Thursday, April 02, 2020

Pandemic Moral Failures: How Conventional Morality Kills

If invited to consider moral errors people have made in relation to the current pandemic, some obvious candidates likely to spring to mind (in an American context) include:

  • General failures of pandemic preparedness (in the CDC and federal government more broadly) before the crisis hit.
  • The specific failure to immediately ramp up production of essential medical supplies, and especially coronavirus testing capacity, as soon as the threat became clear.
  • Lies and misleading messaging from the President and certain other politicians downplaying the need for any such preparations (including from some who privately made stock market trades at odds with their public reassurances that all was fine).
  • Reckless behaviour by private individuals, e.g. Spring Break party-goers who risked infection in large crowds and then returned home to potentially spread it to vulnerable family members and other community-members.
  • Hoarding toilet paper.
But I'm more interested in less widely-appreciated mistakes.  The most important of these may be the failure to adequately explore our option-space, stemming from the conventional moral thinking of many well-meaning people (including public health experts who are leading the response to the pandemic).  Narrow-mindedness may leave us susceptible to uncontrolled, high-risk infection when a lower-risk, more carefully controlled alternative is available.

In countries where fully suppressing the virus is no longer a feasible option, the conventional wisdom is that we must instead "flatten the curve" and simply slow the spread of the virus through widespread "lockdowns", to avoid (as far as possible) overburdening the medical system at any one time.  The most likely end-game (again, given that total suppression is not feasible) is the eventual attainment of herd immunity, either through vaccination (if/when such a breakthrough occurs -- likely 18+ months, possibly much longer), or through the gradual accidental infection and recovery of a sizeable majority of the population (entailing a great many deaths).

The conventional wisdom assumes that infection ought always and everywhere to be avoided for as long as possible.  Of course, it's obviously bad (all else equal) to get infected, compared to remaining always in good health.  And it's natural to be averse to pro tanto bads. But not all else is equal, and we are not (most of us) expected to be able to avoid infection forever.  So we need to be open to the possibility that deliberately accepting an immediate harm now might help us to avoid greater harms in future.  Indeed, much familiar healthcare involves accepting something unpleasant in the present (whether it be exercise, vaccination shots, or undergoing a painful surgery) to avoid worse health outcomes in future.  But for some reason, many still find it difficult to conceive of controlled voluntary infection in these terms.  This needs to change, so that we can assess our options for dealing with the pandemic in an informed and rational manner.

It's an open empirical possibility that by deliberately controlling the spread of the virus we could bring about better outcomes (for infected individuals and whole populations alike) than by leaving its progress wholly a matter of haphazard accident and chance.  There are three major reasons for thinking this:

(1) Early, pre-peak infections (with isolation, of course, to prevent accidental spread to others) help to "flatten the curve", which is helpful for all the familiar reasons.  By avoiding the peak infection period you place less burden on the medical system and are more likely to receive necessary treatment in the event of complications. 

(2) Once recovered, you can (for as long as immunity lasts -- this would, of course, need to be tested!) safely re-enter the workforce, visit Grandma in the nursing home so that she no longer has to spend her last days alone, help out others in your community, etc. etc.

(3) Perhaps most importantly of all: viral dose makes a huge difference to lethality.  Only by controlled infection can we ensure a safer "low dose" exposure to the virus.  (Combining this with anti-viral treatment may help to further reduce risk.)  As explained in the NY Times:
[V]iruses are usually more dangerous in larger amounts. Small initial exposures tend to lead to mild or asymptomatic infections, while larger doses can be lethal. [...]
Low-dose infections can even engender immunity, protecting against high-dose exposures in the future. Before the invention of vaccines, doctors often intentionally infected healthy individuals with fluid from smallpox pustules. The resulting low-dose infections were unpleasant but generally survivable, and they prevented worse incidents of disease when those individuals were later exposed to smallpox in uncontrolled amounts.
Despite the evidence for the importance of viral dose, many of the epidemiological models being used to inform policy during this pandemic ignore it. This is a mistake.

