Pandemic Ethics 8 Big Questions of COVID-19 BEN BRAMBLE AUSTRALIAN NATIONAL UNIVERSITY PRINCETON UNIVERSITY, UCHV ben.bramble@anu.edu.au www.benbramble.com B A R T L E B Y B O O K S Copyright © 2020 (1st Edition) by Bartleby Books Published by Bartleby Books ISBN: 978-0-6489016-0-0 Jacket Design: Emily Mahon Illustrations/collages: Raúl Lázaro This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/ About the Author Ben Bramble is a lecturer in philosophy at the Australian National University. In 2019-2020, he was a Laurance S. Rockefeller Visiting Faculty Fellow at Princeton University. Prior to then, he held tenured academic positions at Liverpool University and Trinity College Dublin. His main interests are moral and political philosophy, with a recent focus on applied topics including bioethics, animal ethics, and the ethics of emerging technologies such as AI. Contents Acknowledgements 1 Open Access Note 2 Introduction 3 1 Lockdown 6 2 Blame 28 3 Immunity Passports 46 4 Masks 56 5 Duties to Assist 66 6 Vaccine Trials 83 7 Triage 96 8 Onlookers 114 Conclusion: Unlocking the Future 124 1 Acknowledgements I want to thank friends and colleagues who have read earlier drafts of this book and offered feedback. Your comments and criticism have made this a much better book. This book was written mainly during my time as a Laurance S. Rockefeller Visiting Faculty Fellow at Princeton University. I owe thanks to everyone at the University Center for Human Values at Princeton, especially Melissa Lane, for providing such a stimulating and friendly environment over this past year. 2 Open Access Note COVID-19 is one of the most serious crises humanity has faced. Discussions of it-especially its ethics-should not be behind a paywall. For this reason, I have decided to release this book Open Access, free for all to download and read. 3 Introduction IT IS AUGUST 2020, AND THE WORLD IS STILL in the grip of the COVID-19 pandemic. COVID-19 is the disease resulting from SARS-CoV-2, a novel (new strain of) coronavirus that seems to have originated in Wuhan, China, in late 2019. There are many strains of coronavirus, but SARS-CoV-2 is a particularly nasty one, since it combines two features: (1) an ability to cause severe illness and death and (2) a very high level of infectiousness. COVID-19 raises a myriad of complex ethical questions-i.e., questions about what to do, how to feel, and who to be. In this book, I will explore eight of the most important of these questions. They are as follows: 1. Lockdown. Should we stay locked down and wait for a vaccine, cure, or treatment, or open up in the hopes of achieving herd immunity without a vaccine? 2. Blame. Who is morally to blame for COVID-19 (both its genesis and its spread)? 4 3. Immunity Passports. Should we allow people who are immune to the virus to leave lockdown? 4. Masks. How should we respond to shortages of facemasks and other PPE? 5. Duties to Assist. What positive moral duties do various parties have in the pandemic? 6. Vaccine Trials. Should we allow people to volunteer to be exposed to SARS-CoV-2 in order to speed up the development of a safe and effective vaccine? 7. Triage. When hospitals run out of life-saving resources (e.g., ventilators, ICU beds, dialysis machines, etc.), who should get their use? 8. Onlookers. How should those who are neither medically nor economically harmed by the pandemic live and feel in these times? For each question, I will carefully set out what is morally at issue, and offer some original thoughts about how best to answer it. I will finish the book with a conclusion that sums up its main ideas, explains what I think deserves to be regarded as The Deep Moral Problem of the Pandemic, and offers a Revolutionary Argument for how and why we should make things better for people post-pandemic. This book is written in plain language. It does not presuppose any background in philosophy or biomedical science. My hope is that people of all levels of education and backgrounds will find something useful in it. 5 I intend this book as both an introduction to the ethics of COVID-19 and an original contribution to the emerging literature on this topic. It is not meant as the final word on any of these questions. My hope is that it will help bring these issues to a much wider audience, so that more people can contribute to the ongoing discussion. 6 1 Lockdown ONE OF THE MOST FRIGHTENING ASPECTS of COVID19 is its ability to lead to hospitals becoming overburdened or running out of vital resources. If too many people become ill with COVID-19 too quickly, then it is not possible for all patients who need life-saving treatment- for example, ventilators, ICU beds, dialysis-to receive it. In this scenario, death rates from COVID-19 skyrocket. Almost everyone agrees that the overburdening of our hospitals is something to be avoided at all costs. How can we avoid it? An effective vaccine, cure, or treatment would accomplish this. But these are all very likely a long way off. 7 In the meantime, there is only one effective strategy for preventing the overburdening of our hospitals: slow the spread of the virus to such an extent that infections are greatly reduced or at least spaced out over time so that there is no single point in time at which hospitals run out of resources. This strategy is known as flattening the curve, and is depicted in Figure 1.1 Figure 1. Flattening the Curve How can transmission be slowed? There are two main ways: 1. Physical Distancing.2 If people spend more time at home than usual, this reduces the number of possible moments when the virus can jump from one person to another. And if, when people are out in public, they stay physically aloof from each other (say, six feet or 1 Flattening the curve can be usefully combined with "raising the line": https://www.vox.com/2020/4/7/21201260/coronavirus-usa-chart-maskshortage-ventilators-flatten-the-curve. 2 "Physical distancing" is a much better term than "social distancing", because it is really just physical distance that is needed here. We can-and should-be trying to remain socially connected. 8 two metres apart), this can also help to reduce transmission. 2. Good Hygiene. Washing hands regularly, or using hand sanitizer, makes it less likely that, if you come into contact with the virus, you will transfer it from your hands to your mouth (and so become infected), or pass it on to others. Similarly, if people cough into their elbows rather than their hands, or wear masks, this also greatly helps to reduce transmission. When enough people do these things, the COVID-19 curve is flattened. The question is: how do you get enough people to do these things? One method is to ask nicely. But this, unfortunately, is not enough. For most people, there are big costs to doing these things. And many people are either forgetful, lazy, or skeptical of the whole project. Given this, flattening the COVID-19 curve has required forcing people to do some combination of the above things-i.e., demanding that they do them on pain of some penalty. Such enforcement is known as lockdown. Lockdown might involve the following sorts of things: • Closing schools, cinemas, restaurants, gyms, etc. • Closing other sorts of shops and businesses. • Banning medium or large gatherings. • Banning flights. • Requiring masks to be worn in public. • Requiring people to stay home unless they need to leave in order to exercise, buy groceries, see a doctor, or perform work classified as 'essential' (e.g., healthcare, food delivery, cleaning, transport, etc.). 9 Exactly what measures are needed to flatten the COVID19 curve differs from place to place, and from culture to culture, depending on how many cases of the virus exist, how willing people are to follow recommendations of the government, how accustomed people already are to practising physical distancing and good hygiene, etc. The Big Question So far, most parts of the world have locked down soon enough to avoid overburdening their healthcare systems. They have, that is, successfully flattened their COVID-19 curves. The big question is what to do next. There are two basic options: 1. Stay Locked Down. Remain in various states or degrees of lockdown until we develop an effective vaccine, cure, or treatment. 2. Open Up. Open up our society as much as we can without again threatening to overburden hospitals, in the hope of having enough recovered patients (say, 70% of the population) to achieve 'herd immunity', at which point the virus will start to die out. What is the case for Open Up? There are two main arguments for it. The first is that there are huge costs of Stay Locked Down. When schools close, children's learning is set back and parents cannot work effectively (even if they can work from home). When businesses close, people lose their salaries and livelihoods. Unemployment, 10 especially combined with social isolation, can lead to mental health problems and domestic violence. Worsening economic recessions can compound these problems, and even produce catastrophic events in poorer countries. Some advocates of Open Up also complain that lockdowns violate citizens' rights-rights to freedom of movement, assembly, work, privacy, and so on. This complaint was voiced, notably, by two Justices of Wisconsin's Supreme Court, in rejecting an extension of the state's stay-at-home order.3 Justice Daniel Kelly wrote: This comprehensive claim to control virtually every aspect of a person's life is something we normally associate with a prison, not a free society governed by the rule of law. And Justice Rebecca Bradley asked: Isn't it the very definition of tyranny for one person to order people to be imprisoned for going to work, among other ordinarily lawful activities? The second argument that has been given for Open Up is that its own costs are small by comparison. Most people who die from COVID-19 are older or otherwise vulnerable (with pre-existing health conditions like obesity, cancer, heart disease, diabetes, and so on). Many of them have little time remaining anyway (in some cases, mere months) or a lower quality of life than most people who are young and healthy. For this reason, their deaths are less bad for them than we might at first suppose, and so less bad period. 3 https://www.nytimes.com/2020/05/13/us/coronavirus-wisconsinsupreme-court.html. 11 As Johan Giesecke, a renowned epidemiologist and chief advisor to Sweden's government, put it: People who will die a few months later are dying now. And that's taking months from their lives, so that's maybe not nice. But [compare] that to the effects of the lockdown.4 Advocates of Open Up often add that the old and vulnerable can voluntarily shelter till we achieve herd immunity. These arguments, though, are deeply flawed. Let me explain why. Health Consequences of Open Up As I have said, advocates of Open Up often downplay the badness of its health consequences, in part by appealing to the fact that it kills mainly elderly people or those with preexisting conditions. But they are wrong to do so. While most people who die of COVID-19 are older, many are not. For example, in New York City, as of May 13, only around 50% of deaths were of people aged 75 or older.5 And while many younger people who die from COVID-19 have pre-existing conditions, by no means all do, and not all of these conditions substantially reduce life expectancy or quality of life. Many younger people who die of COVID-19, even with pre-existing conditions, had long and largely healthy lives ahead of them beforehand.6 4 https://youtu.be/bfN2JWifLCY. 5 https://www.worldometers.info/coronavirus/coronavirus-age-sexdemographics/. 6 For analysis, see this piece from Michael Otsuka: https://allcaution.com/2020/07/09/healthy-workers-as-young-as-45-at12 Even when it comes to elderly victims of COVID-19, many of these people still had much to live for. Dying a few months earlier can mean missing out on valuable experiences of seeing your grandchildren start to walk, talk, or grow into adulthood, your children reach important milestones, various projects of yours progress or come to fruition, or further significant world events take place. As for elderly people for whom additional life would add very little or nothing to lifetime well-being, this is often because society has failed these people. They have wound up in aged care facilities, without friends or family who value them. It is dreadful to call for the sacrifice of some people on the grounds that they have little left to live for when it is largely our own fault that they have so little left. Moreover, it is worth emphasising that a death from COVID-19 is no ordinary death. It is an extremely bad way to go. Not only is it physically traumatic, it is typically in isolation from one's friends and loved ones, and so without a proper chance to say goodbye. How one feels at the end of one's life, and whether one has such a chance, arguably makes a big difference to one's ultimate level of lifetime well-being. Dying like this could even ruin or mar a life.7 We must also take into account the effects of so many older people dying (and in these particular circumstances) on younger people, especially family members. Many of these older people have families who, due to isolation, will greater-risk-from-covid-19-than-workers-deemed-at-increased-risk-bythe-cdc/. 7 For a case study, see: https://www.nytimes.com/2020/08/06/opinion/sunday/coronavirusbaruch-haviv-death.html. For further discussion of the importance of how a life ends, see Stephen Campbell's paper "Well-Being and the Good Death", Ethical Theory and Moral Practice (2020) (https://link.springer.com/article/10.1007/s10677-020-10101-3). 13 not get to properly say goodbye to them. To lose a parent or grandparent like this can profoundly affect one's own life. Also, the sudden loss of so many older people, including the loss of their collective wisdom and memories of former times, can profoundly diminish a society. Independently of death rates, COVID-19 is causing many people-including many younger people-lifelong debilitating conditions, especially lung damage. The full range of such conditions is still poorly understood. Recent studies suggest that even asymptomatic patients might be experiencing significant damage to vital organs.8 Consider, next, that it can be quite difficult to adequately grasp the badness of such a large death toll. To gain a better sense of just how immense the toll is from COVID-19, it is useful to scroll through the New York Times' important graphic, "An Incalculable Loss", marking 100,000 US deaths. This graphic is available online here: https://www.nytimes.com/interactive/2020/05/24/us/uscoronavirus-deaths-100000.html Between then and the time of writing, another 64,000 people have died from COVID-19 in the US. Open Up would lead to this list of victims becoming many, many times longer than it would otherwise be. 8 See, for example: https://www.theguardian.com/world/2020/jul/08/warning-of-seriousbrain-disorders-in-people-with-mild-covid-symptoms, https://www.statnews.com/2020/07/27/covid19-concerns-about-lastingheart-damage/, https://www.npr.org/sections/goatsandsoda/2020/06/23/864536258/westill-dont-fully-understand-the-label-asymptomatic. 14 Finally-and this is of utmost importance-we must remember who is most likely to catch COVID-19 if we Open Up. It is the socio-economically disadvantaged, since it is they who would be most financially pressured to go back to work, and who are most likely to live in overcrowded apartment buildings where it is hardest to avoid COVID19 (or have to rely on public transport).9 Many middleclass and wealthy people would continue to work from home, or even quit their jobs, while waiting for enough other people to be infected for us to reach herd immunity. This is morally intolerable, especially since the socioeconomically disadvantaged are those who are most likely to have the sort of health conditions that make one more vulnerable to severe illness and death from COVID-19. Costs of Stay Locked Down It is true that Stay Locked Down has some significant costs. But there are many things we can do to reduce these. Governments can provide financial assistance to people who have lost their jobs, or even subsidize wages to reduce job losses.10 They can freeze rents, or ban evictions, to prevent people and small businesses from losing their homes. These and other measures can work to reduce the economic downturn from a longer COVID-19 lockdown. 9 https://www.vox.com/identities/2020/4/7/21211849/coronavirus-blackamericans, https://www.theatlantic.com/ideas/archive/2020/04/coronavirus-exposingour-racial-divides/609526/, https://www.wired.com/story/covid-19coronavirus-racial-disparities/. 10 https://www.nytimes.com/2020/07/03/business/economy/europe-usjobless-coronavirus.html. 15 Governments of wealthy countries can also increase their aid to poorer countries, to help the citizens of the latter better cope with the economic fallout from lockdowns.11 It is also vital to realise that if we lock down hard in the first instance, put in place effective testing and contacttracing, and establish a culture of physical distancing and good hygiene (and in particular, as recent studies show, mask-wearing), lockdowns can be greatly relaxed over time. Many of us can go back to work, and economies can restart. Some restrictions will still be necessary, and there might be times when lockdowns need to be tightened again. But these will be mostly small interruptions to our lives.12 Indeed, there are reasons to think that economic hardship might actually be greater on Open Up. If we open up our societies, while many shops will again be open for business, it is unclear how many customers will return. Many people will be too afraid of the virus to go shopping. Moreover, illness and death from COVID-19 will take many consumers and workers out of the economy.13 11 Who will pay for these measures? The burden should fall largely on wealthy companies and individuals, who will have to pay more in taxes. Governments can also borrow more to pay for them. 12 The recent large outbreak in Melbourne was due to a combination of bad luck and bad management. It is an episode that will chasten not only Australia's government going forward but governments of other countries watching on. As we go forward, we will learn from such episodes, and so outbreaks will become smaller and more easily contained over time. 13 https://theconversation.com/ending-lockdown-wont-save-theeconomy-heres-how-the-government-can-aid-recovery-137553, https://www.vox.com/covid-19-coronavirus-economy-recession-stockmarket/2020/5/23/21268500/coronavirus-lockdown-poll-businesseconomy. Moreover, as Umair Haque notes, "America will suffer socially and economically as a plague state. Its people will be shunned, its businesses will be punished, and it will be kept at arms length. Do you think a world that's fought hard to beat the pandemic will want to get infected by it all 16 Turn now to non-economic costs of lockdown. Many of these are greatly reduced when lockdowns are relaxed and people can return to some version of their normal lives. Until then, there are many other things we can do to reduce these costs. Physical distancing, as noted, needn't imply social distancing. There are many ways to connect with others remotely in the modern world. Of course, these cannot entirely substitute for in-person encounters, but they can go a long way. We need to be much more creative about how we can connect, with friends, colleagues, and others more generally, in remote settings. Some people sing together from their balconies, others have 'hangout' nights-dinners or movies-with friends or family using applications like Zoom. Governments have a vital role to play here, too, in ensuring that everyone has access to the necessary technologies and online communities.14 Consider, next, the worry about rights. It is true that in normal times we have a right to freedom of movement, assembly, privacy, and so on. But it does not follow that we retain such rights in a pandemic, or, if we do, that they are rights to move, assemble, work, etc., even in a pandemic. Indeed, such rights are clearly not absolute. If you agree that people can rightly be forced to stay indoors to flatten the curve, you already accept that they are not absolute. over again-just because America's America, and, well, it was too foolish to care as much? Of course not. America will become a pariah state as it becomes a plague state." (https://eand.co/america-gave-up-on-coronavirusnow-the-worst-case-scenarios-coming-true-630dc65f9dd5.) 14 Some have noted a further non-economic cost of lockdown: lives lost due to an inability to access healthcare. This is indeed a significant cost. But it is important to emphasise that with proper testing and contact-tracing, healthcare providers can gradually reopen as well. If we do things properly, the health costs of lockdowns can be made to be relatively small. 17 Why think that the rights we enjoy in normal times don't apply in the pandemic? Simply because in normal times, exercising these rights does not harm others (or does so only minimally or unpredictably), whereas in a pandemic, leaving your house, going to work, meeting other people, etc., has a much higher chance of significantly harming others.15 And if many of us do these things, then it is certain that many people will be greatly harmed as a result. I suspect that a central concern of many who complain about rights violations of lockdown is that if we lose such freedoms during lockdown, we might never get them back, even once the pandemic is over. To be sure, this is a risk, but it seems one well worth taking in the present context. We need vigilance, good journalism, and good policymaking, not a premature end to our lockdowns. Two Further Considerations Big societal decisions, like the one between Open Up and Stay Locked Down, not only reflect the sort of people we are, but affect what sort of people we will become in the 15 In a viral video, Dave Portnoy says: "We've done what you've asked us to do [i.e., flattened the curve]. If you're that scared still of corona, stay inside, [hospital] beds are open...I get it, it's not a great option. [But] there are no great options...There's risk. We're Americans, you have to take risk. If people want to go out, they can go out. If they want to stay in, they stay in...Let me roll the dice and 'play the corona', or at least give me the choice, that's all we want." (https://twitter.com/stoolpresidente/status/1260721488241418240.) What Portnoy overlooks is that leaving the house during the pandemic isn't just taking a risk yourself. It is imposing a risk on many others-including people who may have left their homes only briefly to buy groceries, seek medical care, assist relatives, or do essential work. 18 future. Choosing Open Up, I want to suggest, might damage us as people, in a way that could produce immense harm. Let me explain. Suppose (contrary to what I've claimed) that if we Open Up, the vast majority of young and healthy people can safely return to normal life, but with the downside that many older and vulnerable people-especially the socioeconomically disadvantaged-will become severely ill or die. Now, ask yourself: Could our young and healthy people truly enjoy eating out again, going back to the movies, the gym, big sporting events, and so on, knowing that as a consequence of this many other people will become severely ill and die? If the answer is 'yes', then there is something seriously wrong with these young people. And not just morally. Our young people would be deficient or lacking in the sort of emotional or empathetic capacities necessary to flourish (i.e., to have lives high in well-being themselves). The same capacities that are required to have the best things in life- things like the deepest or richest human relationships, the truest or fullest appreciation of the beauties of nature and the wonders of art, literature, music, and human culture, etc.