Which Of The Following Moral Perspectives Best Represents Singer's Approach To Animal Ethics?ã¢â‚¬â€¹
Bioethics. 2020 Jul; 34(6): 620–632.
Utilitarianism and the pandemic
Julian Savulescu
ane Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford United kingdom,
2 Wellcome Centre for Ethics and Humanities, Academy of Oxford, Oxford U.k. of Bang-up United kingdom of great britain and northern ireland and Northern Ireland,
three Visiting Professorial Fellow in Biomedical Ideals, Biomedical Ethics Inquiry Group, Murdoch Children'southward Research Plant, Melbourne Commonwealth of australia,
iv Distinguished Visiting Professor in Police force, Melbourne Police force Schoolhouse, University of Melbourne, Melbourne Victoria, Commonwealth of australia,
Ingmar Persson
i Oxford Uehiro Heart for Applied Ethics, University of Oxford, Oxford United Kingdom of Great U.k. and Northern Ireland,
5 Department of Philosophy, Linguistics and Theory of Scientific discipline, Gothenburg University, Gothenburg Sweden,
Dominic Wilkinson
1 Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford United kingdom of Uk and Northern Ireland,
2 Wellcome Center for Ethics and Humanities, University of Oxford, Oxford United Kingdom of Great Great britain and Northern Republic of ireland,
6 John Radcliffe Hospital, Oxford United Kingdom of Great Britain and Northern Republic of ireland,
Received 2020 Mar 31; Revised 2020 May fifteen; Accepted 2020 May xx.
Abstract
In that location are no egalitarians in a pandemic. The scale of the claiming for wellness systems and public policy ways that there is an ineluctable need to prioritize the needs of the many. It is impossible to treat all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life. In a pandemic in that location is a strong ethical demand to consider how to practice most good overall. Utilitarianism is an influential moral theory that states that the right action is the action that is expected to produce the greatest proficient. It offers articulate operationalizable principles. In this paper we provide a summary of how utilitarianism could inform two challenging questions that take been of import in the early stage of the pandemic: (a) Triage: which patients should receive admission to a ventilator if in that location 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 non to argue that utilitarianism is the merely relevant upstanding theory, or in favour of a purely commonsensical arroyo. However, conspicuously considering which options will do the nigh practiced overall will help societies identify and consider the necessary cost of other values. Societies may choose either to cover or non to comprehend the utilitarian grade, but with a clear agreement of the values involved and the price they are willing to pay.
Keywords: COVID‐19, pandemic ethics, resource allocation, utilitarianism
1. INTRODUCTION
The COVID‐19 pandemic has posed a formidable and nigh unprecedented challenge to wellness professionals, health systems and to national governments. The potential threat to big numbers of patients has led to restrictions on movement, employment, and everyday life that have impacted the lives of billions and come at massive economic price. Wellness systems, facing existing or predicted need overwhelming capacity, have generated guidelines indicating which patients should receive treatment.
One upstanding theory has been both cited and criticized in public debate about pandemic response.
The civil rights office of the US Section of Wellness and Human Services stated that:
persons with disabilities, with limited English skills, or needing religious accommodations should not be put at the finish of the line for health services during emergencies. Our ceremonious rights laws protect the equal dignity of every man life from ruthless utilitarianism.
After the New York Times reported that some country pandemic plans instructed hospitals non to offer mechanical ventilation to people above a certain age or with particular health conditions (eastward.k. 'severe or profound mental retardation' every bit well as 'moderate to astringent dementia'), the Office for Ceremonious Rights (OCR) responded: '… persons with disabilities should not be denied medical intendance on the basis of stereotypes, assessments of quality of life, or judgments about a person's relative "worth" based on the presence or absence of disabilities or age'.
Utilitarianism is at present oft used every bit a pejorative term, pregnant something like 'using a person equally a means to an end', or even worse, akin to some kind of ethical dystopia. Nonetheless utilitarianism was originally conceived every bit a progressive liberating theory where everyone'southward well‐being counted as. This was a powerful and radical political theory in the 19th century, when big sections of the population were completely disenfranchised and suffered from institutional bigotry. The theory played a role in antislavery, women's liberation and fauna rights movements. Yet utilitarianism remains relevant in the 21st century. As we volition talk over, information technology may be particularly salient and important to consider in the confront of global threats to health and well‐being.
In this paper, we will summarize what utilitarianism is and how it would apply to the COVID‐19 pandemic. Our aim is not to argue that utilitarianism is the only relevant ethical theory, or that a purely utilitarian arroyo must be adopted. However, it is of import to note that whenever a utilitarian solution to a dilemma is adopted, there will be more well‐being or happiness in the world. Typically, some people will be better off. Of course, there may exist good ethical reasons to deviate from a pure utilitarian arroyo, for instance in club to protect rights or promote equality. Nevertheless, considering the culling will help societies to identify and consider the necessary cost of these other upstanding values. Utilitarianism is not the stop of ethical reflection, simply it is a expert identify to start.
1.ane. What is utilitarianism?
About moral theories imply that there is a (moral) reason to practice what is expected to maximize what is good for all, or more precisely, the internet surplus of what is good for all over what is bad for them. This might exist called a principle of beneficence. Utilitarians hold that maximizing what is good for all is all there is to morality. It makes moral decisions simple by supplying a single measure of rightness: maximization of utility. In many situations this may be enough, along with rules of thumb with the help of which information technology could be adamant what maximizes utility.
