Everybody’s Talking About Bioethics Now #COVID19

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Since this pandemic got rolling, it seems everyone wants to talk about bioethics “trolley problem” quandaries like how to decide which of three dying patients gets the one ventilator on hand or whether it is okay to lock up healthy people to prevent the spread of a deadly virus. All the boring stuff suddenly got real and real fast, but maybe it’s not that interesting.

You should give the ventilators to the people with the best chance of surviving, right? I think that is how triage works. And, oh, was it all right to tell people to turn off their lights when bombers were flying overhead in the middle of the night? Sometimes even the rugged individualists have to work as a group. The problem is that some of our rugged individualists have never really been put in a position to make tough decisions, so they aren’t prepared.

And that gets us to the real ethical issues here. It is really unethical to be unprepared for emergencies. Experts in many fields have been warning of coming pandemics for at least 15 years. Even George. W. Bush, bless his tiny heart, knew he had to prepare for pandemics, and he at least took at stab at it. And the ever financially minded Barack Obama prepared for pandemics and even dealt with one on his watch. His didn’t get quite so out of hand, of course, and no one should have to tell you why.

So, the important ethical decisions were made years ago, and many of them had to do with the most attention-starved principle of bioethics, justice. The failure to prepare for a public health emergency affects everyone, as we now see, but too many people have always seen efforts to protect public health as efforts to protect “people not like me.” This isn’t always a sign of racism; sometimes it is just pure classism. Some people just don’t hate based on skin color, religion, sexuality, or any of that stuff. They hate poor people of all types.

This is also not a matter of choosing between the “economy” and the needs of working people. Preparing for a pandemic would have meant having mechanisms in place for extensive testing, tracing, and isolation that would have prevented the need to shut down almost all business activities. With proper preparation, the world would have suffered but could continue functioning.

And I guess a lot of Americans really were satisfied with their employer-provided health insurance that they are now losing, because it turns out their employers really never valued them as much as they assumed. It would seem that intelligent and hard working people should always be able to get healthcare, and that’s what we’ve been trying to tell you. You can be hardworking and intelligent and also poor, and maybe it is good that more people are learning this rather difficult lesson right now. Maybe it will help in the future.

But public health isn’t all about health insurance, though turning infected people away from a hospital because they can’t pay is certainly not a good way to protect the public from a pandemic. No, protecting the public health, which is really protecting national security (and global security) is about being able to deal with emergencies, which would require not selling off all the equipment you might need. Most homeowners have never used a fire extinguisher, but the ones who used them successfully were pretty happy they had invested in buying one and taken the time to learn how to use it.

So, yes, more than a decade ago, epidemiologists, virologists, climate scientists, public health experts, public health ethicists, and environmentalists were warning that the world was becoming much more hostile. How do we prepare to ensure our own long-term survival isn’t really as much fun as debating who gets the last ventilator, maybe, but it can save many more lives.

And maybe you’re saying there’s no point in going on about this now as it’s too late. What’s done is done, you’re saying, but this ain’t over, folks. One way or the other, COVID19 will be resolved, but other pandemics will follow along with drought, flooding, mass migrations, and a host of other public health crises that aren’t that hard to imagine if you only try. You may think I’m crazy, but I’m not the only one. Plenty of experts in relevant fields are already imagining the worst and best case scenarios. Maybe it’s time to listen to them.

Pandemics, Climate Change and the Threat of Innumeracy

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Among other things, this pandemic has shown the danger of innumeracy. Over the past few weeks, many have tried to minimise the effects of the pandemic by posting blogs and memes listing absolutely accurate statistics that are also terrifying to the specialists tracking the number of infections. Just for example, many people said a fatality rate of 2.0 (or even 1.0) was about the same as that for influenza. Of course, a fatality rate of 2.0, would be 20 times as bad as the seasonal flu, and even 1.0 would be tens times as bad.

Among those posting information to minimise the effect of the pandemic were healthcare providers, including doctors who work with infectious diseases. Doctors trained in medicine and not risk assessment are not better at assessing risk and probabilities than the general population. The 1982 book, Judgment Under Uncertainty: Heuristics and Biases, edited by Daniel Kahneman, Amos Tversky, and Paul Slovic, examined the ability of people, with several chapters devoted to medical professionals including doctors, to assess risk based on probabilities. People in general, including doctors, just aren’t that good at it.

Subsequent research in medicine has shown similar results. Without specific training in assessing risk based on statistics and probabilities, doctors are no better than the general public at making decisions. We all need a more robust understanding of statistics, probabilities, and risk assessment.

It would help us better understand the risk of pandemics, and it may help us better understand the risk posed by climate change. Many people still think it isn’t a big deal to have the average global temperature increase by 1 degree.

Climate Catastrophe: Pandemic and Pestilence (#poem)

skull-208586_1920Epidemiologists and public health ethicists have been grappling for some time with the near certainly of widespread disease pandemics resulting from climate change. Changes in non-human animal migration and human migration will bring extant pathogens to new populations as warming releases long dormant pathogens on the world once again. Large swaths of the population could be wiped out in an incredibly short amount of time. Addressing climate change isn’t a matter of preserving the beauty of the plant. Rather, it is a matter of promoting human survival.

A dying planet is a
Planet that kills.
Rising temperatures raise
The spectre of pestilence
In the form of pathogens
Newly released on
Unsuspecting vectors
As other pests breed
Vociferously and march
Into new territories
In a murderous stampede.

