This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Click here to watch the full recording of this session and find all of our previous COVID-19 webinars and recaps here.
To set up our discussion of COVID-19 as it pertains to ethics, I’m going to speak to a few historical examples and then touch on what I call the “three R's” of ethics in epidemics: restrictions on liberty; issues around resource allocation; and responsibilities (both the professional responsibilities of doctors and nurses, but also the responsibilities of politicians, scientists, and researchers). These are also three important guiding values ─ and I certainly recognize there are more, but for today we’ll stick to three ─ which include proportionality, reciprocity, and duties. This framework offers us a way of thinking through some of these questions around epidemics.
We’re going to skip the 1918 influenza pandemic, which has been frequently compared to COVID, and instead look at behavior around other disease outbreaks throughout history. One example is Hansen’s disease (commonly known as leprosy), which affects your sense of feeling and you get areas of skin that have no sensation of pain. The bridge of the nose often collapses, creating what is sometimes called a Leonine face, or a face that looks like a lion’s face.
Leprosy is a paradigm for the many ways in which we manage epidemics that scare us. It was common in Europe in the 10th-13th centuries, with infection rates higher among the poor due to living conditions. People in Spain who developed leprosy were declared legally dead. In Norway, those who developed it had to wear a cowbell around their neck. The disease was concentrated in underserved communities among those who were potentially malnourished or had other co-morbid conditions. And so, people with Hansen's disease were often portrayed as being unclean. Often, they would be refused entrance to hospitals. They were stigmatized and set aside from the rest of the community. And of course, we are seeing many of these same types of dynamics now. The coronavirus is clearly hitting the poorer communities and racial minority communities where people live closer together because of socioeconomic circumstance.
The idea that a pandemic would exacerbate underlying inequalities is something that we have worried about for a long time. The wealthy people will be the first to get it, but they would certainly not get it the worst. There was a recent story about Mexico's wealthy residents coming to Vail and then bringing the pandemic back to Mexico. The first COVID death in the U.S. was in Santa Clara County, California, which is one of the top-10 wealthiest counties in the nation. A Los Angeles Times reporter was telling me recently that their first cases occurred in Beverly Hills. But it very rapidly spread into the communities that are more disenfranchised.
The second historical piece that I want to mention is the personal protective equipment that people used during the plagues. Many of you will probably have seen images of the plague doctor's robe made of muslin cloth dipped in wax and the famous beak-like face mask. That beak would be filled with rags that had been soaked in herbs or other things. This was believed to be the best way to filter the bad humors, which were thought to be what transmitted the plague. Ironically, as is true today, there were people who pushed back against the idea of wearing protective equipment. One of the priests in Italy who would visit people to do their last rites wore the robe because it was recommended, but wrote that he thought it was useless against the plague. The only thing it does, he said, is drape all the way down to the ground and keeps the fleas off. And of course, fleas are what actually transmitted the plague.
The plague is often referenced when talking about choosing how and when to restrict individual liberties in order to protect a community. This was the time when the whole idea of quarantine came about. The word quarantine comes from the Italian quaranta giorni, which is the 40 days that ships had to be kept in the harbor before passengers were allowed to disembark. So we are seeing now these same kinds of debates and deliberations about the extent to which it's acceptable to require ─ or even to strongly recommend ─ that people stay home or that people self-quarantine or that people wear personal protective equipment. Today, we're asking people to wear a mask not so much to protect themselves, but to protect others if they have an asymptomatic case. It’s to prevent them from coughing or sneezing or even talking or singing or shouting and having that lead to additional cases. And we're seeing a lot of pushback on these for a variety of reasons which I'll come back to.