Unfortunately, even the doctors making this observation continue to make the moral mistake of not considering Controlled Voluntary Infection (CVI) as a possible policy solution in light of these empirical facts.  Why do they not even consider it?  The answer appears to lie in their rigid moral assumptions: "It would be unethical to experimentally manipulate viral dose in humans for a pathogen as serious as the coronavirus."

Why would this be unethical?  Presumably the worry is that some patients (even just receiving low-dose infections) would die. (Bioethicist Art Caplan describes the idea as "pretty close to advising homicide.") But if we do nothing then in all likelihood, many more of the same group of individuals would eventually die from uncontrolled, accidental infections.  So a more relevant moral question is whether controlled voluntary infection would increase or decrease an individual's ex ante health risk.

I would like to see public health experts make a serious attempt to honestly assess this question, since we've already seen that there is at least a prima facie case for thinking that individual risks could well be decreased.  Low-dose controlled voluntary infection would certainly be better than uncontrolled infection; the only question is whether one's chances of avoiding infection altogether (perhaps due to an earlier-than-expected vaccine breakthrough) are sufficiently high to outweigh this.

Moreover, even if individual health risks are slightly increased on net by CVI (relative to just taking one's chances and hoping to avoid infection altogether), it is still likely to be socially beneficial to speed acquisition of herd immunity, reduce risk of spread to more vulnerable populations, and restore social and economic activity.  Robin Hanson has estimated that CVI could cut Covid-19 deaths by a factor of 3 - 30x.  This is a big deal.

Americans typically valorize members of the military for being willing to "put their lives on the line" to serve society. Currently, many others in society are being required to sacrifice significant (social and economic) interests for the greater good.  So it isn't clear what moral justification there could be to disallow others from voluntarily taking on a slightly increased medical risk for the greater good.  We should certainly allow healthy young people to volunteer for deliberate exposure to the virus as part of vaccine testing (to speed development), for example.  Similar principles could apply to CVI more broadly.

Further, our interests are not exhausted by our medical interests.  So even if health risks are slightly increased for an individual who opts for CVI, they might still benefit overall by being able to return safely to work and social activities sooner than would otherwise be allowed.  So long as they are informed of the risks, and freely choose to take the socially beneficial option, there is no good ethical reason to prevent this.  If anything, we should incentivize such pro-social choices by further rewarding them (whether financially, or with social esteem and recognition).

Objections & Replies:

What if recovery does not bestow immunity?  
The case for CVI would be weakened if, contrary to expert expectations, recovery did not grant immunity for at least the rest of the current viral "season". (Note that it does not need to grant lifetime immunity in order for CVI to be beneficial.)  That possibility seems remote, and the costs engendered (of more people getting infected twice) aren't obviously massively greater in scale than the costs of refraining from CVI in the (far more likely) event that it is helpful.  I'd welcome more analysis of the empirical details here, but I would be surprised if CVI turned out not to have positive expected value on our current evidence. 

Is CVI "reckless"? 
There are obvious individual-level risks, e.g., some people believed to be "low risk" candidates for CVI will turn out to have hidden vulnerabilities to the virus.  But as explained above, remaining vulnerable to high-viral-load accidental infections is likely to be even more risky (ex ante).  Moreover, from a societal perspective, so long as the process is safely "controlled" and the infected are strictly quarantined to prevent further accidental spread, CVI clearly reduces society-wide pandemic risk (e.g. to vulnerable populations) by increasing herd immunity.

There is a general cognitive bias that can easily mislead us here, of looking at risk in a one-sided way.  Many people have higher standards for new proposals than they do for status-quo ones.  So a new proposal will be dismissed as "reckless" if they can foresee any potential risks, even if maintaining the status quo is actually more risky.  Don't make that mistake.  We need to broadly consider the risks of all our options (including the status quo), and pick the option with overall most favourable risk profile (or expected value).

