what is necessary in order to gain moral knowledge, according to most utilitarians?
Bioethics. 2020 Jul; 34(vi): 620–632.
Utilitarianism and the pandemic
Julian Savulescu
one Oxford Uehiro Center for Practical Ethics, Academy of Oxford, Oxford United Kingdom of Great United kingdom of great britain and northern ireland and Northern Ireland,
two Wellcome Middle for Ethics and Humanities, University of Oxford, Oxford United Kingdom of Great Great britain and Northern Republic of ireland,
3 Visiting Professorial Fellow in Biomedical Ethics, Biomedical Ideals Research Grouping, Murdoch Children's Research Institute, Melbourne Australia,
iv Distinguished Visiting Professor in Law, Melbourne Law School, University of Melbourne, Melbourne Victoria, Australia,
Ingmar Persson
1 Oxford Uehiro Eye for Practical Ethics, Academy of Oxford, Oxford United Kingdom of Britain and Northern Ireland,
5 Department of Philosophy, Linguistics and Theory of Science, Gothenburg Academy, Gothenburg Sweden,
Dominic Wilkinson
1 Oxford Uehiro Middle for Applied Ideals, University of Oxford, Oxford United kingdom of Great Britain and Northern Republic of ireland,
2 Wellcome Heart for Ethics and Humanities, University of Oxford, Oxford U.k. of U.k. and Northern Republic of ireland,
half dozen John Radcliffe Infirmary, Oxford United Kingdom of Great Uk and Northern Republic of ireland,
Received 2020 Mar 31; Revised 2020 May 15; Accepted 2020 May xx.
Abstract
There are no egalitarians in a pandemic. The scale of the challenge for health systems and public policy means that at that place is an ineluctable demand to prioritize the needs of the many. Information technology is impossible to care for all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life. In a pandemic there is a strong upstanding need to consider how to do most adept overall. Utilitarianism is an influential moral theory that states that the right action is the action that is expected to produce the greatest practiced. Information technology offers clear operationalizable principles. In this paper we provide a summary of how utilitarianism could inform ii challenging questions that have been of import in the early stage of the pandemic: (a) Triage: which patients should receive access to a ventilator if there is overwhelming demand outstripping supply? (b) Lockdown: how should countries decide when to implement stringent social restrictions, balancing preventing deaths from COVID‐19 with causing deaths and reductions in well‐being from other causes? Our aim is not to fence that utilitarianism is the just relevant ethical theory, or in favour of a purely utilitarian approach. Nevertheless, conspicuously because which options will do the nearly good overall will assistance societies identify and consider the necessary cost of other values. Societies may cull either to cover or not to embrace the utilitarian course, but with a clear understanding of the values involved and the price they are willing to pay.
Keywords: COVID‐19, pandemic ethics, resource allocation, utilitarianism
i. INTRODUCTION
The COVID‐19 pandemic has posed a formidable and nearly unprecedented challenge to health professionals, wellness systems and to national governments. The potential threat to large numbers of patients has led to restrictions on move, employment, and everyday life that have impacted the lives of billions and come at massive economic price. Wellness systems, facing existing or predicted demand overwhelming capacity, take generated guidelines indicating which patients should receive treatment.
1 ethical theory has been both cited and criticized in public fence about pandemic response.
The civil rights part of the US Department of Health and Human Services stated that:
persons with disabilities, with limited English skills, or needing religious accommodations should not exist put at the end of the line for health services during emergencies. Our ceremonious rights laws protect the equal dignity of every human being life from ruthless utilitarianism.
Subsequently the New York Times reported that some country pandemic plans instructed hospitals not to offer mechanical ventilation to people above a certain age or with item health conditions (e.g. 'severe or profound mental retardation' as well as 'moderate to severe dementia'), the Office for Civil Rights (OCR) responded: '… persons with disabilities should not exist denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person'due south relative "worth" based on the presence or absence of disabilities or historic period'.
Utilitarianism is now often used equally a pejorative term, meaning something like 'using a person as a ways to an end', or fifty-fifty worse, akin to some kind of ethical dystopia. Yet utilitarianism was originally conceived every bit a progressive liberating theory where everyone's well‐being counted equally. This was a powerful and radical political theory in the 19th century, when large sections of the population were completely disenfranchised and suffered from institutional discrimination. The theory played a part in antislavery, women's liberation and brute rights movements. Yet utilitarianism remains relevant in the 21st century. As nosotros will hash out, it may be particularly salient and important to consider in the confront of global threats to wellness and well‐beingness.
In this paper, we will summarize what utilitarianism is and how it would apply to the COVID‐nineteen pandemic. Our aim is non to argue that utilitarianism is the but relevant ethical theory, or that a purely utilitarian arroyo must be adopted. However, information technology is important to note that whenever a utilitarian solution to a dilemma is adopted, in that location volition be more well‐being or happiness in the world. Typically, some people will be amend off. Of course, there may exist skilful ethical reasons to deviate from a pure utilitarian approach, for case in order to protect rights or promote equality. However, considering the alternative will assist societies to place and consider the necessary cost of these other ethical values. Utilitarianism is not the cease of upstanding reflection, but information technology is a good place to start.
1.i. What is utilitarianism?
Most moral theories imply that in that location is a (moral) reason to do what is expected to maximize what is good for all, or more precisely, the net surplus of what is expert for all over what is bad for them. This might be chosen a principle of beneficence. Utilitarians concur that maximizing what is expert for all is all at that place is to morality. It makes moral decisions simple past supplying a unmarried measure of rightness: maximization of utility. In many situations this may exist enough, along with rules of thumb with the aid of which it could be determined what maximizes utility.
According to most moral theories in that location are, however, other moral reasons. For case, utilitarianism has often been criticized for ignoring the question of what is a just or fair distribution of what is skillful for all. The outcome that generates the greatest good overall may be dissimilar from the event whose distribution of goodness comes closest to being just or off-white. Then the principle of beneficence will have to be counterbalanced against the principle of justice. This will about likely accept to be washed in an intuitive way. It is very controversial what a but or fair distribution consists in, e.g. whether it consists in getting what is deserved or in more equal shares. This is far also controversial to exist settled hither. It follows that the issue of balancing justice and beneficence against each other must as well be left aside.