-would naturally lead one to feel deeply sad at the thought of these other people suffering, especially if their suffering is, in the relevant sense, a consequence of one's own prosperity. The sort of people who are most able to flourish (the 'happiest' people, as we might call them) could not enjoy going back to their normal lives under these circumstances, or at any rate would not do so. They would not, on sitting down to a meal in a hip café or restaurant and having their attention drawn to the old and vulnerable, think "it's too 19 bad for them-a shame, really-but we've got to get on with our lives". They would rather prefer to stay locked down, and delay their own return to normality, in order to protect these older and vulnerable people. Suppose this is right. My next claim is that our decision whether to Open Up or Stay Locked Down might itself affect the emotional or empathetic character of current citizens and our children. If we opt for Open Up, this could harden our hearts or shrink or contract our emotional lives in some ways. By contrast, if we choose Stay Locked Down, this might foster or encourage tenderness in our people. Think of Giesecke and the other Swedish policymakers. Many of us find their statements deeply concerning. This, I suspect, is because there is something cold-or coldly rational-about them and what they are saying. And these words and policies shape Swedish culture. They have a huge effect on what Swedes will be like in the future. Some Swedes will be somewhat colder, and so (if I'm right) less able to flourish, because of these significant decisions. Choosing Stay Locked Down, then, not only safeguards the health of the old and vulnerable, it protects the young and healthy from veering off course emotionally and empathetically, and so safeguards their well-being, too. We should also consider the effects of our choice between Open Up and Stay Locked Down on future relations between various groups in society. Choosing to sacrifice many old and vulnerable citizens, and greatly burden the socio-economically disadvantaged, mainly in order to spare the young and healthy (and the wealthy) some economic pain, is liable to poison relations between these groups. How are the old, vulnerable, and disadvantaged likely to feel toward the rest of us after such 20 a choice? How could our relationships with them recover? This could irreparably damage the fabric of our society. By contrast, if the young and healthy choose to take a hit to protect these groups, this would communicate to them how much we value them and their contributions. In this way, it could bring us all closer, greatly enhancing our lives in this respect, and helping society function better. How Strict? Suppose all this is right. Once we have flattened the curve, we should remain in various states or degrees of lockdown until we develop a vaccine, cure, or treatment. The next question is: what states or degrees of lockdown exactly? Or, in other words, how strict should our prolonged lockdowns be? The right answer is that we should stay in a hard lockdown until we have brought the number of cases very close to zero-i.e., until the virus is almost eradicated. How long this will take-and what the lockdown will involve- depends on factors such as how badly we have let the virus get out of control, how effective our testing and contacttracing is, and existing habits of citizens (for example, whether there is a culture of physical distancing and good hygiene, including mask-wearing), among others. Countries that have let the virus get out of control will require longer hard lockdowns, and accordingly greater sacrifice. But there is no viable alternative. There is no substitute for getting cases down to a very low number first. This can be done relatively swiftly with a concerted effort. And once the virus is almost eradicated, countries can greatly relax their lockdowns, and in many ways return to something like normal life, providing that they continue to 21 engage in testing and contact-tracing. There will be new outbreaks from time to time, but these will be mostly spotfires that can be quickly extinguished by tightening lockdowns in the affected areas for shorts periods. What about countries like the US today, where the virus is raging out of control? The same applies. There is no substitute for a hard lockdown, combined with other measures, to get case numbers close to zero. This might take many weeks or even months to achieve. But it can be done, and is the right course, however hard it might be.16 What about countries that lack the resources to engage in effective testing and contact-tracing or provide sufficient economic assistance to their citizens in lockdown? They must get help from other, wealthier countries, in order to avoid humanitarian disaster. The combined wealth of the world is enough that all countries should be able to take these measures to control the virus.17 Protests, Elections, Prisons I want to briefly address three important issues that relate to exactly what form our lockdowns should take. 16 For nice recent statements of this case, see here: https://www.nytimes.com/2020/08/07/opinion/coronavirus-lockdownunemployment-death.html, https://www.nytimes.com/2020/08/08/opinion/sunday/coronavirusresponse-testing-lockdown.html. 17 In any case, it is pointless trying to persuade wealthy countries to Open Up on the grounds that Stay Locked Down would be devastating to poorer countries. Any governments that could be sufficiently moved by the plight of citizens in these poorer countries to Open Up on this basis, could be persuaded instead to Stay Locked Down while greatly increasing aid to poorer countries in order to prevent humanitarian disasters in these places. 22 The first issue is whether public protests should be allowed during the pandemic. Some people have protested the lockdowns themselves (especially in the US). These protesters have been criticised by some for putting lives at risk. But then many of these critics have taken to the streets themselves to protest the police killing of George Floyd (or publicly supported these latter protests). Some commentators have claimed that there is an inconsistency here. Thomas Chatteron Williams, for example, writes: "'Your gatherings are a threat, mine aren't,' is fundamentally illogical, no matter who says it or for what reason," as the author of The Death of Expertise, Tom Nichols, put it. "We've been told for months to stay as isolated as humanely possible," Suzy Khimm, an NBC reporter covering Covid-19, noted, but "some of the same public officials and epidemiologists are [now] saying it's OK to go to mass gatherings-but only certain ones." Public health experts-as well as many mainstream commentators, plenty of whom in the beginning of the pandemic were already incoherent about the importance of face masks and stay-at-home orders-have hemorrhaged credibility and authority. This is not merely a short-term problem; it will constitute a crisis of trust going forward, when it may be all the more urgent to convince skeptical masses to submit to an unproven vaccine or to another round of crushing stay-at-home order. Will anyone still listen?18 But I do not see any necessary inconsistency here. Both protests should be allowed, providing that protesters wear masks and practice physical distancing. The right thing to say about the protests of lockdown is not that they should be prohibited, but simply that they should not happen, 18 https://www.theguardian.com/commentisfree/2020/jun/08/we-oftenaccuse-the-right-of-distorting-science-but-the-left-changed-thecoronavirus-narrative-overnight. 23 morally speaking. Given their bad consequences, people should not participate in such protests. By doing so, they greatly weaken efforts to persuade the country to lock down. When we say such protests should not go ahead, we should mean by this, not that they should be banned, but that people should know better than to participate in them. By contrast, the protests of George Floyd's killing were valuable indeed. This killing was so abhorrent, and the need to protest police brutality in America is so great, that the good consequences of these protests outweighed the bad. It would have been extremely bad for America to have ignored this egregious incident. A big response was needed, especially in the pandemic, when so many Black Americans are suffering so badly due to the current administration's mishandling of the response (both its failure to contain the spread of the virus and to provide adequate assistance to those suffering in lockdown). To clarify, there might well be times when all public protests should be banned. For example, if there is a war, and people leaving their houses en masse would alert enemy bombers to the locations of our towns and cities, then it might be justified to prohibit people from leaving their houses, even to protest something of national importance. But COVID-19 is not such a situation. Masks and physical distancing can allow protests to take place largely safely. The second issue I want to address is whether we can hold elections in the current crisis-especially in the US, where the virus is currently raging out of control. The answer is that we can and should hold elections, even now. By expanding the use of postal ballots, elections can be held without putting citizens at risk. As David Cole writes: 24 At the moment, five states-Washington, Oregon, Utah, Colorado, and Hawaii-conduct their elections almost entirely by mail. Another twenty-eight states and the District of Columbia permit "no-excuse" absentee voting, while the remaining seventeen states and Puerto Rico permit absentee voting only for specific causes, such as being out of state on election day. During the pandemic, absentee voting should be available to all registered voters, without requiring an "excuse." The coronavirus is, after all, a universal excuse. States should send absentee ballot applications to all registered voters, with prepaid return envelopes, to ensure the maximum opportunity to vote.19 President Trump has claimed that postal ballots produce significant election fraud. But there is no evidence of this.20 It is important to note, however, that advocacy of an expansion of postal ballots should not be taken to imply that this is the only way the November election could permissibly proceed. If Donald Trump succeeds in 19 https://www.commondreams.org/views/2020/05/08/why-we-needpostal-democracy. Cole, notes, however that it is "also important to preserve some meaningful in-person voting options, because voting by mail will not work for certain voters, including those with vision impairments who cannot fill out an absentee ballot; people with limited English proficiency, who often do not receive ballots in their own language; voters with limited access to postal service, an especially serious problem among Native Americans on reservations; voters for whom the state lacks a current address, often younger and poorer voters, who are more transient; and unregistered voters, because, while many states permit registration past the deadline to receive an absentee ballot-including through Election Day-that can't be done by mail. For these reasons, the five states that have largely transitioned to voting by mail also maintain some in-person voting options." 20 For details, see: https://docs.wixstatic.com/ugd/ef45f5_81a3affd554e4b5b9b5852f8fb3c10f d.pdf. 25 crippling the US Postal Service between now and then, this would not be grounds for delaying or canceling the election.21 In that case, Americans would have to take to the streets to vote in person, despite the health risks. The final issue I want to address is what to do about prisons. Prisons have proven to be a breeding ground for the virus-many prisoners have become ill. You might say: this is unfortunate, but there is nothing we can do about it. Preventing outbreaks in prisons would take too many resources that are desperately needed elsewhere. Prisoners, in virtue of what they have done, have a reduced entitlement to these scarce resources. But there are some major problems with this way of thinking. First, it is not clear how prisoners' past actions are supposed to reduce their entitlement to help during the pandemic. Their punishment for crimes committed was prison, not prison with no help in the event of a pandemic. If the suggestion is rather that our allocation of resources should be based partly on the moral virtue of recipients, this faces yet other problems. Prisoners have broken the law. It does not follow that they are (all) morally bad. Moreover, it seems clear we should not allocate resources based on moral virtue, but strictly on where they can do the most good. Prisons, currently, are one place where resources can do immense good.22 Moreover, independently of prisoners' own well-being, outbreaks in prisons spread easily to nearby communities (via prison guards and other workers). Protecting prisoners is one way of protecting many others. 21 https://www.bloomberg.com/opinion/articles/2020-08-04/don-t-letthe-postal-service-or-trump-derail-the-presidential-election. 22 Besides, prisoners are charges of the state and the state is responsible for their well-being. 26 There is actually a reason to think that prisoners are entitled to special priority during the pandemic. This is that they are trapped. One reason the pandemic is so morally problematic is that there are differences between people in how easily they can avoid exposure to the virus. Wealthy people can work from home, or give up their jobs altogether, in order to avoid it. But many poorer people- for example, those living in crowded apartment buildings, or who must continue to work in order to pay for food and other essentials of life-have no choice but to come into contact with it. Prisoners are even less able to avoid the virus than these people. At present, prisoners cannot avoid the virus even by trying their very hardest to practise good hygiene and social distancing. This is deeply concerning. What can we do to fix the problem? We can try to reduce the spread of the virus in prisons, even though this is costly. Alternatively, we can have a more lenient policy of granting bail to prisoners who have not yet been sentenced and we can grant some sentenced prisoners early release, or allow them to continue their sentences at home, with monitoring. This would greatly improve things both for these prisoners, and for those who must remain in prison. Conclusion In this chapter, I have argued that once we've flattened the curve, we should stay in various states or degrees of lockdown until we develop a vaccine, cure, or treatment, rather than open up our societies. This is because the health costs of opening up are immense, while the costs of staying locked down can be greatly reduced by smart policies. Moreover, there is a worry that choosing to open 27 up might damage our emotional or empathetic character, which would be extremely harmful for many of us. 28 2 Blame IS ANYONE MORALLY TO BLAME for COVID-19? Or is it 'just one of those things'? There are two questions here: 1. Who, if anyone, is to blame for the genesis of COVID-19 (i.e., its coming into existence)? 2. Who, if anyone, is to blame for the spread of COVID19? Let us consider these questions in turn. 29 Genesis To answer the first question, we need to ask how COVID19 came to exist. Some people believe that SARS-CoV-2 escaped from a lab in Wuhan, China, or was deliberately released. There is no evidence for this claim. The scientific consensus right now is that SARS-CoV-2 jumped from a bat to a pangolin to a human in a wet market in Wuhan. Suppose this is right. In this case, is anyone to blame for the genesis of COVID-19? You might say: Yes, those who were operating the wet markets. It is well known that such markets pose risks of this kind. Famously, SARS-CoV-1, an earlier coronavirus, was traced to palm civets in wet markets in Guangdong Province.23 Those operating Wuhan's wet markets knew, or at least should have known, of these risks, and so should not have been doing so. But this answer is too simplistic. To start with, it is not wet markets per se that pose such great public health threats, but mainly just the live wildlife markets within them that do so. As Stephen Osofsky, professor of wildlife health and health policy at the Cornell University College of Veterinary Medicine, explains, in live wildlife markets, you have species that never under natural conditions would run into each other, all packed together, bodily fluids mixing, and then people come into the equation. Pathogens are meeting species that they've never met before. That's when we have these opportunities for viral jumps, including the ones that lead to humans and create the situation we're in now.24 23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3323399/. 24 https://www.theatlantic.com/culture/archive/2020/04/ban-wetmarkets/609781/. 30 The other parts of wet markets might well be morally problematic-say, for the harms they inflict on animals. But they are not to blame for causing the pandemic. Moreover, the individuals operating these live wildlife markets are part of a bigger web of complicit parties. There are consumers-mostly, it seems, a wealthy elite-who create the demand for these particular animal products in the first place. There are also big companies who have in recent years become involved with wildlife farming, and who spread bogus claims about the health benefits of these products.25 Finally, there is the Chinese government, which permits these markets to exist, apparently in order to appease elites who buy these products and profit from them. Some have argued that if China banned such markets, they would simply go underground, where they might pose even more of a public health threat. But China has the power to prevent this from happening. At the very least, it should be better regulating these markets. Each of these parties-operators, consumers, breeders, and the Chinese government-shares some of the blame.26 Spread Turn now to blame for the spread of COVID-19. The place to start is again with China. In December and early January, Chinese officials concealed from their own citizens important information they had about the virus, including its potential for human-to-human transmission. 25 https://www.vox.com/future-perfect/2020/4/15/21219222/coronaviruschina-ban-wet-markets-reopening. 26 In fact, it might be that the individuals who operate these markets themselves aren't all that blameworthy for COVID-19, given that there seem to be so few good alternative sources of income available to them. 31 This was done, it seems, partly to avoid public alarm and embarrassment ahead of annual meetings and the Spring Festival, the Chinese New Year.27 Had citizens been warned, they could have immediately started physically distancing and wearing masks, which would have greatly slowed transmission of the virus in Wuhan. Although the government was at the time taking measures to try to contain the outbreak, these were behind the scenes. An effective response requires action from individual citizens. Wuhan was locked down on January 23, but by then the city was inundated with cases, and five million people had left the city, many flying to different parts of the world. US and UK Governments While governments outside China are not to blame for the genesis of the virus, or its initial arrival in their countries, many of them share the blame for its spread within their countries. Many of these governments did not properly prepare for a pandemic. Scientists had been warning of the potential for a new catastrophic pandemic for years. Such warnings have been delivered at the highest levels of government, and circulated widely in popular media-most famously, in Bill Gates's 2015 TED talk.28 Many private companies had the foresight to make preparations. For example, in 2003, after the SARS outbreak, Wimbledon took out a hugely expensive pandemic insurance policy. It is now set to receive a hundred million pounds in payout. The Obama administration compiled a "Playbook for Early Response to High-Consequence Emerging 27 https://www.ft.com/content/fa83463a-4737-11ea-aeb3-955839e06441. 28 https://www.youtube.com/watch?v=6Af6b_wyiwI. 32 Infectious Disease Threats and Biological Incidents"29, with the express goal of assisting leaders "in coordinating a complex U.S. Government response to a high-consequence emerging disease threat anywhere in the world". It even listed "novel coronaviruses" among possible threats. There are conflicting views of how useful this document would have been in the present crisis, and whether it was dated. But it was entirely ignored by the Trump administration, which apparently did not even know of its existence. Trump's administration also, according to the CDC, recalled the CDC's four staff members based in China tasked specifically with spotting new infectious diseases. It has also been claimed that Trump dissolved, or greatly reduced in numbers, Obama's pandemic response team.30 In May, Mike Bowen, CEO of America's largest surgical mask company, testified to Congress that he had tried and failed to alert the administrations of George W. Bush, Obama, and Trump to the urgent need for increased production capacity and stockpiling of N95 masks: You can't wait for the pandemic to happen before we do something about it...Nobody listened...We had thirteen freaking years to fix it, and that's the travesty.31 In 2019, a months-long pandemic war game, Crimson Contagion, revealed that the US would need 3.5 billion N95 respirators in its stockpile to protect healthcare 29 https://assets.documentcloud.org/documents/6819268/PandemicPlaybook.pdf. 30 https://www.reuters.com/article/uk-factcheck-trump-fired-pandemicteam/partly-false-claim-trump-fired-pandemic-response-team-in-2018idUSKBN21C32M. 31 https://youtu.be/WneNXuDAJnE, https://www.cspan.org/video/?c4875852/user-clip-mike-bowen-emotional-reply-maskshortage. 33 workers in a pandemic.32 No action was taken. In the UK, emergency stocks of PPE were left to degrade under the austerity policies brought in to deal with the aftermath of the global financial crisis of 2008, and the government did not replenish them.33 Trump regularly defends his response to the pandemic by pointing out that he acted early in banning flights from China. While this was a good move, its benefits were limited. After the ban, more than 40,000 Americans and authorised travellers were still allowed to enter the US from China without adequate screening or quarantine measures.34 The biggest failures, however, have been the US's delayed and mostly soft lockdowns, and its inadequate testing and contact-tracing measures. In a withering assessment of the US's use of testing, Isaac Sebenius and James K. Sebenius draw a contrast with South Korea: By the time South Korea experienced its 15th confirmed case on Feb. 2, it had spearheaded a massive public information campaign, mobilized private sector players to produce testing kits, and expedited regulatory approval for these newly developed tests. Within a week, tests were widely available. Within three weeks, schools and public spaces were closed, large gatherings had been banned, and 26,000 people had been tested. In contrast, President Trump consistently ignored confidential and public early warnings from experts and intelligence agencies prior to the 15th confirmed U.S. case on Feb. 14, then acted far more slowly and inconsistently than South Korea...Three weeks after the 15th Covid-19 case had been confirmed in the U.S., only about 10,000 32 https://en.wikipedia.org/wiki/Crimson_Contagion. 33 https://www.theguardian.com/world/2020/apr/22/eu-turns-uppressure-on-matt-hancock-over-covid-19-ppe-scheme. 34 https://www.nytimes.com/2020/04/04/us/coronavirus-china-travelrestrictions.html. 34 tests had been administered. By an equivalent point in its epidemic, South Korea had administered approximately 17 times more tests per capita than the U.S. had done. This testing fiasco crippled vital early contact tracing efforts when hot spots could have been contained. South Korea's decisive actions during this critical early window produced a dramatic disparity. By midMarch, each of the two countries had suffered about 90 Covid19 deaths. But throughout April, while a total of 85 South Koreans died from the disease, an average of more than 85 Americans died per hour. This divergence only widened as time passed.35 They conclude: With the same actions actually taken by other nations large and small, from East and West, the U.S. could have prevented 70% to 99% of its Covid-19 deaths. This has been a needless tragedy. David Wallace-Wells describes the ongoing failures as follows: It is unfortunate but unexceptional that the White House did nothing in January-in this, it was quite like most of its peer countries. What is remarkable and unforgivable is that it did almost nothing to make up for it in the months that followed, doubling down on a policy of indifference whose most aggressive feature was the president's son-in-law commanding FEMA to seize shipments of critical medical supplies on the way to states and hospitals to redistribute according to unclear criteria. Finally, in the last stimulus bill, some money was allotted for this capacity, 35 https://www.statnews.com/2020/06/19/faster-response-preventedmost-us-covid-19-deaths/. 35 but the initiative didn't come from the executive branch, which spent the time urging states to reopen.36 Why has Trump failed to take the necessary actions? If it was incompetence, that would be bad enough. But some have suggested that, just as China initially played down the threat of the virus to avoid public embarrassment, Trump has done so in order to protect his own image, in a misguided attempt to boost his own re-election chances in November 2020.37 Paul Krugman, for example, writes: The turning point was way back on April 17, the day that Donald Trump tweeted "LIBERATE MINNESOTA," followed by "LIBERATE MICHIGAN" and "LIBERATE VIRGINIA." In so doing, he effectively declared White House support for protesters demanding an end to the lockdowns governors had instituted to bring Covid-19 under control...Republican governors in Arizona, Florida, Texas and elsewhere soon lifted stay-at-home orders and ended many restrictions on business operations. They also, following Trump's lead, refused to require that people wear masks, and Texas and Arizona denied local governments the right to impose such requirements. They waved away warnings from health experts that premature and careless reopening could lead to a new wave of infections...Many [protests of the lockdown] were organized and coordinated by conservative political activists, some with close ties to the Trump campaign, and financed in part by right-wing billionaires...The main driving force behind reopening, as far as I can tell, was the administration's desire to have big job gains leading into November, so that it could do what it knew how to do-boast about economic success...We lost [the war against 36 https://nymag.com/intelligencer/2020/05/white-house-plan-for-endingcoronavirus-stay-at-home-orders.html. 37 See, for example, UC Berkeley professor Robert Reich's commentary here: https://www.facebook.com/watch/?v=2963511040421284. 