THERE is a common saying in moral philosophy that good facts are essential to good ethics. Resting behind is the observation that it is difficult to make a genuinely good choice unless one has an accurate understanding of what they are confronting. To take an analogy from driving – you can’t make good choices on the road unless you can see what’s around you. This insight is all the more important in our so-called post-fact world, in which sources of authoritative information are regularly undermined and truth is seen as a mere matter of opinion.

Even so, when we confront ethical choices it is typically the case that not all of the facts are available to us. We have to work with ambiguities: using the best and most accurate insights available to inform our choices. Unless we are arrogant or foolish, we accept that better information could become available or that we are blind to certain things, and that a correction to either could change the way we choose. In this sense, ethical decision making is more like driving on a country road in the twilight: the road ahead is part illuminated by headlights, part hidden in shadow, and part invisible. Our choices are as much about what we can see as what we assume and predict and – if we are wise – we drive all the more carefully because of this.

Since March 2020, Australians have seen something of this intersection, between what we are able to know and the choices we make, play out regularly in response to COVID-19. The discipline of epidemiology has come to the fore: names such as Nancy Baxter, Catherine Bennett and Raina MacIntyre are now household staples. These remarkable academics and others across a number of scientific disciplines have afforded our decision makers crucial insights. Some of these have been facts: that COVID-19 is highly infectious and can be deadly. And some have been the best insights that can be garnered through hypothesising, modelling and prediction: how the disease spreads, who it is likely to impact and how severely, and how different kinds of measures (such as lockdowns) will likely influence morbidity and mortality across the population.

As the facts of our situation have changed (eg, variants of COVID-19 have arrived and so have vaccines) and our foresight has been refined (we can now better predict how the disease spreads and responds to vaccination rates), decision making has followed suit.

It is true that good facts are essential to good ethics, but good facts alone are insufficient for making ethical choices. Indeed, it is a fallacy to derive an ethical claim (an “ought”) from a factual premise (an “is”). Such a line of argument is fallacious because facts on their own are ethically neutral. This is also true of our more tentative ways of knowing. They too are essential but insufficient for making ethical choices. Our understanding of the world does not result in one or other choice without an ethical framework in which it is held together with particular values to inform a moral decision.

For instance, that the climate is warming (a fact) does not lead to an ethical judgment about what we ought to do in response. Nor do our predictions about what effect various interventions (such as net-zero emissions targets) will have. But where this knowledge meets a set of values (such as a commitment to care for our common home) we begin to develop normative, ethical judgments (eg, we should commit to net zero targets) which can then influence specific instances of choice.

With this in mind, consider the role of government, including the various public health teams around the nation, who have exercised their authority in enforcing specific choices (such as lockdowns and compulsory vaccinations) in response to COVID-19. Just as epidemiologists were thrust into the public eye, we’ve now become accustomed to the likes of Kerry Chant, Brett Sutton, Jeanette Young and their peers in our newsfeed, who have worked alongside various political leaders in charting a course through the pandemic.

When governments make choices in response to COVID-19, they work at the intersection between our best possible knowledge and ethics. Taking what we know about the virus, its effects and the likely outcomes of different courses of action, they choose a course of action because it fits with a set of ethical commitments and what is considered good. They might variously prioritise good, such as the importance of preserving life, psychosocial wellbeing, civil liberties, the economy, and so on. At some level this will be related to a vision of human flourishing and what counts as good for the community as a whole. Internationally, we have seen the stark contrast between governments that prioritise the economy and civil liberties and those that prioritise the preservation of life.

That there are choices available to governments, and that the prioritisation of certain goods informs these choices, brings us into the terrain of ethics. This is significant because differences in policy in response to COVID-19 are not differences of knowledge or circumstance – they are also matters of ethics. What a government determines is “public health” is not neutral. Each vision of public health includes an ethical framework – whether implicit or explicit – which embeds assumptions about what constitutes health for the community, and what common goods are worth pursuing (and sacrificing) to secure health.

Why is this important?

There are better and worse ethical frameworks. To risk stating the obvious, if good facts are necessary for good ethics, good ethics are necessary for good choices. Setting the ethical bar too low, ignoring essential ethical principles, or operating out of a problematic ethical framework will lead to choices which undermine human dignity and the common good. This is critically important in contexts of ambiguity or change: just as the wise driver is all the more diligent on the dimly lit road, so the wise decision maker will be all the more careful to uphold good commitments midst uncertainty.

Unfortunately, we do not have access to the ethical frameworks that have underpinned government or public health decision making during the pandemic. This could be because they are unpublished or simply because they are implicit. It is often the case that we operate out of unarticulated ethical commitments, for better or for worse, and this is particularly the case in moments of crisis. Even so, we can elucidate some features of these frameworks by their fruits: the choices that governments made during the pandemic. And here we find examples of both good and bad ethics.

