Utilitarianism medical ethics has come under heavy fire in recent months. Many commentators have, for example, criticised utilitarian ICU rationing frameworks that discriminate against older people and people with disabilities. Others have condemned the veiled introduction of herd immunity strategies that involve allowing coronavirus to spread through the community to create population-level resistance to COVID-19. These policies seek to maximise the long-term social and economic welfare of society, but many believe that we should instead prioritise the needs of society’s most vulnerable, such as the elderly and those with disabilities, and even if this comes at a considerable cost.
Three ethicists from the University of Oxford, however, have mounted a spirited defence of utilitarian approaches to pandemic management. Utilitarianism is not evil, they contend; it’s just misunderstood.
Julian Savulescu, Ingmar Perrson and Dominic Wilkinson argue that the problems encountered in a pandemic necessitate a utilitarian approach to saving lives and protecting the wellbeing of society:
“the scale of the challenge for health systems and public policy means that there is an ineluctable need to prioritise the needs of the many. It is impossible to treat all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life”.
The authors discuss how utilitarianism could inform two practical issues that have been important in the COVID-19 pandemic: healthcare rationing, and lockdown measures.
Healthcare rationing debates are often characterised by a concern to ensure equity and fairness in our distribution of medical interventions. Yet the authors state that we should instead focus on maximising benefits obtained from our resources, and, in particular, maximising the number of Quality Adjusted Life Years (QALYs) that each intervention produces. When triaging in ICU, we should prioritise “those with the highest chance of surviving and needing the lowest duration of treatment”. “This would maximise the numbers of lives saved”, the authors write.
It is a similar situation when introducing lockdown measures: “the important issue for utilitarians is not the number of deaths, but the QALYs lost”.
The authors suggest that this has practical implications for the way in which we weight the needs of people in care homes. The lives of older people, they contend, are less important as they have a much shorter life expectancy than younger people. There is also some evidence that the lockdown and related factors such as reduced access to medical care has led to additional deaths from causes other than coronavirus.
Discussing Sweden’s more lax physical distancing measures, the authors write: “Because a large proportion of the deaths in Sweden are in care homes, there may be fewer QALYs lost than a policy which caused a smaller number of avoidable deaths of younger, healthier people”.
While for many the conclusions of a utilitarian framework would seem cold and incompassionate, the authors conclude with some suggestions that are less controversial. They write, for example, of the need to get very clear and accurate modelling data before governments decide on a course of action:
“The fundamental difficulty facing all of us during this pandemic is that we cannot know for certain which action will be best overall…[this] would require a detailed understanding of the science and facts, the nature of well-being and an exhaustive understanding of the consequences of our choices. But that is what we should be aspiring to. We must strive to get the facts straight on all the consequences of our choices.”
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