Another moral principle is a principle of autonomy, which gives weight to an individual'southward liberty to choose and to determine, for themselves, how to live their own life. Individual freedoms may conflict with overall good, for example, when individuals choose to flout social distancing laws, or when individuals demand a scarce resource for themselves or their family members. This also brings us to the effect of whether the principle of beneficence should exist impartial and accord the same moral weight to the good of all other individuals or whether it should allow greater weight to the proficient of those who are shut to us (and to human over non‐human beings). For the purpose of discussing what policies societies should adopt to deal with pandemics, it is reasonable to assume impartiality.
A further issue is what constitutes goodness and badness for individuals. Co-ordinate to the most familiar theory, hedonism, what is intrinsically good consists in various positive experiences, of pleasure and happiness. What is intrinsically bad consists in negative experiences of pain and unhappiness. Hedonism is, still, frequently criticized for being too narrow in non recognizing that what we are not aware of tin exist good or bad for us, e.grand. that our partners deceive us, or that the land surveys our behaviour, so cleverly that we never notice it. For such reasons a wider conception of what is intrinsically good or bad for united states than hedonism will be assumed here, though to determine its precise import would take us too far afield.
Some moral theories imply that at that place is a stronger or more stringent moral reason to omit doing harm than to do good. Thus, they imply that at that place is a stronger reason to avoid making things worse for somebody by killing them, causing them injury or pain, than to do good them by preventing them from being killed, injured, etc. With respect to pandemics, considerable moral weight has been fastened to harms such as death and illness that can be prevented by various constraints. Therefore, for the nowadays give-and-take information technology is improve to proceed on the supposition that there is no significant moral departure between harming and omitting to benefit.
Utilitarianism typically accepts that instances of goodness and badness can be aggregated in a quantitative fashion. Thus, consider a very mild pain that is acquired by a physical stimulus of one unit and that lasts for 10 min. Now compare 100 instances of such a pain either spread out over 100 lives or over 1 life lasting many decades with a single instance of excruciating pain caused by 75 units of the physical stimulus lasting for ten min. According to a standard commonsensical calculus the erstwhile consequence is worse than the latter, but this seems implausible. Most of u.s.a. would prefer 100 instances of mild hurting dispersed over our lives than 10 min of excruciating pain. It might exist thought that this result is crucial in the present context, since nosotros volition have to balance the deaths of a lower number of people confronting smaller burdens for a much higher number of people. We will, however, run into that what is morally relevant from a utilitarian perspective isn't expiry in itself only rather the length and quality of life the deceased would have had if they hadn't died.
It might be said that what matters in the end is what activity really maximizes what is good for all rather than what activity is expected to maximize what is proficient for all. Just our best guide to what will actually happen is what is expected to happen on the best available bear witness. So, when nosotros decide what to do, nosotros have to go by what is predicted to be best. This is truthful in most situations (although in some special cases we know that what is expected to exist best is not what will actually exist best). The expected utility of an action is the sum of the products of the probability and value of each of the possible outcomes of that activeness.
1.2. Act and rule utilitarianism
There are two broad schools of utilitarianism. According to deed utilitarianism, the right act is the act that produces the best consequences. Co-ordinate to rule utilitarianism, the right rule is the rule that produces the best consequences. The constabulary is frequently an instantiation of rule utilitarianism: laws are chosen considering they bring nigh the all-time consequences.
These versions of utilitarianism can come apart. Sometimes an human activity volition conspicuously accept better consequences, or no adverse consequences only a rule proscribes that human action.
Principles or laws around non‐bigotry are examples of this. Not considering a person's advanced historic period or severe inability (e.g. severe dementia) in the allocation of resource, including ventilators, might hateful that another person is unable to access those resource who would accept gained greater benefit from it, against human activity utilitarianism. All the same the rule might still overall take better consequences if the not‐discrimination rule has over‐riding benefits.
one.3. Two level utilitarianism
The two dissimilar schools of utilitarianism tin can be combined. The begetter of modern utilitarianism, Richard Hare, argued that moral thinking occurs at 2 levels: intuitive and critical, and that nosotros should motility between these depending on the circumstances. At the intuitive level, nosotros accept many crude rules of pollex that tin can exist rapidly deployed without protracted and demanding reflection: don't kill, don't steal, be honest, etc. These enable us to act efficiently in everyday life. During a pandemic, doctors and other conclusion‐makers require rules of thumb. For example, when faced with multiple simultaneous patients in the emergency department it is important to have a way of reaching a determination rapidly about which patient to nourish to first. Triage rules are potentially justified past a course of rule utilitarianism that enables rapid intuitive decisions.
'Critical level' utilitarianism requires choosing the action that will maximize the good when nosotros are thinking in the 'cool, calm hour', with all the facts at hand. Hare imagined a determination‐maker who had perfect cognition of the outcomes of all available options (he called them a 'utilitarian archangel'). In complex situations, where there is time to do so, we must try to rise to the more reflective and deliberative critical level and ask what activity we should endorse. What really is the right answer? Hare argues that in such situations we should employ act utilitarianism (this corresponds to system 1 and 2 thinking in psychology).
We volition explore some of the implications of critical level utilitarianism for the current COVID‐xix pandemic. We will also depict plausible rules of thumb that would tend to maximize utility and would exist useful in emergency and urgent situations. Box 1 illustrates two questions that have been prominent in the early phase of this pandemic.
1.4. Utilitarian rules of thumb
In that location are several rules of thumb that tin guide rapid decision‐making about these kinds of cases.
1. Number
One utilitarian rule of thumb is to save the greatest number (other things being equal). This rule could be applied to the lockdown question past assessing how many lives would be lost if lockdown is applied, or not practical. It could also exist used for the triage question: in exercise, this would mean considering the following variables:
A. Probability
If Jason has a 90% chance of recovery and Alessandro has a 10% gamble, other things beingness equal, you lot should use your ventilator for Jason. Indeed, if you treat people like Jason rather than people like Alessandro, you will salve nine people instead of one for every ten treated. That is why probability is a relevant consideration.
B. Elapsing of treatment
In a setting of scarcity, duration of fourth dimension on a ventilator has implications for the numbers of lives saved. The longer 1 person will exist on a ventilator, the more people who potentially die because they cannot become access to animate support. If Alessandro needs a ventilator for 4 weeks, and four others (including Jason) need it for 1 week, the choice is betwixt saving i person or 4 people. So doctors should take duration of utilise into account.
