Living in China at this time feels weird. International flights are grounded. Stores are shut. A city with 15 million people closed all civilian roads, railways and airstrips to the outside. Wearing masks is legally compulsory. Checkpoints for body temperature sprung up on the streets, outside buildings, inside supermarkets. Local police & security guards stand by the gates of residential compounds, turning away visitors and take-outs alike. And a 14-day quarantine for anyone who returned from other cities. Even my diehard pro-CCP grandma started voicing her concerns on social media.
I understand. Radical measures for a radical time. In just three months, what started as a local outburst of 40 patients has turned into a global pandemic of 80,000+ confirmed diagnoses, killing 2000+ people in the process so far and wrecking the global economy hundreds of billions of dollars.
And it is a difficult one to contain too. COVID-19 transmits through airborne droplets, faecal-oral contacts, even aerosols. What’s more, the disease has a 14-day incubation period, making early patients challenging to detect. And when thousands of new patients suddenly show up daily at the local hospitals, even a normally functioning medical system begins cracking up. The highly infectious nature of the virus poses severe challenges to disease control in China and around the world. Containing the virus is a priority. But still, one may wonder if emergency policies set dangerous precedents, if crucial considerations are overlooked, if what’s done is absolutely necessary.
This is when I think of my Oxford armchair ethicist dons. A highly intelligent breed, the armchair ethicists often deem it sufficient for the pursuit of moral truth to sit in a chair (though not always with armrests), just read and think. They seek to address the grand challenges of human existing and make a job from topics that people only usually talk about after a few shots – the purpose of life, the existence of god, the fabric of reality, the basis of moral maxims.
Emmanuel Kant is popularly alleged to have never left the city of Konigsberg in his lifetime. It is not true; Kant did briefly teach in Groß-Arnsdorf in today’s Poland 145 km away from Konigsberg. The contemporary sedentary ethicists are not much different. They may travel between conferences and events, but the bulk of their work is done in libraries, offices, bedrooms, and through deciphering, synthesising, analysing, criticising texts written by other fellow armchair ethicists. And, when challenged about the fruitfulness of their work, most of them – or at least those studying practical ethics – protest that it is them who discover the intricacies of human choices and provide considered guidance on trekking the moral path. To those who say ethical theories are useless, the ethicists say only bad theories fail to guide actions; the good ones do.
The popular prefix ‘armchair’ to ‘ethicists’ perhaps implies a false notion of ease with what ethicists do. Mathematicians work similarly to ethicists in many ways – an inquiry of truths by sitting in libraries with pen and paper. Yet few scold them for being ‘armchair mathematicians’. Valuable moral insights can be sharpened from consistent exercises of sharpening moral concepts, entertaining moral scenarios, drawing morally relevant distinctions, debating theories with colleagues. One does not become a pianist by simply pressing a few keys, or a French speaker by mumbling ‘bonjour’. Similarly, one does not become an ethicist by just speaking in sentences containing ‘rights’ and ‘freedom’; it takes consistent training to acquire the expertise. That’s not to say an ‘armchair’ approach to ethics is perfect. A deep connection with the real world is crucial to ethics. However, it is important not to overlook the unique skillset ethicists have.
Ethicists are no strangers to health and medicine. Occasionally, they even get blamed for the spread of virus. In 1666, the Bishop of London accused Thomas Hobbes in Parliament of being the primary cause of the Great Plague (and the Great Fire too), as the atheistic theology of the Leviathan allegedly brought London punishment from God. The Parliament conducted an enquiry in the House of Lords with some bishops desiring to burn him as a heretic. For a while, popular parodies and ballads (the trolls of the time) described Hobbes in hell.
For most part of history, ethicists tried to help with biomedical issues. The Hippocratic Oath has centuries of refinement from ethicists and continues to be sworn by medical students around the world. The contemporary discipline of bioethics began post-WW2 as the world tried to grasp the horrifying reality of Nazis’ medical experiments on Jews. With rapid advances in modern medicine and civil rights movements, bioethics became increasingly relevant in the 20th century not just on the traditional issues of doctor-patient relations or the sanctity of bodies, but the moral dos-and-don’ts of disruptive biomedical technologies. Meanwhile, repeated epidemic outbreaks – of HIV, smallpox, plague, cholera, Nipah virus, etc. – gave rise to the field of global public health and a plethora of moral issues in dealing with public health crises.
In the post-SARS era of early 2000s, the WHO began preparing the world for a Spanish-flu-scale influenza pandemic. This is when pandemic preparedness and responsebegan appearing on the ethical agenda. In 2005, the International Health Regulations became legally binding for governments around the world, obligating WHO member states to collectively control the international spread of diseases. In 2007, the WHO published the ‘Ethical Considerations in Developing A Public Health Response to Pandemic Influenza’, the first official guideline for leaders around the world to incorporate ethical considerations of welfare, equity and liberty in domestic pandemic preparedness plans.