Co-ordinate to most moral theories there are, still, other moral reasons. For instance, utilitarianism has often been criticized for ignoring the question of what is a simply or off-white distribution of what is good for all. The outcome that generates the greatest proficient overall may be unlike from the event whose distribution of goodness comes closest to being just or fair. Then the principle of beneficence will have to be counterbalanced against the principle of justice. This will most likely have to be done in an intuitive way. It is very controversial what a just or fair distribution consists in, eastward.g. whether it consists in getting what is deserved or in more equal shares. This is far also controversial to be settled here. Information technology follows that the issue of balancing justice and beneficence against each other must also exist left aside.
Some other moral principle is a principle of autonomy, which gives weight to an individual's freedom to cull and to make up one's mind, for themselves, how to live their own life. Individual freedoms may conflict with overall practiced, for case, 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 outcome of whether the principle of beneficence should be impartial and accord the same moral weight to the good of all other individuals or whether it should allow greater weight to the skillful of those who are close to united states of america (and to homo over not‐human beings). For the purpose of discussing what policies societies should adopt to deal with pandemics, it is reasonable to assume impartiality.
A farther result is what constitutes goodness and badness for individuals. According 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 hurting and unhappiness. Hedonism is, nonetheless, ofttimes criticized for being too narrow in non recognizing that what nosotros are not aware of can be good or bad for us, e.g. that our partners deceive us, or that the country surveys our behaviour, then cleverly that nosotros never observe it. For such reasons a wider conception of what is intrinsically expert or bad for us than hedonism volition be assumed here, though to determine its precise import would take the states also far afield.
Some moral theories imply that there is a stronger or more stringent moral reason to omit doing harm than to benefit. Thus, they imply that in that location is a stronger reason to avoid making things worse for somebody by killing them, causing them injury or pain, than to benefit them by preventing them from being killed, injured, etc. With respect to pandemics, considerable moral weight has been attached to harms such as death and disease that tin can exist prevented past various constraints. Therefore, for the present discussion it is better to go along on the assumption that at that place is no significant moral departure betwixt 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 hurting that is caused 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 i life lasting many decades with a single instance of excruciating pain caused past 75 units of the concrete stimulus lasting for x min. According to a standard utilitarian calculus the old effect is worse than the latter, only this seems implausible. Most of us would prefer 100 instances of balmy pain dispersed over our lives than 10 min of excruciating hurting. It might be thought that this event is crucial in the present context, since we will have to balance the deaths of a lower number of people against smaller burdens for a much higher number of people. We will, however, meet that what is morally relevant from a utilitarian perspective isn't decease in itself but rather the length and quality of life the deceased would take had if they hadn't died.
Information technology might be said that what matters in the end is what action really maximizes what is good for all rather than what action is expected to maximize what is practiced for all. But our best guide to what volition actually happen is what is expected to happen on the best available evidence. So, when we make up one's mind what to do, we accept 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 be all-time is not what will actually be 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 action.
i.2. Human action and dominion utilitarianism
In that location are ii broad schools of utilitarianism. According to act utilitarianism, the correct act is the act that produces the best consequences. According to rule utilitarianism, the right dominion is the rule that produces the best consequences. The law is oftentimes an instantiation of rule utilitarianism: laws are called because they bring nigh the best consequences.
These versions of utilitarianism can come up autonomously. Sometimes an deed will clearly have better consequences, or no adverse consequences but a rule proscribes that human action.
Principles or laws effectually non‐discrimination are examples of this. Not considering a person'southward advanced age or astringent disability (e.grand. severe dementia) in the resource allotment of resource, including ventilators, might mean that another person is unable to access those resource who would have gained greater do good from it, against act utilitarianism. However the rule might still overall have improve consequences if the non‐discrimination rule has over‐riding benefits.
1.3. 2 level utilitarianism
The two unlike schools of utilitarianism tin be combined. The father of modern utilitarianism, Richard Hare, argued that moral thinking occurs at 2 levels: intuitive and critical, and that we should move between these depending on the circumstances. At the intuitive level, we have many rough rules of thumb that can be chop-chop deployed without protracted and enervating reflection: don't impale, don't steal, be honest, etc. These enable the states to act efficiently in everyday life. During a pandemic, doctors and other determination‐makers require rules of thumb. For instance, when faced with multiple simultaneous patients in the emergency department information technology is important to have a way of reaching a decision chop-chop about which patient to nourish to offset. Triage rules are potentially justified by a form of dominion utilitarianism that enables rapid intuitive decisions.
'Critical level' utilitarianism requires choosing the activity that volition maximize the good when we are thinking in the 'cool, calm hour', with all the facts at manus. Hare imagined a decision‐maker who had perfect knowledge of the outcomes of all available options (he called them a 'utilitarian archangel'). In complex situations, where in that location is fourth dimension to do then, nosotros must try to rise to the more reflective and deliberative critical level and ask what action nosotros should endorse. What really is the right answer? Hare argues that in such situations we should employ act utilitarianism (this corresponds to system i and two thinking in psychology).
We will explore some of the implications of critical level utilitarianism for the current COVID‐19 pandemic. Nosotros will besides describe plausible rules of thumb that would tend to maximize utility and would be useful in emergency and urgent situations. Box i illustrates two questions that have been prominent in the early on stage of this pandemic.
ane.4. Utilitarian rules of thumb
There are several rules of thumb that can guide rapid decision‐making nigh these kinds of cases.
i. Number
One utilitarian rule of thumb is to save the greatest number (other things existence equal). This rule could exist practical to the lockdown question by assessing how many lives would exist lost if lockdown is applied, or not applied. It could also be used for the triage question: in exercise, this would hateful considering the following variables:
A. Probability
If Jason has a xc% chance of recovery and Alessandro has a 10% gamble, other things existence equal, y'all should employ your ventilator for Jason. Indeed, if yous treat people similar Jason rather than people like Alessandro, you will save nine people instead of one for every 10 treated. That is why probability is a relevant consideration.