C. Resources
When resource are limited, resource equate to numbers of lives. The more than resources a treatment or a person uses, the fewer are available for others. Imagine that Alessandro and Jason had identical chances of survival, only Alessandro needed a treatment that required three staff to administrate the handling (due east.g. extracorporeal membrane oxygenation [ECMO]—essentially cardiac bypass) and Jason needed a treatment that required only i staff member (e.g. mechanical ventilation). Nosotros can potentially save three people with ventilation for every patient nosotros save with ECMO. ECMO should be a lower priority than ventilation.
two. Length of life
Co-ordinate to utilitarianism, how long a do good will be enjoyed matters—information technology affects the amount of good produced. Thus for life‐saving treatment, treatment that saves people'due south lives for longer is to be preferred over treatments that save life for shorter periods.
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 dice sooner, utilitarianism would support treating Alessandro, fifty-fifty though he is older.
Historic period is thus a de facto measure of length. Because older people tend to die sooner than younger people, utilitarianism tends to favour saving the lives of the younger. However, historic period itself does not matter: it is the expected length of the benefit. This is why utilitarianism is not unfairly discriminatory, and non 'ageist' in an ethically problematic sense (nosotros will hash out discrimination farther below).
Length of life is also relevant for the lockdown question. It is the length of life extended that matters. This has implications for evaluation of electric current policy. In the UK, the decision to implement national lockdown at the end of March was influenced by modelling produced past Imperial College (Figure i).
The UK Government opted to try to reduce deaths to 20,000. Simply it was not clear from the modelling effigy of 500,000 how many of these people would have died anyway from other causes, or relatively presently later not contracting COVID‐xix. Every year more 600,000 people die in the Uk. For utilitarians, the number of lives saved is irrelevant—it is how long these lives would be prolonged by the intervention.
The average age of death of COVID‐19 patients in Italy was 78. This implies that many of those saved by implementing lockdown would have short life expectancies. The boilerplate life expectancy at age fourscore is nine years, and overall, COVID‐19 has been estimated to lead to a loss of 11 life years on average. According to utilitarianism, the value of a year of full quality life is the same regardless of how old a patient is. However, if the pandemic largely affects patients with short life expectancy, the do good of a lockdown (preventing deaths) would be smaller than a different illness that affected younger patients. The cost of lockdown per year of life saved could be astronomical, when one considers all costs including economical and wider social effects.
At the end of March, economists van den Broek‐Altenburg and Atherly, from the Academy of Vermont estimated the cost‐effectiveness of implanting large scale protective measures to reduce the spread of COVID‐19. They calculated the cost per Quality Adjusted Life Year (QALY) of a $The states 1 trillion economical stimulus parcel against the number of lost life years potentially averted (up to thirteen meg in the U.s.). They estimated that such a bundle would cost between $75,000–650,000 per QALY. (The US government subsequently approved a $The states 2 trillion stimulus packet.) That suggests that such measures are unlikely to be cost‐effective according to the usual thresholds applied to the costs of medical interventions to salvage lives. For case, the upper limit for cost‐effectiveness of an intervention in the USA is often taken to be about $100,000 per year of life saved.
There are two points to make about such an analysis. The first is that assessing the commonsensical answer to the lockdown question is highly dependent on the specific factual answers—the impairment averted by interim, the harm caused by acting. Information technology is exceedingly difficult to make up one's mind which course of activeness would be best from the point of view of critical level utilitarianism, partly considering of enormous uncertainty well-nigh the relevant facts. Secondly, fifty-fifty if lockdown were cost‐constructive, it would not be every bit 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 simply have to salve i‐fifth as many to bring about every bit much benefit. It costs a few dollars to relieve the life of a child in a developing land.
While interventions to prevent COVID‐nineteen may be toll‐effective (though this seems perhaps unlikely), they are unlikely to be the most cost‐effective deportment that we could take. There are probable to exist better investments for utilitarians. As an case, The Gates Foundation has estimated that global eradication of malaria by the year 2040 would price up to $120 billion. Such an initiative (costing simply 1/15th as much as the US pandemic stimulus bundle) would potentially relieve 11 one thousand thousand lives.
3. Quality of life
Utilitarians consider not just how long someone will live after treatment but how well they volition live. They consider quality of life important.
This could be relevant to the triage question (as suggested in the quote from the Office for Civil Rights at the start of this paper).
Consider an extreme example. The terminate point of dementia is unconsciousness. Imagine that of our two patients with respiratory failure Alessandro is nonetheless working, in possession of all of his faculties. Jason, by contrast (in this version of the case) has stop stage dementia. According to utilitarians, nosotros should care for Alessandro if we cannot treat both. Jason would derive zilch benefit from being kept alive in an unconscious state. Indeed, this would apply potentially even if Jason (with dementia) had a higher chance of survival, or were going to survive for longer.
What about lesser degrees of cerebral impairment or other disabilities? According to utilitarians, these would as well be considered in making allocation decisions if they bear upon the person'south well‐being.
However, comparisons of overall well‐being between individuals are not straightforward. Information technology is not necessarily the case that someone with a disability would have lower well‐being than someone without a inability. Probably the near profound question in ethics is what makes a person's life good, or constitutes well‐being. Philosophers accept debated this question for thousands of years. Answers include happiness, want fulfilment or flourishing as human animals (which includes having deep relationships with others and being autonomous, amongst other things).
As a heuristic for triage, it may be that in adult countries a threshold is ready at a level where overall well‐being is certain to be low. One practical cutting off would be unconsciousness or severe disorders of consciousness, such as being in a minimally conscious state. Information technology is highly unlikely to be price‐constructive to provide intensive care for a patient who is permanently minimally witting. Lines could be drawn where at that place is more than incertitude, and may need to be in countries with more express resources, or if the demand were much greater. For example, the threshold might exist set at the ability to recognize and respond meaningfully with other people. And then, on this approach, cognitive impairments that reduced the capacity to take minimal human relationships would reduce priority for handling as a proxy for believed reduced well‐being.
Quality of life may also exist relevant to the lockdown question. If the life years saved by lockdown were likely to be of reduced quality that would influence how much benefit overall is gained, and therefore what economic cost would exist worth incurring.
4. Equivalence of acts and omissions, withdrawing and withholding
For utilitarians, how an result arises is morally irrelevant. It makes no departure if it is the upshot of an act, or an omission.