The 2014 Ebola outbreak in West Africa and 2015 Zika outbreak in Brazil kindled a new wave of ethicists working on pandemic response. The PREVENT Working Group from Johns Hopkins University is particularly noteworthy. In previous outbreaks, emergency vaccine R&D often neglected the needs of pregnant. During the Ebola outbreak, the WHO refused to inject experimental vaccines on pregnant women, despite the disproportionately high risks that unimmunised pregnant women face with Ebola (up to 90% infected pregnant women died, and nearly 100% pregnancies of Ebola-infected women ended in miscarriage or neonatal death). To address the needs of pregnant women in vaccine R&D for epidemic threats, PREVENT hosts an diverse group of scientists, public health scholars and academic ethicists to develop a pregnant-woman-friendly pandemic response guidance for researchers and policy-makers around the world. Their reports bring to light a high-impact neglected area in global pandemic response and demonstrates the power of academic ethics when combined with expert technical knowledge.
So how might armchair ethicists help the fight against the current COVID-19 outbreak? From past lessons, two things are particularly important. First, ethicists need to be adequately informed of the facts of the epidemic. Second, ethicists need to take part in public advocacy and policy-making.
According to the World Health Organization, the core pillars of pandemic emergency response include disease surveillance, disease anticipation, emergency measures and recovery. To fight a virus, governments must be able to firstly detect virus cases, secondly use surveillance data to anticipate future trends (typically through a computer model), thirdly implement policies to contain the anticipated epidemic, and lastly mobilise resources to heal social and economic damages. There are intricate moral issues in each step, demanding answers from trained ethicists.
Medical surveillance is a hotbed of moral contentions. While some see its necessity for health and security, others argue against it to protect privacy, fight discrimination and prevent the abuse of political and corporate power. Failing to report known infections is now a legal offense in some parts of China. Body temperature checks are now so ubiquitous in China that one could hardly open a door in public without pausing for examinations. A recent report tracked a COVID-19 patient who escaped from Wuhan with her home address and identity publicly shown in the article. The Shenzhen government even published detailed information on patients and their inter-relations. The names were hidden, but still the way the authority currently collects medical data elicits an intuitive ethical uneasiness. The Hippocratic tradition of patient confidentiality seems to be under-attack. What are the reasonable expectations of medical privacy during a pandemic? How to maintain human dignity while collecting health information? How to justify mass-scale medical surveillance on healthy citizens? When is it ethically permissible to target certain groups in health checks? These are just some the ethical puzzles of medical surveillance for pandemic response.
Once data are collected, the next step is modelling analysis. Here, a different set of moral conundrums is at play. In the age of big data, the output of computer programmes is the gold standard for evidence-based decision-making. However, it is wise to be cautious of the computer’s ability to produce both inaccuracies and biases.
In the early days of COVID-19, epidemiologists from the Imperial College London used a sample of just three detected COVID-19 cases outside China to infer the size of the outbreak in China. They concluded there were somewhere between 1,700 and 2,300 infections, a result repeatedly quoted by domestic and international media, citing ‘computer modelling’ as a proof of credibility. Yet, how fragile a conclusion about China it was if it rests on a mere three non-China cases. In their defence, the epidemiologists had their hands tied because the Chinese government refused to publish data at the time. However, poor input means poor predictions. And when tentative results hide behind an authoritative veil of mathematical objectivity, to the non-technical science-loving public, it is as good as truth. It is important to be cautious with computer evidence.
Besides, a computer program trained in an unequal, biased world is likely to produce algorithmic biases. In our world, black Africans with low incomes are much more likely to get sick on infectious diseases than rich Europeans. This means, for example, a computer program may recommend insurance companies to deny or charge premiums on people based on social characteristics of income, race, ethnicity, etc. And think of James Watson, the Nobel laureate in biology, who claimed black people statistically have lower IQs than white people. It fed into an existing ‘racial science’ literature whose facts are dubious and interpretations hold little water. During a pandemic, similar claims on the virologic dispositions of certain ‘peoples’ may come up too. Few scientific results are devoid of political significance. Practitioners may speak in the name of facts, but ethicists should seize the interpretation. The ethicists are in no position to tell epidemiologists how to make more accurate epidemic models. Nonetheless, ethicists should alarm modellers against jumping to conclusions too soon, at least before systemic biases are cleansed.
After policymakers have data and predictions, emergency response measures are the next to consider. This is where things are perhaps most impactful and complex. During a pandemic, a whole city may be locked down for the infection of a tiny fraction of the population; countries may deny the movement of people based on their geography; citizens may be arrested for refusing to wear masks or have their body temperature checked; returning travellers may be banned from entering their own home and instead be subject to a compulsory quarantine; patients may be forced to undergo treatment. These are extraordinary policies all currently happening in China. When a virus spreads at a fast pace on a large scale, even the usually abhorrent options of compulsory social distancing start to gain traction and become reality. Extreme precedents set in emergencies will send ripples to public policy for the years to come.
