Required Reading to Accompany these Lecture Notes:
· “Utilitarianism and the Pandemic” by Julian Savulescu, Ingmar Persson, and Dominic Wilkson
[9.] Utilitarianism and the Pandemic.
The lead author of the reading assignment for this Learning Module is Julian Savulescu, professor at the University of Oxford and a former student of Peter Singer, whose ideas about poverty we studied in the previous module.[1]
The paper applies Utilitarianism to two moral issues that can arise during a pandemic like the one we are currently experiencing: triage and lockdown.
They acknowledge that Utilitarianism deprioritizes other moral values compared to overall well-being:
For utilitarianism, well-being is all that matters. Liberty and rights are only important insofar as they secure well-being. Thus a utilitarian approach … may be prepared to override the right to privacy or liberty to protect well-being. (p.628)
But Savulescu et al. also believe that “utilitarianism is not a complete answer: one can sacrifice utility for other values” (p.629).
The purpose of their paper is NOT to argue that Utilitarianism is true or that utility (overall well-being) is always the most important moral value. It is simply to explain how Utilitarianism can help guide decision-making for two issues arising from the pandemic.
[9.1.] Making Utilitarianism More Specific.
Most theories of morality recognize that it is important to do the most good for the most people. In other words, they assume that beneficence is important:
beneficence (df.): “the quality or state of doing or producing good” (m-w.com); the word comes from the Latin bene, meaning “good” (the same as “benefit” and “benefactor”).
Utilitarianism assumes that beneficence isn’t merely important … it’s the only morally important idea: “Utilitarians hold that maximizing what is good for all is all there is to morality” (p.621).
But the idea that we should do what is most beneficial is vague. After all, what counts as a good consequence? What counts as a beneficial effect?
Previously, we’ve seen that classical Utilitarians tended to explain it in terms of increasing overall happiness and reducing overall suffering but that many modern Utilitarians tend to explain it in terms of increasing overall well-being.
Savulescu et al. suggest three additional ideas that can be added to Utilitarianism to make it less vague and more specific:
1. Failing to help someone can be just as wrong as harming them.
Many people believe that causing someone harm is always morally worse than failing to help them. (This is similar to the Doctrine of Doing and Allowing, which says that causing harm is always morally worse than allowing that harm to happen.)
But the authors reject that idea and say that “there is no significant moral difference between harming and omitting to benefit” (p.621).[2]
This implies that a law or social policy that results in death or disease because it fails to help people in some way will be just as morally wrong as a law or policy that actively causes that same death and disease.
An example (not from the article): failing to impose a mask mandate that requires people to wear masks in public. The authors’ view implies that governors, mayors, and other officials who fail to impose a mask mandate are just as morally blameworthy for resulting infections and deaths as they would be had they imposed a law that directly caused the same amount of harm.
In sum, you cannot escape moral blame by saying “I didn’t do anything” when you could have done something to help people.
2. Some deaths are worse than others.
According to the authors’ form of Utilitarianism, not all deaths are equally bad: when we think about consequences, we have to take into account the length of time someone might have lived and how good that life would have been. “[W]hat is morally relevant … isn’t death in itself but rather the length and quality of life the deceased would have had if they hadn’t died” (p.622).
This means that if Amy would have a long and happy life ahead of her, and if Bill would not live that much longer or wouldn’t have a very happy life, then it would be worse for Amy to die than for Bill to die.
3. Two-Level Utilitarianism.
The authors use the framework of Two-Level Utilitarianism, which combines two different kinds of Utilitarianism:[3]
Act Utilitarianism (df.): the morality of an individual action depends on nothing but that specific action’s own effects. If that action increases utility, it is moral; if it decreases utility, it is immoral. [This is basically the sort of Utilitarianism we’ve been studying up to now—“Act Utilitarianism” is just a more specific name for it.]
Rule Utilitarianism (df.): the morality of an individual action does not depend on its own effects; it depends on what rule the action follows and on what would happen if everyone followed that rule. If everyone following the rule would result in increased utility, then any action that follows the rule is moral. If everyone following the rule would result in decreased utility, then any action that follows the rule is immoral.