Doctors, patients and families, even so, agree that there is a moral departure between acts and omissions. Many people hold a causal account of responsibility: they tend to recollect that nosotros are responsible for the consequences of our acts but not for our omissions. Thus people tend to believe that withdrawal of life‐sustaining handling is morally worse than withholding life‐sustaining handling.
This folk commitment to a causal sense of responsibility and the acts/omission distinction has a number of bad consequences.
It means that there is considerable attending in pandemic guidelines to decisions about initiation of treatment. The 'triage question' is largely or entirely focused on whether to start treatment. Withholding of treatment from patients with poorer prognosis is oft thought to exist ethically acceptable. Notwithstanding, some apparently poor prognosis patients will do well and a trial of handling might provide more accurate prognostic information. Thus, under weather condition of doubt, a trial of treatment with the possibility of withdrawal would exist preferable to withholding treatment.
Utilitarianism would decline the thought of employing whatsoever form of 'showtime come, first served' to decide about treatment. The timing of when a patient arrives needing treatment is morally irrelevant to whether or not they should receive treatment. This is a principle that we have elsewhere labelled the principle of temporal neutrality. According to utilitarianism, doctors should exist prepared to withdraw treatment from poor prognosis patients in order to enable the treatment of better prognosis patients if they get in later.
Consideration of acts and omissions is also relevant to wider social questions raised by the pandemic. Failing to implement a good policy is equivalent to actively implementing a bad policy, when the consequence of the two decisions is the same. So utilitarians hold policy makers responsible not just for what they do, simply for what they fail to practice. Declining to implement other policies, with the issue of avoidable, foreseeable deaths is equivalent to killing for utilitarians. (This ways that policy makers are just every bit blameworthy for failing to eradicate malaria every bit they would take been if they had failed to act in response to coronavirus.)
5. Social benefit
According to utilitarianism, all the consequences of actions, both short and long term, direct and indirect are relevant to decisions. Thus it may be relevant to consider not simply the do good to the person directly affected by an activity (for instance, by being placed on a ventilator), but also others. This can exist chosen 'social benefit' or social worth.
In pandemics, one rule of pollex likely to maximize utility would be to give priority to health care workers, those providing cardinal services and others who are necessary to provide essential benefits to others. This has been applied in many countries, including the United kingdom of great britain and northern ireland, to testing for coronavirus. Notwithstanding, it might too apply to admission to ventilators or other medical treatments. A reason given for this is that it will potentially hateful that they can as well return to work sooner.
What about the social worth of others? Should criminals have a lower priority in accessing limited resource? What about scientists working on a vaccine? Related to social benefits is the issue of dependents. Should meaning women and parents of dependent children be given greater priority for health care? Developing rules of thumb for assessing social worth is ethically and epistemically circuitous, liable to abuse and hard to enforce fairly. Critical level utilitarianism would likely not endorse such priority rules, perhaps beyond prioritizing disquisitional essential services workers (which is relatively clear cut and easy to enforce and has broad social acceptance).
Utilitarianism is sensitive to the potential for abuse of its operationalized principles. If at that place is a risk that a principle will exist driveling, this should be taken into business relationship in deciding whether to operationalize it or non. For example, social worth is easily abused past the powerful to claim privilege and priority.
6. Responsibility
For utilitarians, we are morally responsible to the extent that the effects of our acts or omissions are foreseeable and nosotros have control over them. Intentions are irrelevant for utilitarians. It is not what we desire to happen that matters: it is what we tin foresee, and what actually happens. So even if consequences are unintended, we are still responsible if they are foreseeable and avoidable.
This implies that failing to take a course of action that would bring nigh more proficient, or avoid more harm, is equivalent to intentionally causing that harm. The moral responsibleness for choosing an junior policy is high for utilitarians and actions that result from this are subsequently blameworthy.
Utilitarianism is a very demanding theory in several ways. Whenever we foreseeably and avoidably bring almost a less adept state of affairs, we are morally responsible and blameworthy. If bringing about the best policy requires more than enquiry, nosotros are responsible for the deaths that occur because that research was not done.
Another issue in resource allocation is responsibility for illness. Many people take the intuition that responsibility for illness should be taken into account in the allocation of limited resources. Smokers should receive lower priority for lung transplants, drinkers for liver transplants. The UK regime has also encouraged the public to take responsibility for their health. In the case of COVID‐xix, people with various comorbidities accept worse prognoses. For example, type II diabetes is one such comorbidity, and its chance factors include so‐chosen 'lifestyle' factors such as diet and practise.
At that place are numerous issues with trying to utilise responsibleness for affliction in the allocation of resources. Utilitarians eschew all direct consideration of causal contribution to disease and, indeed, any 'astern looking' considerations similar desert. They are merely concerned with bringing about the best effect. If, for example, diabetes reduces the chance of survival, it is relevant insofar as information technology reduces the gamble of survival, not because it was the result of whatsoever voluntary behaviour.
Responsibility (or the disposition to behaviour that led to sick health) is only relevant for utilitarians insofar equally information technology affects probability, length or quality of survival. This is in line with how responsibility is generally used in the NHS.
seven. Avoid psychological biases, intuitions and heuristics
Utilitarianism seeks to avoid biases, emotions, intuitions or heuristics that prevent the most good being realized.
For instance, humans are insensitive or numb to large numbers. They are also more moved by a unmarried identifiable individual suffering than by large numbers of anonymous individuals suffering each to the same extent (this is the then‐called 'rule of rescue'). Thus they will be motivated to alleviate the suffering of a single highly publicized individual, rather than taking action that prevents suffering of a larger amount of unknown or unidentifiable individuals. To some extent, national responses to COVID‐nineteen might represent a massive form of the 'rule of rescue'.
Probably almost relevant to political decision‐making is bias towards the virtually future. The want to avoid deaths at present is stronger than the desire to avoid deaths in the futurity. It is psychologically easier to impose severe lockdown now in the name of saving lives threatened now, even if the toll of loss of life would be greater in the hereafter. There is some evidence that the lockdown and related factors such every bit reduced access to medical care are leading to boosted deaths from causes other than coronavirus. It might be anticipated that there will exist large numbers of hereafter deaths caused by the economic downturn induced by the pandemic. Afterwards the 2008 financial crash information technology is estimated that at that place were 250,000 excess cancer deaths just in Arrangement for Economical Co‐functioning and Development countries.