36 COVID-19] because Trump and those around him decided that it was in their political interests to let the virus run wild.38 Trump himself has admitted that by testing "we make ourselves look bad"39, and even claimed that he requested reduced testing for this reason. His staff later said he was joking, but it seems fair to take him at his word on this.40 Some have suggested that something even more sinister is taking place. Pointing to the disproportionate effect of the virus on poor Americans, Gregg Gonsalves, professor of epidemiology at Yale, asks: How many people will die this summer, before Election Day? What proportion of the deaths will be among AfricanAmericans, Latinos, other people of color? This is getting awfully close to genocide by default. What else do you call mass death by public policy?41 The suggestion here seems to be that Trump is deliberately allowing the virus to run rampant in order to wreak havoc among the communities whose votes Democrats traditionally rely on. 38 https://www.nytimes.com/2020/07/06/opinion/covid-19-trump.html. See also Jamelle Bouie here: https://www.nytimes.com/2020/07/10/opinion/trump-schoolsreopening.html. 39 https://www.whitehouse.gov/briefings-statements/remarks-presidenttrump-vice-president-pence-meeting-governor-reynolds-iowa/. See also: https://www.nytimes.com/2020/07/14/us/politics/trump-cdccoronavirus.html. 40 For further details of Trump's mishandling of the pandemic response, see: https://www.nytimes.com/2020/04/11/us/politics/coronavirus-trumpresponse.html. 41 https://twitter.com/gregggonsalves/status/1257978332567801864. 37 A related suggestion has been that Trump is allowing the virus to spread so that he will have an excuse to put off or cancel the election in November. Couldn't Americans simply use postal ballots? Trump has repeatedly claimed that this would open the door to massive election fraud. Moreover, as noted earlier, he recently appointed a former financial supporter as the new head of the Postal Service, who is currently presiding over huge cuts and slowing of mail.42 Things are not much better in the UK. For a while the government had decided to have no lockdown at all, which would have been catastrophic. A proper lockdown was delayed. Now, the UK is opening up again, against the advice of experts, putting thousands of lives at risk. Other Governments What of other governments? Take Sweden's. Unlike the Trump adminstration, the Swedish government was wellorganised from the start of the pandemic, and followed the advice of its senior health officials. However, these experts chose the wrong course-a version of Open Up (see Chapter 1)-which has resulted in much higher death rates with almost no benefits. The government is to blame for this choice. It should have known better, as it should have understood roughly the arguments I made in Chapter 1. Consider, next, governments of countries where the virus has been effectively suppressed-for example, Taiwan, South Korea, Singapore, Australia, and New Zealand. 42 https://www.bloomberg.com/opinion/articles/2020-08-04/don-t-letthe-postal-service-or-trump-derail-the-presidential-election, https://www.nytimes.com/2020/05/07/us/politics/postmaster-generallouis-dejoy.html. 38 These countries locked down quite early. They deserve praise for this. But we might wonder whether some of these countries look good only in comparison to the US and UK. For example, Australia had a prime opportunity to eradicate the virus. It has failed to do so, and is currently having to endure tightened lockdowns in various places. Individual Citizens It is not only governments that are to blame for the spread of COVID-19. Many ordinary citizens share some of the blame as well. While many people in the US and UK have been practising physical distancing and good hygiene, many have not been. And some have even been protesting the lockdowns. The actions of these people have greatly contributed to the spread of COVID-19 in these countries. Let us consider, first, protesters. You might say: they cannot be blamed, for they sincerely believe that lockdown is the wrong policy, that it is tyrannising their nations. But they should know better. Most of them have sufficient intelligence and access to expert opinion for it to be reasonable to expect of them an understanding of the vital importance of lockdown and associated measures. We have a responsibility to form our beliefs-including our moral and political opinions-carefully, by properly listening to those whom we have reason to believe possess relevant expertise. In June, some citizens spoke out, at a Palm Beach County Commission meeting, against the public use of face-masks.43 Many of them spoke with great passion, even a sense of indignation. Here is a sample of what was said: 43 https://www.youtube.com/watch?v=433b5RJ9BME. 39 I haven't worn a mask yet. I'm not wearing it today...I'm not wearing one tomorrow. I was born free, I will stay free. My rights come from God, not from you. I'm not wearing it. You're going to have to hold me down and put it on me. I say Trump 2020, and I hope every one of you gets voted out who votes for a mask today. Shame on you for voting for a mask. I also heard you say this is a democracy, and I'm sick and tired of hearing you say that. It's a republic! Every single one of you that are obeying the devil's laws are going to be arrested. And you, doctor, are going to be arrested for crimes against humanity. We will get together and do a citizen's arrest on every single human being that goes against the freedom of choice. Okay? You cannot mandate-you literally cannot mandate-somebody to wear a mask knowing that that mask is killing people. It literally is killing people. Every single one of you have a smirk behind that little mask, but every single one of you are going to get punished by God. You cannot escape God. I'mma say that again. You cannot escape God, not even with the mask or with 6 feet. 6 feet, like I said before, is military protocol. You're trying to get the people to train them so when the cameras, the 5G, comes out, they're gonna scan everybody. They're gonna scan everybody?! We gotta get scanned?! We gotta get temperatured?! The kids have to go to school with masks?! Are you insane?! Are you crazy?! I think all of you should be in a psych ward, right the heck now. In the beginning, God formed man out of the earth and breathed his breath in him, and he became a living soul. Where do you derive the authority to regulate human breathing? What you say is the political dogma that they're trying to shove down our throats on every commercial, on every store, and it's disgusting. 40 You did not listen to we the people. I would die for that country. I would die for the constitution. You know what? You disgrace me.44 Some of these people, to be fair, might not be in their right minds. But some of them are and should know better. The passion with which they defend their views, far from being an excusing factor, is part of what they are to blame for. They are guilty of a tremendous and dangerous hubris. It might be objected that many of these people believe what they do only because they are living in a bubble, or a social media echo chamber. They listen only to, say, a combination of Fox News, the preachings of their local pastor, and Trump's Twitter feed. Given this, how can we rightly blame them for not knowing better here? But many of these people are to blame for getting into the bubble to begin with. They have had plenty of opportunities at earlier moments in their lives to get off this path, opportunities they should have taken. Their earlier actions make them responsible now for the harmful consequences of their being so cut off from reasonable opinions. That said, part of the blame for these people's gross epistemic failures lies with others: Republican Party officials and media organisations like Fox News. One study has shown that more than 40% of Republicans believe that Bill Gates will use a COVID-19 vaccine to implant a location-tracking microchip in recipients, and only 26 percent of them regard this as false.45 As David Atkins writes, to be a card-carrying Republican right now, 44 See also in the UK: https://www.vice.com/en_au/article/wxqpnn/hundreds-people-attendanti-mask-protest-london. 45 https://www.businessinsider.com.au/republicans-bill-gates-covid-19vaccine-tracking-microchip-study-2020-5. 41 requires believing in a jaw-dropping series of claims: a cabal of evil scientists is making up climate science in exchange for grant money, that there is rampant, wide-scale voter impersonation fraud carried out by thousands of elections officials nationwide; that the 'Deep State' concocted a scheme to frame Trump for Russian collusion but chose not to use it before the 2016 election; that shadowy forces are driving migrant caravans and diseases across American borders in the service of destroying white Republican America; that the entire news media is engaged in a conspiracy against the Republican Party...and so on.46 The Republican Party has done little to counter this spread of misinformation within its base, and has perhaps even encouraged it. For this, it deserves blame. But its responsibility for this does not remove the blame of individual citizens who should have known better. It might be objected that some have been protesting lockdowns only because they have been struggling to make ends meet. These people need to work again so that they can put food on their tables. Surely they cannot be to blame for their actions. Consider the following case for this put by a reporter in an exchange with Governor Cuomo: There are protesters outside right now honking their horns and raising signs. We did speak to a few of them before we came in and these are regular people who are not getting a paycheck. Some of them are not getting their unemployment check. And they are saying that they don't have time to wait for all of this testing and they need to get back to work in order to feed their families. Their savings [are] running out. They don't have another week. They're 46 https://washingtonmonthly.com/2020/05/23/we-need-to-speakhonestly-about-the-gops-evolution-into-a-conspiracy-cult/. 42 not getting answers. So, their point is, the cure can't be worse than the illness itself.47 But while they might be less blameworthy than other protesters, they might still be to blame for a lack of imagination as to what is possible from protest. They should be protesting the lack of assistance from governments for people in lockdown, rather than the lockdown itself. There are others who oppose or protest the lockdown, not from a sincerely held belief that it is tyrannical or morally wrong in some way, but from a simple concern for their own businesses or stock portfolios. Many of these people can work from home, or in relative safety from COVID-19. The moral failing of these people might be a simple indifference to victims of COVID-19 (or lack of concern for them). Just as we have responsibilities to form our beliefs carefully, we have responsibilities to care about what merits concern. These people should care more about others. Finally, some people are failing to observe lockdown out of sheer laziness. Think, for example, of young people partying on beaches in Florida, Bournemouth, or Bondi, while authorities are telling them to stay at home.48 Or consider people who don't practice good hygiene when it would be easy for them to do so. When you consider how easy it is to observe lockdown (compared with, say, making the sort of sacrifices commonly made during wartime), these people really do seem significantly blameworthy here. Owing to gullibility, hubris, lack of imagination, selfishness, laziness, or an outright indifference to the welfare of others-especially that of the old and vulnerable, and the socio-economically disadvantaged-many citizens 47 https://youtu.be/omxhz3FevkY. 48 https://www.theguardian.com/us-news/2020/apr/27/california-beachescoronavirus-orange-county. 43 in countries like the US and the UK are blameworthy indeed for the spread of the virus within their countries. Companies Some companies and business leaders also share some of the blame for the spread of COVID-19. A prominent case is Elon Musk. Determined to get Tesla up and running again, Musk went on the airwaves to denounce lockdown as tyrannical, even going so far as to call it "fascist" and "forcibly imprisoning people." "FREE AMERICA NOW", he tweeted.49 This surely set back efforts to persuade citizens to properly observe lockdowns. Facebook's Mark Zuckerberg has also taken up the language of freedom and liberty to defend his decision not to take steps to adequately police the spread of misinformation on his platform. In so doing, he has contributed greatly to the spread of COVID-19 as well. Anger and Desert Suppose I am right that these parties are to blame for the genesis and spread of COVID-19. It doesn't follow that we should actually be getting angry with them, or engaging in blaming behaviours toward them. Doing so might just make matters worse-say, by alienating or inflaming them. In particular, when it comes to engaging with citizens who oppose lockdown, expressions of anger or blame seem 49 https://twitter.com/elonmusk/status/1255380013488189440. See also: https://www.nytimes.com/2020/05/19/technology/elon-musk-tesla-redpill.html. 44 singularly counterproductive.50 A better strategy is to continue to calmly and without a hint of condescension explain the reasons for lockdown, and to try to counter the spread of misinformation. That said, it might be useful in talking to these citizens to blame our governments. What about blaming China? Spending too much time blaming China right now is likely to take attention away from blame that is owed to the US, and so set back one of the main ways we have of improving the US's response to the pandemic. Indeed, one of Trump's key tactics in defending his response to the pandemic is to shift the blame to China. That said, it is important that China feels the disapproval of the rest of the world right now. This might be necessary for it to take certain actions to help other countries respond better to the pandemic-for example, by providing essential aid or sharing vaccines. Of course, reproaching China must be approached carefully. Expressions of blame can provoke conflict or even war. It is a separate question what these various parties deserve or owe for their roles in the pandemic. What do 50 There are some expressions of blame for ordinary citizens that might be helpful. Consider Colorado Governor, Jared Polis's post on Facebook: "the emerging scientific data is clear: wearing a mask doesn't only protect others, it also significantly reduces your own risk of getting Coronavirus. So if you're a selfish bastard and wearing a mask to protect others isn't enough of a reason to do so, then maybe protecting yourself is?" (https://thehill.com/homenews/state-watch/507711-colorado-governorissues-statewide-mask-mandate.) See also Jonathan Pie's "Put a F**king Mask On!" https://www.youtube.com/watch?v=wZQkBHysrig. This sort of direct language by people in their positions might help to awaken, or sting in a helpful or productive way, more people than it will alienate or inflame. 45 governments in the US and UK deserve? Clearly, they deserve to lose office for their terrible preparation for, and mishandling of, the pandemic. It might also be proper that they face charges under domestic or international law. What does China owe to the rest of the world? For not shutting down live wildlife markets, and for concealing important information about the virus in late December and early January, the Chinese government owes the rest of the world a great deal indeed-not only practical assistance in responding to the virus (supplies and technology), but also a more open political system going forward, both internally and in its dealings with other countries. While its crime seems to be mainly one of negligence, it is a gross form of negligence that has resulted in as much global suffering as many of our worst wars have. Conclusion In this chapter, I have argued that blame for COVID-19, both its genesis and its spread, lies with numerous parties. Blame for its genesis lies primarily with the Chinese government, live wildlife industries, and the wealthy elites who buy these animal products. Blame for its spread lies with China, other governments like those of the US and UK, individual citizens, Republican Party officials, and various companies and business leaders. However, while these parties are to blame, it does not follow that we should be directing blame toward them. Doing so can alienate or inflame them. This seems especially true of citizens. A better strategy is to continue to explain the case for lockdown, try to stem the flow of misinformation, and direct appropriate levels of blame toward governments. 46 3 Immunity Passports LOCKDOWN USUALLY INVOLVES some people having to stay home for long periods-typically, non-essential workers. But what if people who have been infected with COVID-19, and recover from it, are immune? Should they be permitted to resume work, travel, and socialising? According to the idea of immunity passports, yes. We should give these people documents to certify they are immune, and then let them back out into the world. Why might such passports be a good idea? There are three basic reasons: 47 1. It would be good for these people themselves. Lockdown can be unpleasant or costly in various ways. It might greatly benefit some of these people to be allowed back out into the world. 2. It could allow some essential workers who are not immune to be "subbed-out". Those who hold immunity passports could take over the jobs of these workers for the duration of the pandemic, allowing them to go into the safety of isolation.51 3. It would be good for the economy. To have more people back at work being productive again could boost the economy, and in this way benefit everyone. Despite these benefits, many bioethicists have expressed serious ethical concerns about such passports. Leading journals like Nature52 and The Lancet53 have published pieces setting out some of these concerns. In one of these pieces, Natalie Kofler and Francoise Baylis go so far as to say that the idea of immunity passports "has so many flaws that it is hard to know where to begin". 51 As Ezekiel Emanuel says, "we would love to have teachers who we know are Covid-immune. We would love to have people working in the hospital, or in nursing homes, who we know are Covid-immune." (https://www.nytimes.com/2020/04/10/magazine/coronavirus-economydebate.html.) A related point is that such passports could also allow "friends, relatives, and clergy who are immune [to] visit patients in hospitals and nursing homes." (https://jamanetwork.com/journals/jama/fullarticle/2765836.) 52 https://www.nature.com/articles/d41586-020-01451-0. 53 https://www.thelancet.com/journals/lancet/article/PIIS01406736%2820%2931034-5/fulltext. 48 I disagree with these critics. I think that in certain circumstances immunity passports can be justified. Here, I will set out these critics' concerns and respond to them. Inaccuracy The first major worry people have about immunity passports is that our immunity testing is, at present, not very accurate. If we introduced immunity passports today, we would likely be allowing many people who are not immune to go back out into the world, where they might either catch the virus or unknowingly spread it to others. But while it is true that we should not implement a system of immunity passports unless our testing is highly accurate, this is not a reason to reject such a system outright. Soon our testing will be highly accurate. Feasibility Kofler and Baylis argue that "the volume of testing needed is unfeasible". They write: Tens to hundreds of millions of serological tests would be needed for a national immunity certification programme. For example, Germany has a population of nearly 84 million people, so would require at least 168 million serological tests to validate every resident's COVID-19 immune status at least twice. Two tests per person are the minimum, because anyone who tested negative might later become infected and would need to be retested to be immune certified. Repeat testing, on no less than an annual basis, would be necessary to ensure ongoing immunity. From June, the German government will receive 5 million serological tests a month from the Swiss firm Roche Pharmaceuticals-a leading supplier of one SARS-CoV-2 serological test that has been 49 approved by regulators. This will allow only 6% of the German population to be tested each month. But we don't need to test everybody in order for a system of immunity passports to be extremely valuable. We could test only those who are most likely to have been exposed to the virus, or whose jobs are especially socially useful. In any case, it seems reasonable to think that our testing capacity will increase greatly in coming months. While there are certainly opportunity costs to increasing it, the potential benefits of immunity passports are so great that it is hard to imagine a better use of these resources. Only Small Numbers The next concern is that there would not be enough immune people "to boost the economy". Kofler and Baylis write: The proportion of individuals known to have recovered from COVID-19 varies widely in different populations. Reports from hot spots in Germany and the United States suggest some locations could have recovery rates between 14% and 30%. In New York state, for example, where 3,000 people were tested at random in grocery shops and other public locations, 14.9% had antibodies against COVID-19 (see go.nature.com/2waaku9). But these seem to be the exception. In an April press conference, the WHO estimated that only 2–3% of the global population had recovered from the virus...A cafe can't open and serve customers without risk if only a fraction of its staff are certified as immune. A shop can't turn a profit if only a minuscule proportion of customers are allowed to enter. But even if a system of immunity passports would not allow many cafes or similar shops to re-open, there are plenty of 50 other businesses that might benefit from it. Consider, for example, various kinds of factories, construction companies, gardeners, home repair companies, etc. Moreover, the proper justification for such passports is not only that it would help boost the economy. As I've said, such passports would allow many non-immune essential workers to go into isolation while immune people take their places. This could prevent much illness and death. Deliberate Exposure The next concern is that immunity passports might incentivise deliberate exposure to the virus. People might try to infect themselves in the hope of recovering, gaining immunity, and then getting to leave lockdown. Why is this a concern? Because such people might become severely ill or die, or infect others by accident. Moreover, it would be mainly poorer people who would deliberately infect themselves. Few wealthy people would be under enough pressure to take such a risk. This is morally intolerable. But if governments are doing their jobs properly and adequately assisting people in lockdown, the incentive to deliberately expose oneself to the virus is greatly reduced. Moreover, if governments are taking proper measures to reduce the spread of the virus-i.e., testing, contacttracing, etc.-then there will soon be so little of the virus left circulating in our communities that it would be hard to deliberately infect oneself in the first place. Instead of calling for a ban on immunity passports, we should be lobbying governments to take these other measures. Any governments that would be sufficiently moved by the plight of those who would deliberately infect themselves to ban such passports could also be persuaded 51 to take these other measures. And when it comes to governments who could not be persuaded to take these other measures, it is a waste of breath to try to persuade them not to implement such passports out of a concern for those who might deliberately infect themselves. Moreover, as Emanuel points out, we can minimise the risk of deliberate infections by initially offering immunity passports only to essential workers who are likely to encounter the virus anyway, or to members of high-risk groups, who are less likely to seek out infection. Discrimination The next concern is that immunity passports could give rise to unfair discrimination in the workplace, or to practices in breach (in the US) of the Americans with Disabilities Act. Seema Mohapatra writes: allowing only people with immunity-or evidence of past infection-to work would disadvantage those who haven't gotten sick or those without the antibodies to prove it. It's as if, in the eyes of their employer, their lack of infection constitutes a disability. The inequality that immunity passports could foster in these situations may be illegal under the ADA...As long as an employee is able to perform the essential functions of his or her job, those without immunity are most likely protected under the ADA.54 It is true that immunity passports are discriminatory-that is their whole point, to discriminate between those who are 54 https://theconversation.com/why-covid-19-immunity-passports-mayviolate-us-law-138165. 