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Survival of the Most Moral?

By: Austin Lam, University of Toronto


Austin Lam is currently a medical student at the University of Toronto. He obtained his B.Sc. Honours in Psychology and Philosophy (minor) from McGill University.

The medical humanities as well as the nexus of issues at the intersection of medicine, ethics, and socio-political factors are of great interest to me. I chose to write this paper because of my interest in these aforementioned areas, but also because I wanted to reconcile the strong visceral emotions that I felt in response to seeing the news of lockdown protestors (and now those who refuse to wear masks on dubious grounds). Neither unprocessed emotions nor some pseudo-stoic, isolated ‘rationality’ are appropriate responses, I thought. Instead, careful intellectual considerations that weave together differing concerns and underlying issues are needed. Here, I tried to do that.

A quote that I have been carrying since this pandemic has been: “But where the danger lies, also grows the saving power” — Friedrich Hölderlin.

Should lockdown protesters who subsequently contract COVID-19 receive less priority in the allocation of scarce medical resources?

Understandable though it may be to wish that lockdown protesters receive less priority in relation to limited medical resources should they contract COVID-19, this is not a tenable position.

There are two layers to this problem. The first layer deals with what we should do in principle. The second deals with what we should do when these principles come up against reality.




Regarding the first layer of what we should do in principle, I appeal to two commonly held principles: fairness and compassion. Fairness in the provision of health care resources can mean many things. However, one firmly entrenched belief is that individuals ought to receive care irrespective of their moral character. To conflate the matter of personal morality and the receipt of proper care leads down a dangerous path of reductio ad absurdum [reduction to absurdity; i.e., the aforementioned belief must be accepted because its rejection would be untenable] to a place where the mantra becomes “survival of the most moral”, and with it all the intractable ambiguities of how personal morality is defined in the first place. Thus, personal morality and the allocation of resources must be clearly demarcated.

Fairness, nonetheless, has many dimensions. A different interpretation is that the fairness of health care allocation is brought into disrepute (i.e., loses its good reputation) in the eyes of the public by allowing lockdown protesters to receive an equitable level of care as compared to non-protesters. In other words, public confidence would fall with respect to the perception of how health resources are allocated/provided. “They are breaking the social contract with regard to physical distancing and directly undermining community solidarity; why should I, a non-protester and a reasonably rule-abiding citizen, be lumped with them when it comes to receiving care if both of us became ill?” This is the question that becomes impossible to ignore.

As a stand-alone viewpoint, the latter interpretation of fairness might stand. However, a complete view that takes into account the principle of compassion favours the former interpretation of fairness. Here, I do not use compassion necessarily in the sense of close/intimate feeling for another person/persons. Instead, I mean compassion in a ‘thin’ sense, reflecting philosopher John Finnis’ characterization of friendship in contrast to the egoism of ‘game’ or ‘decision’ theorists (i.e., that each person has their own welfare as their ultimate aim):

There is a natural friendship, affectively thin but real and intelligent, of every person with every other person. … The essence of friendship is this: A is interested in B’s well-being for B’s sake, and B in A’s for A’s sake; and so A has reason to be interested in A’s own well-being not only for its own sake but also for B’s; and B likewise.(1)

In this way, Finnis argues that friendship and justice meet, or share a common capability of being understood.

Compassion is one of the basic human goods that renders consistent egoism impossible. In other words, the theoretical primacy of self-interest is inconsistent with our social reality. There is more to our social fabric than a mere compilation of self-interested agents. There is an affectively thin yet commonly intelligible sense of compassion that upholds justice in society.

The elaboration of fairness and compassion in this way, still, does not absolutely preclude the proposition at hand. That is to say, even if we accept the above elaborated fairness-compassion thesis, to give it a shorthand, it does not necessarily force us to exclude the belief that lockdown protesters should receive less priority in relation to limited medical resources. Although reduced, there are still multiple degrees of freedom in interpretation: we can still interpret the thesis in a way that supports the proposed differential provision of care.

For instance, the fairness-compassion thesis sets the groundwork for a communitarian view (i.e., a philosophy that emphasizes shared understandings and communal relationships, broadly speaking, in contrast to the individualistic tendency to see the person as a stand-alone entity). The fairness-compassion thesis gives way to the view that no one has a properly conceived right to put others in harm’s way. Lockdown protesters are, effectively, placing their community members in harm’s way (or at least likely so), especially the vulnerable, e.g., the elderly and the immunocompromised. In what way can this be said to meet the standard of an affectively thin yet shared sense of compassion? It does not.

Following from this, the lockdown protesters might be better described as exercising a ‘right’ that does not properly exist. It exists insofar as they detach themselves from the community and exist as atomistic entities, such as characterized by Charles Taylor (2). However, a right, grounded in a communal sense via T. H. Green (3), is a capacity to live with others and contribute to their good as well as to one’s own based on a shared common good, i.e., a shared conception of a collective end. Protesting lockdown does not meet this standard. So, it cannot be properly thought of as a legitimate exercise of a right.

In this light, lockdown protesters have detached themselves from their community; they have subverted a collective effort aimed at achieving a common good. The spotlight is now on the following question: in what way does society still owe them equitable allocation of health resources given that they broke away from the communal cohesion that is the basis of rights?

And so, we come up against reality now. The second layer makes clear that thought in the abstract rarely suffices. The problem is this: how do we practically identify/determine those who have subverted the collective effort to such an extent as to warrant a lower prioritization in health resources allocation — what is essentially a severe assault by the state on these individuals with respect to their membership in the community in a broad sense, access to communal health resources, and their liberty.

Given the severity of depriving a group of individuals from equitable access to community health resources, there must be a reliable, rigorous, and certain way of making this determination. To the extent that the possibility of error must be eliminated, the determination is impossible. To evoke a common law motto, it is better that one hundred people be incorrectly deemed as having not undermined their community than that one be wrongly deprived of or limited in their access to communal health resources. Practically executing this prioritization scheme is not possible without substantial compromises in principles and perhaps excessive, unrealistic levels of bureaucracy.

So, how should the question be approached? First, on principle, the fairness-compassion thesis reduces the degrees of freedom in terms of interpretations, precluding many, but not all, interpretations that favour a prioritization of non-protesters over protesters. Second, even on a possible account of the fairness-compassion thesis that favours this prioritization scheme, the practical problems of real life, including all the engendered ambiguities, effectively render the proposed prioritization either impossible or unconscionable.

[This piece was written with specific reference to individuals who were/have been protesting against physical distancing measures (i.e., “lockdown”), not with reference to demonstrations against systemic racism, which involve other fundamental considerations (e.g., principle of double effect). The author has written about this nexus of issues in a different piece: https://blogs.bmj.com/medical-ethics/2020/06/11/covid-systemic-racism-protests-anti-lockdown-protests-making-sense-of-it-all/.

Additionally, while this piece was written in response to a specific question prompt, the underlying argument could plausibly be applied to/adapted for the related issue of mask wearing.]

References:

1. Finnis JM. A grand tour of legal theory. In: Finnis JM, editor. Philosophy of law. 4th volume. New York: Oxford University Press Inc.; 2011. p. 91-156.

2. Taylor C. Sources of the self: The making of the modern identity. Cambridge: Harvard University Press; 1989.

3. Harris P, Morrow J, editors. T. H. Green lectures on the principles of political obligation and other writings. Cambridge: Cambridge University Press; 1986.

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