These future and non‐identifiable deaths might be greater than or less than those prevented by lockdown. They are hard to predict and even to confidently assign, which is one reason that they are difficult to accept into account. However, they are merely as ethically relevant every bit the deaths caused by COVID‐19. We should non ignore them considering they are less psychologically existent and motivating.
Utilitarianism aims to the maximize the good, impartially conceived. Statistical lives affair as much as identifiable lives.
Some other bias is to one'due south family and friends. According to utilitarianism, nosotros should give equal weight to the lives of strangers, even those in other countries. The effects on the pandemic in Africa are nevertheless to be documented or manifest. Given that at that place are fewer advanced life support systems, the mortality is likely to be greater. Utilitarianism would favour diverting resources there if the effects would be greater.
Much of ordinary decision‐making is driven past emotion, biases and heuristics. Thus, much of utilitarianism will strike ordinary people equally counterintuitive.
ane.5. The triage question
The higher up rules of thumb could be assembled into an algorithm for allocation of ventilators (Figure 2). Such an algorithm could exist used to inform rapid decisions if there were overwhelming numbers of patients presenting in futurity surges relating to COVID‐19. Alternatively, information technology might be used to inform decisions about highly scarce and expensive treatments such as ECMO. Because of the need for rapid decisions, based on limited information, this represents an attempt to guide 'intuitive level' decisions in a way that would generate near benefit overall. It is thus different from what act utilitarianism (or the critical level approach) would recommend.
An upstanding algorithm for rationing life sustaining treatment
The algorithm divides determination‐making into stages, and prioritizes on the ground of different criteria, depending on the availability of resources. For case, information technology starts past giving highest priority to those with the highest chance of surviving and needing the lowest duration of treatment. This would maximize the number of lives saved. If there are sufficient ventilators to treat all patients with at to the lowest degree a moderate run a risk of surviving, at that place would be no need to invoke other criteria. Thus, for example, health care systems with ample pre‐existing intensive care chapters, or who have been able to expand their capacity acutely, might accept no demand to ration on the footing of life expectancy or quality of life.
If there are insufficient ventilators, boosted principles might exist invoked. Every bit noted, utilitarianism does not necessarily seek to save well-nigh lives, but would aim to accomplish the about well‐existence overall, including elements of both length of life and quality of life. At a second level, triage might assess both of these factors for patients in need of treatment. In practice, however, estimation of predicted quality adapted life years for individual patients is highly circuitous (and may be uncertain). It would exist quicker to ready a threshold of length and quality of life worth saving. As an instance, we accept suggested that a health system under astringent force per unit area might elect to only provide mechanical ventilation to patients predicted to survive for at least v years with normal quality of life, but the specific threshold used will depend on the level of resource availability and on the level of demand.
ane.6. The lockdown question
While the triage question lends itself to heuristics, and the development of a rule that might generate the best effect overall, it is difficult to know what intuitive‐level response would be all-time for the lockdown question. Because of the scale of the impact of the pandemic, at that place is a danger that rapid dominion‐based responses might become badly wrong and lead to a much worse outcome overall. Instead, this is a question that would be better answered by drawing on disquisitional level utilitarianism. In large role considering of dubiety, there are dissimilar views about which strategy for entering or leaving lockdown would generate the best result overall. For example, there remains debate about whether the approach in Sweden (avoiding a national lockdown) is improve or worse than the approach of Sweden'south Scandinavian neighbor Norway, which implemented a lockdown in early March. At the fourth dimension of writing, Sweden has reported 2,769 deaths, (274 deaths/million population), compared with 214 deaths in Norway (39/million population).
The important consequence for utilitarians is not the number of deaths, merely the QALYs lost. Because a large proportion of the deaths in Sweden are in care homes, there may be fewer QALYs lost than 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 less than Kingdom of norway, overall, as a event of the policy. It is far from clear at this point the respond to that question.
Moreover, at that place tin can exist difficulties in comparing countries, since they differ in more than just the policy applied. They may also differ in other characteristics. The bloodshed of Stockholm stands out in Sweden: half of Sweden'due south deaths were in Stockholm, yet its population is roughly 1/5thursday of Sweden's: specifically, 1,428 out of ii,854 deaths (May five, 2020). The mortality rate of a region in the s of Sweden with a population of 1.iv million was half that of Oslo, the capital region of Kingdom of norway (Apr 21, 2020), in spite of non having had a lockdown policy for 5 or 6 weeks. The number of deaths in this southern region is 78 compared to one,428 in Stockholm whose population is only a couple of hundred thousand greater (May five, 2020). I potential explanation for differences in bloodshed relates to differences in population density. Another relates to the amount of circulating coronavirus prior to any change in customs behaviour (which may or may non take been imposed formally as a lockdown). A further cistron 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 but due to a national lockdown is confirmed by the fact that this mortality effigy is lower both than that of the neighbouring Danish capital letter, Copenhagen, 293, and the county surrounding it, 93 (May 5, 2020), despite that fact that shops, etc. accept been locked down in Copenhagen since mid‐March.
It might be that conditions all over Sweden will soon exist worse than in Norway and Denmark because of the absenteeism of a national lockdown. However, it is possible that Norway and Kingdom of denmark'due south arroyo might pb to more deaths at a afterward phase considering of further surges of the virus when lockdown is relaxed. More importantly, equally nosotros take argued, the number of deaths from COVID‐nineteen at a given betoken in fourth dimension is not decisive. The question is which strategy volition prevent the about deaths from any cause (and more importantly preserve the most years of life in total heath). We must keep in mind the prospect of wider harms to the customs as a upshot of lockdown and the economic consequences.
It is difficult to know what overall strategy would be best. There are several articulate points, though about how utilitarianism would inform a policy response to the lockdown question.
1.7. Evidence sensitivity
Utilitarianism is highly dependent on authentic information about the globe. It requires skilful evidence. Without good evidence, it is less probable that we would choose means that will bring about the most good.
Utilitarianism is thus complementary to science—it requires science. Thus utilitarianism will urge more inquiry to get better estimates of consequences and probabilities from a wide range of possible courses of action. Utilitarianism invites scientific research. The Swedish arroyo to lockdown has been informed by epidemiological models of the impact of coronavirus that were lower and less dramatic than some of the models used elsewhere (for example in the UK). Whatsoever modelling or data that is used to inform decision‐making should be openly bachelor and field of study to peer review. If the evidence changes, or the modelling needs to be revised, policy should also modify. This means that countries might need to change their policy. That could mean relaxing lockdown, or implementing stricter lockdown. The Britain regime changed tack in its response to coronavirus in late March in response to revised modelling. That does necessarily hateful that the previous policy was mistaken. Every bit noted, utilitarianism directs decisions on the footing of expected utility. Where our expectations change, decisions should modify besides.