B. Duration of treatment
In a setting of scarcity, duration of time on a ventilator has implications for the numbers of lives saved. The longer one person will be on a ventilator, the more than people who potentially dice because they cannot become admission to breathing support. If Alessandro needs a ventilator for four weeks, and 4 others (including Jason) need information technology for one week, the choice is between saving ane person or four people. So doctors should have duration of use into business relationship.
C. Resources
When resources are limited, resources equate to numbers of lives. The more 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 iii staff to administer the treatment (e.g. extracorporeal membrane oxygenation [ECMO]—essentially cardiac bypass) and Jason needed a treatment that required only one staff member (eastward.g. mechanical ventilation). We tin potentially save three people with ventilation for every patient we salve with ECMO. ECMO should be a lower priority than ventilation.
2. Length of life
According to utilitarianism, how long a benefit will exist enjoyed matters—it affects the amount of good produced. Thus for life‐saving treatment, handling that saves people'southward lives for longer is to be preferred over treatments that save life for shorter periods.
According to this benchmark, 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 information technology were Jason who was expected to die sooner, utilitarianism would back up treating Alessandro, fifty-fifty though he is older.
Age 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. Even so, historic period itself does not thing: information technology is the expected length of the benefit. This is why utilitarianism is not unfairly discriminatory, and not 'ageist' in an ethically problematic sense (we will discuss bigotry farther below).
Length of life is besides 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 Great britain, the decision to implement national lockdown at the end of March was influenced by modelling produced by Royal College (Figure 1).
The UK Government opted to try to reduce deaths to 20,000. But it was not articulate from the modelling figure of 500,000 how many of these people would take died anyway from other causes, or relatively soon after non contracting COVID‐19. Every year more than 600,000 people die in the United kingdom. For utilitarians, the number of lives saved is irrelevant—it is how long these lives would be prolonged by the intervention.
The boilerplate age of death of COVID‐19 patients in Italy was 78. This implies that many of those saved by implementing lockdown would take short life expectancies. The average life expectancy at age 80 is 9 years, and overall, COVID‐19 has been estimated to lead to a loss of eleven life years on average. According to utilitarianism, the value of a twelvemonth of total quality life is the same regardless of how sometime a patient is. However, if the pandemic largely affects patients with curt life expectancy, the benefit of a lockdown (preventing deaths) would be smaller than a different illness that affected younger patients. The price of lockdown per year of life saved could exist astronomical, when one considers all costs including economic and wider social furnishings.
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‐nineteen. They calculated the price per Quality Adjusted Life Year (QALY) of a $US ane trillion economic stimulus package confronting the number of lost life years potentially averted (upward to 13 meg in the U.s.a.). They estimated that such a package would price between $75,000–650,000 per QALY. (The U.s.a. government subsequently approved a $US 2 trillion stimulus package.) That suggests that such measures are unlikely to be price‐effective according to the usual thresholds applied to the costs of medical interventions to save lives. For example, the upper limit for cost‐effectiveness of an intervention in the USA is often taken to be almost $100,000 per twelvemonth of life saved.
At that place are 2 points to brand virtually such an analysis. The first is that assessing the utilitarian reply to the lockdown question is highly dependent on the specific factual answers—the impairment averted past acting, the impairment caused by acting. It is exceedingly difficult to determine which course of activeness would exist best from the point of view of critical level utilitarianism, partly because of enormous uncertainty about the relevant facts. Secondly, fifty-fifty if lockdown were cost‐constructive, information technology 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 lot would only accept to relieve one‐fifth as many to bring about every bit much benefit. Information technology costs a few dollars to save the life of a kid in a developing country.
While interventions to prevent COVID‐19 may be cost‐effective (though this seems peradventure unlikely), they are unlikely to be the most cost‐effective actions that we could take. In that location are probable to exist better investments for utilitarians. As an example, The Gates Foundation has estimated that global eradication of malaria by the year 2040 would cost up to $120 billion. Such an initiative (costing merely 1/15th as much as the Usa pandemic stimulus package) would potentially save 11 million lives.
3. Quality of life
Utilitarians consider non just how long someone will live after handling but how well they will alive. They consider quality of life of import.
This could be relevant to the triage question (as suggested in the quote from the Role for Civil Rights at the start of this newspaper).
Consider an extreme example. The stop 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, past dissimilarity (in this version of the case) has cease stage dementia. According to utilitarians, nosotros should care for Alessandro if we cannot treat both. Jason would derive zero benefit from being kept live in an unconscious state. Indeed, this would employ potentially even if Jason (with dementia) had a higher chance of survival, or were going to survive for longer.
What about lesser degrees of cognitive harm or other disabilities? According to utilitarians, these would also be considered in making resource allotment decisions if they affect the person's well‐being.
Still, comparisons of overall well‐being between individuals are not straightforward. It is not necessarily the case that someone with a disability would take lower well‐being than someone without a disability. Probably the most profound question in ethics is what makes a person's life good, or constitutes well‐being. Philosophers take 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).
Equally a heuristic for triage, information technology may exist that in developed countries a threshold is set at a level where overall well‐being is certain to be low. One practical cutting off would be unconsciousness or astringent disorders of consciousness, such as being in a minimally conscious state. It is highly unlikely to exist price‐constructive to provide intensive care for a patient who is permanently minimally conscious. Lines could be fatigued where in that location is more doubtfulness, and may demand to exist in countries with more limited resources, or if the demand were much greater. For example, the threshold might be set up at the ability to recognize and answer meaningfully with other people. And so, on this arroyo, cognitive impairments that reduced the capacity to accept minimal man relationships would reduce priority for treatment as a proxy for believed reduced well‐being.