52 immune and those who are not. But is this form of discrimination unfair, or on balance unjustified? Should the immune have an advantage in competition for certain jobs? In the present crisis, I believe, they should. Some jobs require close physical contact with other people. If more bus drivers are needed, it would seem entirely appropriate to prioritise applicants who are immune to the virus. In normal times, such immunity isn't relevant to the duties associated with driving a bus. But in a pandemic, part of what we should be looking for in bus drivers suddenly becomes a tendency to not infect passengers. Appointing non-immune people to do these jobs instead of the immune, when the former are no better able to (say) drive a bus, is needlessly putting many other people at risk. Inequality and Stratification The next concern is that such passports would lead to inequality and social stratification. Kofler and Baylis write: Labelling people on the basis of their COVID-19 status would create a new measure by which to divide the 'haves' and the 'havenots'-the immunoprivileged and the immunodeprived. Such labelling is particularly concerning in the absence of a free, universally available vaccine. If a vaccine becomes available, then people could choose to opt in and gain immune certification. Without one, stratification would depend on luck, money and personal circumstances. Restricting work, concerts, museums, religious services, restaurants, political polling sites and even health-care centres to COVID-19 survivors would harm and disenfranchise a majority of the population. It is true that such passports should not be available only to the wealthy or well-connected. But the risk of this 53 happening is not a reason to reject a system of such passports, but to ensure that it is implemented properly. It would remain true that if we implemented immunity passports, some people would have access to certain goods that others lack through sheer luck. But the alternative is one where nobody has access to these goods. To deny the immune access to these goods on the grounds that their immunity is sheer luck would seem to be sour grapes. Besides, access to concerts, cafes, sporting events, etc., might be considered a proper reward for these people's doing the essential jobs in the pandemic. Alternatively, it might be a fitting compensation for one's having gone through the suffering and worry of being infected. Moreover, as lockdowns are gradually relaxed, many non-immune people will be allowed to return to versions of these daily activities (like concerts, museums, religious services, restaurants, etc.). So, the inequality here between immune and non-immune would be reduced over time. International Harms The next concern is that such passports could harm people in developing countries. Kofler and Baylis write: Immunity passports could also fuel divisions between nations. Individuals from countries that are unable or unwilling to implement immunity passport programmes could be barred from travelling to countries that stipulate them. Already people with HIV are subjected to restrictions on entering, living and working in countries with laws that impinge on the rights of those from sexual and gender minorities-such as Russia, Egypt and Singapore. 54 Of course, it is not only travel restrictions that are concerning here. If only wealthy countries are able to implement immunity passports, this might allow their economies to recover more quickly and so give them further advantages over the economies of poorer countries, which could be extremely bad for people in the latter countries. This is a real worry. But the correct response to it, I believe, is not to ban immunity passports, but to try to ensure that wealthy countries use their economic gains here to increase their aid to poorer countries-in particular, to help them recover more effectively from COVID-19. Counterproductiveness The final concern I want to address is that putting in place a system of immunity passports might reduce the chances that governments will properly assist citizens in lockdown, as well as carry out the necessary testing and contacttracing to successfully suppress the virus. As Alexandra Phelan writes: Until a COVID-19 vaccine is available, and accessible, which is not guaranteed, the way out of this crisis will be built on the established public health practices of testing, contact tracing, quarantine of contacts, and isolation of cases. The success of these practices is largely dependent on public trust, solidarity, and addressing-not entrenching-the inequities and injustices that contributed to this outbreak becoming a pandemic.55 Similarly, Kofler and Baylis write: 55 https://www.thelancet.com/journals/lancet/article/PIIS01406736%2820%2931034-5/fulltext. 55 Strategies that focus on the individual-using conceptions of ethics rooted in libertarianism-contradict the mission of public health. They distract attention from actions that benefit all, such as funding international collaborations, practising effective public-health measures and redressing income inequity. But I do not see why a system of immunity passports must be rooted in libertarianism, or set back these other efforts. It would, of course, be a mistake to think that we should respond to the pandemic by implementing immunity passports in order to prop up the economy, and then do nothing else. That would be terrible indeed. But assuming that governments are aiming for a vaccine, immunity passports could greatly reduce the costs of lockdown, not only for the immune, but for everyone.56 By making lockdown more tolerable, this might even help to ensure that we maintain our lockdowns until we find a vaccine. Conclusion In this chapter, I have responded to some prominent concerns about immunity passports. Such passports would not only benefit those who receive them, but could save many lives and play a valuable role in helping to make lockdown more tolerable for everybody. While it is true that some people might be tempted to deliberately expose themselves to the virus in order to gain immunity, this risk can be reduced by properly assisting people in lockdown, and taking effective measures to suppress the virus. 56 Economic boosts can help governments to increase their assistance to people in lockdown. 56 4 Masks IN THE FIRST FEW MONTHS of 2020, many people in Western countries were wondering whether they should be wearing face-masks out in public. After all, masks were commonly worn in many Asian countries, and some of these countries were doing extremely well at suppressing the virus. 57 But health officials in the US were clear: masks should not be worn by healthy members of the general public, but only by healthcare workers or other carers (as a way of protecting these workers or carers), or by ill people themselves (to prevent their spreading the virus). As Dr. Anthony Fauci said in a widely watched 60 Minutes interview: "There's no reason to be walking around with a mask."57 Different reasons were given for why healthy members of the public should not be wearing masks. These included: 1. There is a dire shortage of masks, and we need to keep enough for our healthcare workers. 2. Masks offer little or no protection to the wearer. 3. Improper mask use can actually increase one's chance of infection-say, by making it more likely that one will touch one's face, or by making one feel safer than one really is when in close proximity to others. Fauci made all these claims on 60 Minutes. And Jerome Adams, the US Surgeon General, tweeted: Seriously people-STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can't get them to care for sick patients, it puts them and our communities at risk! Many people found the advice of these officials confusing. If masks offer little or no protection to wearers, then why do healthcare workers need them so badly? And if masks do protect wearers when they are correctly used, then why 57 https://www.youtube.com/watch?v=PRa6t_e7dgI. 58 not simply explain to people how to use them correctly, instead of discouraging their use altogether? In retrospect, it seems clear that these officials had one overriding goal in offering their advice: to deter people from buying (and especially stockpiling) masks so as to maximise their availability for healthcare workers. Was this the right advice? I believe it was not, for several reasons. Here, I will set out these reasons, and then address some other important moral questions raised by masks. Asymptomatic Transmission The main reason this advice was flawed is that it turns out that one can be infected with COVID-19 and pass it on without suffering any obvious symptoms. Asymptomatic transmission of COVID-19 is common. Moreover, and connected with this, it seems that COVID-19 is in some sense airborne-capable of being spread not just via large respiratory droplets (say from coughs or sneezes), but via short-range [aerosols], particularly in specific indoor locations, such as crowded and inadequately ventilated spaces over a prolonged period of time.58 For these reasons, many experts now believe that fostering a culture of mask-wearing among the general public is one of the keys to slowing the spread of COVID-19, and perhaps even (given the virus's extensive spread) now an 58 https://www.who.int/news-room/commentaries/detail/transmission-ofsars-cov-2-implications-for-infection-prevention-precautions. See also: https://www.nature.com/articles/s41598-020-69286-3, https://www.medrxiv.org/content/10.1101/2020.05.31.20115154v1. 59 essential step.59 If this is true, then actively discouraging people from wearing masks was a monumental mistake. What of the importance of safeguarding masks for healthcare workers? This was important, and remains so. But given how much the virus has spread in the US, and how very exposed to the virus healthcare workers are right now (and have been for months), these workers might have been better protected on balance if officials had tried to foster a culture of mask-wearing among the general public from the start-rather than doing the opposite-even if this meant fewer masks for healthcare workers at the time. Moreover-and this point is crucial-it is not even clear there was much of a trade-off here. Health officials could have done what Brazil's health minister, Luis Henrique Mandetta, did, namely, tell people to buy or make their own cloth masks instead of buying medical grade masks. This advice could have safeguarded supplies for healthcare workers, while greatly reducing the spread of COVID-19. It might be objected that health officials had no idea back in March about the possibility, let alone likely frequency, of asymptomatic and airborne transmission. But this is doubtful. There was some evidence at the time of these things, though it was inconclusive. In any case, officials should have realised that if it turned out that COVID-19 was airborne and that there was widespread 59 According to the Institute of Health Metrics and Evaluation, 33,000 deaths could be avoided by October 1 if 95 percent of people wore masks in public (http://www.healthdata.org/news-release/new-ihme-covid-19model-projects-nearly-180000-us-deaths). See also: https://www.cnbc.com/2020/07/14/cdc-says-us-could-get-coronavirusunder-control-in-one-to-two-months-if-everyone-wears-a-mask.html. 60 asymptomatic transmission, then their advice could prove disastrous, and then erred on the side of caution.60 Trust A second important reason these officials' advice was flawed is precisely that it was so confusing. Giving confusing advice suggests that one is oneself confused, and appearing confused can damage public confidence in one. Alternatively, it suggests dishonesty. Many people felt that these officials were lying to them when they said that masks would not protect members of the general public. Worse still, and related to this, these officials' advice has led some people to question their moral character. What sort of an expert, some have felt, could look people in the eye and tell them, when they are in the middle of a pandemic trying to protect their own families, that there is no benefit to doing something that provides a benefit? These officials' advice has damaged people's trust in them-in their competence, their honesty, and their moral fibre. This loss of trust has been, and continues to be, extremely dangerous, given that these officials are America's best hope of getting the virus under control. Trump himself is now invoking their February/March advice on masks to discredit them and their continued efforts to persuade the US to lock down properly. In an interview with Sean Hannity in July, Trump said: Dr. Fauci's a nice man, but he's made a lot of mistakes...They've been wrong about a lot of things, including face masks. Maybe 60 Nonetheless, as I argued in Chapter 2, the blame for the spread of COVID-19 throughout the US lies mainly with Trump, for failing to put in place proper lockdowns and effective testing and contact-tracing. 61 they're wrong, maybe not. A lot of them said don't wear a mask, don't wear a mask. Now they're saying wear a mask. A lot of mistakes were made, a lot of mistakes.61 I don't for a second question the moral character or integrity of Fauci and Adams. They are some of the best people the US currently has, and are doing, by and large, an excellent job in extremely hard circumstances. But their advice to not wear masks was a huge strategic error. Mask-Culture Today In April, the official US advice on masks abruptly changed. The CDC started recommending that everyone wears cloth masks when out in public.62 This was a good move, but it raises a different kind of problem: how upfront should officials be about the fact that it is mainly surgical and N95 masks, rather than cloth masks, that offer significant protection to the wearer (or, in other words, that the main point of wearing a cloth mask is to protect others in case one is already infected)? You might say: officials should not emphasise this fact, and should perhaps conceal it. If people believe that wearing a cloth mask will protect themselves, then this will make them much more likely to wear one. As Nobel Prize laureate in chemistry, Mario Molina, says, 61 Quoted here: https://www.cnbc.com/2020/07/14/cdc-says-us-could-getcoronavirus-under-control-in-one-to-two-months-if-everyone-wears-amask.html. 62 https://www.youtube.com/watch?v=tPx1yqvJgf4, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/clothface-cover-guidance.html. 62 You use the face mask so that you don't catch the infection. It's not just so that you don't propagate it to other people. So that's crucial to convince people to use it.63 I think this is another big mistake. People can clearly be persuaded to wear cloth masks for the sake of others. This, after all, is why so many people wear masks in Asia.64 Indeed, I suspect that a large part of the reason some people are so opposed to mask-use is precisely that they are thinking of those who wear them as being excessively concerned about themselves, or contemptuous or distrustful of others. Mask-use has a tendency to seem elitist or snobbish to many people in the US and UK. If it came to be widely known in these countries that people in Asia wear masks largely to protect others rather than themselves, and if people in the US started explicitly wearing masks for this reason, this could go a long way to reducing opposition to masks. To help this along, we must widely publicise the fact that asymptomatic transmission of COVID-19 is common. When people realise this, they will realise that failure to wear a mask is putting others at risk. A final matter. While N95 masks offer excellent protection to the wearer, there is evidence that their filters can allow quite a bit of the virus to escape during exhalation.65 Given this, if everyone wore N95s in public places, this would be nowhere near as effective in slowing the spread of COVID-19 as if everyone wore cloth masks. 63 Quoted here: https://www.wbur.org/commonhealth/2020/06/30/facemasks-most-effective-defense-coronavirus. 64 https://qz.com/299003/a-quick-history-of-why-asians-wear-surgicalmasks-in-public/. 65 https://healthnewshub.org/health-news-hub/top-news/do-not-use-amask-with-a-filtered-valve-it-can-spread-covid-19/. 63 For this reason, the sort of mask-wearing culture governments need to foster is one where it is exclusively cloth (or perhaps also surgical) masks that are worn in public, rather than N95s. Only old or vulnerable people should wear N95s. N95s While we should be discouraging people from wearing N95s in public, we might wonder whether people are morally obliged not to wear them (and to wear cloth masks instead). Are people required to give up this form of personal protection because it releases the virus? The answer, I think, is yes. Providing you are not old or vulnerable, then you are morally required to wear a cloth mask rather than an N95, even though you would be better protected with an N95. This is due to the huge importance of trying to foster a culture of wearing cloth masks among the general public. When some people wear N95s, this encourages others to do so as well, resulting in a sort of arms race. We need many people to put others first, in order to encourage everyone to do the thing that, if everyone did it, would maximise protection to us all. That said, one's responsibilities here might depend on where one happens to be. If one is in an environment where everyone is wearing N95s rather than cloth masks, then it might be permissible for one to wear an N95 as well. But if few others are wearing N95s, and many are wearing cloth masks, then there is no excuse for not wearing a cloth mask. 64 Shortages Suppose that in March you did not believe health officials when they said that masks were not protective for members of the general public. Could you have permissibly gone out and bought yourself (and your family) some masks? I think so. It was reasonable at the time to think that masks might be at least somewhat protective against COVID-19, and one can hardly be blamed during a pandemic for trying to protect oneself and one's family. It would have been wrong, however, to stockpile masks (and other essential goods, like hand sanitizer, medicines, certain foodstuffs, etc.)-i.e., to buy more than you and your family could reasonably use in the foreseeable future. What counts as the "foreseeable future"? This depends on what sort of actions governments and companies are taking to boost supplies. It would not have been reasonable, for example, in early 2020 to think that shortages of these products in the US would last indefinitely, and so on this basis purchased as many of these things as one could have. A final point. Shops are clearly morally required in this pandemic to ration supplies of such goods-i.e., limit the amount individuals can buy on any given occasion. Trump Those who today are protesting mask-use are acting not just wrongly, but reprehensibly. This is especially true of the President, whose actions are so hugely influential in the United States. At one point recently, Trump said: I just don't want to wear one myself...I am feeling good...I just don't want to be doing-I don't know, somehow sitting in the 65 Oval Office behind that beautiful Resolute Desk, the great Resolute Desk, I think wearing a face mask as I greet presidents, prime ministers, dictators, kings, queens. I don't know, somehow, I don't see it for myself.66 In making such statements, Trump is effectively killing thousands of Americans.67 Conclusion In this chapter, I have argued that US health officials made a monumental error in advising against mask-use by the general public back in February/March. I then argued that we should be trying to encourage everyone to wear cloth masks, not as personal protection, but in order to protect others (given the existence of widespread asymptomatic transmission). Citizens have a duty to wear such masks, and not N95s (as these latter allow the virus to escape during exhalation). Finally, one can permissibly buy masks and other vital goods during shortages, but not stockpile them. 66 During a coronavirus task force briefing. 67 On at least one occasion in July, Trump wore a mask in front of cameras. He also said that wearing masks is patriotic. But these are the only times he has supported mask-use to date. 66 5 Duties to Assist I HAVE ALREADY ARGUED for the existence of certain duties: China had (and continues to have) a duty to ban its live wildlife markets, the US and UK governments have duties to properly lock down their countries and engage in adequate testing and contact-tracing, many citizens of these countries should be doing much better than they 67 currently are at observing lockdowns. These are all duties to avoid causing harms to various other individuals. I now want to consider a different class of possible duties: duties to assist, or to take positive steps to help others. Essential Workers Essential workers-doctors, nurses, bus drivers, cleaners, food delivery workers, and so on-are in much greater danger than most during the current pandemic. Many of them are exposed to COVID-19 on a daily basis. Not only are they more likely to be infected with the virus, some of them (especially doctors and nurses) are more likely to be exposed to a high viral load and so become very ill. What are the responsibilities of these workers during the pandemic? In particular, is it morally incumbent on them to keep going to work? Or is it permissible for them to bail out and stay home? You might say: Of course they must go to work! I disagree. Naturally, I strongly want these workers to stay at their posts. But I do not think we can reasonably insist that they do so (or blame them for not doing so)- or, at least, we cannot unless two important conditions are met: 1. We are adequately protecting these workers.68 2. There are not others who are willing to step up and take their places, and who are able to be adequately trained to work in these jobs sufficiently quickly that relatively little will be lost in the changeover. 68 For a similar view, explained in much greater detail, see Udo Schuklenk's important paper: https://jme.bmj.com/content/46/7/432. 68 Start with (1). If governments are not taking sufficient efforts to protect workers by sourcing PPE, locking down, and engaging in adequate testing and contact-tracing, then it is morally acceptable for these workers to leave their posts. This applies even to medical workers, who might be harder, or perhaps even impossible, to replace. If, under these conditions, these workers walk off the job, the fault here lies with governments, not with these workers. Likewise, if not enough citizens are observing lockdown, then once again these essential workers can permissibly stay at home. They owe it to citizens to carry on working only if citizens are themselves pulling their weight here. If, however, governments are taking these measures, and citizens are observing lockdowns, then these essential workers are morally required to stay at their posts even if doing do is still extremely dangerous (say, because the benefits of these measures and observances haven't kicked in yet). The only exception to this is if there are others who are able and willing to take over their jobs, without much being lost in the transition. If a young and healthy person currently in lockdown wants to become, say, a postal worker during the pandemic in order to allow an older and at-risk employee to go into the safety of lockdown, then it is permissible for this employee to step down. But if noone is willing or able to take their place, then they must remain (providing they can still properly do their job)69. Note that governments have a duty to ensure not only that these workers are adequately protected, but that they 69 Note that different jobs might count as essential at different times. Also, it might be possible for some people to leave certain professions without substantially interfering with the provision of the relevant services. In this case, some older or vulnerable people could permissibly leave even if there are no others to take their spots. 69 are adequately compensated for remaining at their posts. This might involve substantial salary rises, and commitments to improve their working conditions later on. Teachers What about teachers returning to school when lockdowns are eased? Many teachers are in their sixties or older and so at greater risk of illness and death from COVID-19. Do they have a duty to return to their posts? The answer is that schools shouldn't be going back 'inperson' unless the virus has been suppressed to a point where case numbers are very close to zero and effective testing and contact-tracing measures are in place. Schools going back before this time, even if some protective measures are in place, will cause more harm than good (by spreading the virus). While it is clearly not ideal for children to be doing their learning exclusively from home70, it is far worse to set back efforts at suppressing the virus. If schools are opening before the virus has been suppressed to this point, then teachers are under no moral obligation to return to school. Indeed, they might have a duty to stay home, even if this puts their jobs in jeopardy, as a form of protest at governments re-opening schools. 