For example, in order to get meliorate estimates of truthful mortality, utilitarianism would support random population testing to come across the incidence of COVID‐19 in asymptomatic or minimally symptomatic customs members.
Sometimes the opportunity costs of gathering more than information or bear witness will be prohibitive when urgent activeness is needed. In these cases, it is important that beliefs are every bit rational equally possible. They should result from broad expert dialogue, embracing the possibility of dissensus.
1.8. Global, impartial equality
Disquisitional level utilitarianism requires impartial and equal consideration of the well‐beingness of all sentient creatures. In this case, it requires consideration of people now and in the futurity, likewise as people without coronavirus who might be affected by lockdown. It includes the well‐being of all people, erstwhile and young, sick and well, in 1'south ain country and internationally.
This means that it is critical to assess both the well‐beingness costs of COVID‐19, and the well‐being costs of lockdown. There is currently huge attention to quantifying the numbers of cases of COVID‐nineteen infection and the number of consistent deaths. However, there is much less attention to the possible consequences of lockdown measures for people without coronavirus. Recent figures (at the stop of April) suggest that the UK has had a large increment in all‐crusade mortality—the highest in Europe, and that this rate has non been decreasing even as reported deaths from COVID‐19 have fallen. There is an urgent need to identify and quantify deaths (and more importantly loss of years of well‐being) from all causes in order to inform decisions. Deaths or illness from COVID‐nineteen might exist greater in number than other causes (or they might not), only they are non ethically more important than those from other causes.
Lockdown measures themselves volition have direct morbidity and bloodshed (through deprival or delay of medical treatment), as well as indirect furnishings through economic recession. 1 estimate is that 25 one thousand thousand jobs will exist lost worldwide with associated loss of well‐being and decease.
According to utilitarianism, the right policy is the one that maximizes well‐being overall, across all people across all countries. Utilitarianism embraces radical impartial equality—all well‐existence and deaths are equal (other things being equal). The cause of loss of well‐being does not matter. Thus, a utilitarian policy volition only invest in preventing loss of life from COVID‐19 provided it is the virtually efficient style of saving all lives.
We have noted already that other global wellness priorities might exist considerably more toll‐effective than the financial costs of responding to coronavirus. However, in that location are other important global considerations. The UK has banned the sale of fourscore drugs to other countries in a bid to forbid NHS shortages. From a utilitarian perspective, this may be the incorrect course of activeness if the sale of the drugs would salve more lives globally if exported. There may be a moral obligation to help others that overrides the obligation to one's ain citizens. Many countries have sourced large numbers of ventilators in lodge to be able to run across anticipated demand in their own country. However, the consequences of the pandemic may be much more astringent in low and middle income countries (LMIC). Some of the investment that countries take made into their own (already well‐resourced) health care systems would yield much greater benefit for LMIC. That might include making ventilators available (poor countries have been outbid by wealthy countries in the scramble to buy ventilators). It might include back up for LMIC policies that are less costly but potentially constructive means of averting the crisis (for example, Vietnam employed mass testing and contact tracing to prevent the spread of COVID‐nineteen, and equally a result, reported zero COVID‐nineteen deaths at the stop of April). Policy makers in LMIC may benefit from some of the modelling and scientific expertise available in other countries to support their conclusion‐making. Information technology has been questioned whether isolation will piece of work in Africa or whether information technology will kill more young people through its economic effects and subsequent malnutrition.
For utilitarians, policy will need to be sensitive to context and facts about individuals and local communities. The policy that is best for one country may be worst for another.
Utilitarianism is a theory with no national boundaries.
1.9. Well‐being matters more than rights and liberty
For utilitarianism, well‐being is all that matters. Liberty and rights are only of import insofar as they secure well‐beingness. Thus a commonsensical arroyo to the lockdown question may be prepared to override the right to privacy or liberty to protect well‐being.
Vietnam, Singapore, Taiwan and China take used methods such as tracing contacts and enforcing self‐isolation using mobile phone data, with astringent penalties for failure to comply (in Singapore, it is upwards to vi months gaol). These countries accept been highly effective at containing COVID‐nineteen, more then than liberal Western countries with greater emphasis on rights and liberties. Utilitarians support the East Asian approach of constraining liberty and privacy to promote security and well‐beingness. This arroyo too appears cost‐effective while delayed response may not be.
One recent proposition has been an app that facilitates contract tracing. Withal, participation in the programme is meant to exist voluntary: people would need to agree to share information nigh their whereabouts and wellness status. Utilitarianism would favour a more than coercive approach if this is more constructive. Those who favour such voluntary programmes give greater weight to consent and privacy than to well‐being and life. This is a value choice: it chooses private rights over overall reduction in the spread of disease. Of course, countries are free to pursue private freedom, simply if the liberty based approach is less effective, information technology will necessarily come at the cost of additional cases of COVID‐19 and additional deaths.
Importantly, the extent of the liberty restriction or rights violation should be commensurate with the effect on well‐being. Utilitarianism would support isolating certain groups if the benefit to them was greater or the benefit to others was greater. Thus a utilitarian approach to lockdown might favour selective isolation of the elderly and other vulnerable groups if that was the about cost‐constructive mode to secure overall well‐being.
Likewise, the restriction of freedom of low risk groups may also be necessary to secure large collective benefits. This justifies, for case, in the case of influenza, vaccinating children, who are at low take chances of flu complications, in lodge to protect the elderly, who have less effective immune responses to vaccination and are at greater hazard of flu complications. Although children have piddling expectation of do good themselves from vaccination, vaccinating children is necessary to secure benefits to overall well‐being that cannot otherwise be achieved. (It would as well support challenge studies beingness performed [voluntarily] on low chance populations for a COVID‐19 vaccine, e.thou. young people.)
It is often objected that utilitarianism leads to discrimination against those in 'protected' categories, such every bit the elderly, disabled, women, ethnic minority groups, etc. For example, in COVID‐19, it appears that elderly, male person, obese, and BAME patients have a worse prognosis than other groups (to varying degrees). Utilitarians, it is argued, will give lower priority to some or all of these groups for access to express resources and/ or a higher priority to isolating these groups, which is bigotry.