Quality of life may also be relevant to the lockdown question. If the life years saved past lockdown were likely to be of reduced quality that would influence how much do good overall is gained, and therefore what economic cost would be worth incurring.
4. Equivalence of acts and omissions, withdrawing and withholding
For utilitarians, how an outcome arises is morally irrelevant. It makes no departure if it is the effect of an human action, or an omission.
Doctors, patients and families, however, hold that there is a moral difference between acts and omissions. Many people hold a causal business relationship of responsibility: they tend to think that we are responsible for the consequences of our acts only non for our omissions. Thus people tend to believe that withdrawal of life‐sustaining handling is morally worse than withholding life‐sustaining treatment.
This folk delivery to a causal sense of responsibility and the acts/omission distinction has a number of bad consequences.
It ways that there is considerable attention 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 often thought to exist ethically acceptable. Yet, some plain poor prognosis patients will do well and a trial of treatment might provide more accurate prognostic information. Thus, nether atmospheric condition of uncertainty, a trial of treatment with the possibility of withdrawal would be preferable to withholding treatment.
Utilitarianism would reject the idea of employing whatsoever form of 'start come, first served' to decide almost treatment. The timing of when a patient arrives needing treatment is morally irrelevant to whether or not they should receive handling. This is a principle that we take elsewhere labelled the principle of temporal neutrality. According to utilitarianism, doctors should be prepared to withdraw treatment from poor prognosis patients in order to enable the handling of better prognosis patients if they arrive subsequently.
Consideration of acts and omissions is also relevant to wider social questions raised past the pandemic. Declining to implement a skillful policy is equivalent to actively implementing a bad policy, when the upshot of the 2 decisions is the same. And so utilitarians concur policy makers responsible not only for what they practise, just for what they fail to do. Failing to implement other policies, with the event of avoidable, foreseeable deaths is equivalent to killing for utilitarians. (This means that policy makers are simply equally blameworthy for failing to eradicate malaria as they would have been if they had failed to deed 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 only the do good to the person directly affected by an action (for case, by being placed on a ventilator), just besides others. This can be called 'social benefit' or social worth.
In pandemics, ane rule of thumb likely to maximize utility would be to give priority to health care workers, those providing key services and others who are necessary to provide essential benefits to others. This has been applied in many countries, including the Uk, to testing for coronavirus. However, it might also apply to admission to ventilators or other medical treatments. A reason given for this is that it will potentially mean that they can also return to work sooner.
What nearly the social worth of others? Should criminals take a lower priority in accessing limited resources? What well-nigh scientists working on a vaccine? Related to social benefits is the issue of dependents. Should significant women and parents of dependent children exist given greater priority for health care? Developing rules of thumb for assessing social worth is ethically and epistemically complex, liable to abuse and hard to enforce adequately. Critical level utilitarianism would probable non endorse such priority rules, perchance across prioritizing critical essential services workers (which is relatively clear cutting and like shooting fish in a barrel to enforce and has wide social acceptance).
Utilitarianism is sensitive to the potential for corruption of its operationalized principles. If there is a take a chance that a principle volition be abused, this should be taken into account in deciding whether to operationalize it or not. For instance, 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 we have control over them. Intentions are irrelevant for utilitarians. It is not what we desire to happen that matters: it is what nosotros tin foresee, and what actually happens. So fifty-fifty 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 virtually more good, or avert 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 skillful state of affairs, we are morally responsible and blameworthy. If bringing about the best policy requires more research, we are responsible for the deaths that occur because that research was not washed.
Another effect in resource allocation is responsibility for disease. Many people have the intuition that responsibility for illness should be taken into account in the allotment of limited resources. Smokers should receive lower priority for lung transplants, drinkers for liver transplants. The UK government has as well encouraged the public to take responsibleness for their health. In the case of COVID‐19, people with diverse comorbidities have worse prognoses. For case, type Ii diabetes is one such comorbidity, and its adventure factors include then‐called 'lifestyle' factors such equally diet and practise.
In that location are numerous issues with trying to use responsibility for affliction in the allocation of resources. Utilitarians eschew all directly consideration of causal contribution to illness and, indeed, whatever 'backward looking' considerations similar desert. They are only concerned with bringing about the best issue. If, for instance, diabetes reduces the chance of survival, information technology is relevant insofar equally information technology reduces the take chances of survival, not considering it was the consequence of whatsoever voluntary behaviour.
Responsibility (or the disposition to behaviour that led to ill health) is only relevant for utilitarians insofar as it affects probability, length or quality of survival. This is in line with how responsibility is by and large used in the NHS.
7. Avoid psychological biases, intuitions and heuristics
Utilitarianism seeks to avert biases, emotions, intuitions or heuristics that prevent the almost adept being realized.
For example, humans are insensitive or numb to large numbers. They are also more moved by a single identifiable individual suffering than by large numbers of anonymous individuals suffering each to the aforementioned extent (this is the so‐called 'rule of rescue'). Thus they volition be motivated to convalesce the suffering of a unmarried highly publicized individual, rather than taking action that prevents suffering of a larger corporeality of unknown or unidentifiable individuals. To some extent, national responses to COVID‐19 might represent a massive form of the 'dominion of rescue'.
Probably most relevant to political decision‐making is bias towards the near future. The want to avoid deaths at present is stronger than the want to avoid deaths in the hereafter. Information technology is psychologically easier to impose severe lockdown now in the name of saving lives threatened at present, even if the price of loss of life would be greater in the future. There is some evidence that the lockdown and related factors such every bit reduced admission to medical care are leading to additional deaths from causes other than coronavirus. Information technology might be anticipated that there will be large numbers of hereafter deaths caused by the economic downturn induced by the pandemic. After the 2008 financial crash it is estimated that there were 250,000 backlog cancer deaths simply in Organisation for Economic Co‐operation and Development countries.