The conventional (curve-flattening) approach condemns vast numbers of people to extremely dangerous, uncontrolled infection, on the vague hope that an early vaccine will save us.  This strikes me as far more reckless than a carefully controlled approach.

Am I missing something?

8 comments:

  1. It's a tough sell, politically. But it's a good idea.

    Better yet, they should release an experimental vaccine right away. Like, tomorrow. An experimental vaccine has some chance of working as intended, some chance of doing nothing, and some chance of giving you the virus (at a very low dose).

    Personally, I'd be hesitant about signing up to be given the virus, but the prospect of being immunized without contracting it might be enough to get me to volunteer.

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    1. If it's true that those are the only possible outcomes of taking the experimental vaccine, then I certainly agree! (Again, assuming strict isolation afterwards in case you become infectious.)

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  2. People from low SES backgrounds seem more likely to take the incentives if offered with CVI.

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    1. Yes, that's because poorer individuals would benefit more from such a policy. (That's a count in its favour, surely.)

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  3. I am surprised that your article keeps saying "voluntarily". Why do you shy away from making this mandatory? It is simply another form of the draft that is used in most wars, where the young are told to go and put their lives in danger for the good of their country ( Note: not simply asked if they want to do so, but are forced to do so). And the odds of dying are probably much less for the young than in a war against a human enemy. If this is a war, as many leaders have said, why not use this obvious tactic? And yet I will bet that no leader, no matter how dictatorial, is going to do this. And even you, with your cold and logical mind, don't even countenance it, let alone recommend it. Why not? Please have the courage to carry your argument through to its logical conclusion.

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    1. Hank - it's always preferable for things to be voluntary, not least as a protection against misguided authoritarian policies that don't give the individual's interests due weight. The military draft is a perfect example of this: instead of a draft, the government should simply increase compensation to whatever level is necessary to incentivize a sufficient number of volunteers. If it isn't worth paying them the amount that would be required to secure their free agreement, then it likely isn't worth demanding such sacrifice from them either.

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  4. Hey Professor Chappell, I really enjoyed your (provocative) proposal.

    I want to raise an objection inspired by the Velleman paper that we read in the Bioethics course.

    As Velleman points out, the status quo prevails by default. Introducing a new choice forces one to make a choice between the new choice and the status quo. One can have the status quo, but must explicitly choose it now rather than have it by default.

    The status quo of social distancing is quite bad, but adding the choice of CVI might make things worse—at least for some. In particular, I am thinking of people with low SES and people in industries with widespread “tough guy” attitudes. These people may feel severe pressure—economic and cultural—to participate in CVI.

    If I am right, then CVI becomes less “voluntary” than we had hoped—not mandatory, but certainly not completely voluntary. So, some people will feel heaps of pressure to play a low (ish) risk game of Russian roulette with a virus. Many people forced into this game would be better off personally if this choice never existed: The status quo by default would have suited them better.

    If CVI is less than fully voluntary, is it more problematic morally? I think so. Pressuring people to take such a risk strikes me as asking too much. We might think that there is a parallel to the way we valorize people (military, first responders, medical personnel, etc.) who take risks and sacrifice for the greater good. But there is typically not social pressure for any particular individual to pursue those routes—they are usually considered to be supererogatory paths. But with CVI, I have explained why I think there will be social pressure that makes it much less than a supererogatory act, maybe even close to a requirement for some. So the pressure to opt-in to CVI asks too much of us morally. And CVI should not be introduced in the first place.

    Please let me know why I am wrong!

    Hoping you and your family are safe and healthy,

    Zach Gluckow

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    1. Hi Zach, thanks, that's a great objection! It's hard to predict how likely it is that many would end up feeling pressured in the way you describe. The risk might be similar even without CVI: once 'immunity passports' are introduced, you might worry that some would deliberately seek out infection (even in a high-risk, uncontrolled way, e.g. 'coronavirus parties') in order to be able to return to work. Offering a controlled, low-dose option would at least reduce the health risk that anyone inclined to seek out swift infection/immunity (for whatever reason) would thereby face.

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