Consider some of the morally praiseworthy choices we’ve witnessed over the past couple of years: difficult lockdowns designed to protect the most vulnerable among us, exemptions to restrictions in hospitals where the end of life draws near, housing the homeless – the list goes on.

And yet we have also seen some morally suspect choices. I note three here. First, the immediate and complete lockdown of public housing towers in Melbourne, enforced by a strong police presence, prior to a plan being made for assuring essential goods such as food and medicine for residents. Second, the absolute nature of border restrictions – particularly in Queensland and Western Australia – wherein reasonable exemptions, such as crossing the border by road for medical treatment or visiting a loved one at the end of life, were regularly denied. Third, the failure to adequately train and protect hotel quarantine staff, exposing them to grave risk of contracting COVID-19.

In each we see the ethical framework known as consequentialism at play: the end (infection control) justifies the means chosen to get there (locking down the towers, inflexible borders, placing people in harm’s way while running hotel quarantine). Such consequentialism is contentious. While we all accept that pursuing good ends is worthwhile, it is crucial that the means chosen to achieve those ends are ethical. In other words, we should not sacrifice our moral commitments in the pursuit of good ends.

This was the view of the Victorian Ombudsman, Deborah Glass, in her critique of the lockdown of the public housing towers. Glass argued that this choice violated human rights, noting that “in a just society, human rights are not a convention to be ignored during a crisis”. Something similar could be said in critique of the absolutist border closures of WA and Queensland or knowingly placing staff in harm’s way in hotel quarantine: there are many goods that we should commit to preserving, even in pursuit of a good as serious as infection control in a pandemic.

During the pandemic, we have rightly sought assurances from our governments that their choices are based on the best knowledge available. Epidemiology and its sister disciplines have been essential, and it has been refreshing to see the role of science at the forefront of our pandemic response. But epidemiology is not ethics, and good ethics are also essential for good choices. Just as we have asked governments to be transparent about the knowledge that underpins their decisions, we should also ask for clarity about the ethics that rest behind their choices. Only then do we have the opportunity to consider whether their ethical principles are worthy of the grave responsibility they have been entrusted with.

In closing, consider the Victorian Government’s response to the Ombudsman’s recommendation that the government apologise to residents of the housing towers: “We make no apology for saving people’s lives.” Saving lives is a good end, and it may be a fact that the snap lockdown helped to achieve this end. But neither are sufficient to justify the ethically dubious means taken – other choices were available, even if they weren’t immediately clear in a moment of crisis. We can and should pursue good ends, but always by means that are consistent with good ethics.

Dr Daniel Fleming is head of ethics for St Vincent’s Health Australia. From 2022 he will begin an appointment as Adjunct Professor in the School of Medicine at the University of Notre Dame, Australia.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

3 thoughts on “Epidemiology and ethics are different

  1. Neil Donovan says:

    Thank you so much for this clear explanation. Never before hit such an illuminating way to navigate why we make the decisions we do. I think I will borrow it many times with patients TA

  2. Dr Greg Mewett (Palliative Care Physician) says:

    So many good points there Daniel.
    The strict, and I would say harsh, restrictions to hospital and nursing home visitors has resulted in countless people dying in these facilities alone, unsupported by their loved ones. This “policy” has varied significantly depending on where your loved one happened to be, and certainly in our health service, no one was owning up to any consideration of an ethical response to dying patients and their possible visitors..
    Who, for example, gets to decide who is “dying” and therefore can have a visitor? No explanation of ethical “weighing-up” here, just some form of subjective decision-making by faceless “committees”!

    The incidence of complicated/prolonged grief is already being seen in our area of palliative care and in the general hospital setting, as so many people have been unable to properly be present with, and farewell, a dying loved one.

    Clinical ethics is so misunderstood in our modern health care system and needs more transparent discussion so that we can make some judgment of the best (or least worse) way forward.

  3. Henry Kilham says:

    Overall, I’m favourably impressed by this addition to the mountains of commentary, information and research prompted by the COVID pandemic. My only objection is the suggestion that the consequentialism, as an ethics framework, is ‘to blame’ for many of the serious failings in decision-making seen worldwide to attempt to limit pandemic damage. Condemning consequentialism has been a favourite sport for many ethicists for years, now, though without exception they use it personally whenever convenient, e.g. whenever driving on roads (Fleming likes driving analogies). In attempting harm reduction in a pandemic, there is no alternative to choosing actions based on balancing benefits against costs, i.e. a consequentialist approach. Properly interpreted, consequentialism then requires ethically justifiable actions, to aim for best outcomes, and doesn’t condone just any action at all (like police guarding towers, in Melbourne). Abuse of consequentialism was and continues to be extensively used by the politicians and others who have condemned public health measures that conflict with their political principles and profits. If it isn’t already clear, I believe that Australia’s relatively good pandemic outcome, to date, has largely resulted from the power of good public health, largely based on the best of consequentialism, and often despite the worst of politicalising the issues.

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