These time to come and non‐identifiable deaths might exist greater than or less than those prevented by lockdown. They are hard to predict and fifty-fifty to confidently assign, which is one reason that they are difficult to take into account. Still, they are simply every bit ethically relevant as the deaths acquired by COVID‐19. We should not ignore them considering they are less psychologically real and motivating.
Utilitarianism aims to the maximize the proficient, impartially conceived. Statistical lives affair as much every bit identifiable lives.
Another bias is to one's family unit and friends. Co-ordinate to utilitarianism, we should give equal weight to the lives of strangers, fifty-fifty those in other countries. The effects on the pandemic in Africa are yet to exist documented or manifest. Given that there are fewer advanced life support systems, the mortality is probable to be greater. Utilitarianism would favour diverting resource there if the effects would exist greater.
Much of ordinary decision‐making is driven by emotion, biases and heuristics. Thus, much of utilitarianism will strike ordinary people as counterintuitive.
1.5. The triage question
The in a higher place rules of thumb could be assembled into an algorithm for allotment of ventilators (Effigy 2). Such an algorithm could exist used to inform rapid decisions if there were overwhelming numbers of patients presenting in hereafter surges relating to COVID‐nineteen. Alternatively, information technology might exist used to inform decisions about highly scarce and expensive treatments such equally ECMO. Considering of the need for rapid decisions, based on limited information, this represents an effort to guide 'intuitive level' decisions in a manner that would generate most do good overall. Information technology is thus different from what human activity utilitarianism (or the disquisitional level approach) would recommend.
An ethical algorithm for rationing life sustaining treatment
The algorithm divides decision‐making into stages, and prioritizes on the footing of different criteria, depending on the availability of resources. For example, information technology starts by giving highest priority to those with the highest take a chance of surviving and needing the lowest duration of treatment. This would maximize the number of lives saved. If there are sufficient ventilators to care for all patients with at least a moderate chance of surviving, at that place would be no need to invoke other criteria. Thus, for case, wellness intendance systems with aplenty pre‐existing intensive care capacity, or who accept been able to expand their capacity acutely, might have no need to ration on the basis of life expectancy or quality of life.
If in that location are bereft ventilators, additional principles might exist invoked. Every bit noted, utilitarianism does not necessarily seek to relieve nigh lives, but would aim to reach the most well‐beingness 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 handling. In practice, nonetheless, estimation of predicted quality adjusted life years for individual patients is highly circuitous (and may be uncertain). It would be quicker to set a threshold of length and quality of life worth saving. Every bit an example, we take suggested that a health organisation under severe pressure might elect to only provide mechanical ventilation to patients predicted to survive for at least five years with normal quality of life, simply the specific threshold used will depend on the level of resource availability and on the level of need.
1.6. The lockdown question
While the triage question lends itself to heuristics, and the development of a dominion that might generate the best outcome overall, it is hard to know what intuitive‐level response would exist best for the lockdown question. Because of the scale of the impact of the pandemic, there is a danger that rapid dominion‐based responses might go badly wrong and lead to a much worse event overall. Instead, this is a question that would be better answered by cartoon on critical level utilitarianism. In large function because of uncertainty, at that place are different views well-nigh which strategy for entering or leaving lockdown would generate the all-time outcome overall. For example, there remains debate about whether the approach in Sweden (fugitive a national lockdown) is meliorate or worse than the approach of Sweden's Scandinavian neighbour Norway, which implemented a lockdown in early on March. At the fourth dimension of writing, Sweden has reported two,769 deaths, (274 deaths/million population), compared with 214 deaths in Kingdom of norway (39/one thousand thousand population).
The of import event for utilitarians is not the number of deaths, but the QALYs lost. Considering a large proportion of the deaths in Sweden are in care homes, in that location 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 Norway, overall, every bit a result of the policy. Information technology is far from clear at this point the answer to that question.
Moreover, there can exist difficulties in comparing countries, since they differ in more than just the policy applied. They may likewise differ in other characteristics. The bloodshed of Stockholm stands out in Sweden: half of Sweden's deaths were in Stockholm, yet its population is roughly 1/5th of Sweden's: specifically, 1,428 out of 2,854 deaths (May 5, 2020). The mortality charge per unit of a region in the south of Sweden with a population of 1.4 one thousand thousand was half that of Oslo, the capital region of Norway (April 21, 2020), in spite of not having had a lockdown policy for five or 6 weeks. The number of deaths in this southern region is 78 compared to 1,428 in Stockholm whose population is just a couple of hundred thousand greater (May 5, 2020). One 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 community behaviour (which may or may not take 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 past the fact that this mortality figure is lower both than that of the neighbouring Danish capital, 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 weather all over Sweden will soon be worse than in Norway and Denmark because of the absenteeism of a national lockdown. Yet, it is possible that Norway and Denmark's approach might atomic number 82 to more deaths at a afterward stage because of farther surges of the virus when lockdown is relaxed. More importantly, as nosotros take argued, the number of deaths from COVID‐nineteen at a given point in fourth dimension is not decisive. The question is which strategy will prevent the most deaths from whatsoever cause (and more than importantly preserve the most years of life in total heath). We must go along in mind the prospect of wider harms to the community as a result of lockdown and the economic consequences.
It is difficult to know what overall strategy would be best. There are several clear points, though about how utilitarianism would inform a policy response to the lockdown question.
1.7. Bear witness sensitivity
Utilitarianism is highly dependent on accurate information about the world. Information technology requires good evidence. Without expert evidence, it is less probable that we would cull means that will bring about the most good.