The migration of
Pests and pestilence brings
Pandemic and pandemonium.
Rising waters drive life from
Coasts as rising temperatures
Dry the plains; bake the deserts.
Human refuse scatters into
Constant conflict, seeking refuge
Away from the water or away
From the drought, the ice, the disease.

The oceans killed the fish,
And the sun killed the crops.
Infrastructure fails,
Transportation halts,
Medical care is a memory,
And society is preserved
Only in bits and bytes
Scattered to the sands.

The few who remain
May be resilient enough
To restart the madness.

Modern Libertarians Hate Thomas Malthus

Whether they are familiar with his work or not, many modern libertarians echo some of the ideas of Thomas Malthus when they advocate austerity in public policy. Most notably, Malthus claimed that the “poor laws” of England of his time deprived the poor of any liberty and independence. He felt that the poor would have more self-respect and freedom if they could provide for themselves and their families through their own labor.

Thomas Malthus

It was Malthus, not Darwin, who first mentioned a struggle for existence. In his 1798 screed, “An Essay on the Principle of Population,” he

“Restless from present distress, flushed with the hope of fairer prospects, and animated with the spirit of hardy enterprise, these daring adventurers were likely to become formidable adversaries to all who opposed them. The peaceful inhabitants of the countries on which they rushed could not long withstand the energy of men acting under such powerful motives of exertion. And when they fell in with any tribes like their own, the contest was a struggle for existence, and they fought with a desperate courage, inspired by the rejection that death was the punishment of defeat and life the prize of victory.”

In the essay, Malthus basically argued that hardship limits population but abundance leads to population explosions. For this reason, feeding the poor is a bad idea, as it will encourage wanton reproduction and the survival of infants into adulthood. By helping the poor survive, they would then multiply and deplete the planet of all its resources. It is the wealthy, of course, who consume the most resources, but even at that, Malthus did not have quite the same view of some austerity minded people of the 21st century.

For one, Mathus wanted to protect the value of farm labor. He said,

“Every endeavour should be used to weaken and destroy all those institutions relating to corporations, apprenticeships, etc., which cause the labours of agriculture to be worse paid than the labours of trade and manufactures. For a country can never produce its proper quantity of food while these distinctions remain in favour of artisans. Such encouragements to agriculture would tend to furnish the market with an increasing quantity of healthy work, and at the same time, by augmenting the produce of the country, would raise the comparative price of labour and ameliorate the condition of the labourer.”

Efforts to drive down the wages of farm labor are, then, anti-Malthusian. He also did not believe in leaving the poor with no help for work and redemption. While he objected to the “poor laws” of his day, he did believe in a tax-supported programs to provide employment for the poor. Thus,

“County workhouses might be established, supported by rates upon the whole kingdom, and free for persons of all counties, and indeed of all nations. The fare should be hard, and those that were able obliged to work. It would be desirable that they should not be considered as comfortable asylums in all difficulties, but merely as places where severe distress might find some alleviation. A part of these houses might be separated, or others built for a most beneficial purpose, which has not been infrequently taken notice of, that of providing a place where any person, whether native or foreigner, might do a day’s work at all times and receive the market price for it.”

Public works projects, such as those put in place by FDR, can alleviate much suffering while also benefitting the public good through improved infrastructure and public service. Note that Malthus did not advocate putting poor people in prison and forcing them to work for free.  Malthus did believe in treating the poor with respect and providing opportunities for honest employment for the betterment of society. Modern libertarians would do well to recognize the basic human desire for dignity and self-respect. When we help one another, we are free.

Corporate funding of research.

Many of us are suspicious of health and safety claims based on research funded by corporations that get rich off public confidence in the health and safety of their products. I don’t really trust manufacturers of drugs or genetically modified foods to tell me that they are safe. I also would feel better hearing that an oil spill is no threat to life or environment from someone other than the company that spilled the oil. (Many people seem to have made one inexplicable exception to this rule, which I will mention in the postscript.)

Further, when corporations fund research projects or labs, they gain control over what information is published. The scientists involved may have enough integrity to conduct rigorous research, but unwanted results are likely to be suppressed, especially if they will hurt the bottom line. This may be justified by claiming that only “useful” data need be published, but negative data can also be useful and can avoid wasted money and energy. If one researcher finds that something doesn’t work, publishing that data can help others avoid the same mistakes. Of course, researchers do share data, but some studies are also suppressed. Publication of misleading data and suppression of useful data are two possible hazards of corporations funding research that will affect their bottom line.

On the other hand, if corporations are the ones to benefit from research, it seems they should bear the cost of supporting labs, scientists, and related endeavors. Of course, some research is in the public interest, and I believe the public should fund it, which may be the topic of another blog. To avoid obvious conflicts of interest in research, companies should not be permitted to hire and promote researchers directly. Funding should go in to a pool and be dispersed anonymously to research labs, scientists, and universities. For profit labs could still exist, but researchers should not be beholden to a specific entity. It was not that long ago that much university research was conducted in this manner. In that sense my proposal is regressive, not progressive.

Postscript: When people get sick, many of them demand the latest drug available, even if it hasn’t been tested thoroughly. They seem to feel that their suffering from the disease is always going to be worse than the effects of the drug. I recently had a student (not a medical student) argue vehemently with me that no one had ever died during a drug trial. For those who know anything about drug trials, this over confidence is baffling, but I fear many share his optimism regarding the safety and effectiveness of experimental drugs. If you don’t know this already, let me tell you that drug testing is there for a reason; not every drug tested turns out to be safe and effective.