Can You Handle Herd Immunity? Ask These Philosophers
(Bloomberg Opinion) - Welcome to the weekend. We have special return points today, but rest assured that markets or investments have nothing to do with it. Instead, I hope you are interested in my latest essay on the moral dilemmas of the coronavirus. The idea of "herd immunity" through infection, which was ruled out almost everywhere six months ago, is now being seriously considered in capital cities around the world. It is an extremely complex scientific problem, but it also poses an inevitable moral dilemma. I hope that the following will help frame this moral question and make it easier for all of us to participate in a very difficult debate. This is the fourth article in a series that has been published approximately two months apart since the pandemic began. Register here to have the newsletter delivered straight to your inbox.
Six months ago, populations around the world signed up to lockdowns to fight the Covid-19 pandemic with minimal debate. Amid confusion and terrible deaths, the standard position was to protect the elderly and minimize the loss of life.
Now the question is different. In Britain, which limits social gatherings to six, the Boris Johnson administration is facing a rebellion by MPs from his own Conservative Party and a campaign group called Keep Britain Free, according to which Johnson has "used lockdown to remove our freedoms". Anti-lockdown protests have broken out in the US and even the ultra-Orthodox Jewish community in New York has burned masks in public. With six months of experience, people know that bans take a terrible toll. Even after the shocking news of President Donald Trump's infection, the tide in the US is heading towards reopening, allowing people to get sick and thus build immunity until a vaccine arrives to resolve the dilemma. So there is a new question: is a “herd immunity” strategy acceptable?
Finding an answer requires both scientific and moral judgments. To achieve herd immunity through infection, one has to admit that society will not try to save people from disease and that some preventable deaths will occur. Science and ethics interact. If scientists can show that herd immunity is within range, that cost is lower.
However, scientists on both sides of the debate made extremely inaccurate predictions at the start of the pandemic, and they remain divided over the potential human cost. Even then, the moral question remains, what cost is acceptable.
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The level of immunity in the population that is needed before a virus dies out varies from disease to disease. In measles it is up to 90%. The scientific journal Nature estimates that the threshold for Covid-19 could be 50% of the population. The bad news: For countries like France and the US, this would mean "100,000 to 450,000 and 500,000 to 2,100,000 deaths, respectively".
There are now influential epidemiologists who believe that the threshold of herd immunity has been reached in regions where major outbreaks have already occurred. They argue that Covid-19 can be asphyxiated if only 20% of the population is infected.
What do you suggest? This week epidemiologists from Oxford, Harvard and Stanford launched the Great Barrington Declaration, which recommends moving to a strategy called focused protection. They also briefed officials in the Trump administration. This is how Sunetra Gupta, the Oxford professor who co-authored and signed the declaration, defined the idea earlier this year:
Herd immunity is just a technical term for the fraction of the population that needs to be immune to prevent the disease from spreading. ... It's a basic epidemiological concept that has clearly been undermined. The truth is that herd immunity is a way to prevent vulnerable people from dying. This is done at the expense of some dying people, and we can prevent it from happening by protecting the vulnerable class in the process. In an ideal situation, you would protect the vulnerable as much as possible, keep people going about their business, let herd immunity build, make sure the economy doesn't collapse, make sure the arts are preserved, and ensure the qualities of kindness and tolerance remain consist.
Centuries of moral philosophy have left us with various tests for making decisions like this. Gupta's version of “focused protection” exists in some, but not others.
The greatest good of the greatest number
Utilitarianism, which was proclaimed by Victorian liberal reformers in 19th century England and has been influential ever since, is not concerned with people's duties or rights, but judges actions based on their consequences. When an action in its grossest form benefits “the greatest good of the greatest number”, this is justified by utilitarian calculation. Hence, it may be justified to sacrifice a few, provided that it clearly benefits the many.
When it comes to health care rationing, utilitarian decisions involve concepts like the QALY: the quality-matched year of life. How many years of life will be lost comparing two alternative avenues and how good will those extra years of life be? A healthy teenager takes precedence over an 85-year-old with pain and disability. The QALY measurement aims at a quantitative solution for more difficult decisions, e.g. B. between a healthy 40 year old and a disabled 20 year old.