70 This is especially so given that many socio-economically disadvantaged children aren't as able to access online learning. Governments should be doing much more to try to ensure that all children have access to adequate online education in this time. An important question is whether wealthy families have a moral obligation not to enrol their children in 'learning pods', given that these not only benefit their children, but disadvantage those who cannot afford to participate in them. For discussion, see: https://www.nytimes.com/2020/07/22/parenting/school-podscoronavirus.html. 70 But in places where the virus has been effectively suppressed, teachers should return to school (with proper PPE and distancing in place), even if they'd rather not. To Clap Or Not To Clap? On March 26, Britons started a ritual of clapping healthcare workers, following similar rituals in Italy, France, and Spain. New Yorkers soon joined in. Many felt that they owed this to these workers. Were they right? It has been pointed out that when government officials clap these workers, and more generally laud them for their heroism, this is disingenuous, given that these same officials have often been failing to adequately protect these workers from the virus. As Owen Jones says, in the UK, Every ministerial clap is an act of hypocritical performance art, a patronising ruffle of the hair, an insult in lieu of an act of genuine care.71 In framing essential workers as heroes, these officials make it seem as though their poor conditions are inevitable, or that these workers are so selfless that they are not so concerned about the risks they face, when the reality is extremely different. As Dahlia Lithwick puts it, The language of "heroism" is...used to distract attention from the fact that some of our newfound heroes do not have any choice in the matter. The appalling infection rates among transportation workers and drivers and food workers is a result of an economic arrangement in which they may well be a paycheck away from losing their homes, or cars, or- 71 https://www.theguardian.com/commentisfree/2020/apr/23/uk-keyworkers-ppe-ministers-clapping-protect-nhs. 71 ironically enough-their health care. Yes, they are all heroes, but they are also stuck, and if calling them "angels" deflects from how broken their compensation and job protection arrangement really is, then we need to find a new way to talk about it. Heroism is associated with unnatural martyrdom, willing sacrifice, and, above all, choice.72 I worry that clapping even by ordinary citizens can have a similar effect. At best, it is, as one doctor put it, "a sentimental distraction from the issues facing us"73. At worst, it might reduce pressure on governments to implement proper lockdowns (and testing and contacttracing), roll out more and better PPE for these workers, properly compensate them, and restore and boost funding for public services in the aftermath of the pandemic. Furthermore, clapping rituals might make citizens themselves feel like they have discharged their duties to such workers, when their principal duty to workers here is to lobby governments to take the above sorts of actions, not to mention to observe the lockdowns themselves. But don't clapping rituals buoy healthcare workers? Yes, to an extent. And many citizens who clap do care deeply for these workers and are trying to convey their heartfelt concern, appreciation, and thanks. But there is a temptation to think that some citizens-say, those who have repeatedly voted for governments that have stripped funding from public services-are clapping in order to cajole or pressure these workers to continue going to work, 72 https://slate.com/news-and-politics/2020/04/coronavirus-humans-vsheroes.html. Some companies, like Amazon, are guilty of similar tactics: https://www.nytimes.com/2020/05/29/opinion/coronavirus-amazonhazard-pay.html. 73 https://www.theguardian.com/society/2020/may/21/nhs-doctorenough-people-clapping. 72 in case they come to need help themselves. If healthcare workers pick up on this, it could be the opposite of buoying. It is a dreadful situation where we must not cheer on our healthcare workers lest this leads to their facing even greater peril. But this does seem to be the reality here. Sadly, in present circumstances, we owe it to them not to clap. The Immune In Chapter 3, I argued that we should allow people who have been proven immune to the virus to leave lockdown and resume work. Suppose this is right. Do these people have a moral duty to make use of such passports and return to work? Even if they quite like being in lockdown and are not suffering financially, must they leave lockdown to "subout" non-immune essential workers, including ones whose jobs are hard or unpleasant (like, for example, hospital cleaners or grave diggers), or simply to resume their old jobs at no net financial gain to themselves (given the assistance they might be receiving in lockdown) in order to boost the economy and provide services to others? I believe that the answer to this question is yes. These people have the gift of immunity, and in a crisis like this, must use it to save lives and advance the general good. Could governments rightly force them to use it (i.e., require this on pain of some penalty)? Could governments even be justified in going door to door, testing people to see if they are immune, and then demanding that the immune return to work? This might seem at first glance to breach various rights people have. But I think it might be justified if such people's help was sufficiently badly needed. 73 Of course, many people would be keen to return to work anyway, even to work that is hard or unpleasant. This could be from a desire to help others or simply to leave the house. So, there would likely be no need to force people to do so. Could we justify forcing non-immune workers in risky essential jobs to be subbed-out by immune people? What if they are stoic and want to keep on working? In many cases, there is a clear justification for forcing these workers into isolation: allowing them to keep working puts others at risk. But it might also be right to do so simply for their own sakes, especially if they are older or vulnerable. We do not, after all, allow people to work in needlessly dangerous conditions during normal times, and so we should not allow vulnerable people to work in the pandemic when others can safely perform their jobs. Vaccinations & Tracing Apps Suppose we develop a safe and effective vaccine for COVID-19. Would citizens be morally required to receive it? The answer seems clearly to be 'yes'.74 The more difficult question is whether, if not enough people are being vaccinated to get us to herd immunity, we could justify mandating vaccination. This would not involve forcibly jabbing people, but merely a penalty for non-compliance. Given what is at stake, the answer again seems to be yes. This, however, is only on the assumption that the vaccine has been adequately tested and shown to be safe.75 74 For a useful discussion, see: https://www.3quarksdaily.com/3quarksdaily/2020/06/are-we-obligatedto-be-vaccinated.html. 75 Although there is a tricky question here about what exactly 'safe' amounts to in this context. All medicines have at least a very small risk of minor sideeffects in some people. 74 In any case, I doubt we will have to confront this scenario, since there will be many unofficial penalties or costs of not being vaccinated. Many shops, schools, museums, restaurants, sporting events, and so on, will simply deny entry to people who are not vaccinated. So, even if some people are reluctant, enough will volunteer. What about contact-tracing apps, which track your movements and others' in order to alert people that they have been exposed to the virus? Are we morally required to download and use these apps, despite the risks they pose to our privacy? Again, the answer is clearly yes. And governments could be justified in penalising those who do not use them. Privacy is unimportant by comparison.76 Twitter In recent months, Twitter has started adding notes to some of President Trump's tweets, indicating that they are in breach of Twitter's Rules. Here is one example, where Twitter has added "Get the facts about mail-in ballots", and included a link to relevant information (Figure 2.): 76 Are the duties we are discussing here duties to assist or rather to avoid harming others? I will not consider this question here. 75 Figure 2. Trump Tweet #1 A second example (Figure 3.): Figure 3. Trump Tweet #2 76 What should we make of Twitter's actions here? Let us ask first whether they are morally permissible. In an interview with Fox News, Zuckerberg suggests they were not: We have a different policy than, I think, Twitter on this...Facebook shouldn't be the arbiter of truth...Private companies...especially these platform companies, shouldn't be in the position of doing that.77 While Facebook engages in fact-checking, it does not factcheck politicians' posts. Why not? Here is its explanation: Our approach is grounded in Facebook's fundamental belief in free expression, respect for the democratic process, and the belief that, especially in mature democracies with a free press, political speech is the most scrutinized speech there is. Just as critically, by limiting political speech we would leave people less informed about what their elected officials are saying and leave politicians less accountable for their words.78 It is certainly true that America has a freedom of speech problem. But this problem is that, because of platforms like Facebook, many people are getting trapped in echo chambers where they are exposed to only one side of the story, the side that companies like Facebook predict (having harvested their data) will most appeal to them. Facebook makes money (from advertising) when people are viewing pages and clicking on links. To maximise its profits, it tailors news and commentary to individuals based on what it thinks these individuals are most likely to view 77 https://www.foxnews.com/media/facebook-mark-zuckerberg-twitterfact-checking-trump. 78 https://www.facebook.com/business/help/182222309230722. 77 and click on. So, people with Trumpish friends and sympathies get given pro-Trump stories, while anti-Trump folks get given anti-Trump stories. As a result, both sides of politics fail to have access, practically speaking, to the best arguments of their opponents, and drift further apart. This insulation from others' views that Trump's supporters have attained has been a necessary condition of his rise, and so led directly to the public health and environmental catastrophes unfolding in the US today. Truly promoting freedom of speech in America today- and accordingly, preventing the unfolding of these catastrophes-involves breaking up these echo chambers. This is exactly what Twitter's actions are calculated to do- bust people out of the pro-Trump echo chambers they are stuck in. Twitter is not restricting what people can hear, but expanding it. Their actions are not only permissible, they are obligatory for a company like Twitter. Facebook should be doing exactly the same sort of thing itself. It might be objected that Trump's followers will simply flock to other platforms where they can read his messages unfiltered. However, while some will do so, others will have been woken up by this very public rebuke from a company that has been Trump's principal enabler over the years, and has a huge financial stake in his remaining on the platform. "If even Twitter is this concerned by Trump's tweets", many will twig, "something might be amiss here." International Aid What do countries owe each other in the pandemic? In particular, what do wealthier countries owe poorer ones? Some governments have seized or stolen shipments of PPE and other medical supplies bound for other countries. "Modern day piracy", it has been called. This harmful 78 behaviour is clearly beyond the pale. But what about wealthy countries legally purchasing supplies in a way that prevents other countries from accessing them? The US has done this on several occasions, outbidding poorer countries and leaving them with nothing. Most recently, it bought up almost all current stocks of remdesivir (a drug that reduces recovery time in severe cases of COVID-19), leaving none for Europe or the UK for several months. US health secretary, Alex Azar, announced: President Trump has struck an amazing deal to ensure Americans have access to the first authorised therapeutic for Covid-19. To the extent possible, we want to ensure that any American patient who needs remdesivir can get it. The Trump administration is doing everything in our power to...secure access to these options for the American people.79 There is a worry that a Trump administration might also serve America first with a vaccine (when one comes), rather than sharing it or prioritising its use by poorer countries. You might say: this is America's right, for being able and willing to invest in, develop, or purchase these valuable medicines. You might go even further and say: governments have obligations to their own citizens first and foremost. They are required to give them priority. But this is wrong. Governments have obligations not only to their own citizens, but also to the rest of the world. These duties include not only a duty not to steal from other countries, but to provide aid to those that are in greatest need. It is not only the US that has such duties. China has special duties in the present context, given its responsibility for the genesis of COVID-19 and its initial spread. 79 https://www.hhs.gov/about/news/2020/06/29/trump-administrationsecures-new-supplies-remdesivir-united-states.html. 79 Companies Many companies have duties in the present crisis to marshal their resources to help with the pandemic response. Some big companies have been doing so-for example, Ford has been refitting its car assembly lines to make ventilators, and 3M has been increasing its production of masks. But many other companies should also be chipping in. Even if their products are not relevant to the pandemic, they should be doing their best, say, to keep workers on, rather than firing them at this time. Athletes What are the obligations of athletes in this time? Should major sporting events go ahead (without spectators)? On the one hand, you might say that it is now more than ever that we need live sport on television-to entertain us, distract us, and give us hope that there is life after COVID19. On the other hand, resuming sports would be risky for athletes, not to mention others involved in running them. One view is that these athletes are rightly considered essential workers in the present time, and accordingly must bear the associated risks to their health. If bus drivers, healthcare workers, cleaners, food workers, and so on, must risk their health, then athletes surely must do so as well. But there are a number of problems with this view. First, while many of us might like to watch live sports right now, we do not need to in the same way that we need a food supply, access to healthcare, etc. We can do without. Indeed, we might ask whether we should enjoy watching live sports right now, knowing of the risks posed to athletes 80 and others. While elite athletes are unlikely to die from COVID-19, they might still be vulnerable to long-term health effects from infection. Given the small margins at the high end of sports, any drop in performance could mean the end of a career. If athletes are reluctant to compete, and doing so only because they do not want to lose their contracts, then there might be something wrong with enjoying sports right now. It might signal that one is cold in some way. It might be like what seems wrong with ancient Romans watching combatants in the Colosseum. Second, these sporting events might prove to be a distraction from the more important task of properly responding to the virus. Tennis player Nick Kyrgios writes: The ATP is trying to make the US Open go ahead. Selfish with everything going on at the moment. Obviously Covid, but also with the riots, together we need to overcome these challenges before tennis returns in my opinion.80 While the US Open and the French Open are going ahead, Wimbledon cancelled its tournament back in April. This early and decisive move might have aided lockdown efforts in the UK by communicating to people the seriousness of the situation, and how long it might take to relax lockdowns.81 82 80 https://twitter.com/nickkyrgios/status/1270963096022994944. 81 Even so, we shouldn't be too quick to congratulate Wimbledon. Wimbledon's main motivation here might really have been to cash in on its pandemic insurance policy. Unlike the US Open, Wimbledon does not allow on-court advertising (a huge proportion of its income is ticket sales), and so if it had gone ahead, this would have been far more costly. 82 On the other hand, it is worth considering whether these sports going back at this time might make such a significant contribution to lockdowns becoming more tolerable for citizens, that this helps suppress the virus. 81 Meal Deliveries During lockdown, we have been encouraged to leave home to get groceries only rarely and to buy in bulk to reduce our number of trips, or else to have groceries delivered to our homes. This makes sense. But what about ordering meals to be delivered? This might seem like a good idea as well because it doesn't involve our leaving our homes, and might also help to support local restaurants and meal deliverers. Some have even claimed we have a duty to order meals. But there is a problem with these claims: if you live in high-density housing or apartment buildings, ordering meals can put delivery workers at higher risk of catching COVID-19. Elevators especially are a risk for delivery workers, given the confined space and lack of ventilation.83 According to some commentators, the benefits to these workers outweigh the risks. Saru Jayaraman, the director of the Food Labor Research Center at UC Berkeley, says: Right now, I think workers would largely ask you to please keep ordering. It's essential for these workers to be able to survive. Our industry is definitely worried about people's safety, including their own, but they're also worried about survival and feeding their kids...It's not that they don't think this is a scary time to be doing delivery, but they also need their jobs.84 Alberto Giubilini agrees and adds: If there is no compensation scheme in place-either by the government or by the individual employers-then there certainly 83 https://www.nytimes.com/2020/03/19/nyregion/coronavirus-nycdelivery-workers.html. 84 https://www.theatlantic.com/family/archive/2020/04/grocery-deliverytakeout-eating-ethically-pandemic/610111/. 82 is a moral obligation to tip a lot. We ought to tip way more than we do in normal circumstances.85 I disagree. If you live in an apartment building-especially one with elevators-or in other busy locations, and you can order groceries in bulk or buy your own, then you shouldn't be ordering meals for delivery right now.86 By doing so, you put other people's lives at risk. Won't this lead to job losses for delivery workers? Yes. But it is not our responsibility as consumers to provide financial support for these workers in these times. This is the responsibility of governments. In the height of the pandemic, such workers should be safe and sound at home with their families in lockdown. Conclusion In this chapter, I have considered a large number of possible duties to assist others. Essential workers have duties to go to work, but only if governments are protecting them properly, and no one else is willing and able to sub them out. Non-essential workers have duties, not to clap such workers, but to pressure governments to protect them properly and to observe lockdowns themselves. The immune have duties to resume work and sub-out essential workers who are non-immune. We all have duties to be vaccinated and use tracing apps. Twitter and Facebook have duties to better regulate their platforms. Wealthy countries have a duty to greatly increase their aid to poorer countries in this time. Athletes do not owe us a return to sport. And we have duties not to have meals delivered. 85 https://www.theatlantic.com/family/archive/2020/04/grocery-deliverytakeout-eating-ethically-pandemic/610111/. 86 There is an exception, of course, for disabled people who cannot assemble their own meals. 83 6 Vaccine Trials WE URGENTLY NEED A VACCINE for COVID-19. It is only when we get one (or else a cure or treatment) that we can fully end our lockdowns. The trouble is such vaccines usually take years to develop and test for efficacy and safety. Some bioethicists have recently proposed a way of speeding up this testing process by several months: allow volunteers to receive one of the trial vaccines and then directly expose them to the virus (in isolation, of course, so that they cannot infect others, and with the best medical care on hand in case they get ill).87 These "human 87 See especially pieces from Richard Yetter Chappell and Peter Singer (https://journals.sagepub.com/doi/full/10.1177/1747016120931920), and Nir Eyal, Marc Lipsitch, and Peter G Smith (https://academic.oup.com/jid/article/221/11/1752/5814216). 84 challenge" (or simply "challenge") trials would speed things up because we would not have to wait for subjects to encounter the virus in the normal course of their daily lives. But are such trials ethical? Could it be morally permissible to expose people, even volunteers, to such a risk of severe illness and death, without a treatment available? Many people feel that the answer is 'no', because such trials would exploit, or take unfair advantage of, subjects. Advocates of such trials have defended them in a number of ways. Many have claimed that we can greatly reduce the risks to volunteers by selecting only young and healthy people, since these people are much less likely to become severely ill or die if infected with COVID-19. Some have added that we can further reduce risks to subjects by choosing only people who already have a high risk of catching the virus-say, people who live in high transmission areas, or who are essential workers (e.g., doctors, nurses, bus drivers, cleaners, food workers, etc.). These people's net health risks from involvement in the trials might actually be extremely low. It could even be in their best interests to participate, given that if they do get ill, they will get the best medical care available, rather than having to compete with others for resources in overcrowded hospitals. A second defense is that even people for whom involvement in the trials would be very risky can still freely consent providing we properly inform them of the risks. To refuse their offers of help would be to disrespect them or their autonomy. It would be objectionably paternalistic.88 Finally, advocates of such trials have pointed out that there are plenty of other contexts in which we allow people 88 For this point, see the following piece by Julian Savulescu and Dominic Wilkinson: https://blogs.bmj.com/medical-ethics/2020/04/23/extremealtruism-in-a-pandemic/. 85 to serve the community in ways that expose them to health risks. What is the difference between allowing people to enrol in such trials, and allowing them to, say, become police officers, firefighters, soldiers, etc., or donate a kidney to a stranger? We allow essential workers to go to work each morning during the pandemic, despite the considerable risks involved, yet it does not seem to us that we are taking unfair advantage of these good people. In this chapter, I will consider each of these defenses in turn. I will argue that each faces serious problems. Still, I will argue, such trials might be permissible, after all. 'High-Risk' Individuals Consider, first, the proposal to select only volunteers who are essential workers or who live in high transmission areas. Start with the claim that it might actually be in some of these people's best interests to participate in the trials, given that they already face such a high risk of catching the virus in their work or home environments, and might otherwise have to compete for resources in overcrowded hospitals. An immediate problem with this claim is that essential workers should be given priority in hospital triage anyway. If hospitals become overcrowded, these workers should be among the first to get ventilators, ICU beds, etc. Now, if a patient has access to these vital resources, there is not much more one can do for them, medically speaking (at least, at this stage in the pandemic). Whether they survive COVID-19 or not-and what sort of long-term conditions they suffer if they do survive it-seems to depend on a combination of their inherent constitutions, pre-existing conditions, viral load exposure, and luck. Given this, it 86 cannot plausibly be in these worker's best interests to participate in the vaccine trials unless governments are failing in their duties to give proper priority to such workers in hospital triage systems. It has recently been suggested that it might be in the best interests of essential workers to participate in such trials because it would protect their families from COVID-19.89 At present, such workers run a daily risk of returning home from work and infecting their families. But if they participate in these trials, then they will be exposed to the virus in isolation, likely recover from it, and can then return home to their families safe in the knowledge they are immune. Similarly, it might be said, it could be in the best interests of people living in high transmission areas to participate in these trials. There is no reason to prioritise them in hospital triage. On the contrary, they are precisely the people who are most likely to fall victim to overcrowded hospitals. And even if participation in these trials is not in these people's best interests, it is surely true that, given their high-risk status, such participation would represent only a small additional net risk they would be taking on. But there is still a major problem with these claims. This is that if governments are doing their jobs properly-e.g., locking us down, testing and contact-tracing, providing adequate PPE to essential workers, etc.