There have been deliberations over the years about when is it acceptable for public health authorities to use what are called coercive public health measures to require people who are ill to go into isolation and to require that people wear face masks. The Siracusa Principles came out of a conference of health law and public health scholars and practitioners in Italy in the 1980s. These principles established the notion that coercive measures must be both legitimate and effective. These measures must fit into the legal framework of your country and must actually be necessary for the achievement of the public health goal. This was sort of a reaction to strongman dictators who were implementing things like martial law or crackdowns ostensibly because of a threat to the national security or public health when in fact they were just mechanisms to seize control of a country. And of course, that concern remains today that leaders would use public health threats as a way to cement authority. These international principles are remarkably similar, by the way, to US Constitutional principles requiring that if the state is going to implement some kind of a restrictive measure, that measure needs to be the least-restrictive means necessary, it must serve a compelling interest, and there must be due process.
One of the ways in which these ideas are discussed in public health ethics is as the “principle of proportionality.” This is the idea of not using a sledgehammer when a flyswatter will do, or not using a chainsaw when a pocketknife will do. It comes up a lot in discussions about restricting liberties. It also comes up when talking about resource allocation issues. Don't start to triage people if you don't actually need to, and be constantly aware of the evolving resource constraints. You want to try to ensure that the people making triage decisions, if it ever came to that, would be aware of where resources are. The last thing you want is for people in hospital A to think that we're all out of ventilators when in fact there are ventilators available at hospital B just a few miles away. We saw this play out during Hurricane Katrina when a number of patients who were initially told that they were not going to survive a triage situation ended up surviving when new resources arrived. There’s a need for excellent situational awareness and repeated re-assessments as a situation develops.
This gets us to the question of how you would allocate resources in the event that there were a real shortage. For example, would you give any preference to people who are healthcare workers? Should a healthcare worker caring for COVID patients get preference in receiving a ventilator if there aren’t enough for everyone? I’ll lay out some arguments for and against this. There’s the idea of reciprocity, that people who have taken an extra risk should also get some extra benefit. There's a sort of implicit contract there, that if you're going to continue a job that’s very risky and you fall ill, you should get some benefit. The other argument is what's called the multiplier effect, or the idea that if you are a healthcare worker, your survival can actually help other people survive. If you save one healthcare worker, that might end up saving additional lives later.
There are a number of arguments against, too, starting with the question of how you define a healthcare worker. And how do you know whether someone got ill while they were on the job? How do you separate out healthcare workers from other first responders like policeman or firefighters or even people forced to work in supermarkets or meatpacking plants? There’s also the idea that healthcare professionals already sit in a position of relative privilege in our community. [Editor’s note: In a poll, over 50% of the live audience responded that healthcare workers should get some preference, but only as a tiebreaker.]
The poll results reflect what’s currently on the books for the state of Colorado. If we ever needed to triage, we would first look at clinical factors. But if there's a tie between two or three or five people and one of them got the illness as a result of their work, that person would get some preference. This has been very controversial nationally. There are states that have done what we've done and there are states that have very explicitly said there will be no preference given to healthcare workers.
When it comes to rationing, we often oversimplify. We say that in a lifeboat situation, where you only have a certain number of seats in the lifeboat, you should just save the most lives and all other ethical considerations get shoved to the side. There are a number of potential problems with that, starting with the practical problem of: How do you know who's most likely to survive? For COVID-19, our capacity to predict who's going to survive and who's not is not very good. So it's difficult for us to use just clinical criteria to decide. And when we talk about saving lives, do we mean the people who will survive for the next six weeks or the next six months or the next year or the most life years? Should a 20-year-old and a 60-year-old who both have the same likelihood of surviving the immediate illness get the same consideration?
There's a lot of debate about these issues. Some have even talked about looking at productive or quality life years. I would say most of us in the ethics field have argued against that, especially the idea that someone in medical care would get to determine someone else's quality of life and decide that quality of life is not worth saving. We know from history where that kind of thinking can lead. But what about, say, “women and children first?” That's a very traditional way of deciding who gets in the lifeboat. What about “first come, first served?” In that case, you basically use the resource until you're done and then when people arrive, you just say sorry, we ran out. That could be a real problem if it turns out that the first people who show up are already the privileged people in society. What about the ability to pay? Which is, after all, how we allocate many things in our society. In the United States, people who could pay more often get more access, and if that is not how we want to distribute things in a pandemic, then we're going to have to specifically organize the triage processes to avoid that kind of thing.