In ordinary situations when we have to make relatively quick decisions about what to do and don’t have time to think things through carefully, we rely on “rules of thumb,” like “don’t kill, don’t steal, be honest, etc.” (p.622). These intuitive-level* rules reflect Rule Utilitarianism: generally speaking, there will be more happiness and well-being in the world if people don’t kill, don’t steal, don’t lie, etc.
*Here the word “intuitive” means something like this: not based on argumentation and reasoning but instead known at a common-sense or “gut” level.
But in a complex situation in which we have time to think carefully about all of the relevant details, we might discover that in this specific situation, it is better to violate one of those rules of thumb: being dishonest, or stealing, or even killing might have better overall consequences. If we engage in this critical* level of thinking (when critical thinking is possible), we should do whatever specific action has the best consequences—and this reflects Act Utilitarianism (or as we’ve called it up to now: Utilitarianism). It’s also at this critical level that existing rules are evaluated and new rules are formulated.
*Here the word “critical” doesn’t necessarily mean expressing or involving a negative judgment. Rather, it just means involving a rational judgment or evaluation.
Savulescu et al. will apply Rule Utilitarianism to the issue of triage and Act Utilitarianism to the issue of lockdown.
[9.2.] Triage.
triage (df.): the process of sorting medical patients according to which ones should be treated first and, in extreme cases, which ones might have to go without treatment altogether; from the French verb trier, meaning “sort.”
To illustrate the problems that arise when patients must be triaged, Savulescu et al. relate the story of Alessandro and Jason:
Alessandro is a 68-year-old doctor. He has moderate chronic obstructive airways disease. He contracts COVID-19 while caring for patients with the same disease. He develops respiratory failure. Jason is a 52-year-old businessman who contracted COVID-19 while traveling for business reasons. He is otherwise well but develops respiratory failure. The triage question: There is only one ventilator* remaining. Who should receive ventilation? (Savulescu et al. p.622)
*ventilator (df.): “a device for maintaining artificial respiration especially: a mechanized device that enables the delivery or movement of air and oxygen into the lungs of a patient whose breathing has ceased, is failing, or is inadequate" (m-w.com); also known as a respirator.[4]
When there are not enough ventilators to save all of the patients, those patients will have to be triaged—sorted into a group of patients who will be placed on ventilators and a group who won’t.
Savulescu et al. provide seven kinds of Utilitarian rules of thumb that can be applied to decide who gets sorted into which group. We will consider five of them (omitting 4 and 7).
Rule 1. Save the greatest number of patients possible by saving those who have the greatest probability of surviving. [5]
When faced with limited resources—such as a limited number of ventilators, or a limited quantity of a life-saving drug—it might not be possible to save everyone. In that case, doctors will have to consider which patients have the greater probability of surviving. Saving those who are more likely to live will result in a higher number of patients saved overall. For example:
Jason and Alessandro: “If Jason has a 90% chance of recovery and Alessandro has a 10% chance, other things being equal, you should use your ventilator for Jason. Indeed, if you treat people like Jason rather than people like Alessandro, you will save nine people instead of every 10 treated. That is why probability is a relevant consideration.” (p.623)
Rule 2. Consider which patients would live longer.
“According to utilitarianism, how long a benefit will be enjoyed matters—it affects the amount of good produced. Thus for life-saving treatment, treatment that saves people’s lives for longer is to be preferred over treatments that save life for shorter periods” (p.623).
This will frequently mean choosing to save a younger person over choosing to save an older person. But what makes the moral difference isn’t their ages, considered as isolated facts; it is their life expectancy. If an older person is expected to live more years into the future than a younger person, then the older person should be saved.
Jason and Alessandro: “According to this criterion, priority should be given to the younger Jason rather than the older Alessandro, because Alessandro is expected to live less long if successfully treated. If it were Jason who was expected to die sooner, utilitarianism would support treating Alessandro, even though he is older.” (p.623)
Rule 3. Consider which patients would have the greatest quality of life.