-then when it comes time to carry out the vaccine trials (months from current discussions of the ethics of such trials), these workers, their families, and people who live in high transmission areas, would no longer be facing such high risks of contracting the virus. Their risks might be higher than most people's, but not so 89 See Nir Eyal's recent piece here: https://onlinelibrary.wiley.com/doi/full/10.1002/eahr.500056. 87 much higher that it would be in their best interests, or even close to being in their best interests, to do the trials. Doing the trials would be a significant net addition to their risks. It might be objected that, while governments should indeed be taking such measures, many of them are not. Governments in the US and UK are failing abjectly. In months from now, when these trials are ready to be run, these workers, their families, and people in high transmission areas, will still be facing grave threats. Suppose this is true. Could governments then permissibly call on such people to enrol, on the grounds that it would involve only a slight increase in their net risks of harm? The answer is still 'no'. In calling on them, governments would be saying to these people, in effect, "Due to our repeated culpable blunders, you're still at a very high risk of something really, really terrible. Sorry about that. But now, seeing as though you are already so very imperilled, would you mind terribly if we increased your risk even further, to help us all get out of this giant pickle?" There seems something deeply wrong with asking people this. To compound the worry, a very large proportion of essential workers and people living in high transmission areas are socio-economically disadvantaged. They are already in bad positions through no fault of their own. For many of these people, the alternative to doing the kind of work they are doing or living in these areas is to be out on the street and (if they are in the US) without adequate health insurance. Calling on people in these difficult positions to worsen their positions even more, while many more fortunate members of society are sitting at home, safe and sound from the virus-both medically and economically-is problematic indeed. Why should it be some of the worst off people in society-people who are badly off through no fault of their own-who must step up 88 to be exposed to the virus? This isn't fair. Perhaps it's the turn of those who have not had to contend with such hardship in the first place to step up, even if their net risk of harm is greater (or indeed because their net risk of harm is greater). Can I say more about exactly why asking this of people is morally problematic? One reason is this: If we call on people whom we have so neglected and imperilled to take on further risks for the rest of us, on the grounds that they are already imperilled, and they agree to it, then we reduce our incentives to improve their positions in the future. They are clearly amenable to helping, and we might need their help again. By contrast, if we refuse to let these people volunteer even though the addition to their net risks might be fairly small, we make a statement that we are not going to tolerate economic and social exploitation of such people in the future, that we are committed to improving their positions. Can Volunteers Be Sufficiently WellInformed of the Risks? Consider, next, the claim that even those for whom participation in these trials would be risky indeed (say, because they are currently safe and sound in lockdown) can still freely consent to participation providing that they are properly informed of the risks to them of participation. I have several worries about this claim. First, there is still a huge amount scientists do not know about the health consequences of COVID-19. Even though young and healthy people rarely die from COVID-19, there is growing evidence that it can leave even the young and healthy with debilitating conditions that can diminish life89 quality or shorten their lives. It is possible that it can cause such conditions even in those who are asymptomatic.90 Second, young and healthy people have not had firsthand experience of severe illness. So even if they are able to have a good theoretical grasp of COVID-19 and its possible health consequences, it is doubtful that they can well anticipate, subjectively (from the inside), what it would be like to suffer in these ways. Without this ability, it is hard to see how they could adequately understand the risks to themselves. What is so bad for a person about suffering severe illness (or at least what is worst about it for most people) is precisely how it feels from the inside. Third, many of these young people might lack the life experience or maturity needed to properly understand how becoming so ill or dying from this disease could affect their lives in a wider sense, or the lives of their loved ones. How bad would it be for them to be unable to complete their studies, find a partner, travel the world, have children of their own, care for their parents in old age, etc.? How would their parents, spouse, friends, or children feel if they were to succumb to the virus? Many of these young people would not have adequately thought these things through, and might be unable to do so at their early life stage. Related to this, we know that the experience of severe illness can fundamentally change one as a person. These young people cannot know in advance, if they do get ill, what sort of a person they will emerge as (if they recover), 90 See, for example: https://www.theguardian.com/world/2020/jul/08/warning-of-seriousbrain-disorders-in-people-with-mild-covid-symptoms, https://www.statnews.com/2020/07/27/covid19-concerns-about-lastingheart-damage/, https://www.npr.org/sections/goatsandsoda/2020/06/23/864536258/westill-dont-fully-understand-the-label-asymptomatic. 90 and how their preferences and values might change. We should allow people to sign up for these trials only if we have reason to believe they would still do so after acquiring the knowledge that this experience would give them-but this is precisely something we cannot know in advance.91 Finally, even if we tell these young people that they have a certain chance of becoming severely ill or dying from the virus, and they tell us that they understand what we have said, they might not genuinely accept that they have such a chance, and it might be hard or impossible to ascertain whether they do in fact genuinely accept it. Many young people feel invincible. They think "it won't happen to me". In summary, asking young and healthy people to participate in these trials, and then allowing them to do so, is asking and then allowing them to do something that could harm both them and their loved ones in ways that they cannot possibly be expected to grasp, and might change them in ways that would change their willingness to be involved. And even if some of them can grasp these things, how can we possibly tell which people these are? Analogies with Other Professions Consider, next, the claim that because we allow people to become firefighters, police officers, etc., donate kidneys, and allow essential workers to go to work in the pandemic, we should allow people to volunteer for these vaccine trials. This claim, also, faces some significant problems. 91 For related discussion, see Laurie Paul's Transformative Experience (OUP, 2014). Précis available here: https://lapaul.org/papers/PPR-TEsymposium.pdf. 91 Start with essential workers. Yes, we allow them to go to work each day even though some of them face a high risk of being infected with the virus. But we allow this only because they are essential. If they all stopped going to work, society would collapse. We'd face a truly existential crisis. The same goes for soldiers in (a just) war: without them, we would perish. Police officers and firefighters are also indispensable. By contrast, if we do not allow people to volunteer for challenge trials, society will not collapse. There is a viable alternative: run trials in the normal way. What about kidney donation? It is true that we allow people to donate a kidney to a stranger, even though there is (for a healthy young person) a 1 in 3000 chance of dying as a result. But the health risks to challenge trial volunteers are much higher, especially when you factor in the possibility of organ damage and other debilitating conditions that are afflicting even young and healthy patients.92 Two Further Worries I now want to raise two further worries for the moral permissibility of challenge trials. First, we need to consider why so many people-often young adults-rush to volunteer for activities such as these trials when they arise. Part of the reason, I suspect, is that Western societies offer precious few opportunities in the normal course of life for the average person to contribute to something greater than themselves. We are told by parents, teachers, and our culture more broadly, to focus more or less exclusively on ourselves: work hard at school, get a good job that pays well 92 It is also not obvious that we should be allowing healthy young people to donate kidneys to strangers. 92 even if it contributes little of true value to society, all so we can raise a family of our own, and keep on making as much money as we can. In pursuing this path, many people feel a great dearth of meaning or purpose in their lives, not to mention a powerful disconnection from wider society and social networks. There is something problematic about allowing people to participate in risky vaccine trials who are volunteering only because they feel a dearth of meaning in their lives or a sense of social disconnection93, especially when they feel this way because we have failed to provide them with ways of helping others, and connecting with others, that are safer. By allowing them to volunteer, we reduce our incentives to improve the basic structures of our societies. By contrast, if we do not allow them to volunteer, we make a statement that we are committed to improving these structures. The second worry is that the benefits of such trials seem to be much smaller than most advocates claim. These advocates often say that such trials will save thousands (or even millions of lives). But this is exceedingly unlikely. The months that would be taken off the wait for a vaccine would come at the end of this wait (say, a year from now or longer), by which time our societies will have become much better at suppressing the virus and protecting citizens. Indeed, many countries outside the US have already reduced their case numbers to nearly zero using a combination of hard lockdowns, testing, and contact-tracing measures. The benefits of these trials would not be thousands of lives saved, but only a bit less time in lockdown. And not only this, the sort of lockdown we will be enduring a year from now is likely to be one that is far more relaxed than 93 To say that their volunteering is motivated in part by a dearth of meaning in their lives is consistent with acknowledging their altruism and praising them for it. 93 those we are used to at present, as we will become much better at relaxing lockdowns without sacrificing lives. Consider also that within the next year, we might discover an effective treatment or cure, in which case the benefits of an earlier vaccine might be smaller still.94 Is it really worth risking the long-term health, not to mention the lives, of trial volunteers-especially given the problems I've raised-for a smaller benefit like this one? Why Such Trials Might Be Permissible, After All Despite the concerns I have raised in this chapter, I believe such trials might be permissible, after all. Suppose that at some point in the future, our lockdowns have proven so effective that there is no longer enough of the virus still circulating in our communities for a normal vaccine testing process to yield a result. At such a point, we would face a choice between staying in various states of lockdown indefinitely (assuming we are unlikely to find a cure or treatment soon), and conducting these human challenge trials. At this point, it might be permissible to conduct these trials, because the alternative to doing so would be a permanent and substantial diminishment of our societies. Trial volunteers would then be truly analogous to our essential workers, needed to prevent a kind of societal collapse. If we found ourselves in this position, we could further reduce the morally problematic nature of these trials by making a public and concrete commitment to improve our societies in various ways once the pandemic is over-by reducing socio-economic disadvantage, improving people's 94 Though in this case, challenge trials would immediately become permissible, since we could treat subjects if they became ill. 94 options for contributing to society in a safe way, and making it easier for people to forge genuine and rewarding connections with people outside their nuclear families. Suppose this is right. Something else follows: if we immediately commit to properly locking down, testing, and contact-tracing, and then do these things, then we can conduct morally permissible human challenge trials in several months from now, when vaccines are ready to test. There is yet a further consequence. Suppose vaccines are ready to be tested now, but because of past failures to properly lock down, test, and contact-trace, there is still enough of the virus circulating in the community to test these vaccines in the normal way. At this point, it would still be true that if we immediately committed to properly locking down, testing, and contact-tracing, and then actually did these things, then we could permissibly conduct challenge trials in months from now. But now, given this, we might as well conduct such trials immediately. If we're going to do them (permissibly) in some months from now anyway, we might as well just do them now.95 The upshot? We can make challenge trials permissible, not only in several months from now, but immediately, by committing to properly locking down, testing, and contacttracing, and then actually carrying out these things. A second possible way in which challenge trials could be permissible is if the people responsible for the genesis or spread of the virus-i.e., government officials in China, the US, or the UK, or those who voted for them or have been pressuring governments to prematurely end lockdowns- volunteered, out of a sense of remorse. This might help 95 If we went ahead with the challenge trials, but then failed to make good on our commitment to lock down, test, and contact-trace, then it would turn out that our conducting them had not been morally permissible, after all. 95 these people to feel better about what they have done, and also be a valuable gesture to those who have suffered so badly from lockdowns or the pandemic more generally. China Suppose China goes ahead and conducts challenge vaccine trials for COVID-19 in a way that is unethical-say, by exerting great pressure on some of its citizens to participate in them, or forcing some (say, prisoners) to participate. Suppose its tests yield a safe and effective vaccine. Could Western countries permissibly make use of this vaccine? This is a hard question. I think it would depend on how well our own science was progressing. If we were likely to soon develop a safe and effective vaccine of our own using morally permissible testing methods, then we should refuse China's vaccine, given the way (in this hypothetical case) it was tested. But if our own prospects for developing a safe and effective vaccine were dim, then we might have most reason to accept China's offer of help, given that the morally dubious activities would have taken place already, and it might be important not to fall too far behind China. Conclusion In this chapter, I have argued that challenge trials for COVID-19 might be morally permissible, but not for the reasons most defenders have proposed. They might be permissible if we commit to effective lockdowns, testing, and contact-tracing, since these measures could result in there being too little of the virus left circulating in our communities for vaccines to be tested in the normal way. 96 7 Triage THE PANDEMIC HAS RESULTED in shortages not only of masks and other PPE, but of life-saving ventilators, ICU beds, dialysis machines, and trained staff to administer these. In times of such shortages, who should get the use of these precious resources?96 How, in other words, should we triage in COVID-19? There are two fundamental questions here: 1. If multiple patients are waiting for a ventilator to become available, who should get priority? 96 In what follows, I will talk mainly of ventilators, for the sake of simplicity. 97 2. When, if ever, should we take someone off a ventilator, allowing them to die, in order to give it to somebody else? I will consider these questions in turn. A brief note before I proceed. Readers not already acquainted with the philosophical literature on triage might find the following discussion uncomfortable. It can seem cold to think about, let alone make claims about, whether or how we should prioritise some patients over others. This is indeed a grim topic. But there is no escaping it in the present crisis. When hospital resources run out, clinicians need to decide whom to treat. The goal of this chapter is to help them do so in the best way possible. Ask The Patient? Some bioethicists believe that the first thing we should do when it becomes clear that a severely ill patient needs a ventilator (or might come soon to need one) is ask them whether they want to be considered for one given the shortages. For example, Savulescu et al write: When a competent patient presents with a diagnosis (e.g. viral pneumonia), they should be provided with the facts about the available treatments and given the opportunity to express their personal wishes, priorities and values. Requests may not be able to be accommodated, but competent refusals must be respected.97 97 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264035/. My emphasis. 98 Matthew Wynia goes so far as to say: "One thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients"98. But I do not agree with this. If we adopt such a policy, then we are likely to end up with some heroic young people in excellent health with their whole lives ahead of them refusing treatment. This must not be allowed to happen. A second problem is that asking patients whether they wish to be treated given the shortages puts some of them- especially older patients-in a terrible position, of feeling tremendous pressure to sacrifice themselves for complete strangers even though they desperately want to survive (not only for their own sake, but for that of their relatives). These people shouldn't have to face such a choice at a time like this. There is a further problem. Savulescu et al speak of "competent" patients in this context, but it is extremely doubtful whether anyone so ill with COVID-19 could count as competent in the relevant sense. When you are so ill, you cannot be cool, calm, and collected enough to autonomously authorise something as dire as a premature end to your own existence. It might be suggested that in the present crisis we should be asking all healthy people whether they want to make advance directives to refuse treatment if they get COVID19 and need a ventilator. The Save Other Souls (SOS) project proposes just this.99 Pittsburgher Darlene Freyer is one citizen who has decided to make such a directive. She says: 98 Quoted here: https://www.nytimes.com/2020/03/21/us/coronavirusmedical-rationing.html. 99 https://www.saveothersouls.org/sos-directive. 99 I've lived my life...I am willing to give up my ventilator to someone who still has a life to live...I don't want to take some college student's ventilator...I don't want to take some young mother with four children's ventilator.100 This is very noble. But it isn't necessary or desirable in the present context that people like Freyer should have to think about whether to make such directives. For many people, having to think about this would produce extreme anxiety, and they would feel great pressure to do so, despite having a very strong desire to live. Upsetting people in this way isn't worth it when we can develop a triage algorithm that ensures that very old people are not given priority over healthy young people. A further reason not to put people in this difficult situation is that we face shortages of ventilators only because of epic failures of government (both to prepare for a pandemic, and then to respond adequately). It is morally intolerable for governments to fail us in this way and then to ask for volunteers who are willing to sacrifice their lives. Governments must not be allowed out of this tight moral spot through voluntary sacrifices of some of our best citizens. That is not only inherently objectionable, but sets a dangerous precedent. Am I proposing that we forcibly treat some people? No. My claim is only that we shouldn't be actively soliciting people's preferences on this matter in the first place. If somebody, of their own initiative, and in a cool, calm frame of mind, decides that they do not want to be treated for COVID-19 given the shortages, then we should not force 100 http://medicalfutility.blogspot.com/2020/04/altruistic-living-wills-saveother.html. 100 treatment on them.101 Similarly, if someone has expressed a desire, prior to the pandemic, to not receive treatment for an illness if survival for them would mean ongoing breathing difficulties of the sort typical in patients who have recovered from COVID-19, then this might also justify our not treating them (depending on their prospects). But we should not go around asking people whether they are willing to sacrifice themselves for others. Savulescu's Algorithm According to Savulescu et al, after consulting the wishes of patients, doctors should determine a patient's Resource Adjusted Probability Ratio (RAPR). This is a figure that takes into account two factors: a patient's probability of surviving this particular stay in hospital, and the expected length of their treatment (or, more generally, the expected resource usage of their treatment). Savulescu et al write: Those whom clinicians are confident have a high probability of survival (and low resource use) should receive the life sustaining treatment...For example, this might be approximately >80% survival but the absolute threshold will be relative to the numbers of patients needing the life sustaining treatment resource and the availability of the resource at a time. In cases of extreme scarcity, it may be that only those with >90% chance of survival can be treated, while in health systems with greater resources relative to demand, the threshold could be lower. There is a big problem, however, with this proposal: there might be some patients who are only just below the relevant threshold-say, because their illness is somewhat more 101 Though if this is a healthy young person, we should try our hardest to talk them out of it. 101 progressed than others', or because they have certain preexisting conditions-but who are young and otherwise healthy, with their whole lives ahead of them if they survive. On the system proposed by Savulescu et al, such patients will be put behind all patients who are just above the threshold, including some who might be very old with only a few more years of life remaining. This is a very bad result. White's Algorithm A better system is proposed by White et al.102 On it, while a person's chance of survival is taken into account in determining who qualifies for the highest priority group, there is another factor to be taken into account as well: patients' likelihood of achieving longer-term survival based on the presence or absence of comorbid conditions that influence survival. Specifically, if somebody is likely to live for less than a year if they survive, then they are heavily deprioritised. If they are likely to live for only some period between one and five years, then they are also deprioritised, though not as much. This is an improvement on Savulescu et al, because it virtually prevents the possibility that a young and otherwise healthy patient with their whole life ahead of them will be placed behind elderly patients with few years left simply because the young person is slightly below some threshold. 102 "Allocation of Scarce Critical Care Resources During a Public Health Emergency", available as a supplement here: https://jamanetwork.com/journals/jama/fullarticle/2763953. 