Now we know the cost of locking, and it's high. The listing of these costs arouses great passion. Beyond the verifiable economic damage, mental and physical health is damaged. Conditions of the past six months have forced an unnatural way of life for humans - and the current strategy requires a commitment to live like this until enough people have access to a safe and effective vaccine.
So, on a utilitarian basis, a herd immunity strategy has much to praise. One comment in response to a column by Bloomberg Opinion's Tyler Cowen asking how close society is to herd immunity says it all, "If you could add a year to the lives of everyone over 65 by the Destroying the future of 25% of the people among us 20, would it be worth it? "If that is the choice, most of us, including all utilitarians, would say 'no'.
But the choice is not as clear as it seems. "Letting Grandma die isn't just a compromise," says Arthur Caplan, director of bioethics for NYU Langone's medical system. “You will still have to pay hospital bills to try to save Grandma before she dies. This is an additional burden on hospital systems. And then a certain percentage of people will be disabled for many years. How many do we not know. When the people with herd immunity refer to the mortality statistics, they are not being honest. "
The long-term damage from Covid-19 is not yet known, so the cost of herd immunity is also unknown. Some reject reports of "long-haul Covid" as revised, pointing out the long-term effects that the flu can have. But the questions raise doubts about the utility calculation.
Freedom and survival of the fittest
The opposition to lockdowns has been led by libertarians who prioritize the human right to self-determination. The remarkable history of libertarianism goes back to the British philosopher John Locke and the founding fathers of the United States. In its modern incarnation, libertarianism is associated with the 19th century British thinker Herbert Spencer and most recently with the Russian émigré writer Ayn Rand. Libertarians do not advocate irresponsible behavior, but they believe that decisions like going to the office or wearing a mask should be left to responsible, informed people.
This, of course, rules out strict bans. But if we don't want to lock up any longer, are we ready to lead libertarianism to its logical conclusion? Jeremy Corbyn, former leader of the UK Labor Party, summed up the argument against this mindset, complaining that he had not spoken about herd immunity since working on a pig farm 40 years ago. "It was absurd: you would strengthen herd immunity by letting people die," he said.
Social Darwinism, or the abandonment of humans to the cruel judgments of nature, originated with Spencer, who coined the term “survival of the fittest” a few years before Charles Darwin's publication of “On the Origin of Species”. In Social Statics, Spencer argued for "weeding out those with the lowest evolution".
Kentucky Republican Senator Rand Paul, one of the most famous libertarians in American life and a vocal opponent of lockdowns, used similar Darwinian logic when he asked in the Senate whether “man is really capable of surviving an infectious disease through a crowd to change control. "
To avoid “crowd control”, the weak in society must perish. This applies not only to the elderly, but also to those who are hardest hit by Covid for a number of reasons - especially the poor and minorities. Will people follow libertarian logic until now?
The golden rule
Doctors get their ethics from the Enlightenment philosopher Immanuel Kant, who based morality on the biblical "golden rule" - that we shouldn't do to others what we don't want to do to ourselves. This is in accordance with Christian teaching and underlies the Hippocratic oath of medicine to “do no harm first”. It also supports the influential theory of Harvard political theorist John Rawls that we should make decisions as if we were behind a "veil of ignorance" without knowing if we are worst off in society.
As a result, some useful tradeoffs can be impossible to justify: "I think the arguments are stacked pretty heavily against herd immunity," says NYU Langone's Caplan. “First, it violates the 'do no harm' principle of medicine. Many doctors would not be able to do this. They just couldn't watch. "
Caplan points out that the death rate among people over 70 with the disease is up to 7% despite improved care. “Unfortunately, you have to write Grandma off to do the experiment. I think Grandma should stay away forever, ”says Caplan. "If it's around 50 or 60 percent to get herd immunity, I'm not sure you can ever get protection for the most vulnerable."
Caplan also complains that "we don't know how long immunity will last". If it only lasts a few months, we have no choice but to wait for annual vaccinations, much like the flu.
Giving up the vulnerable for their fate is incomprehensible. But would it meet the golden rule of banning them until herd immunity is achieved?
Maybe not. If people did not distance themselves or wear masks, entering the outside world would be even more dangerous and the vulnerable even more isolated. This runs the risk of creating a group of second-class citizens.
