If you have to choose between killing one person to save the lives of 5 others, and doing nothing even though you knew that 5 people would die as a result of you doing nothing – what would you do? What would be the right thing to do? That is the hypothetical scenario that is becoming more relevant in today’s society and is a moral & ethical dilemma that most nations are facing when deciding on what policies to implement in the COVID world.
Side-line observation tells me that the pandemic strategies our government has been employing since our first lockdown a year ago were a mixture of Utilitarian and non-utilitarian approaches. In the case of a pandemic, utilitarian policies focus on looking after younger, healthy people as it’s most likely to produce the best outcomes. Non-utilitarian approaches focus on protecting everyone equally, it’s not just about the consequences but rights, duties and obligations. Now, the reason that I’m exploring this is so that I can make some sense of the decisions that the government is making and why there is an ever-increasing division within the society. It is not intending to criticise the government’s approach to pandemic management, however, what I’m trying to achieve is to figure out which option will do the best overall not just for individuals but also for society as a whole.
As much as we would like to believe we are living in a society, where all people are equal and deserve equal rights and opportunities, there seem to be no egalitarians in a pandemic. The scale of the challenge the pandemic created for our healthcare system means that there is an ineluctable need to prioritise the needs of many due to the lack of resources. Take the capacity of our ICUs and the availability of ventilators for an example of a moral dilemma that the frontline staff in the hospital are facing. What if, knowing that there are only 10 ventilators available but there are 11 patients admitted who require its use. How would you decide who should get the treatment?
In a situation where money and resources are abundantly available, the argument is simple – everyone has an equal right to access ventilators, and therefore it is wrong to prioritise some over others. We cannot simply abandon our most vulnerable to save more lives, right? Yes, that is very true and should always be our goal to strive towards. However, does the ‘non-utilitarian approach still apply when resources are scarce? At some point, people will have to think about how they can do the best with the limited resources they have, and that means prioritising those people who have the best chance of recovering and living a long and healthy life. Although we are lucky enough to not need to make such dire decisions of who gets a ventilator or not, our government is very well aware that we do not have the necessary resource to cope if a widespread pandemic occurs. This explains the adaptation of a more or less ‘utilitarian’ approach when distributing medical resources like medicines and PPE. However, when it comes to deploying the lockdown strategy, a non-utilitarian approach was at the forefront. The logic to this approach is rather easy to understand: The decision of going into lockdown was purely based on the fact that not only do we need to prevent the number of infection cases and mortality rates from rising but also our healthcare system cannot cope if a widespread community transmission is present. At the initial phase of the pandemic, such strategy makes a lot of sense and it did serve its purpose in controlling the transmission rate within the community while preventing our already stretched healthcare system from overloading.
Some of you might ask, considering that the case-fatality rates of COVID-19 are sitting globally at around 2% (in comparison to 1% of the influenza virus), and the hospitalisation rate and death rates heavily skewed towards those 85 years and older Then why do policymakers still believe reducing and suppressing the number of cases and case-fatality rates should be the end game we all strive towards? Even at the expense of 5 million people’s freedom and putting the economy on the line for a virus that can be detrimental to a smaller group of the population? Not to mention the repercussions of the lockdown on our mental health and wellbeing. One of the reasons being is that we do not have enough information to know how the virus behaves over time. And time has proven that virus mutation does exist and hence a more contagious delta strain emerged earlier this year. The second reason is that we did not have the vaccination available to us for protection. We all know that there is nothing utilitarian in the lockdown approach at all. However, it is the best strategy available at the time to cope with the pandemic. Hence, the need to sacrifice the many to protect the minority.
So how should countries decide when to implement stringent social restrictions, balancing preventing deaths from COVID-19 with causing deaths and reductions in well-being from the cause of lockdowns? I have to reiterate that I’m not trying to argue that utilitarianism is the only relevant ethical theory, or in favour of a non-utilitarian approach. What I do believe in is that each approach has its place in time and the government should be fluid enough about the approaches they use depending on the given situation.
One of the determinant factors on deciding on the type of approach that policymakers consider when making decisions that affect the nation is a cost-effective analysis. It is extremely likely the government has run their numbers in terms of the cost of letting the virus spread freely in the community versus the cost of implementing strict lockdowns hoping to stomp out the virus. At the initial phase of the pandemic, it makes so much sense that a short burst of lockdown may be the answer that we are looking for before a mass vaccination to protect the population becomes available. It does not cause a significant impact on our economy while at the same time stamping out the virus to reduce the burden on our already stretched healthcare system and reducing the ongoing cost involved with managing and treating patients with COVID. The strategy did prove its success where we did enjoy a fair bit of time in level 1 last year after the success of the initial level 4 lockdown. However, is this still relevant when the virus can no longer be contained or stomped out?
Unfortunately, the amount of money spent on maintaining our economy during the lockdowns, while not forward-thinking to revamp our healthcare system with the necessary resources to cope with the pandemic– really, this leaves us with not much of an option but to carry on lockdown until the majority of us are vaccinated.
Ever since the government announced the rollout of the COVID-19 vaccination program, I’ve been pondering this question – could we have done this more efficiently? Have we missed the crucial window to vaccinate that would have allowed us to avoid the lockdown we are in at the moment? Being a front-line healthcare professional, seeing first-hand how our healthcare system operated during the pandemic, and the kind of resistance and bureaucracy that I’m seeing in action, yes, we could have done a lot better. However, in hindsight, being a small country at the bottom of the world and with limited financial capability in comparison to mega countries, maybe that is the reason why we are still in lockdown, maybe we have already done the best we can. Who knows?
Hindsight is 20/20. What makes it powerful is that it allows us to make better decisions for the future. There is no doubt that minimising the loss of lives due to COVID-19 is important. Equally, if not, more important, is the well-being of all people – both with and without COVID-19 – which must be balanced and should not be dismissed. There is huge attention to quantifying the number of cases of COVID-19 infection and the number of consequent deaths. However, our government should also place more attention to the possible consequences of lockdown measures for everyone. There is no doubt that lockdown measures themselves will have a direct effect on morbidity and mortality due to the denial and delay of medical treatments. The tremendous amount of pressure and stress generated by the lockdown will have a long-term effect on people’s mental health the many years to come. Besides the direct implication on our health and wellbeing, lockdown measures also have indirect effects through an economic recession. We simply do not know the number of job losses with associated loss of well-being and death.
Policy is often driven by politics or popular options, not ethics. Choosing an appropriate approach is not an easy task regardless of whether it is utilitarian or non-utilitarian. It requires that we choose the best course of action that will benefit the majority of the population to the greatest degree. There is no doubt that there will be a minority of people who would rather bear the consequences of their own decisions than to comply. However, those in the minority must be safeguarded by the policy that protects them as much as possible with full transparency so that they can be as autonomous as possible. I agree that no matter what approach the government takes, there is no win in the court of public opinion. However, what the pandemic has taught us in the last 20 months is that successive governments have neglected our healthcare and hospital systems for decades, sequentially explaining why our health system cannot cope with the burden that the pandemic has created. We have also observed significant mismanagement, injustice, and infringements of rights over the past 12 months which resulted in a divided nation. Sometimes is easy to put our own agenda forward while neglecting people’s wellbeing and their right to autonomy. That is why it is more important than ever that our government must fill the gap of effective management that was missing throughout the pandemic and start making decisions by not only taking into consideration the pandemic itself but also the wellbeing and livelihood of its people.