102 But, I think, it doesn't go far enough. It still leaves open the possibility of some healthy young patients being placed behind much older patients who have slightly more than 5 years remaining, purely on the grounds that the former have a slightly lower chance of surviving COVID-19.103 I do not claim that it could never be appropriate to prioritise a healthy older person over a young person whose chances of survival are lower. On the contrary, as we will see, I do think that this could be appropriate in certain cases. But White et al open the door for this to happen more often than it should. A Better Algorithm We can solve these worries by directly taking into account the expected number of years remaining for each patient. I propose a simple points-based system with only a single round of triage, where priority is given to those with more points. When it comes to expected years remaining, points should be allocated roughly like this: For each expected year remaining in their 20s, a patient receives 30 points. For each expected year remaining in their 30s, a patient receives 15 points. 103 Note that this is true even on White's option of using "3 priority categories based on patients' raw priority scores (e.g., high priority, intermediate priority, and low priority)" and having "life-cycle considerations" operate as a tiebreaker. Suppose you had the following two patients: Patient A (a 20-year-old, otherwise healthy individual, expected to live into old age, but with a SOFA score of 12 due to progression of illness) and Patient B (a 70-year-old expected to live to 80, but with a SOFA score of 11). White's system will prioritise Patient B. But this seems wrong, given the fine margin between them in SOFA scores, but the big gulf in expected years remaining. 103 For each expected year remaining in their 40s, a patient receives 10 points. For each expected year remaining in their 50s, a patient receives 8 points. For each expected year remaining in their 60s, a patient receives 4 points. For each expected year remaining in their 70s, a patient receives 3 points. For each expected year remaining in their 80s, a patient receives 2 points. For each expected year remaining in their 90s, a patient receives 1 point. The main reason that remaining years are worth more the earlier they occur in a person's life is that it is one's younger years that typically contribute most to one's ultimate level of lifetime well-being. For many people, it is their 20s, 30s, and to a lesser extent their 40s and 50s, that contain most of the most beneficial events and experiences of their lives (meeting friends and lovers, learning about or traveling the world, discovering music and art, experimenting with their lives and working out how they want to spend it, etc.). Note that in proposing these numbers, I am not claiming that people's 20s are in some sense twice as important for them as their 30s regardless of what happens during these years. I am generalising. In general, it is a much bigger harm to miss out on your 20s than your 30s, to miss out on your 30s than your 40s, to miss out on your 40s than your 50s, and so on. It is also worth emphasising that I am not saying that older people are in some sense worth less than younger people. On the contrary, I have taken pains during this book to emphasise their great and equal value. Note that there might be further considerations at play. We seem to have reason to prioritise a 20-year-old who is expected to live to 40 over a 40-year-old who is expected 104 to live to 60, other things equal. Part of this, I have claimed, is that it is one's 20s and 30s that tend to contain more of the most valuable events and experiences of one's life. But even if this wasn't the case, since the 20-year-old has had less time, an extra 20 years for them will likely add more to their lifetime well-being than an extra 20 years would add to the lifetime well-being of somebody who has already had 40 years. In addition, there might be a consideration of fairness at play. Since the 40-year-old has already had so much more, it might be fairer to save the life of the 20-year-old, who has not yet had a chance to experience their 20s and 30s. This might itself provide a reason here. I do not want to commit one way or the other on this. My key point is just that by allocating points in the way I propose we can arrive at intuitively correct outcomes when it comes to prioritising people in a system of triage. In a moment, I will give some examples to show how this framework is to be applied. But first I want to note something about life expectancies. There are many ways of calculating these. I propose to do so by looking only at the current health conditions of the patient that reduce life expectancy-say, cancer, diabetes, and so on.104 Doctors should ignore factors like race, socio-economic background, gender, and even family history. Now, to the examples. On my system: A 20-year-old who is expected to live to 80 receives 300 points + 150 + 100 + 80 + 40 + 30 = 700 points. A 45-year-old who is expected to live to 80 receives 50 points + 80 + 40 + 30 = 200 points. 104 Perhaps they should also take into account whether a person is a drinker, smoker, etc., given that these habits have a marked effect on life expectancy. But I am unsure about this. 105 A 65-year-old who is expected to live to 80 receives 20 points + 30 = 50 points. An 80-year-old who is expected to live for a few more years, say, receives 6 points. So, on my algorithm, if all other factors are equal (and we will come to these other factors shortly), these four patients are to be prioritised simply in order of age. This is intuitively the right result. Consider now some patients with health conditions that reduce life expectancy. So, suppose there is a 20-year-old patient who is expected to live only another 10 years (say, due to cancer). In this case, they receive 300 points all up. So, their level of priority (setting aside other factors) is roughly the same as a 37-year-old who is expected to live to 80. Or suppose there is a 20-year-old who is expected to live only another 5 years. They end up on 150 points, which gives them equal priority as a 50-year-old who is expected to live to 80. Or suppose there is a 20-year-old who is expected to live only 1 more year. They end up on 30 points, which gives them equal priority as a 70-year-old who is expected to live to 80. Or suppose we must decide between a 65-year-old who is expected to live to 80, and a 45-year-old who is expected to live to only 50. The 45-year-old receives 40 points. The 65-year-old receives 50 points. So, the 65-year-old receives priority (setting aside all other factors), but only just. Again, this seems like roughly the right result. It is hard to have especially clear or precise intuitions about who should be prioritised in these sort of matchups. But the priorities recommended by my proposed algorithm seem at least in the ballpark, which is enough for my 106 purposes here. It is enough to improve on the algorithms of Savulescu et al and White et al. We can improve my suggested point allocations further by considering further pairs of cases and reflecting on who, intuitively, should receive priority. It might be objected that this is all too complicated. There simply isn't time in an emergency setting to crunch numbers in this way. Emanuel, for example, writes: Limited time and information in a COVID-19 pandemic make it justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim. The latter becomes relevant only in comparing patients whose likelihood of survival is similar.105 This might be true in natural disaster scenarios, where huge numbers of patients arrive at the hospital at the same time. But in COVID-19, the arrival of severely ill patients at hospitals is far more gradual. And when ventilators are all in use, there will be plenty of time to crunch numbers while waiting for the next ventilator to become available. Let us now turn to some of the other factors to consider. Essential Workers We should give extra points to essential workers. This is not, as some have suggested, in order to make it more likely that they will return to work. If somebody is ill enough with COVID-19 to need ventilation, it is very unlikely that, if they recover, they will be well enough any time soon to return to work. It is rather because, as Emanuel et al. 105 https://www.nejm.org/doi/full/10.1056/nejmsb2005114. 107 note, it "recognizes their assumption of the high-risk work of saving others, and it may also discourage absenteeism"106. How should we prioritise such workers? One option would be to put them at the very top of the list (this seems to be preferred option of Emanuel et al). But if an essential worker is so progressed in their illness that they are unlikely to survive ventilation, then it might be preferable to give the ventilator to a young, healthy person instead. I propose we give extra points to essential workers in a way that boosts their priority status without putting them at the top of the list. For example, we could give emergency doctors and nurses an additional 100 points each. A healthy 65-year-old doctor, then, might go from 50 points to 150 points, almost in line with a healthy 45-year-old patient who is not an essential worker. What about other kinds of essential workers, whose risk status is lower but still significant (for example, bus drivers, food workers, cleaners, etc.)? We could give them 50 bonus points each. Parents of Dependent Children We should also give extra points to people with dependent children. If such people die, this will significantly damage the lives of others, in a direct and immediate way. Even if a parent who is ventilated and survives will be incapacitated to such an extent that they might have trouble carrying out their parental duties, their sheer survival (providing they are still able to enjoy a decent quality of life) will be so 106 https://www.nejm.org/doi/full/10.1056/nejmsb2005114. 108 valuable for their children that it justifies their receiving a boost in the algorithm. How many points? One suggestion is that we could give an extra 50 points for every child one has under 16, and then double points if one is a single parent. Socio-economic Disadvantage On my proposed algorithm, someone's having reduced life expectancy (due to some health condition) reduces their priority in triage. But this raises a serious worry. Many people with such conditions have them only because they have been subject to significant socio-economic disadvantage. It seems unfair to give less priority to people as a result of their having been victims of such disadvantage. The solution to this, I think, is to give extra points to the socio-economically disadvantaged. How should we do so? One way would be by looking at where the patient resides using a metric like the Area Deprivation Index (in the US)107, and giving extra points to those living in the most disadvantaged areas. Another way would be by looking at who is already registered for certain kinds of welfare payments. A third option would be to give extra points to people from races or ethnic groups whose life expectancy is 107 https://www.neighborhoodatlas.medicine.wisc.edu/. White et al propose something like this to correct for unfairness in allocations of remdesivir for COVID-19 (https://www.health.pa.gov/topics/disease/coronavirus/Pages/Guidance/E thical-Allocation-Framework.aspx). 109 lower than average (given that socio-economic disadvantage falls disproportionately on certain racial or ethnic groups). So, for example, in the US, average life expectancy is 79 years. For Black Americans, it is only 75 years, and for Native Americans, it is 77 years. So, using my numbers from above, we could give each Black American an extra 12 points, and each Native American an extra 6 points. Similarly, Indigenous Australians have 10 years less life expectancy than non-Indigenous Australians, so they could each receive 30 points extra. Giving extra points to people in these categories could also be a way of recognising that it is considerably harder for people in these categories to avoid exposure to COVID-19. Such people often live in overcrowded apartment buildings, or do not have access to private vehicles and so must use public transport to get around. Disability According to some bioethicists, people with disabilities that reduce life quality should have reduced priority in triage. This is to maximise benefits to patients. The idea is that someone without such a disability will gain more from survival, other things equal, than somebody with one. This suggestion has force when considering some of the more severe disabilities. Consider somebody whose mental age will always remain that of an infant, or who cannot communicate at all with the outside world, or who is in unrelenting pain with no hope of relief, but whose life expectancy is (somehow) still normal. If it is a choice between somebody in one of these predicaments, and a healthy person, we should choose the healthy person. 110 The trouble is that most disabilities are nowhere near as harmful as this. While many disabilities prevent various kinds of well-being-say, the pleasures of music for a deaf person, the pleasures of moving about for a quadriplegic, and so on-the vast majority of disabilities (including deafness and quadriplegia) are compatible with many significant kinds of well-being, and so with having a life that is not only well worth living, but rich and rewarding. It seems wrong to deprioritise people with disabilities like deafness and quadriplegia on the grounds that these disabilities reduce life quality.108 And since it is too hard to work out where to draw a line between these disabilities and the most severe ones, I propose that we do not reduce people's priority at all on the grounds that their disability reduces life quality. Note that my claim here is just that we should not deprioritise disabled people on grounds of life quality. It is still proper, on my algorithm, to deprioritise a disabled person if their disability reduces life expectancy. While the disabled are subject to discrimination, most disabilities are not the result of discrimination.109 This makes them relevantly different from health conditions of the socioeconomically disadvantaged that reduce life expectancy. It is, of course, unfortunate for disabled people whose disabilities reduce their life expectancy that they will have reduced priority. But this is also unfortunate for those who 108 This, I suspect, is because so many of these people can have rich and rewarding lives, or else because of various bad effects of doing so on the community (say, reinforcing harmful stereotypes of disabled people). 109 There are some disabilities that both reduce life expectancy and have social causes. I am thinking especially of certain kinds of mental illness. Perhaps people with these kinds of disabilities should receive extra points in order to correct for their disadvantage here. 111 have heart disease, diabetes, etc., but who are not members of socio-economically disadvantaged groups. Chance of Survival & Expected Length of Treatment Finally, we need to factor in a patient's chance of survival and expected length of treatment. How should we do so? Doctors, I believe, should determine each patients' chance of survival and expected length of treatment. They should then compare these with the average patient's chance of survival and expected length of treatment, and then apply this comparison to their total score from other factors. So, for example, a given patient might-due to having various health conditions or an especially progressed illness-be half as likely to survive as the average patient. In this case, we should halve their total number of points. If their treatment is likely to last twice as long as the average patients', then we should halve their points again. A patient whose chance of survival and expected length of treatment is the same as the average would simply remain on the same number of points they were on beforehand. To return to one of the examples from above, if you are a 20-year-old who, due to cancer, likely has only 10 years remaining, you are not an essential worker, a parent of dependant children, or from a disadvantaged group, then according to the calculations you will have 300 points. Now, suppose you much less likely to survive than most people-say, one tenth as likely to survive as the average patient. In this case, you would end up with 30 points. And if your expected length of treatment is, say, twice as long as average, then these points would be halved to 15. That's the same as a healthy 75 who has an average chance of 112 survival and likely length of treatment. Intuitively, this seems like roughly the right result. A Major Benefit A major benefit of this algorithm is that it can be carried out largely by triage officers, reducing the stress and emotional burden on doctors and nurses, and freeing them up to spend their time on treating patients. While doctors and nurses would be needed to calculate some of the inputs into the algorithm-for example, life expectancy, and likelihood of surviving COVID-19-these inputs could then be taken by triage officers who would crunch the numbers and determine the rankings of patients. When, If Ever, To Withdraw Treatment When, if ever, should we take someone off a ventilator, allowing them to die, in order to give it to somebody else? One time we should do this is when it becomes clear that the patient will not recover. Another time is when it becomes clear that if they do recover, it will be in a state they have indicated they would not want to survive in. But what if there is still some chance that a patient who is on a ventilator will recover, and in a state they'd be happy to live in (or at least haven't indicated they wouldn't be happy to live in), but this chance has dropped quite a bit since they went on the ventilator? At what point should we take them off? This is a difficult question. One possible answer is: we should take them off if their triage score, updated with their current chance of survival and expected length of 113 treatment, becomes lower than someone else's who is waiting. But this is wrong. If a patient has only just gone on a ventilator and then their score drops slightly, we shouldn't take them off again. This would be highly inefficient. Patients need to be given much more of a chance than this. Since removing someone from a ventilator can be hugely traumatic for the doctor or nurse who must do it, I suggest that we leave the question of whether and when to remove people from ventilators to these healthcare professionals. This is a burden on them, but the alternative seems worse. Conclusion In this chapter, I have tried to improve on the COVID-19 triage algorithms of Savulescu et al and White et al. My algorithm directly takes into account the expected number of years remaining for each patient. In this way, it offers a more fine-grained approach than these other algorithms, while delivering highly intuitive results. It would allow triage officers to do much of the job of determining which patients get priority, freeing up clinicians to focus on treating patients, as well as greatly reducing stress on them. 114 8 Onlookers COVID-19 HAS CAUSED widespread hardship. Many people have become severely ill or died. Many more have lost their jobs. Many more still have had to endure the deprivations of lockdown. But for some fortunate people COVID-19 has involved none of these costs. They have been able to work from home in nice environments-or are wealthy enough that they do not have to work at all during this time-and have never really been in danger of catching the virus110. For many of these people, there have even been 110 Either because they can get their groceries delivered and have no other important reasons to leave the house, or because they live in parts of the 115 some upsides to COVID-19. Some have been spared an unpleasant commute. Some have gotten to spend more time with their families. Some have had enough extra time to take up a hobby, catch up on their reading, etc. I will call these fortunate people onlookers.111 The question I want to ask in this chapter is: how should onlookers live and feel during the pandemic? Celebrity Partygoers I want to start by considering a particular kind of onlooker: the celebrity partygoer. During the pandemic, a number of celebrities have been caught partying or living it up.112 Some of these celebrities have breached lockdown or even quarantine, and so put others' lives at risk or set a bad example for fans or the general public. But the problem, intuitively, goes deeper. Even if they hadn't gotten caught or risked infecting others, there would still have been something 'off' about their behaviour. Intuitively, they shouldn't have been having such good times in the first place. Is this mere sour grapes? I don't think so. These people should not have been engaging in these activities for the same sort of reason that somebody attending a funeral should not be watching cat videos on their phone in the back row, even if they can be sure that nobody can see them. What is this reason? I will now try to explain it. world where the virus has not yet reached or where it has been effectively suppressed. 111 I owe this label to John Seymour, ANU College of Law. 112 For example, tennis players Novak Djokovic and Alexander Zverev: https://www.youtube.com/watch?v=EQ0cIwB1dUc, https://www.youtube.com/watch?v=f-6q68pfpzs. 116 An Explanation What concerns us about such people's behaviour, I think, is that it suggests they do not sufficiently understand or care about the suffering that is going on around them at this time. Somebody who truly understood what is happening in the world right now and how bad it is, and who was appropriately moved or concerned by it, would not want to party like this, in such a flashy or ostentatious fashion. Why is such a lack of understanding here so worrying? It is because it suggests a lack of interest in the condition of others or in the state of the world, which itself suggests a lack of concern. A lack of concern here is worrying because it suggests a deficiency in the sort of emotional capacities needed to truly flourish. While these people can 'live it up' in some sense, they cannot enjoy the deepest human relationships or the fullest appreciation of art, music, literature, and the wonders of human culture. Part of our concern here is a concern for these people themselves. But it goes beyond this. It is a concern also for the state (or the fate) of the world if many others are shallow like them. Implications This suggests a way of answering the question of how onlookers, more generally, should live and feel during the pandemic. To answer it, we should turn our minds to what those who properly understand what is going on in this crisis, and are appropriately moved or concerned by it, would be able to enjoy, and to what they would want to do. So, what would these people be able to enjoy and want to do? Here is one possible answer: Not much of anything right now. Knowing of others' suffering, these people could take 117 little or no pleasure in food, family, books, music, films, exercise, the beauties of nature, and so on. They might feel gloomy or solemn a lot of the time. They might even want to fast or deprive themselves of the basic comforts of life. This answer, though, seems wrong to me. It is not plausible that those who understand what is going on right now, and are appropriately moved by it, would feel like this. On the contrary, such understanding and concern is compatible with continuing to take joy in many parts of one's life, including food, family, natural beauty, etc. It's just that these enjoyments would be different during this time-not necessarily reduced in pleasurableness, but at least coloured in some way by one's awareness of the pandemic, and one's concern for those who are suffering. An onlooker who truly understands what is happening in the world right now, and is appropriately moved by it, and who happens to, say, live by a lovely beach in a remote location, might well take a stroll along that beach each day and take pleasure in that. But it wouldn't be the same sort of fully relaxed or carefree pleasure they might feel in normal times. It would be a mixed pleasure, one in some sense backgrounded by an awareness of the dire state of things elsewhere, pain at these far off events, and a sense of humility at themselves having been spared the worst of it. These onlookers might get married, give birth, celebrate New Years Eve, and so on, during the pandemic, but even at such times they wouldn't entirely forget what was happening in the rest of the world. This is not to say that they would necessarily be consciously thinking about it at these times. But some kind of awareness of it would be with them during all these significant life events and pleasures. They would remain, at such times, prone to becoming emotional if the topic of the pandemic came up, or some new terrible news broke. After reading the news of America 118 passing 100,000 deaths, or a story about children developing a Kawasaki-like syndrome from COVID-19, they would feel emotional in a way that would prevent other pleasures. They would not, at such times, feel like going to get a massage or find themselves starting to hum a jingle or the theme song of their favourite sitcom. While there are many activities and pleasures such onlookers could still enjoy, there are some they could not enjoy, or would not go in for, at any rate. Ginia Bellafante notes that in a time where beaches are closed and people would be "taken right out of the water", a number of wealthy New Yorkers are moving up the coast and building swimming pools.113 She says: The wealthy are not facing the indignity of getting fished out of the Atlantic. They have already situated themselves far from the urban shoreline-in New England, for instance, where I recently caught up with Steve Reale, the construction manager for a company called Custom Quality Pools. Mr. Reale builds expensive pools on Cape Cod and in Rhode Island, and he has been fielding approximately 30 inquiries about them a week, three times the number he usually receives at this point in the year. "It is everyone calling today for tomorrow," he told me. Similarly, Molly Osberg, writing for Jezebel, notes that: "Huge properties at the top of the market-think koi ponds, ranches, helipads-are going for onceunimaginable prices."114 113 https://www.nytimes.com/2020/05/22/nyregion/quarantine-richpools.html. 114 https://jezebel.com/lets-check-in-with-town-country-a-magazinewith-its-1844689313. 