Emergency, Values and Evidence: How Applied Ethics Can Help in Making Very Difficult Decisions

This first issue of Etikk i praksis – Nordic Journal of Applied Ethics for the year 2020 comes out amidst the havoc caused by the global spread of COVID-19. The outbreak started in Wuhan, China on December 12, 2019 (Peng Zhou et al. 2020) and has infected millions after five months of rapid spreading. Societies around the world implemented quarantine measures and public health interventions – such as safe physical distancing, closing schools, churches and places where the public could gather – in order to slow down transmission of the new coronavirus SARS-CoV-2. The World Health Organization declared it a global pandemic on the 12^th of March 2020. The growing number of cases caused by the new coronavirus threatened to overwhelm healthcare systems, so it became urgent to slow down transmission to a level that was within the capacity of those systems. Quarantine measures suppressed the surge but still many lives were lost. These measures unavoidably slowed down economic activity, and many lost their jobs as businesses were forced to close down. The price of oil plunged and stock markets were pummelled. Many big cities that used to be choked by extreme pollution have experienced unprecedented clean air. Flights around the world were brought to a virtual halt. The world did not avoid flying to slow down pollution as environmental activists like Greta Thunberg urged many to do for the sake of future generations. Air travel stopped instead for the urgent reason of slowing down the spread of COVID-19.

Slowing down the spread of SARS-CoV-2 is undeniably the most urgent health emergency that the world has acted on since the last global influenza pandemic of 1918-1919 killed at least 50 million people and infected 500 million worldwide (U.S. Centers for Disease Control and Prevention 2020). It is of imminent importance to prevent avoidable illness, suffering and deaths due to COVID-19. Public health strategies are necessary to prevent surges and the further spread of the new coronavirus. While some measures remain controversial, such as the decision in many countries to close down schools even for the smallest children, some degree of isolation and quarantine, social distancing measures such as gathering bans, the cancellation of public events, and restricted transportation seem strictly necessary (Hastings Center 2020).

On the other hand, drastic measures to stop the spread of the virus may have serious negative impacts, for instance by slowing the economy and causing massive unemployment. In Norway, the unemployment rate in March reached 14.7%. The rate compares to 2.3% in the month before, and is the highest recorded unemployment rate in the country (Solsvik 2020). On March 19, the Bank of America “officially declared” that the US economy had fallen into depression (Stevens 2020). In Sweden, almost 14,000 employees were given redundancy notice between March 16 and 22, which compares to just over 3,000 for the whole month of March 2019 (Arbetsförmedlingen 2020). These are just a few examples of how national economies are affected by the virus and the measures taken against it. The most dramatic consequences, however, are likely to be felt by poorer countries (Harvey 2020, WFP 2020), and the long-term impacts on the national and global economies have yet to be seen.

 
The challenges of isolation and working from home that is required by the quarantine measures can also affect mental health. Protecting people’s psychological well-being is very important, but the risks of quarantine may be necessary in order to protect our healthcare systems and prevent the avoidable deaths that could result if the system collapses from an uncontrolled surge.

Viewing health and economic considerations as competing concerns is ethically problematic. Still, we sometimes have to triage them, for example when economic considerations prevent us from offering equal treatment to all, or when shorter term public health and safety measures have long-term effects on economic activity (which might in turn affect the health and well-being of present and future people). Deciding which of the competing concerns to give more weight to is not an easy choice. The field of applied ethics has generated a number of tools for making reasoned choices between competing values, such as conceptual analysis, critical reasoning and moral evaluation. We may analyse what reciprocity means or specify what harm is when we talk about balancing harms and benefits; examine what evidence is required to establish claims about effectiveness of quarantine measures; or discuss what it means to trade off essential goods such as the freedom to publicly gather in groups without following infection control measures in place to protect life and health. Using the tools of applied ethics requires sensitivity to facts and attention to the best evidence available. This may also require taking reasonable precautions when the risks are great despite the absence of definitive evidence.

The nature of the public health emergency brought about by the global COVID-19 pandemic has shifted the value focus of healthcare professionals from patient-centred considerations of respect for individual autonomy to that of social justice and concern for fairness in the distribution of risks and benefits. The classic harm principle that limits individual liberty directs healthcare providers to reasonably restrict patient’s freedom when this freedom threatens harm to others. A patient showing symptoms of COVID-19 must self-isolate even if it is against her preference. In a similar manner, public health officers are legally empowered by their societies to impose restrictions on individuals to move freely for the sake of preventing harm to the collective, including to the individual whose movement is restricted.   

Healthcare professionals in hospitals around the world that have experienced the greatest surge of COVID-19 cases faced tragic decisions in triaging sick patients. When the number of staff, personal protective equipment (PPE), medicines and medical devices are less than the number of patients needing treatment, these care providers have to make difficult decisions (Frakt 2020) that may cause them moral distress (White & Lo 2020).

It is for this reason that applied ethicists need to go beyond merely practising impassioned reasoning in addressing the challenges of ethical decision-making in a pandemic. Ethicists who are equipped with interdisciplinary knowledge and skills need to engage the virtues of compassion, courage and integrity. Healthcare ethicists have the opportunity to provide moral distress support to their traumatized clinical colleagues in addition to providing expert ethical decision-making guidance and policy advice (Hamric & Epstein 2017). Academic ethicists have the opportunity to help untangle conceptual and logical confusion amidst the chaos of the pandemic.    