In a column for a Danish newspaper, a disabled Swedish writer said this about life in his home country, the developed nation that has made the clearest attempt to achieve herd immunity without bans:
It soon became clear that the world had an intersectional approach that Sweden lacked. They understood that people of color, poor people, old people and disabled people carried the brunt of the virus and died. We couldn't isolate and protect ourselves in the same way. The right thing was evident once we got an uncontrolled expansion of fellowship. Quarantine the entire population until you are in control of the spread and use the time to create a comprehensive testing plan. That would have given everyone a short stay at home - and not Sweden's incessant and fatal isolation just for "risk groups".
Even with protective measures for vulnerable people, a herd immunity strategy could discriminate against certain population groups. It's hard to reconcile that with the golden rule.
The common good
What about the search for "the common good" in society, an idea that is often referred to as "communitarianism"? These ideas go back at least to the French thinker Jean-Jacques Rousseau and his social contract and appeal to socialists and cultural conservatives alike.
The echoes of social Darwinism make the idea of herd immunity an abomination for communitarians. Ben Bramble, philosopher at the Australian National University and author of “Pandemic Ethics: 8 Big Questions of COVID-19”, argues that lockdowns benefit society: “To sacrifice many old and vulnerable citizens and severely burden the socio-economically disadvantaged all in order to spare the young and healthy (and the rich) some economic pain, it can poison relationships between these groups. How could our relationships with them recover? This could irreparably damage the fabric of our society. "
In contrast, he writes, young and healthy people who want to protect these groups could bring everyone closer together, improve our lives, and "help society function better." The pain of the imprisoned could be alleviated with government support.
But this argument may not be as clear as it looks. Gupta, the Oxford epidemiologist, says people should think about compromises at a “communitarian” level and suggests that young and healthy people can make their contribution to society by becoming infected.
Noting that young people are afraid of infecting a friend or grandparent, she complains that the "chain of guilt" "is somehow individualized rather than being distributed and shared". She adds, “We have to share the blame. We have to share responsibility. And we have to take certain risks ourselves in order to meet our obligations and comply with the social contract. "Young people who are accelerating herd immunity should be thanked for ensuring that" the social contract is properly run ".
Bramble disagrees. "It's incredible to me that she believes that young people have a moral duty to get infected in order to bring us closer to herd immunity."
Leave it to the scientists
Six months ago I wrote that “we are all Rawlsians now” - in the face of the pandemic, governments and societies had reacted as if they had a duty to undergo great privation to protect the sick and the elderly. Now we know that this was an illusion. Many died lonely and unnecessary deaths in nursing homes, the economy stalled, and vocal libertarian opposition to lockdowns soon began.
Trump's illness shows the disease is still with us, while his speedy recovery so far shows that our ability to treat it and keep victims alive is improving. With new information, the same decisions have to be made again. But now the balance has moved away from strict barriers and the utilitarian position has become the standard. After the historic economic conquest of spring, the clarity of the golden rule has given way to a complex compromise.
How complex? While Scandinavia struggled to grapple with Sweden's epidemiological experiment, Finnish philosopher Matti Hayry set out the problem. "We just don't know which choice will end up being the best lifesaver, health promoter, or quality-adjusted life-year producer overall," he wrote. Since many of the negative effects of the two decisions are inadequate, no utilitarian decisions can be made, "much less accurately communicated to the public."
Unless the public tries to save most of the lives, "the most serious obstacle to utilitarian truth-finding" will be that the choice is uncomfortable. If the government tries to give priority to revitalizing the economy, it would have to "tell the truth to predict how many people would be lost as a result."
He predicted that "people would then argue that the victim is immoral, suggesting that the lives lost would be in vulnerable groups." Or they can't.
We do not know it. What we do know is that the ball is back in the scientist's court - philosophers can only help us make a decision that requires good data. It is up to science to shed light on the costs and it is up to executives to communicate these costs to the population. The difficulty of comparing two ugly alternatives can reveal the great limit of utilitarianism: sometimes it is necessary to compare things that cannot be compared.
This column does not necessarily reflect the views of the editors or Bloomberg LP and its owners.
John Authers is Senior Editor, Markets. Prior to Bloomberg, he was with the Financial Times for 29 years, where he was head of the Lex Column and chief market commentator. He is the author of "The Fearful Rise of Markets" and other books.
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