The ideas of quality of life and overall well-being can be difficult to explain in a precise way:
Probably the most profound question in ethics is what makes a person’s life good, or constitutes well-being. Philosophers have debated this question for thousands of years. Answers include happiness, desire fulfillment or flourishing as human animals (which includes have deep relationships with others and being autonomous, amongst other things). (p.624)
Because of this, it can be difficult to compare the likely quality of life of one person to that of another.
Still, some comparisons are very straightforward. Imagine that we have two patients and can save only one. If one has end-stage dementia and is only minimally conscious, but the other is conscious and psychologically healthy, we should save the conscious patient, even if they are much older and would live for a shorter period of time than the patient with dementia.
In practical terms, it might be necessary to decide on a threshold below which a patient’s quality of life will definitely count as low. Savulescu et al. suggest two possible thresholds:
· “unconsciousness, or severe disorders of consciousness, such as being in a minimally conscious state”;
· “the ability to recognize and respond meaningfully with other people” (p.624).
The authors consider a different version of the Jason/Alessandro story to illustrate these views:
Jason and Alessandro: “The end point of dementia is unconsciousness. Imagine that of our two patients with respiratory failure Alessandro is still working, in possession of all of his faculties. Jason, by contrast (in this version of the case) has end stage dementia. According to utilitarians, we should treat Alessandro if we cannot treat both. Jason would derive zero benefit from being kept alive in an unconscious state. Indeed, this would apply potentially even if Jason (with dementia) had a higher change of survival, or were going to survive for longer.” (p.624)
Rule 5. Consider social benefit.
social benefit (df.): the total good that results from some action, including the good consequences for those who are directly affected and for anyone else who is indirectly affected; also known as social worth.
Taking social benefit into consideration might lead to prioritizing some people’s lives over others.
Jason and Alessandro (returning to the original case, where neither patient has dementia). Jason is a businessman, while Alessandro is a doctor. And so saving Alessandro’s life is likely to result in greater social benefit than saving the life of a businessman, since Alessandro could go on to save other people’s lives once he’s recovered.
Another example: saving the life of a parent of a dependent child or of someone who is pregnant might have greater social benefit than saving the life of someone who has no children, since the parent or parent-to-be would go on to take care of their children.
These rules of thumb—prioritize the lives of health care workers; prioritize the lives of parents and parents-to-be—might be acceptable to many people. But there are other rules that could be based on concern for social benefit that might be harder to accept, like prioritize the lives of business owners who employ lots of people, or deprioritize the lives of convicted criminals.
Rule 6. Do not consider whether someone is responsible for their illness.
Some people believe that if someone is responsible for bringing an illness upon herself, then that should be taken into consideration when they are prioritized for health care. For example, someone who has lung cancer after years of smoking tobacco cigarettes should be deprioritized for a lung transplant; someone who has liver disease after years of heavy drinking should be deprioritized for a liver transplant.
But these backward-looking considerations are irrelevant to Utilitarianism. All that a Utilitarian cares about is creating the best possible consequences going forward.
When we think about people’s past behavior and consider whether they deserve to receive to medical care now based on that past behavior, we are not focused on creating the best future outcomes, and so we have stopped outside of the Utilitarian framework.[6]
This does not mean that a person’s present physical health is irrelevant to how they are prioritized. “If, for example, diabetes reduces the chance of survival, it is relevant insofar as it reduces the chance of survival, not because it was the result of any voluntary behavior.” (p.625)
Jason and Alessandro. (Here I am adding some details to the authors’ story in order to see how this rule of thumb could be applied to this case.) Suppose that Alessandro, who is a doctor, was infected with SARS-CoV-2 while treating patients; he was always extremely careful to wear PPE (personal protective equipment) while at work, and he never took any unnecessary risks outside of work. On the other hand, Jason never took the pandemic seriously and frequently went to bars and restaurants without ever wearing a mask. According to this rule of thumb, how they were infected is irrelevant to which one of them should receive medical treatment now.
[9.3.] Lockdown.
“Lockdown” refers to dramatic efforts to enforce social distancing like the ones we’ve been living through in 2020, like closing bars, restaurants, and stores to slow the transmission of SARS-CoV-2.