The need for making careful, evidence-based ethical decisions is particularly acute as societies plan to reopen following months of quarantine and restricted economic activities. Among other essential things, there must be clear evidence that sufficient testing, effective contact tracing measures, supported self-isolation and healthcare system readiness are in place to allow reopening safely (Allen et al. 2020). If these essential safety measures are not ready it would be unethical, if not reckless, to reopen. We can employ the decision tools of conceptual analysis, critical reasoning about values and evidence, and moral evaluation in making these difficult decisions collectively and with sufficient stakeholder engagement. 

This open issue of the Nordic Journal of Applied Ethics consists of four papers that discuss topics covering vaccination, sustainability, development ethics research and family ethics.

The first article of the issue is entitled Mandatory childhood vaccination: Should Norway follow? In the article, Espen Gamlund, Karl Erik Müller, Kathrine Knarvik Paquet, and Carl Tollef Solberg discuss whether Norway should follow countries such as France and Italy in making their childhood vaccination programmes mandatory. The authors give a brief history of vaccines and the current Norwegian childhood vaccination programme, and then go on to discuss the most central arguments against mandatory childhood vaccination: the argument from the standpoints of parental rights, bodily integrity, naturalness, mistrust and immunisation coverage. Next, they examine the central arguments in favour of mandatory childhood vaccination from the standpoints of harm, herd immunity and as a precautionary strategy. The paper concludes that there are convincing moral arguments in favour of adopting a policy of mandatory childhood vaccination in Norway.

In the second article, Staying within planetary boundaries as a premise for sustainability: On the responsibility to address counteracting sustainable development goals, Heidi Rapp Nilsen takes a fresh look at this well-known concept of sustainability. Nilsen adopts the framing of environment, society and economy and notes the widely acknowledged claim that environmental sustainability is essential to establishing societal and economic sustainability. This paper addresses the gap in discussions about the competing dynamics between these three sustainability pillars and the assumed connection between them expressed in the sustainable development goals of the United Nations. By conceptual analysis, the reinforcing links, as well as competing goals, of these three kinds of sustainability are explored. Examples of how to apply the proposed method of analysis on research and development at different levels are presented, such as on the level of project development at the global level of the United Nations. The main goal of the discussion is to motivate responsibility in tracking the timing and manner in which competition between sustainability goals occurs. The author proposes to do this by identifying specific ways the global ecological system boundaries are violated together with the harms that result from trading off environmental sustainability. Another proposed step is drawn from the guidance provided by the Norwegian National Research Ethics Committee, which proposes the inclusion of research findings about how planetary boundaries are breached and the damaging effects of such breaches on human safety.

 
In the third article, Using Insights in Sen’s Capability Approach to Overcome Design and Execution Challenges in Empirical Development Ethics Research, Almas Mazigo & Johan Hattingh discuss how Sen’s capability approach (CA) can offer helpful guidance to development ethicists in the design and execution of empirical methods in development ethics research. This demonstrates another example of how empirical methods can be combined with ethical reflection (Alvarez 2001). Engagement with relevant stakeholders fills the information gap about the assumptions we make regarding what these stakeholders may believe or value. The reflections on and assessments of stakeholders’ actual individual and collective values, capacities, roles and interests in the fisheries sector in Tanzania’s Ukerewe District contribute to understanding the context and are an example of how stakeholder engagement enriches ethical analysis. These stakeholders are better positioned to unpack the nature and causes of the poverty of small-scale fishers and what is required to overcome these deficits. The stakeholders improve their understanding of the cause and prevalence of institutional and professional apathy towards poverty, and collaborate on what they think should be done to address the challenges small-scale fishers face. Empirical data enhance the moral reflection by enabling robust theorising about the changes that can be made to alleviate this specific type of poverty and about the relevant ethical reflection appropriate for guiding future actions to reduce poverty and increase the wellbeing of fishing communities in the Ukerewe District.

Finally, Marcus William Hunt, in his article What grounds special treatment between siblings?, proposes a theory of why siblings ought to treat one another in ways that they need not treat others. The paper begins by presenting intuitive judgments about how siblings ought to treat one another – for example, that they ought to have relationships with each other’s children, provide financial aid in certain situations, and offer advice to one another about various aspects of their lives. The author then discusses three theories that might explain the judgments, adapted from the literature on filial piety: the gratitude theory, the friendship theory, and the special goods theory. He argues that these theories fail to explain some of the central intuitive judgments. He proposes instead a familial belonging theory, which starts with the idea that the institution of the family has certain goals that impose normative demands on family members. It is suggested that one such goal is that every member feel familial belonging towards every other member – a goal which according to the author grounds the ways in which siblings ought to treat one another specially.

This issue includes Espen Dyrnes Stabell’s review of the recently published book Finance or Food? The Role of Cultures, Values and Ethics in Land Use Negotiations, edited by Hilde Bjørkhaug, Philip McMichael and Bruce Muirhead. Toronto: University of Toronto Press.