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Balancing Lives, Economics, and Public Policy in This Plague

I am a physician, and while I don’t treat coronavirus patients personally (I’m a neurosurgeon), I work in a regional coronavirus center and have first-hand knowledge of the medical impact of this pandemic. The danger the virus poses to life is substantial — in vulnerable people, it causes severe pulmonary compromise, often requiring the patient to be placed on a ventilator, and a substantial portion of these ventilated patients will die. The virus is highly contagious, and has a rather long incubation period, which helps it spread — people who have it continue to walk around and spread it for quite a while before they become sick and realize that they are contagious. 

A Framework for the Wisest Decisions

For a variety of reasons, the coronavirus plague is devastating to our country. Public policy decisions are agonizing — do we destroy our economy to save lives? What are the risks to life from economic devastation, and how can these risks be weighed against the risks to life from the virus? What are the psychological and sociological consequences of the pandemic and of our response to it? What are the political ramifications? There are no easy answers. I think that we should insist on three principles which will help us make the wisest decisions possible.

  1. Experts must keep in their lane — medical recommendations must be based entirely on medical rationale. Legal recommendations must be based entirely on legal rationale. Economic recommendations must be based entirely on economic rationale. Foreign policy recommendations must be based entirely on foreign policy rationale. The final decisions by our leaders — the political recommendations and policy — must incorporate scientific, legal, medical, and economic input and arrive at a “best course” decision for our nation. This principle, “Experts: keep in your lane,” is vital. The reason is that expertise is specific to discipline. There is no reason to think that expertise necessarily extends out of that discipline, and confusing personal or ideological perspectives with expert knowledge muddles final decision-making. For example, an epidemiologist should give advice based strictly on epidemiological science. This would include advice to close borders as soon as a risk of transmission from outside of the country is identified, advice for social distancing, tracking of carriers, making medications and equipment available, etc. The personal beliefs of the scientists on the legal or moral aspects of immigration policy, etc., should play no role in their expert recommendations. The feasibility and public policy wisdom of these scientific recommendations is not the concern of scientists, acting in their professional capacity. Whether closing the borders is morally or legally or politically viable is not the bailiwick of scientists. Scientists should inform the public and policy makers of the scientific issues, without personal bias. In this sense, expert opinion must be rarified. Experts must stick to their lane. 
  2. Transparency — exactly what is our calculus? The ultimate decision on management of this crisis is political (in the sense that it is for the well-being of our polis), and our political policy makers (the President, Congress and the Senate, governors, etc.) should make their calculus transparent. How many deaths are we willing to risk to save our economy? What is the likelihood of exacerbating the pandemic if we open businesses, in quantitative terms? Leaders should think this through carefully, and in a nation in which the people are sovereign, the people should know the calculus. 
  3. Final public policy decisions must be well-informed and must be made based on sound ethical guidelines. 

The Principle of Double Effect 

Thomas Aquinas’ Principle of Double Effect, which is a venerable ethical framework that forms the basis for much of Western law and ethics, provides a good framework. It is based on the observation that ethical choices usually need to be made without full knowledge of all variables and without guarantees of outcomes. Ethical decisions are based on probabilities, and some of the possible outcomes of even the most sound decisions may be bad. For example, your decision to drive to work in the morning is generally an ethical good — you need to earn a living, do right by your job and coworkers, etc. But driving to work might cause a fatal car accident, which obviously is ethically bad. A reasonable ethical decision would be to drive to work on most days, but under some circumstances (you are too tired to drive safely, or there is a blizzard which make the roads hazardous), you may want to stay home. 

The Principle of Double Effect can be formalized. In order for a decision to be ethically good, it must conform to four criteria:

  1. We must will the good. The policy makers must have good intentions — for example, policy decisions on the pandemic that are motivated by considerations of private gain or partisan political advantage are ethically unsound. 
  2. We must not will the bad. Bad intentions must be completely absent from policy decision-making. It is not enough to will some good and some bad. Our leaders’ rationales must be based entirely on securing the welfare of the American people. 
  3. The good must be much more likely than the bad — that is, there must be an excellent chance that the good will prevail. This means that we should weigh the likelihood of good and bad outcomes. If reopening the economy next week stood an 80 percent chance of exacerbating the pandemic and causing 100,000 excess deaths, it probably would be ethically wrong to do so, even though there is a 20 percent chance of success. A 20 percent chance of success is not good enough when the downside is 100,000 deaths. If we stood only a 1 percent chance of causing 1,000 excess deaths, it might be ethically right to do so, when the risks to health and well-being of economic devastation are factored in. Succinctly, the decision to pursue a course of action must be based on solid reasons to believe that a good outcome is much more likely than a bad one. We have to consider the odds of good vs. bad outcomes. 
  4. The bad must not be the means by which the good is accomplished. We must never intend the bad, even if it is to obtain the good. This is perhaps the most subtle, and dangerous, temptation in ethical decision-making. If bad outcomes occur, they must be incidental, not instrumental, to our purposes. For example, it would be ethical, in extremis, to triage patients for respiratory support in a crisis in which there were not enough ventilators or resources to save everyone. We would do the very best we could to save all the lives possible with the means at our disposal, and we would accept (but not intend) some tragic deaths. It would not, however, be ethical to euthanize patients (e.g., the elderly with medical conditions) in order to free up resources for others. We cannot morally intend and do evil (euthanasia) in order to accomplish good. If evil happens — if people die because we do not have the resources to save them — it must be incidental to our purposes, and not an instrument of our purposes. Evil must never be deliberate. 

In this difficult time, there are no easy public policy answers to the coronavirus pandemic. Some expert recommendations may be easy, in the sense that epidemiological or legal principles may be quite clear — closing borders to potentially infected carriers, social distancing, respecting statutory and constitutional rights, etc. In this sense, the experts have the easiest job. They should speak based only on what they know.

Our leaders, who have the responsibility to make the final policy decisions, should consider the legitimate opinions of experts, should be transparent about their calculus, and should base public policy decisions on a rational ethical framework. 

We should hold our experts, our leaders, and ourselves to these principles.