response, assuming that the ex ante risk of harm indeed was high enough. Finally, to come briefly back to the WELLBY approach, once again much the same applies. The purported justification offered to those who end up suffering would be cast in terms of subjective well-being, of course. The Safe people would have to try to defend keeping the restaurants open by appealing to their losing more happiness in the aggregate in the event of closing than the At-Risk people stand to lose without restrictions. The effective reply would be simply that you must be prepared to lose more happiness than others in order to avoid taking away what's theirs. After all, it's not morally permissible even to save your own life, if in order to do so you must kill an innocent person. The WELLBY approach is no more successful at capturing the asymmetry than the GQALY one. 4 Conclusion: The Difficulty of Deliberation Suppose I'm right, and using any common currency will result in ignoring morally relevant differences between goods and actions. How, then, should we assess the inevitable trade-offs between health and other goods? While I've emphasized that without any social distancing measures, ordinarily harmless behavior poses a significant risk of causing serious harm to AtRisk groups in pandemic conditions, it still remains the case that long-term unemployment, domestic violence, and social isolation are also serious harms, which must somehow be weighed against the benefits of any particular measure that makes them probable. 22 This is not the place to attempt a proper answer to this question, but I can give a short answer: by balancing the heterogeneous reasons for and against alternative policies as best we can. We have to be able to justify the policies we adopt to their losers on some other morally relevant basis than total utility (to put things in a contractualist vein along the lines of Scanlon 1998). As a heuristic, we can ask ourselves what we could say to them in face-toface discussion to justify our actions, assuming they're reasonable, as I've done above. Or, famously, we can ask ourselves what we'd want if we didn't know in whose shoes we'll find ourselves (Rawls 1971). I don't think that these suggestions, even if more fully fleshed out, qualify as methods for resolving trade-offs. They really are at best rules of thumb that may help in a discussion that must include representatives from all affected groups speaking for themselves and trying to convince others by appeal to considerations they recognize as bearing on the issue.8 That, after all, is how democratic politics ideally works. 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