Friday, February 12, 2021

"The Duty to Aid" and the Pandemic

7 years ago I published my article "Empirical Ethics and the Duty to Extend the "Biological Warranty Period" in the journal Social Philosophy and Policy (reprinted in Biologically Modified Justice).  In that article I examine extending Singer's principle of preventing bad occurrences (what I call the "duty to aid") to the predicament of aging and preventing late life morbidity and mortality.  

My goal in doing so was to draw attention to the reality that biological aging itself possesses the most significant public health threat to the world's aging populations (something that is still true today, even with the current pandemic).  

I think it is fair to say that the topic of aging, and its health implications and the science of biogerontology, are all pretty much non-existent topics and concerns in philosophical debates about ethics and political philosophy.  I have tried my best to redress this situation within the discipline for well over a decade now, but there is significant inertia coming from many fronts.  And then along came the pandemic of 2020, which I thought might help open the discipline's eyes to the biological realities of today's aging populations.        

The arrival of the COVID-19 pandemic in early 2020 posed a real challenge for the discipline as philosophers scrambled to figure out what morality and justice requires with respect to this pandemic.  The vast majority of COVID-19 fatalities are among older persons (in the US over 80% of COVID-19 deaths occur among persons age 65 and older), and yet many of the strictest public health measures proposed to limit the spread of the virus (such as closing schools, stay-at-home orders, banning travel, etc.) have imposed significant health and economic burdens on the whole population, but especially the young (age 20 and younger) who face minimal health risks from the virus itself.  

The discipline's neglect of real-world empirical insights- such as the prevalence of other causes of preventative deaths worldwide, the reality of multi-morbidity in late life, and the fact that there is a biological limit to the human lifespan- has resulted (IMHO) with distorted moral analyses of this pandemic.  I have seen commentators invoking general appeals to "saving lives at all costs", as if, prior to this pandemic, no one in the world ever died from preventable causes of death!  Such commentators do not seem aware of the fact that there are nearly 10 million cancer deaths each year1.6 million diabetes deaths per year, 1.35 million deaths each year from traffic accidents, 400 000 deaths per year from malaria, 700 000 deaths from HIV, and 800 000 people commit suicide each year.  These total more than 7 times the number of COVID-19 deaths in 2020.  Our response to this pandemic must be placed in the context of these other realities vs being treated in isolation from them.  

Now if one had their head buried in the sand about these other global problems, which are ALL causes of death for people much younger than COVID-19, and then in 2020 when one took their head out of the sand and read the headlines about COVID-19 they could easily form the false impression that it was the leading, or perhaps even only, pressing cause of death for humans.  This "perception of reality" distortion will thus lead to a distorted moral analysis of the moral landscape as the former will be consumed by a concern to only prevent COVID-19 mortality.  

So if we don't want to tackle the issue of pandemic ethics from this "head in the sand prior to 2020 perspective", where might we begin?  I believe the analysis of the duty to aid I advanced in my 2014 article is a good starting point.  It advances an "operational level" analysis of the duty to aid, one which rejects ageism but also takes seriously key empirical concerns that many have ignored in our public health response to this pandemic.

When it comes to aging and longevity I have noticed two polarized extreme positions, and I believe both are morally objectionable (but the "default" setting for many people's moral intuitions).  The first extreme attitude is the one I have faced for 15 years of my research on these topics- the ageist view that there is no moral duty to extend (healthy) life because (a) there are too many people in the world already, OR (b) in a world with early and mid-life mortality we shouldn't give any attention to tackling late life morbidity or mortality, OR (c) extending life would mean less jobs for younger people OR (d) aging is "natural" OR (e) people live too long already, etc. (there are more versions but these are the most common ones I encounter).  

Until the year 2020 (a)-(e) were the most prevalent attitudes I would hear from students and other academics.  