Utilitarianism is thus complementary to science—it requires science. Thus utilitarianism volition urge more enquiry to go amend estimates of consequences and probabilities from a wide range of possible courses of activeness. Utilitarianism invites scientific inquiry. 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 instance in the UK). Whatever modelling or data that is used to inform decision‐making should exist openly available and subject to peer review. If the evidence changes, or the modelling needs to be revised, policy should also modify. This means that countries might demand to alter their policy. That could mean relaxing lockdown, or implementing stricter lockdown. The Uk regime changed tack in its response to coronavirus in belatedly March in response to revised modelling. That does necessarily mean that the previous policy was mistaken. As noted, utilitarianism directs decisions on the basis of expected utility. Where our expectations change, decisions should alter too.
For example, in order to go better estimates of truthful bloodshed, utilitarianism would support random population testing to see the incidence of COVID‐19 in asymptomatic or minimally symptomatic community members.
Sometimes the opportunity costs of gathering more data or testify will be prohibitive when urgent action is needed. In these cases, it is important that beliefs are as rational as possible. They should issue from wide expert dialogue, embracing the possibility of dissensus.
1.8. Global, impartial equality
Critical level utilitarianism requires impartial and equal consideration of the well‐being of all sentient creatures. In this example, it requires consideration of people now and in the futurity, equally well as people without coronavirus who might be affected by lockdown. Information technology includes the well‐being of all people, erstwhile and young, sick and well, in one's own country and internationally.
This means that it is critical to assess both the well‐being costs of COVID‐xix, 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 consequent deaths. However, at that place is much less attending to the possible consequences of lockdown measures for people without coronavirus. Recent figures (at the end of April) advise that the UK has had a large increment in all‐cause 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 guild to inform decisions. Deaths or illness from COVID‐19 might be greater in number than other causes (or they might not), but they are non ethically more important than those from other causes.
Lockdown measures themselves will have directly morbidity and mortality (through denial or delay of medical handling), as well every bit indirect effects through economic recession. One judge is that 25 million jobs will be lost worldwide with associated loss of well‐being and expiry.
According to utilitarianism, the right policy is the one that maximizes well‐being overall, beyond all people across all countries. Utilitarianism embraces radical impartial equality—all well‐being and deaths are equal (other things being equal). The crusade of loss of well‐being does not matter. Thus, a utilitarian policy will only invest in preventing loss of life from COVID‐19 provided information technology is the nearly efficient way of saving all lives.
Nosotros have noted already that other global health priorities might be considerably more cost‐constructive than the financial costs of responding to coronavirus. However, in that location are other important global considerations. The United kingdom of great britain and northern ireland has banned the auction of 80 drugs to other countries in a bid to prevent NHS shortages. From a commonsensical perspective, this may be the incorrect course of action if the auction of the drugs would save more lives globally if exported. There may be a moral obligation to help others that overrides the obligation to i'due south own citizens. Many countries have sourced large numbers of ventilators in club to be able to encounter anticipated need in their ain 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 have 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 accept been outbid by wealthy countries in the scramble to purchase ventilators). It might include back up for LMIC policies that are less plush but potentially constructive ways of averting the crisis (for example, Vietnam employed mass testing and contact tracing to prevent the spread of COVID‐19, and as a event, reported zippo COVID‐nineteen deaths at the stop of Apr). Policy makers in LMIC may do good from some of the modelling and scientific expertise bachelor in other countries to support their determination‐making. It has been questioned whether isolation will piece of work in Africa or whether it will kill more immature people through its economic effects and subsequent malnutrition.
For utilitarians, policy will need to be sensitive to context and facts well-nigh individuals and local communities. The policy that is best for ane country may be worst for another.
Utilitarianism is a theory with no national boundaries.
1.9. Well‐existence matters more rights and liberty
For utilitarianism, well‐being is all that matters. Liberty and rights are but important insofar every bit they secure well‐being. Thus a utilitarian approach to the lockdown question may be prepared to override the right to privacy or liberty to protect well‐being.
Vietnam, Singapore, Taiwan and Communist china take used methods such equally tracing contacts and enforcing self‐isolation using mobile phone data, with severe penalties for failure to comply (in Singapore, it is upward to six months gaol). These countries have been highly effective at containing COVID‐19, more than then than liberal Western countries with greater accent on rights and liberties. Utilitarians support the East Asian arroyo of constraining liberty and privacy to promote security and well‐being. This approach also appears toll‐constructive while delayed response may not be.
One recent suggestion has been an app that facilitates contract tracing. Yet, participation in the program is meant to exist voluntary: people would demand to concord to share information almost their whereabouts and health condition. Utilitarianism would favour a more coercive approach if this is more than effective. Those who favour such voluntary programmes requite greater weight to consent and privacy than to well‐existence and life. This is a value choice: it chooses individual rights over overall reduction in the spread of illness. Of course, countries are gratis to pursue individual freedom, only if the liberty based approach is less constructive, it volition necessarily come at the cost of additional cases of COVID‐19 and additional deaths.
Importantly, the extent of the freedom restriction or rights violation should exist commensurate with the effect on well‐existence. Utilitarianism would back up isolating certain groups if the benefit to them was greater or the do good 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 most toll‐effective way to secure overall well‐being.
Likewise, the restriction of liberty of low chance groups may also be necessary to secure large commonage benefits. This justifies, for example, in the case of flu, vaccinating children, who are at depression risk of flu complications, in order to protect the elderly, who have less effective allowed responses to vaccination and are at greater risk of flu complications. Although children take little expectation of benefit themselves from vaccination, vaccinating children is necessary to secure benefits to overall well‐being that cannot otherwise be achieved. (It would too support claiming studies being performed [voluntarily] on low risk populations for a COVID‐nineteen vaccine, e.g. young people.)