119 No one who properly understood and cared about what was happening in the world right now would be building luxury add-ons to their houses at the moment, or buying new ones. Further examples abound. Osberg quotes New York fashion writer Lynn Yaeger, who writes: At times like these, when the world feels as if it has gone crazy and the ground has shifted beneath our feet, we find ourselves reassessing what is really important to us...Here is what we know right now: If you love fashion, what you desire at the moment are clothes that present the kind of artistry and aesthetic brilliance that my plaid collar possesses-things that are worth acquiring, regardless of cost. Osberg goes on: [Town & Country Magazine] asks: "Bangles in a Pandemic?" The answer is, of course, yes. We meet a mother who has been thrilled to have a quiet moment with her family during their quarantine in Southampton and wants to memorialize it with gold, and another who is favoring a diamond necklace decorated with scorpions and bears to symbolize members of her family. "Women bought personal and symbolic jewelry to remember this moment," one says. A final case: An Israeli jewelry company is working on what it says will be the world's most expensive coronavirus mask, a gold, diamondencrusted face covering with a price tag of $1.5 million. The 18karat white gold mask will be decorated with 3,600 white and 120 black diamonds and fitted with top-rated N99 filters at the request of the buyer, said designer Isaac Levy.115 Onlookers who appreciated what was happening now would not be splashing out on such luxury items. Survivor's Guilt Some onlookers seem to be feeling a version of 'survivor's guilt'. That is, they feel in some sense bad about not having become ill, lost their jobs, or hating their lives in lockdown. As Nancy Keates writes in the Wall Street Journal: Guilt is a subject that is coming up a lot in therapists' offices around the country right now. Counselors say clients who can work from home are expressing discomfort with the dichotomy between the improvement in their lives during lockdown and the devastation caused by the coronavirus pandemic. They are asking themselves whether it is fair that they are not experiencing the same pain they are seeing in the news.116 She quotes Carla Marie Manly, a clinical psychologist in Santa Rosa, California, who says "Ninety percent of my clients who are doing well feel an edge of guilt". These feelings of guilt, I think, are mostly inappropriate. If one isn't emotionally affected by the thought of what others are enduring, then it isn't guilt one should be feeling, but rather concern about one's own capacity to flourish. And if one is suitably emotionally affected by the 115 https://abcnews.go.com/Weird/wireStory/israeli-jeweler-makes-15mgold-coronavirus-mask-72270494. 116 https://www.wsj.com/articles/guilt-is-powerful-for-those-doing-finein-the-lockdown-11590090101. 121 thought of others' suffering, then one shouldn't feel guilt at all. Note that while it is appropriate for onlookers to be emotionally affected by the suffering of others, it isn't appropriate for them to be so affected that they cannot function, or feel the sort of despair that those who are medically or economically affected by the virus might feel. For onlookers to feel such despair would be melodramatic, and to allow themselves to feel it is disrespectful. Schadenfreude It goes without saying that onlookers who understand what is going on right now, and care, would not experience schadenfreude-i.e., pleasure taken in the suffering of others. But might they still find what is happening right now in some sense fun or exciting? Josh Wilbur writes: Here's a little secret about the coronavirus crisis: If you and your loved ones are healthy and financially secure-for now-then some not-so-small part of you might just be enjoying this whole thing. Lazy days at home, ALL CAPS headlines, desolate parking lots, that warm-and-fuzzy-end-of-the-world feeling. The turmoil is thrilling from afar...These pandemic days flow by in waves of exhilaration and stillness. Who knew a trip to the grocery store could be so exciting? Bread-and-milk runs have become surgical raids: Sterilize the grocery cart with a disinfectant wipe, scout out the TP aisle, exchange sideways glances with the could-be infected, grab the essentials, and get the hell out of there. Later, as another news alert interrupts the Netflix stream, the group text explodes: "This is crazy," everyone says from their respective couches. Few hasten to add that crazy is also sort of fun...Human beings are fascinated by war, death, and calamity. Like disaster movies and combat sports and blood-soaked videogames, the coronavirus crisis scratches a deep-seated, rarely 122 acknowledged itch...The feeling of being in the midst of a real historical event is exhilarating. You'll tell your grandkids with pride, "I was there. I lived it. It was terrible." That you ate frozen pizzas for six weeks straight won't be mentioned.117 Wilbur adds that there's also a sense of solidarity or hopefulness that comes out of this calamity. We are all focused on a common enemy, and hope that some longterm good will come out of this. He writes: Every MAGA Trumper and Bernie Bro agrees, albeit for very different reasons, that American society is fundamentally broken. People are exhausted, overworked, and world-weary. Like draft day for a suffering sports team, our response to the pandemic represents a rebuild opportunity...Best of all, like John Lennon's revolution from bed but with a Slack-connected laptop, Americans can overturn the system while wearing their PJs. A different kind of change is in the air...In spite of our physical isolation, there's something nice about everyone paying attention to the same thing for once. Typically fractured into dozens of "national conversations," American public discourse is now rallied against a common, nonhuman enemy. It's the most coherent that our gossip and smalltalk has been in years. He concludes: In today's United States, a country seemingly in search of a mission statement, people yearn for excitement and meaning. Whatever its tragic costs, the coronavirus crisis offers both. I think that the feelings Wilbur describes here are consistent with a proper appreciation of what is going on 117 https://www.wired.com/story/coronavirus-cozy-catastrophe-americanssecretly-crave/. 123 in the world right now. Indeed, some of them are positively called for by it. Onlookers with a proper appreciation of current events can find today's events exciting, or even, on certain occasions, thrilling. But the key point is that they wouldn't find them only thrilling. They would, at other times, feel quite sad about what is happening. And even while they are feeling excitement, they would be prone to being overcome with sadness if more bad news breaks. Conclusion In this chapter, I have claimed that we can answer the question of how onlookers should live and feel during the pandemic by thinking about how onlookers who properly understood and cared about what is happening right now would live and feel. How would they live and feel? I have argued that they could still take pleasure in many things, but that these pleasures would have a different quality or character than they would have in normal times. Nonetheless, I said, there would be some activities these onlookers would not want to engage in-like, for example, ostentatious partying, building luxury add-ons to their homes, commissioning diamond-encrusted masks, etc. 124 Conclusion: Unlocking the Future COVID-19 SHOULD NEVER HAVE been allowed to happen. The live wildlife markets that gave rise to it should have been closed long ago. There should been a better monitoring system in place for potential new pandemics and greater transparency by China in December 2019 and January 2020. Countries like the US and UK should have banned all visitors and put in place effective quarantines for returning citizens much earlier on. After the failures to do all these things, countries like the US and UK should have had hard lockdowns in the first instance, accompanied by massive testing and contact-tracing measures. Their leaders should have tried to foster a culture of cloth maskwearing among citizens. Citizens should have been receiving adequate financial assistance during lockdown, and should have done a better job of staying home and observing lockdowns. 125 This is what should have happened. If it had happened, then the death tolls in the US and UK would be considerably lower than they are, and lockdowns would have been greatly relaxed and something like normal life resumed in many of these places, without the threat of further serious outbreaks, while the wait for a vaccine continues. When I say that all this should have happened, I do not mean only that it would have been better if it had happened. I mean that these parties could reasonably have been expected to do these things. Responsible people in their positions would have done them. These failures were morally culpable. Am I expecting too much? Am I speaking merely with the benefit of hindsight? No. These actions were all prescribed by leading experts at the time. At every stage, experts were saying do X in order to prevent the chance of catastrophe, but too many people ignored their words. It is not too much to ask-especially of policy-makers, whose primary job it is to protect us from dire threats-to prioritise preventing catastrophe, when the costs of doing so are so small by comparison. We all need to do a much better job of listening to and heeding the advice of experts, and erring on the side of caution in the face of existential threats.118 118 Speaking of which, a key lesson of COVID-19 is that we must urgently heed scientists' warnings on climate change. COVID-19 is our big wake up call on the climate. If you think COVID-19 is bad, wait until sea levels start to rise, major cities are flooded, and droughts cause mass famine and hundreds of millions of refugees. The big difference between past predictions of a new pandemic and ongoing predictions of catastrophic climate change is that scientists are far more confident in the latter. Unlike the pandemic, environmental catastrophe is virtually inevitable if we do not take immediate aversive action. 126 In the rest of this conclusion, I want to explain what I consider the Deep Moral Problem of the Pandemic, and then a Revolutionary Argument for how we should change things post-pandemic. The Deep Moral Problem of the Pandemic There is a further way in which we are morally responsible, not for the pandemic itself, but for its harmful effects. Even if (contrary to fact) the pandemic had been completely unpredictable, and unstoppable, and so we were not responsible for its occurrence, we would still have been morally responsible for many of its worst effects on people. This is because: 1. the reason the pandemic is so bad for so many people is that these people were vulnerable (medically or economically) in the first place, and 2. we are responsible for these people having been so vulnerable in these ways. Consider (1). It is largely because people already have preexisting conditions or are in poor health that they are likely to become so ill or die from COVID-19. And it is largely because people have a combination of little or no savings and ongoing financial obligations (such as rent, mortgages, or other debt) that losing their jobs right now can mean financial ruin. What about (2)? Despite countries like the US and UK being among the wealthiest in the history of human civilization, we have failed to safeguard the health of our citizens, allowing many of them to develop major health problems as a result of poor-quality work, housing, 127 healthcare, and dietary options. And we have failed to give all citizens reasonable opportunities to earn decent pay, own property, and accumulate wealth.119 In normal times-and if the pandemic had not occurred-any one of these vulnerable citizens could have suffered hardship equal to that which they are suffering now during the pandemic, if they had been unlucky enough to develop a new illness or lose their job. In that case, we would have been responsible for these people's hardship. And so, we are responsible for their hardship now. By allowing so many citizens to come to be in such precarious positions, we made ourselves responsible for any hardships befalling them as a result of sudden illness or job loss. In the pandemic, it just so happens that there is a mind-boggingly large amount of such illness and job loss, and a correspondingly huge amount of hardship from these sources. Therefore, we are responsible for it all. A Revolutionary Argument Up till now, I have been concerned with what we should be doing during the pandemic. In this final section, I want to explain how and why we should be changing things postpandemic. The pandemic has helped us to see just how dire things are for many citizens even in normal times. It has done so in virtue of the fact that so many people are still prepared to go to work in the pandemic despite the greatly increased risks of catching COVID-19. They are going to work because 119 For useful discussion, see: https://www.washingtonpost.com/outlook/2019/06/19/why-racialwealth-gap-persists-more-than-years-after-emancipation/, https://www.nytimes.com/2018/04/14/opinion/blacks-still-face-a-redline-on-housing.html. 128 otherwise they could not buy food, pay their rent, or keep their existing health insurance. This is a dire state, when your best option is to expose yourself and your family to a potentially lethal virus. But this is a state they were in even before the pandemic struck.120 Seeing how dire things are for so many people even in normal times reveals to us how important it is that, once the pandemic is over, we take actions to improve their lives. But suppose you do not accept this conclusion. You agree that things are dire for many people in normal times. But you don't think it follows that once the pandemic is over we must radically change things to improve their lives. In this case, I want to try a different way of talking you around, via what I call a Revolutionary Argument. This argument starts with some of the key claims I have made throughout the book about what we should be doing during the pandemic. It then moves to a conclusion about how and why we should change things post-pandemic. Here are the claims about what we should be doing during the pandemic: 120 Note also that such people are not simply badly off, they are trapped. If they had any ability to escape or improve their situations, they would surely exercise it now, during a pandemic. The fact that they cannot do so shows how little freedom to change or improve things they possess in normal times. And-it is worth emphasising-they did not wind up trapped in this way because of their own past mistakes, but simply because of lack of opportunity. For many, it was more or less inevitable that they would end up in this dire predicament they find themselves in. As we have seen, many opponents of lockdown denounce tyranny and champion the free society. But where is their concern for those who are so trapped that they feel compelled to continue to go to work even in a pandemic even if it means exposing themselves and their loved ones to a lethal virus? 129 1. While the virus is raging out of control, non-essential workers should not be allowed to go to work. Instead, we should be supporting them to stay at home. 2. Nobody should have to pay for healthcare for testing or treatment for COVID-19. 3. We should put in place postal voting to ensure that everyone has an opportunity to vote at this time. 4. We should give individuals and small businesses rent breaks or reductions, or prohibit evictions, at this time. 5. The wealthiest companies should be switching their production lines to things that are so badly needed but in short supply right now. 6. There are certain activities we shouldn't be engaging in right now given the extreme suffering of others. We shouldn't, for example, be holding flashy parties, building luxury houses, commissioning diamondencrusted masks, etc. I hope you agree that these claims are all highly plausible. Now, for a surprising claim: the reasons for which we should be doing these things for the sake of most people during the pandemic apply equally in normal times, to assist and protect a significant subset of us (including many socio-economically disadvantaged citizens). These reasons are exactly the same in kind. If you accept that the former exist, you must also accept that the latter exist. Start with (1). Why shouldn't non-essential workers be working right now? It is because of the health risks posed to them (as well as to others whom they might infect) by going to work right now. It is unacceptable that these people be exposed to such a risk of severe illness, death, or long-term health complications that might reduce their life quality in the long run or result in early death. 130 But now, many workers in normal times face equivalent risks from the work they do over the course of their lifetimes. While few face exposure to a killer virus, or even to much of a chance of dying on the job121, many have significantly increased risks of illness in the long run. These risks are due to, for example, prolonged standing or sitting, staring at screens, stress, boredom, lack of opportunity for creative expression or autonomy, repeated exposure to contaminants, job insecurity, and so on. The health conditions they face include hypertension, heart disease, cancer, musculoskeletal disorders, and mental illness.122 If it is unacceptable to allow most people during the pandemic to risk their health by going to work, then it is also unacceptable to allow so many workers in normal times to face equivalent risks by working their normal jobs. The solution, of course, is not to keep the latter workers at home in normal times, but simply to improve their working lives-say, by allowing them to work fewer hours for better pay, or in better conditions. Turn now to (2). Why shouldn't people today have to pay for healthcare due to COVID-19? Part of it is that the virus is so hard to avoid right now. And part of it is that the treatments are, for most people, prohibitively expensive. If people had to pay for these treatments right now, many wouldn't seek medical care when they should do so. It is inhumane to have a system that deters people from seeking treatment right now because of the high costs involved. 121 Due to occupational health and safety regulations. 122 For a brilliant summary of research conducted on the connections between low-quality work and health risks, see Sarah A. Burgard and Katherine Y. Lin's "Bad Jobs, Bad Health? How Work and Working Conditions Contribute to Health Disparities" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3813007/). 131 But now, in normal times, while there is no killer virus circulating (at least, not in wealthier countries), there are countless other health conditions that affect people more or less indiscriminately (through no fault of their own) and are for many people prohibitively expensive to treat. It follows that in normal times, we should be providing free healthcare to people for these conditions. To fail to do so is inhumane in precisely the same way that it is inhumane not to treat people who are sickened with COVID-19. Turn now to (3). Why should everyone have access to postal ballots at this time? It is because it is unacceptably burdensome right now to go to polling stations. But this is exactly the same sort of situation that a large subset of citizens face with respect to voting in normal times. They have to work, or look after children, or cannot drive, etc. So, in normal times, for the exact same reason, we should be making voting far easier for these people than it is-say, by increasing the number of polling stations, helping to drive people to stations, or improving access to postal ballots. Turn now to (4). Why should we give rent breaks or prohibit evictions during the pandemic? It is because the reason so many people cannot pay rent is that they have suffered job loss or illness through no fault of their own. But now, in normal times, it is also often the case that people cannot pay rent because of job losses or illness that is no fault of their own. We should assist them, too, then. This is not to say they should be allowed to stay on, rentfree, indefinitely. But greater assistance should be given.123 Turn now to (5). Why must companies help out in this time? It is because of the dire threats people are facing. 123 For further discussion, see Matthew Desmond's acclaimed book Evicted. (https://www.evictedbook.com/books/evicted-tr.) 132 But, as I've argued, many people in normal times are facing equivalently dire threats. These threats are partly workplace-related over the course of their lifetimes. But they go beyond this. People on low incomes are much less able to afford healthy food, housing that is near to green spaces, leisure time or holidays, good quality healthcare that allows them to get early diagnoses or treatments for health conditions, and so on. All of these things greatly increase one's chance of bad health problems later in life. Just as large private companies should be marshalling their resources now during the pandemic to contribute to preventing bad health outcomes for people, they should be doing much more in normal times to do so as well. How? The place to start would be by paying more taxes.124 Turn now to (6). Why shouldn't we be doing these sorts of things during the pandemic? It is because many others are suffering terribly right now through no fault of their own, which makes these activities 'off' or in bad taste. But in normal times many people throughout the world are suffering equally badly. They include not only the poorest citizens in countries like the US and UK, but many citizens of poorer countries. The suffering that exists in normal times, especially in poorer countries, is horrific. What is the upshot? Simply that it is in bad taste in normal times also to be building mansions, sailing on luxury yachts, buying helicopters, private jets, cars worth hundreds of thousands of dollars, and so on. In normal times, one can permissibly have some nice things, but there 124 For valuable discussion, see economist Joseph Stiglitz's 2014 White Paper: https://rooseveltinstitute.org/publications/reforming-taxation-topromote-growth-and-equity/. For a recent interview with Stiglitz on this topic, see: https://www.facebook.com/watch/?v=482133225814031. 133 is a point at which rampant consumerism becomes morally problematic.125 In summary, if you accept that non-essential workers should not have to work right now, then you should also accept that once the pandemic is over we should greatly improve the working lives of many of our citizens. If you accept that nobody should have to pay for healthcare for COVID-19, you should accept that healthcare should be free in normal times as well. If you accept that we should expand postal voting during COVID-19, you should accept that we should greatly improve people's access to voting in normal times as well. If you accept that individuals and small businesses should get rent breaks right now, then you should accept that we should be doing much more to help renters in normal times as well. If you accept that the wealthiest companies should be marshalling their resources right now to help with the pandemic, then you should accept that they should be paying much more in tax in normal times as well. If you accept that we shouldn't be splashing out on luxury goods right now, then you should accept that we shouldn't do so in normal times either. In all these cases, the reasons to do these things are the same. In normal times, life is, for a certain subset of the population, relevantly like how the pandemic is for most people today. If we should make sacrifices to help the latter today, then we should make sacrifices once the pandemic is over to help the former. If we do not do this, then we risk escaping the pandemic only to leave many of our citizens still trapped within something equivalently bad. 125 I won't attempt here to locate where exactly this point is.