But since the outbreak of the pandemic in 2020 the pendulum has swung in the opposite direction, but so far it has gone to the extreme end.  Now it is not uncommon to hear people say "We should do everything possible to save lives!", even if this means indefinite stay-at-home orders for healthy people, cancelling school for children, violating basic individual rights and freedoms (including the right to protest), massive unemployment, increased risks of obesity, mental illness, delays in screening and other medical appointments, increases in suicides, more drug addictions, and potential economic ruin from unmanageable government debt. 

Witnessing the train wreck of the public health response to this pandemic, coupled by the emotive and mostly ill-informed public discussion and debate on this topic on social media and print media/TV has really driven home to me how important the "intellectual virtues" are, like paying attention to the relevant details, exercising the detective's virtues, and having intellectual humility.  

Below I reproduce a few paragraphs from my 2014 article, that seem more relevant than ever given this pandemic.  It tries to steer us to the mean between the ageist view which disregards the moral equality of all and the fanatical commitment to save lives regardless of the prospects of success, or costs/burdens doing so imposes on others.  During the pandemic governments have struggled to find this mean between the COVID-deniers and the strict lock-down enthusiasts.  The details of the argument in that paper make the case for this judicious middle ground approach:  

Return again to Singer’s example of the drowning child. Instead of the young child drowning in a pond, let us now imagine that it is 60 years into the future from Singer’s imagined drowning example. The child is now a 65 year-old adult, in fact she is a grandmother, and has returned to the very same pond where she almost drowned 60 years earlier. She has brought her grandson with her, to enjoy a picnic lunch and explore the pond. While chasing tadpoles with her grandson in the pond, the grandmother slips on a rock and hits her head. She now lays unconscious at the bottom of the shallow pond that nearly took her life 60 years earlier. You are walking by the pond and hear the grandsons’ pleas for someone to help his grandmother (he is not strong enough to rescue her). What do you do?

I shall assume that most readers share my conviction that we should aid the drowning grandmother. Furthermore, I believe the stringency of the duty to aid in this example is very pressing, and of equal strength to the imperative to help her when she was a child. The urgency to prevent suffering and death does not dissipate, or even severely diminish, simply because the grandmother is now older than she was 60 years earlier. She still deserves to be treated as a moral equal to other persons, her chronological age does not erode this status as an equal. She, like all of us, has interests, aspirations and goals that are worthy of respect and consideration. Thus we ought, if it is within our power to prevent something bad from happening without sacrificing something of comparable moral importance, to aid her.

This modified version of Singer’s drowning example illustrates the point that the age of the person in need of assistance by itself has no ethical relevance in the drowning example. The person who saves drowning children, but is unmoved to aid drowning grandparents, acts unethically. Their actions are “ageist”. Robert Butler, the first director of the NIH’s National Institutes of Aging, coined the term ‘‘ageism’’ in 1969,16 which means a systematic stereotyping of, and discrimination against, people because they are old. Ageism violates the humanist conviction that all persons’ interests matter, and they matter equally. The age of a person in need, just like the nationality of those in need, has no ethical significance.

However, it is important to note that, at the operational level of implementing DA in practice, the age of those in need of assistance can be relevant as age often functions as a proxy for estimating the “expected utility” (or benefits) of an intervention and this can be a relevant consideration when the resources available to aid those in need are insufficient to redress all preventable suffering and death in the world.

Recall that modified DA ("DA" means the "duty to aid") has the stipulation the greater the benefits of preventing something very bad from happening, all else being equal, the greater the moral duty to prevent the bad in question. But all else is not necessarily equal, and this reality means that the duty to aid cannot be simply partitioned into serially ordered duties, with the duty to save children having lexical priority over the duty to prevent suffering, disease and death late in life. We must attend to both kinds of harm, and the stringency of the duty to prevent the risks associated with premature death should depend upon the considerations which modified DA stipulates (e.g., the probability that non-intervention will result in harm, the probability that intervention be successful, the cost of intervention, and the magnitude of the benefits of intervention).