Savulescu et al. introduce the topic by describing the situation faced in the United Kingdom (England, Scotland, Wales, and Northern Ireland) in early 2020:
The UK government received modelling that predicted that COVID-19 would lead to 500,000 deaths in the absence of measures to reduce spread. This could be reduced to 20,000 by implementing major social distancing measurers (lockdown). The economic effects arising from restriction of liberty will predictably result in large numbers of job losses, metal illness, and increased medical risk (e.g. unemployment is associated with increased risk of coronary heart disease). Cancellation of elective operations and interventions will result in prolongation of suffering and potentially death. Those suffering from non-COVID illness may not be able to receive treatment in hospital because there are no beds available.
The lockdown question: How should we balance precenting deaths from COVID-19 with causing deaths and reductions in well-being from other causes? (p.622)
The authors believe that the sort of Utilitarian thinking needed when a government is contemplating a lockdown is different than what medical professionals should use when triaging patients.
Whereas triage is best guided by the rules of thumb discussed above, a decision about lockdown should involve critical-level thinking and Act Utilitarianism.
Because of the scale of the impact of the pandemic, there is a danger that rapid rule-based responses might go badly wrong and lead to a much worse outcome overall. Instead, this is a question that would be better answered by drawing on critical level utilitarianism. (p.626)
Savulescu et al. suggest some Utilitarian ideas that should guide a government in deciding whether to impose a lockdown.
1. The quality of the years of life saved is more important than the number of lives saved.
One way of thinking about the effectiveness of a public health intervention like lockdown is in terms of QALYs:
Quality Adjusted Life Year (QALY) (df.): “A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality-of-life score (on a 0 to 1 scale). It is often measured in terms of the person’s ability to carry out the activities of daily life, and freedom from pain and mental disturbance.”[7]
A simple illustration of the idea of a QALY: Suppose that the introduction of a new drug into the U.S. will result in 10,000 lives being saved. Now suppose that on average, each person whose life is saved will live an extra 20 years, for a total of 200,000 years of life saved by the drug (10,000 x 20). If we assume an average quality-of-life score per year of .8 (so, a year of less-than-perfect but still very good quality of life), we get a total of 160,000 QALYs (200,000 x .8). If the cost of developing and distributing the drug is, say, $1 billion, then the cost of each QALY saved by the drug is $6,250 ($1,000,000,000 / 160,000).
The authors use the idea of a QALY as they discuss the different approaches that the neighboring countries of Norway and Sweden took to the pandemic: Norway chose to implement a lockdown, which began in early March 2020, while Sweden did not.
Current numbers: As of March 4, 2021,
· there have been 632 COVID deaths in Norway out of a population of 5,421,241: about 116 deaths per million people;
· there have been 12,977 COVID deaths in Sweden out of a population of 10,099,265: about 1,285 deaths per million people—a much higher number of deaths per million than in Norway.[8]
Although many more people per million died in Sweden than in Norway, those raw numbers don’t tell the whole story. In particular, they don’t reveal how many QALYs were in lost one country compared to the other.
The important issue for utilitarians is not the number of deaths, but the QALYs lost. Because a large proportion of the deaths in Sweden are in care homes, there may be fewer QALYs lost [because of the failure to lockdown in Sweden] than [because of] a policy that caused a smaller number of avoidable deaths of younger, healthier people. What is important is whether the QALYs lost in Sweden are greater or [fewer] than [in] Norway, overall, as a result of the policy. It is far from clear at this point the answer to that question. (p.627)
Update: As of early late February 2021, Sweden is experiencing a severe spike in SARS-CoV-2 infections and deaths, and the government is warning that some regions may be locked down for the first time in order to stop the virus from spreading further.[9]
2. It can be difficult to know the facts needed to make an informed decision about whether to go into lockdown and to know what results a lockdown has actually had.
On a Utilitarian view, you have to know facts in order to figure out which course of action will have the best overall effects and therefore to know which course of action is the morally right one. In particular, you have to know the answers to these factual questions: what benefits will my action bring about, and what harms will my action bring about?