Information technology is often objected that utilitarianism leads to bigotry confronting 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, obese, and BAME patients have a worse prognosis than other groups (to varying degrees). Utilitarians, information technology is argued, will requite lower priority to some or all of these groups for admission to limited resources and/ or a higher priority to isolating these groups, which is discrimination.
The first upshot at hand is the accuracy of the data. For example, apparent differences in mortality between groups may be mere proxy correlations, that arise from unrelated factors such as faster spread among different groups in the community significant there is uneven distribution of cases in the first place (we all the same do not know the true number of cases due to testing shortages in almost all countries), the presence or absence of different groups in high‐risk occupations (in addition to uneven distribution of cases, there may exist a 'dose‐dependent' consequence of the viral load on the severity of affliction making some workers more vulnerable), existing comorbidities that are correlated with different groups, only unrelated to them and should be considered separately, or poorer care due to bias or lack of admission. Moreover, identification and analysis of these factors may lead to the ability to apply constructive focussed measures such as equipping care homes with improve 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 grouping of people with higher mortality is indeed both accurate and predictive of a higher mortality, and the clan is of sufficient forcefulness, and the proposed policy is both necessary and effective, and so assigning resources or burdens such equally lockdown selectively is no more discriminatory than other policies, such every bit the selective isolation of people on the ground of a proxy take chances factor for infection, such as travel history or contact with someone who has COVID‐nineteen (this was the early strategy).
Nevertheless, there would still be utilitarian reasons to turn down 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 even exist the direct cause of vulnerability to COVID‐nineteen. Justice requires that they not exist further disadvantaged. Accepting the validity of justice need not mean rejecting utilitarianism. Utilitarians must consider all the effects of their policies and deportment. If some policy will perpetuate or exacerbate discrimination or injustice with concomitant furnishings on well‐beingness, these must be considered. Loss of short‐term utility is justified by the larger long‐term gains of a more only society.
In any case, as nosotros outlined at the get-go of this paper, utilitarianism is not necessarily a complete answer: i can sacrifice utility for other values. Thus, there might exist straightforwardly utilitarian reasons for treating unlike groups in the same way: the resulting fractures in society arising from a policy that did not do so would ultimately crusade a greater loss of well‐being. Or there might be pure justice reasons: upholding key values such equally justice is more important than the net departure in expected health outcomes.
A key aspect of the law on bigotry is proportionality. In a pandemic, very large numbers of lives are at stake. Equality, even for those opposed to utilitarianism, is only 1 value amongst others. Discrimination may be proportionate if the stakes are loftier enough and alternative measures are not available.
i.x. Separateness of persons
One prominent objection to utilitarianism is that it fails to respect the separateness of persons. One instantiation of this problem that is relevant to pandemic management is that utilitarianism tin favour very small run a risk reductions spread over very large numbers of persons rather than the saving of i long life. Small goods can be summed to outweigh ane big good.
Insofar as this is a problem, information technology can be avoided in practice by only comparing and summing comparable goods, for case lives. For example, one could count merely the saving of lives or the saving of a life for a sufficiently long flow of time (say one year) every bit a minimum good to be counted.
This vice tin can also be a virtue. The significant misery that a big number of people feel during lockdown (unemployment, depression, being victims of domestic violence, etc.) should non be ignored and must be recognized every bit an ethical toll. If that well‐existence loss is great enough for a large enough number of people it could outweigh even the loss of some years of life for a relative few.
1.11. Conclusion
Utilitarianism is a enervating and counterintuitive theory. Why should we consider it? If the utilitarian course of activeness is not adopted, someone (often many) people volition suffer or dice avoidably. There may be expert reasons (such as the preservation of freedom) to sacrifice well‐being or lives. But such choices need to be made transparently and in full awareness of their ethical cost. One must have good reasons to deliberately choose a grade of action that will exist worst overall.
Policy is often driven by politics or popular opinion, not ideals. This is morally wrong. Much of ethics in the public sphere involves social signalling, moralism and sometimes wishful thinking (for instance, trying to wish away difficult ethical dilemmas). Careful consideration of the consequences of our actions requires us to face the facts and our values. A utilitarian approach is not simple, or easy. It requires that we choose the course of activity that will do good most people to the greatest degree, nevertheless difficult or counterintuitive that is.
There is some back up for utilitarianism. In one survey investigating the public's views on how to allocate intensive care beds amongst critically ill infants, we constitute the general public widely supported utilitarian allocations. They supported allocating the intensive intendance bed to salvage the infant with a greater hazard of survival, who would have a longer life or less disability. They also supported saving the greater number. This suggests that at that place may exist public support for the algorithm that we have proposed for the triage question. When people sympathise that at that place is an unavoidable need to choose between patients, they appear to recognize that securing the most benefit overall is both logical and ethical.
One of the psychological biases that dominates decision‐making is loss disfavor. Losses loom larger than gains. And when we evaluate a policy we are liable to focus on the negatives, rather than the positives. Thus governments, such as East Asian governments, who radically curtail liberty and protect health and security are criticized for existence overly authoritarian. Liberal governments that protect liberty and incur greater infection risks (such equally the United kingdom of great britain and northern ireland and Australia) are criticized for failing to protect the vulnerable and secure public health. In that location is no win the in the courtroom of public opinion.
That is why we need, in the absurd, calm hour, to fix our policy objectives and priorities. Utilitarianism gives a clear framework for that. And information technology gives criteria to judge success.
The universal common upstanding currency is well‐being. What matters to each of the states is how well our lives go. This is the very heart and ground of utilitarianism: it takes an impartial approach to everyone's well‐being. While people may contend other things matter (autonomy, privacy, dignity), anybody can agree that well‐being matters.