The first result at hand is the accurateness of the information. For case, apparent differences in mortality between groups may be mere proxy correlations, that arise from unrelated factors such as faster spread amongst different groups in the community pregnant there is uneven distribution of cases in the first identify (nosotros withal do not know the true number of cases due to testing shortages in well-nigh all countries), the presence or absence of different groups in high‐run a risk occupations (in addition to uneven distribution of cases, at that place may be a 'dose‐dependent' effect of the viral load on the severity of affliction making some workers more vulnerable), existing comorbidities that are correlated with different groups, but unrelated to them and should exist considered separately, or poorer care due to bias or lack of admission. Moreover, identification and assay of these factors may atomic number 82 to the ability to apply constructive focussed measures such equally equipping care homes with better testing and protective equipment, or focussed testing measures. Utilitarianism fails if it is applied unscientifically, without fine‐grained data, or if it fails to consider the best policy responses.
If the evidence associating a group of people with college mortality is indeed both authentic and predictive of a higher mortality, and the clan is of sufficient strength, and the proposed policy is both necessary and effective, then assigning resource or burdens such as lockdown selectively is no more discriminatory than other policies, such as the selective isolation of people on the basis of a proxy risk factor for infection, such every bit travel history or contact with someone who has COVID‐19 (this was the early on strategy).
Nevertheless, at that place would still be utilitarian reasons to refuse policies that give lower priorities to these groups. In particular, these groups (with the exception of males) have already been disadvantaged, and indeed this disadvantage may fifty-fifty be the direct crusade of vulnerability to COVID‐19. Justice requires that they not be farther disadvantaged. Accepting the validity of justice need not hateful rejecting utilitarianism. Utilitarians must consider all the effects of their policies and actions. If some policy volition perpetuate or exacerbate discrimination or injustice with concomitant furnishings on well‐being, these must be considered. Loss of brusk‐term utility is justified by the larger long‐term gains of a more just society.
In any case, as we outlined at the starting time of this newspaper, utilitarianism is not necessarily a consummate respond: one can sacrifice utility for other values. Thus, there might be straightforwardly commonsensical reasons for treating different groups in the aforementioned way: the resulting fractures in gild arising from a policy that did non practice then would ultimately cause a greater loss of well‐being. Or there might be pure justice reasons: upholding central values such as justice is more of import than the net difference in expected wellness outcomes.
A fundamental aspect of the law on discrimination is proportionality. In a pandemic, very large numbers of lives are at stake. Equality, even for those opposed to utilitarianism, is just i value amidst others. Discrimination may be proportionate if the stakes are high plenty and alternative measures are non available.
1.10. Separateness of persons
One prominent objection to utilitarianism is that information technology fails to respect the separateness of persons. One instantiation of this problem that is relevant to pandemic management is that utilitarianism can favour very small take chances reductions spread over very large numbers of persons rather than the saving of ane long life. Minor appurtenances can be summed to outweigh 1 large good.
Insofar as this is a trouble, it can be avoided in practice by only comparing and summing comparable appurtenances, for example lives. For instance, ane could count just the saving of lives or the saving of a life for a sufficiently long menstruum of fourth dimension (say 1 yr) equally a minimum good to be counted.
This vice can also be a virtue. The significant misery that a large number of people feel during lockdown (unemployment, depression, being victims of domestic violence, etc.) should non be ignored and must exist recognized as an ethical cost. If that well‐beingness loss is neat enough for a large enough number of people it could outweigh even the loss of some years of life for a relative few.
one.11. Conclusion
Utilitarianism is a demanding and counterintuitive theory. Why should we consider information technology? If the utilitarian course of activity is not adopted, someone (ofttimes many) people will suffer or dice avoidably. There may be practiced reasons (such as the preservation of freedom) to sacrifice well‐being or lives. Merely such choices need to exist fabricated transparently and in full awareness of their ethical toll. One must have good reasons to deliberately cull a class of action that will be worst overall.
Policy is frequently driven by politics or popular opinion, not ethics. This is morally wrong. Much of ideals in the public sphere involves social signalling, moralism and sometimes wishful thinking (for instance, trying to wish away difficult upstanding dilemmas). Careful consideration of the consequences of our actions requires united states of america to face up the facts and our values. A utilitarian approach is not simple, or easy. It requires that we choose the course of action that will benefit nigh people to the greatest degree, still difficult or counterintuitive that is.
There is some support for utilitarianism. In one survey investigating the public's views on how to allocate intensive care beds amid critically ill infants, nosotros found the full general public widely supported commonsensical allocations. They supported allocating the intensive care bed to salvage the babe with a greater gamble of survival, who would have a longer life or less disability. They also supported saving the greater number. This suggests that there may exist public support for the algorithm that we have proposed for the triage question. When people sympathise that there is an unavoidable demand to choose between patients, they announced to recognize that securing the nigh benefit overall is both logical and upstanding.
One of the psychological biases that dominates decision‐making is loss aversion. Losses loom larger than gains. And when we evaluate a policy nosotros are liable to focus on the negatives, rather than the positives. Thus governments, such as Due east Asian governments, who radically curtail freedom and protect wellness and security are criticized for being overly authoritarian. Liberal governments that protect liberty and incur greater infection risks (such as the United kingdom and Australia) are criticized for failing to protect the vulnerable and secure public health. In that location is no win the in the court of public opinion.
That is why we need, in the cool, calm 60 minutes, to set our policy objectives and priorities. Utilitarianism gives a clear framework for that. And it gives criteria to estimate success.
The universal common ethical currency is well‐existence. What matters to each of the states is how well our lives become. This is the very middle and footing of utilitarianism: it takes an impartial arroyo to everyone'south well‐being. While people may debate other things matter (autonomy, privacy, dignity), everyone tin can agree that well‐existence matters.
It is doubtful that any of the policies currently beingness adopted by any governments worldwide are purely or simply utilitarian. However, some are potentially reflecting more conspicuously and advisedly about the costs and benefits of different courses of action and policy. The cardinal difficulty facing all of us during this pandemic is that we cannot know for sure which action volition be all-time overall. Nosotros do not know what a commonsensical 'archangel' would cull: it would require a detailed understanding of the science and facts, the nature of well‐being and an exhaustive agreement 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. Our societies may and so choose to cover or cull not to embrace the utilitarian course. Merely at least we volition then practise and then with a clear understanding of our values and the price nosotros are willing to pay for them.