But in some situations—including the current pandemic—it can be very difficult to figure out what those facts are before deciding whether to impose a lockdown:
· A lockdown would have the positive consequence of saving lives of people who would otherwise be infected.
· But it would also have negative consequences, including the loss of employment and postponement of medical care that would lead to the diminished health and even death of some other people.
· What’s more, the US government will have to spend billions of dollars (increased unemployment benefits, loans to businesses) to help sustain the economy during a lockdown.
It can be very difficult to figure out how many QALYs would be saved by a lockdown and therefore how much will the government would be paying for each QALY saved.
It can also be difficult to tell what the consequences of an intervention like a lockdown have been, as well as what the consequences of not having such an intervention have been. For example, early in the pandemic, the mortality rate in Sweden overall was much higher than in Norway, but a region of southern Sweden that was not under lockdown had a much lower mortality rate than of Oslo, the capital of Norway, which was under lockdown. There must be some explanation for this, but it can be difficult to discover what that explanation is:
One potential explanation for difference in mortality relates to differences in population density. Another relates to the amount of circulating coronavirus prior to any change in community behavior (which may or may not have been imposed formally as a lockdown). A further factor may be whether the virus has had access to vulnerable groups. The virus may have been more effectively kept out of aged care in the south of Sweden. That it isn’t simply due to a national lockdown is confirmed by the fact that this mortality figure [for southern Sweden] is lower both than that of the neighboring Danish capital, Copenhagen … and the county surrounding it …, despite th[e] fact that shops, etc. have been locked down in Copenhagen since mid-March. (p.627)
3. There are sometimes other interventions that would have even better consequences.
Even if we could know the exact consequences of a lockdown—how many lives and QALYs it would save and what the economic cost would be—and even if we could know that those consequences would be good overall, that would not necessarily make it the morally best thing to do.
That’s because there might be other interventions that would save even more QALYs and cost even less money.
[E]ven if lockdown were cost-effective, it would not be as cost-effective as different interventions that save babies or young people. For example, if an intervention saved the life of a younger person with a different disease for 50 years, you would only have to save one-fifth as many to bring about as much benefit. It costs a few dollars to save the life of a child in a developing country. (p.624)
The authors mention one particular intervention that would cost less and save more lives: “… The Gates Foundation has estimated that global eradication of malaria by the year 2040 would cost up to $120 billion. Such an initiative (costing only 1/15th as much as the US pandemic stimulus package) would potentially save 11 million lives.” (p.624)
4. Failing to implement an intervention can be just as bad as implementing a bad intervention.
Because Utilitarians reject the Doctrine of Doing and Allowing, they believe that the failure to implement some life-saving social policy, such as a lockdown (or a mask mandate), is just as morally wrong—just as blameworthy—as the implementation of a policy that directly causes the same number of deaths: “[U]tilitarians hold policy makers responsible not only for what they do, but for what they fail to do. Failing to implement other policies, with the result of avoidable, foreseeable deaths is equivalent to killing for utilitarians” (p.625).
[1] For more information about Savulescu, see his webpage on the University of Oxford website.
[2] So are the authors rejecting the Doctrine of Doing and Allowing like Rachels did? That depends. If allowing a harm is the same thing as omitting a benefit, then the authors are rejecting that Doctrine.
[3] In adopting this framework, they are following the work of philosopher R. M. Hare (1919–2002).
[4] This page contains useful information on the different meanings of the words “ventilator” and “respirator.”
[5] Savulescu et al. also mention the following considerations that are relevant to saving the greatest number of patients:
Which patients will take less time to save? We’ll save more lives if we use scarce resources, like a ventilator, to save four people each of whom needs it for one week than if we use it to save one person who needs it for four weeks.
Which patients require fewer resources to save? If one patient can be saved only by a treatment that requires three staff, and a second patient can be saved by a treatment that requires only one staff, we should save the second patient, freeing up two staff to help other patients.
[6] We will come back to this conflict between forward-looking Utilitarian considerations and backward-looking considerations involving what people deserve in a few weeks, when we consider justifications for the punishment of criminals, including capital punishment.