The main point I want to make is that while saving the most lives is important, it is also important to remember these other principles, including things like proportionality, equity, protecting the most vulnerable, and looking at the hardest hit communities. In trying to figure out how to make sure that resources are getting to those communities, the notion of reciprocity comes up, the notion of protecting the continuation of a good society. How do we make sure that in the process of doing triage, we don't destroy social trust and end up making decisions which lead for people to mistrust the healthcare system?
There’s also the question of personal liberty and protecting the community. To pose a provocative question, I’ll ask: If you are choosing not to wear a mask and you were to get sick, should you be put to the back of the line for critical care during a shortage? [Editor’s note: By a 54-46% margin, the live audience responded that those not wearing masks should have the same chance at a ventilator as everyone else.]
So we’re roughly split here, but this poll result lines up with our traditional ethic. Right now, in the healthcare system, we do not punish people for bad choices that they make. There are people who choose to ride a motorcycle without wearing a helmet. When they show up to the emergency room with a traumatic head injury, we don’t say, “Well, you know, that was your choice. You have to live with it.” We allow people to make bad decisions in this country and many of us think it is a fundamental human right to make bad health decisions and not be punished for it. But this has been a real question that people have asked. The biggest difference between COVID and the motorcycle example is that there's not usually a shortage of care resources for motorcycle accidents.
The issue of balancing public safety and personal liberty seems very stark. Back in the AIDS era, many in the public health field viewed them as radically distinct. But I will say that more nuanced understandings of this have arisen in the years since and the reality is that sometimes implementation of public safety measures in an enforcement type of way can actually backfire. I'll give you a couple of examples. During the SARS outbreak in 2003, there was a rumor that the city of Beijing was about to be quarantined. It didn’t end up happening, but 245,000 migrant workers fled the city anyway. A quarantine is supposed to keep the disease in that area, but if implementing a forcible quarantine causes people to disperse out into the local communities, that is a quarantine that backfires. Similarly, one of the initial hotspots of SARS was Hong Kong's Amoy Gardens apartment complex. They implemented quarantine, but when the police arrived to enforce it, half of the apartments were completely empty. In many instances, perhaps counter-intuitively, voluntary quarantines have actually proven to be more effective than enforced ones.
Similarly, how could a recommendation to wear a mask backfire? Well, if you try to force people to do it, you will get some people who say, “You can’t make me wear a mask, that's an infringement of my personal liberty,” and the consequences of that have been far-reaching. It’s a major problem when a reasonable action comes to be seen as taking a side in a political argument, as opposed to stemming from a shared understanding of what’s reasonable and responsible. Layered on top of that, we have mistrust of authority and the polarization of our country, plus the value that we place on personal liberties in the United States and, you add all this together and you can imagine some people being told to wear a mask and it causes them to enter a defensive crouch. What we're seeing now from some is a refusal to cooperate on principle, out of defensiveness of their personal identity and political affiliation.
Inconsistent communication doesn’t help, either. We’ve obviously had inconsistent messaging from the top, but it’s not just the administration to blame. The CDC actually recommended against wearing face masks for the general public at first. The reason they did that is because, first, we had a mask shortage and second, we didn't realize early on how effective masks are at preventing transmission. But here’s an illustration of how effective masks can be. There were two hairstylists in Missouri, who were both infected with COVID-19. They saw 140 clients between them, but they and their clients all wore masks. We all know how close someone gets to you when they cut your hair, and yet not a single one of their clients got infected. So we see pretty vividly that face masks work, primarily to prevent transmission. I like to think that every time we have a pandemic, we learn more about how best to manage these kinds of situations and improve as a community going forward.
Lightning Round: Questions from Viewers
Has there been any national polling around attitudes on critical care for non-mask wearers in the event of a shortage?