Containing the virus is hugely important. But the world would be a dark place if it holds off the virus only to find itself battling a rising political authority tramping on rights and encroaching freedom all in the name of health. Trained in the normative issues of welfare, freedom, rights, duties, justice and power, the ethicists have a unique position in highlighting the moral loss in an at-all-cost approach to public policy. As so often, the right way is the middle way – between doing nothing and doing all we possibly can. Some policy options should remain ruled out even in an emergency. Public policy and legal scholars will have their take. The ethicists should help highlight the normative arguments to aid the deliberative process.
Once the emergency passes, recovery begins. Halted industries will resume production. Families will grapple with the reality of losing their loved ones. Citizens will need to again see each other as fellow human beings rather than the wary loci of diseases. How should society reward heroes, punish villains and create a more robust disease control system to do better next time? How should rich countries work together to assist the poor ones where the damage of pandemics is often disproportionately large? Where are apologies due in the process, and to whom? These are questions demanding an ethicist’s answer.
Emergency recovery is when policymakers implement corrective and preventive measures to move on from the relics of crisis. Sometimes, emergency measures get to stay. The income tax was initially introduced in Britain and the US to fight wars; yet when wars ended, the taxes remained. As the society resets social norms post-crisis, the powerful will be tempted to maintain their new-found emergency power posthumously.
Of course, not all emergency measures need to go. During the current outbreak, R&D agencies in China began forming alliances to further the innovation of drugs, vaccines and diagnostics for the disease. That network infrastructure will be still useful in peacetime. But the public should stay alert when politicians begin tightening surveillance regimes and expanding legal powers, all in the name of health. The 2020 federal budget for national defence in the US is $750 billion, enough to cover anything tangential to ‘national security’, and more. In a post-pandemic reality, public health may be elevated to the status of national security. Power abhors vacuum. Left unchallenged, the authority will find it convenient to normalise the use of medical quarantines, racial profiling, arrests and many other emergency powers as part of the routine governance toolkit. The social scientists may fact-check politicians, but it is the ethicists who are trained to morally call them out.
It is important for ethicists of diverse background to contribute their expertise. The bioethicists may be familiar with medical privacy, but are less specialised in jurisprudence. Similarly, the political theorists may highlight the distributive duties of rich nations towards the poor ones, but have little idea about computer algorithmic biases. Responding a pandemic requires a whole-of-society approach. It is important to involve ethicists from a broad walk of topics.
And ethicists can’t do it alone either. Their specialisation is in normative arguments, in talking about right and wrong, and not (usually) in virology, epidemiology, legal theories, public policy, vaccination, NGOs, and the many related fields. To present an informed and useful voice, an interdisciplinary group of actors must fill each other’s gaps. If united, such a diverse group of experts will provide powerful insights across a spectrum of angles, ensuring that pandemic response avoids patching up one hole and exploding another. Instead of leaving public health reforms for public health practitioners only, governing bodies around the world should actively promote diversity in pandemic policy deliberations.
Imagine bankers were asked to reform the British financial system post-2008 or the military to restructure the British army post-WW2. Of course, they had valuable insights, but from a limited domain and with skewed incentives towards promoting their own profession. The same is true whenever a group is instructed to propose reform on itself. To be clear, public health practitioners are not bankers or military generals. Their work around the world has saved hundreds of millions of lives, and they continue to be some of the most selfless, skilled and reliable forces in keeping the world healthy. In fact, the dedication and professionalism of public health may well qualify them for a dominant role in the post-pandemic policy forum. But still, the forum must contain diverse voices to respond to challenges beyond public health.
In the past, the WHO has routinely involved multidisciplinary forums with a strong presence of ethicists in forming rules and conventions. However, the same approach is not always replicated at country levels. This week, I saw a list of experts invited by the Chinese government to propose reform to the disease control system in China. Those invited are almost exclusively epidemiologists and health officials, with a handful trained in public policy. Policy-makers are unlikely think of WHO ethics guidelines when making decisions; it is difficult enough to even get states comply with the supposedly legally binding International Health Regulations. If ethicists are missing from national level policy-making processes, they will risk being shelved in the ivory tower of academia no matter how much wonderful work ethicists produce.
Missing the voice of ethicists is a loss for the society. Technocracy reaches its limit when the issue is no longer technical but ethical, when the question is not how to stop the virus but what sort of society we ought to live in. We all want the virus gone. But people also want to be free, be prosperous, be respected, be secure from arbitrary laws, be able to lead a meaningful life. These are not epidemiological, but moral questions. Ethicists have a role to play.
I do not sit in my room and pray that ethicists will save the day against the virus. Frontline healthcare workers and public health practitioners will do a much better job. But I do wish to see ethicists speaking up in public and through policy-making channels, to slam the brakes on when technocracy goes too far. Giving up liberty for security is a constant theme of human civilisation; that is not new from COVID-19. However, when the same trade-off comes back, it takes a different form each time. The ethicists must grapple with new facts and respond to the new moral battle.
Ethical theories need to guide actions. The time is now.
The author is an ex-PPE student at Oxford, currently working on public health in Beijing.