Acknowledgements
JS and DW were supported by the Wellcome Trust (WT203132). JS through his involvement with the Murdoch Children's Research Institute was supported past the Victorian Government'south Operational Infrastructure Support Program.
Biographies
•
Julian Savulescu has held the Uehiro Chair in Applied Ethics at the Academy of Oxford since 2002. He has degrees in medicine, neuroscience and bioethics. Since 2017, he has been Visiting Professorial Fellow in Bioemedical Ethics and group leader for the Biomedical Ethics Research Group at the Murdoch Children's Inquiry Institute, and Distinguished International Visiting Professor in Constabulary at Melbourne University. At the University of Oxford, he directs the Oxford Uehiro Heart for Practical Ideals within the Kinesthesia of Philosophy, co‐directs the Wellcome Centre for Ethics and Humanities, and leads a Wellcome Trust Senior Investigator laurels on Responsibility and Health Intendance.
•
Ingmar Persson is Emeritus Professor of Practical Philosophy, University of Gothenburg, and Distinguished Research Swain, Oxford Uehiro Center of Practical Ethis. His books on ethics include Inclusive Ethics (OUP, 2017) and, with Julian Savulescu Unfit for the Time to come (OUP, 2012).
•
Dominic Wilkinson is Professor of Medical Ethics at the Oxford Uehiro Centre for Practical Ethics, University of Oxford. He is besides a consultant in newborn intensive intendance at the John Radcliffe Hospital, Oxford. His co‐authored books include 'Medical Ethics and Law, tertiary edition' (Elsevier 2019); 'Ethics, Conflict and Medical treatment for children, from disagreement to dissensus' (Elsevier, 2018). He is the writer of 'Death or Inability? The 'Carmentis Machine' and decision‐making for critically ill children' (OUP 2013).
Footnotes
4Come across Jackson, F. (1991). Determination‐theoretic consequentialism and the nearest and dear objection. Ethics, 101, 461–482.
5Hare, R. Thousand. (1981). Moral thinking: Its levels, method and point. Oxford, United kingdom of great britain and northern ireland: Clarendon Press.
6Kahneman, D. (2011). Thinking fast and slow. London, UK: Farrar, Straus and Giroux.
46Information drawn from Ferguson, N. Thousand., Laydon, D., Nedjati‐Gilani, Yard., Imai, North., Ainslie, K., Baguelin, M., … Ghani, A. C. (2020, March sixteen). Study 9: Touch on of not‐pharmaceutical interventions (NPIs) to reduce COVID‐19 bloodshed and healthcare need. https://doi.org/10.25561/77482. Retrieved from https://www.royal.ac.britain/media/imperial‐college/medicine/sph/ide/gida‐fellowships/Royal‐College‐COVID19‐NPI‐modelling‐xvi‐03‐2020.pdf
10Hanlon, P., Chadwick, F., Shah, A., Wood, R., Minton, J., McCartney, G., … McAllister, D. A. (2020). COVID‐19 – exploring the implications of long‐term condition type and extent of multimorbidity on years of life lost: a modelling study [version 1; peer review: awaiting peer review]. Wellcome Open Research 5, 75.
xvParfit, D. (1984). Reasons and persons. UK: Oxford Academy Press; Griffin, J. (1988). Well‐being: Its meaning, measurement and moral importance. Oxford, UK: Clarendon Printing.
16Wilkinson, D., & Savulescu, J. (2018). Prioritisation and parity: Which disabled infants should be candidates for scarce life‐saving handling. In A. Cureton & D. Wasserman (Eds.), Oxford handbook of philosophy and disability (pp. 669–692). Uk: Oxford University Press.
17Arora, C., Savulescu, J., Maslen, H., Selgelid, M., & Wilkinson, D. (2016). The intensive care lifeboat: A survey of lay attitudes to rationing dilemmas in neonatal intensive care. BMC Medical Ethics, 17, 69.
18Wilkinson, D., Brick, C., Kahane, G., & Savulescu, J. (2020). The relational threshold: A life that is valued, or a life of value? Journal of Medical Ethics, 46, 24–25.
19Wilkinson, D., & Savulescu, J. (2014). A costly separation between withdrawing and withholding treatment in intensive care. Bioethics, 28(three), 127–137.
22Friesen, P. (2018). Personal responsibility within health policy: Unethical and ineffective. Journal of Medical Ethics, 44, 53–58; Brown, R., & Savulescu, J. (2019). Responsibility in healthcare across fourth dimension and agents. Journal of Medical Ethics, 45, 636–644.
23Pillutla, V., Maslen, H., & Savulescu, J. (2018). Rationing elective surgery for smokers and obese patients: Responsibleness or prognosis? BMC Medical Ethics, xix, 28.
24Savulescu, J., & Persson, I. (2012). Unfit for the future: The need for moral enhancement. UK: Oxford Academy Press.
25Jonsen, A. R. (1986). Bentham in a box: Applied science assessment and health care allocation. Police force, Medicine and Health Care, fourteen, 172–174.
xxxWilkinson, D., & Savulescu, J. (2018). Ethics, conflict and medical treatment for children: From disagreement to dissensus. Elsevier.
31The EuroMOMO hub. (2020). Graphs and maps. EuroMOMO. Retrieved from https://world wide web.euromomo.european union, accessed May five, 2020.
39Bambery, B., Douglas, T., Selgelid, Yard., Maslen, H., Giubilini, A., Pollard, A., & Savulescu, J. (2018). Flu vaccination strategies should target children. Public Health Ethics, eleven(2), 221–234.
twoscoreSavulescu, J., Cameron, J., & Wilkinson, D. (2020, in printing). Equality or utility? Ideals and law of rationing ventilators. British Journal of Amazement. https://doi.org/x.1016/j.bja.2020.04.011
41Harris, J. (1987). QALYfying the value of life. Journal of Medical Ethics, 3, i–xviii; Harris, J. (1995). Double jeopardy and the veil of ignorance – A reply. Journal of Medical Ethics, 21, 151–157.
42Cameron, J., & Savulescu, J. (2020). Why lock down of the elderly is non ageist and why levelling down equality is wrong. Under review.
43Savulescu et al., op. cit. annotation xl.
44Rawls, J. (1971). A theory of justice. Cambridge, MA: Belknap Printing of Harvard University Press.
45Arora et al., op. cit. note 17.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276855/
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