I have not seen any polling around it, but I would reiterate that it would be extremely contrary to the current fundamentals of medical ethics to say that anyone should be punished for making a bad healthcare decision. And I think even the folks who have recommended that path have essentially backed off from enforcement. The most you might be able to do would be to persuade people that if they’re not going to wear a mask, then they should volunteer to forego a ventilator or ICU treatment if they get sick. That’s what’s sometimes known as a Ulysses contract, referring to the mythology of when Ulysses had his crew tie him to the mast of the ship as they sailed past the Sirens and instructed them keep him there no matter what he said or did to the contrary. But in practice, it would be difficult to enforce that, too.
There has been some talk of “immunity passports” for those who’ve had the disease and recovered. What do you think about the implications there?
An immunity passport implies that there is immunity to begin with, and that’s still somewhat of an open question. Recent studies suggest that just a couple months after having had a documented infection, many people lose their antibodies. That doesn't necessarily mean they completely lose immunity, but it’s a possibility. As with a number of other coronaviruses, you could get this more than once. So the first question is whether immunity means enough to bother trying to work out a passport system. Second, the best estimate for the state is that maybe 2 – 4 percent of Coloradans have had COVID. That leaves a huge percentage of the population that’s still susceptible. So right now, it’s hard to envision that a passport would matter that much.
But if you were to try and implement one, there would be a lot of concerns about stigma and discrimination. Plus, if the passport conveys economic benefits of some kind, you could envision people intentionally infecting themselves at COVID parties and that could be very damaging. That said, there's been a disproportionate burden from this illness on minority and disenfranchised communities and if that's the case, those are going to be the first people to get immunity passports. I actually think it'd be okay to give that financial benefit to the communities that have been hardest hit so far. There’s a lot left to be worked out, though.
Do you think if there had been clearer messaging from leaders from the start, there would be less resistance to mask wearing?
The importance of consistent communication from leadership really cannot be overstated. Hong Kong and the U.S. had their initial cases at about the same time in late February. Hong Kong and New York City have similar population sizes. But Hong Kong lived through SARS and they were scared to death of it. When this virus came, the government was all over it. At the protests in the streets, everyone wore masks. 99% of people in Hong Kong in surveys said they wear a mask every time they go out in public. Hong Kong has had something like nine deaths. Nine. New York has had over 20,000.
Singapore, South Korea, Germany, New Zealand: there are a number of countries around the world that took it very seriously from the onset. And they still have flare ups too, so they're not immune. But their experience has been so dramatically different from ours, and it's partly because the public took it seriously from the beginning. The reason the public takes it seriously is in part because the leaders took it seriously as well.
How do you reconcile the uncertainty of science with making policy decisions in real time?
In research, the way we move things forward is by questioning the status quo, so we thrive on uncertainty. But of course, that's very disconcerting when you get outside of science, especially when you get into policymaking where people really want to know for sure that what they're doing is going to work. It's a completely understandable human impulse. And yet, it is irreconcilable with the reality of the world. Early on, the CDC recommended that the public not buy masks and not wear masks and they made that recommendation in good faith. But that was based on the facts as they knew them at that time. We needed to save them for the doctors and nurses, and we weren’t sure how effective a cloth mask was.
Those facts have since changed. A cloth mask made at home is actually OK. It’s not great, it's not an N95 mask, and it's not going to protect you from getting it from someone else. But it is absolutely good for preventing you from giving it to others. So everyone ought to be wearing a mask right now. That was a big switch.
In one sense, it's kind of heartening that so many politicians on both sides of the aisle say they are following the science. They're not all really doing it, to my mind, but the fact that they all say they are is probably a good thing, because it does mean there's the possibility of coming to a consensus about where the science is.
But science is also about values. You end up making trade-offs and those trade-offs are not pure science, like we were talking about earlier with triage protocols. Being explicit about those values and trade-offs is how we ensure that we are living in a world that we want to live in. Most of us don’t want to live in a purely utilitarian world where if someone isn't contributing enough, they get killed. That's a terrible world. So we need a world in which we balance efficiency and effectiveness with things like respect, equity, reciprocity, and proportionality.
Director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.
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