It is doubtful that any of the policies currently being adopted by any governments worldwide are purely or simply commonsensical. Notwithstanding, some are potentially reflecting more conspicuously and carefully nearly the costs and benefits of different courses of activeness and policy. The fundamental difficulty facing all of united states of america during this pandemic is that we cannot know for sure which activity will be best overall. We exercise not know what a utilitarian 'archangel' would choose: it would require a detailed agreement of the science and facts, the nature of well‐being and an exhaustive understanding of the consequences of our choices. But that is what nosotros should be aspiring to. We must strive to get the facts directly on all the consequences of our choices. Our societies may and so choose to embrace or choose non to embrace the utilitarian course. But at least we will so do so with a clear understanding of our values and the price we are willing to pay for them.
Acknowledgements
JS and DW were supported by the Wellcome Trust (WT203132). JS through his interest with the Murdoch Children'due south Inquiry Institute was supported by the Victorian Government's Operational Infrastructure Support Program.
Biographies
•
Julian Savulescu has held the Uehiro Chair in Practical Ethics at the University 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 Ideals Research Group at the Murdoch Children's Enquiry Found, and Distinguished International Visiting Professor in Law at Melbourne University. At the University of Oxford, he directs the Oxford Uehiro Centre for Practical Ethics within the Kinesthesia of Philosophy, co‐directs the Wellcome Centre for Ethics and Humanities, and leads a Wellcome Trust Senior Investigator honour on Responsibility and Health Care.
•
Ingmar Persson is Emeritus Professor of Practical Philosophy, University of Gothenburg, and Distinguished Research Young man, Oxford Uehiro Centre of Practical Ethis. His books on ethics include Inclusive Ethics (OUP, 2017) and, with Julian Savulescu Unfit for the Futurity (OUP, 2012).
•
Dominic Wilkinson is Professor of Medical Ideals at the Oxford Uehiro Centre for Practical Ethics, Academy of Oxford. He is as well a consultant in newborn intensive care at the John Radcliffe Hospital, Oxford. His co‐authored books include 'Medical Ethics and Law, third edition' (Elsevier 2019); 'Ethics, Conflict and Medical treatment for children, from disagreement to dissensus' (Elsevier, 2018). He is the author of 'Death or Disability? The 'Carmentis Motorcar' and determination‐making for critically sick children' (OUP 2013).
Footnotes
4See Jackson, F. (1991). Determination‐theoretic consequentialism and the nearest and dearest objection. Ethics, 101, 461–482.
5Hare, R. K. (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, United kingdom of great britain and northern ireland: Farrar, Straus and Giroux.
46Data drawn from Ferguson, N. M., Laydon, D., Nedjati‐Gilani, G., Imai, N., Ainslie, One thousand., Baguelin, Thou., … Ghani, A. C. (2020, March 16). Report ix: Impact of non‐pharmaceutical interventions (NPIs) to reduce COVID‐nineteen bloodshed and healthcare demand. https://doi.org/x.25561/77482. Retrieved from https://www.regal.ac.uk/media/imperial‐college/medicine/sph/ide/gida‐fellowships/Majestic‐College‐COVID19‐NPI‐modelling‐16‐03‐2020.pdf
xHanlon, P., Chadwick, F., Shah, A., Wood, R., Minton, J., McCartney, One thousand., … McAllister, D. A. (2020). COVID‐xix – 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.
15Parfit, D. (1984). Reasons and persons. Uk: Oxford Academy Press; Griffin, J. (1988). Well‐beingness: Its meaning, measurement and moral importance. Oxford, UK: Clarendon Printing.
sixteenWilkinson, D., & Savulescu, J. (2018). Prioritisation and parity: Which disabled infants should exist candidates for scarce life‐saving treatment. 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? Periodical of Medical Ideals, 46, 24–25.
nineteenWilkinson, D., & Savulescu, J. (2014). A plush separation between withdrawing and withholding treatment in intensive intendance. Bioethics, 28(3), 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). Responsibleness in healthcare across time and agents. Journal of Medical Ethics, 45, 636–644.
23Pillutla, Five., Maslen, H., & Savulescu, J. (2018). Rationing elective surgery for smokers and obese patients: Responsibility or prognosis? BMC Medical Ideals, 19, 28.
24Savulescu, J., & Persson, I. (2012). Unfit for the future: The demand for moral enhancement. UK: Oxford University Press.
25Jonsen, A. R. (1986). Bentham in a box: Technology assessment and wellness care resource allotment. Law, Medicine and Wellness Care, 14, 172–174.
30Wilkinson, D., & Savulescu, J. (2018). Ethics, conflict and medical handling for children: From disagreement to dissensus. Elsevier.
31The EuroMOMO hub. (2020). Graphs and maps. EuroMOMO. Retrieved from https://www.euromomo.eu, accessed May v, 2020.
39Bambery, B., Douglas, T., Selgelid, Thou., Maslen, H., Giubilini, A., Pollard, A., & Savulescu, J. (2018). Influenza vaccination strategies should target children. Public Wellness Ethics, 11(2), 221–234.
xlSavulescu, J., Cameron, J., & Wilkinson, D. (2020, in press). Equality or utility? Ethics and law of rationing ventilators. British Journal of Amazement. https://doi.org/10.1016/j.bja.2020.04.011
41Harris, J. (1987). QALYfying the value of life. Journal of Medical Ethics, iii, 1–18; 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 downward of the elderly is non ageist and why levelling down equality is wrong. Under review.
43Savulescu et al., op. cit. annotation 40.
44Rawls, J. (1971). A theory of justice. Cambridge, MA: Belknap Press of Harvard University Press.
45Arora et al., op. cit. note 17.
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276855/
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