The Ethics of Contagion: How We Should Respond to the Spread of Infectious Diseases

The SARS outbreak in 2002-2004, the swine flu pandemic in 2009-2010, and the Ebola epidemic in 2014-2016 were stark warnings of what could come. Yet, the COVID-19 pandemic became an unexpected challenge for most governments. Are we better prepared next time? The pandemic revealed a lack of preparedness and raised several unresolved ethical issues: What restrictions can authorities legitimately impose on citizens to protect public health? How should we distribute the burdens of combating the disease within the population? What role should markets play in allocating scarce resources in times of crisis? To limit the spread of infectious diseases, many countries have implemented highly intrusive measures. These measures are often justified by public health concerns, but can we also justify them to those bearing the heaviest burdens? To answer this question, we need to understand our moral obligations to prevent the spread of infectious diseases. In this project, I have developed a theory on how governments can respond to the spread of infectious diseases based on our individual moral obligations, making the measures justifiable to those affected. I argue that highly intrusive measures to prevent the spread of infection can be justified as contributions to a social insurance scheme that is rational for even young and healthy individuals to participate in. In expectation, we are all vulnerable to a pandemic and dependent on others for protection. Therefore, we should do more to protect others during pandemics than in other situations. What role should the market play in allocating scarce resources in a crisis? Many are sceptical of the market as an allocation mechanism during pandemics when lives and health are at stake. But this underestimates how markets can be designed with redistributive purposes in mind. In an article in the Journal of Medical Ethics, we present a new mechanism for the fair and efficient global distribution of vaccines—a redistributive auction. This mechanism combines the best of both worlds: efficient vaccination and a better allocation of scarce resources. A key lesson from the pandemic is that we must consider the third-party effects of our health interventions (infection is such a third-party effect) and that health interventions should not only promote health but also consider broader consequences that affect people's welfare. In this project, we have developed a new theory of health prioritization that incorporates lessons from the pandemic. Health prioritization should consider both third-party effects and the welfare consequences of our choices. A controversial implication of this is that a patient’s societal utility may influence who receives treatment. Pandemics are situations where many lives and much health are at stake. This was the reason vaccines were developed and distributed at record speed. However, one of the vaccines was withdrawn when it was suspected to have a deadly side effect. A consequence of this might have been delaying the vaccination process, which in turn could have prolonged the pandemic restrictions and the risk of infection. Was this a justified policy? In the project, I explore plausible justifications for this policy, and I argue that the best justification is a principle of beneficence: people are entitled to the healthcare that puts them in the best possible position. A problem during the pandemic was that measures could have significant consequences for others. Therefore, I propose that this principle cannot be used to justify the policy during the pandemic. A better solution would have been to provide people with vaccines that carried some risk of side effects and compensate those affected by those side effects.

The primary outcome of the project is a framework that can guide and justify the actions of decision-makers as well as individuals during epidemics of infectious disease. The project also provides a better understanding of our moral responsibilities in situations where people are both victims and “perpetrators” and where each person only makes a small contribution to the total harm. This is relevant for our understanding of how we should respond to climate change, existential risks, and our responsibilities to bring about beneficial norms. The project also provides a novel mechanism for global vaccine allocation in public health emergencies, a redistributive auction for vaccines. The model could also be relevant in other situations where people have a moral claim on a good and there is radical scarcity. It also examines the principled justifications for excluding vaccines with potentially harmful side effects, such as AstraZeneca during the Covid-19 pandemic, and offers a novel argument for using money to equalise risk from vaccines.

What are the ethical limits to what governments may do to stop the spread of infectious disease? While the consensus in the field of public health ethics is that governments are justified in imposing coercive measures, it remains unclear what measures are justifiable under what conditions, what lines (if any) may never be crossed, and how restrictions on individuals’ freedoms are justified. In this project, which is a collaborative effort between Faculty of Health at OsloMet, Faculty of Philosophy at University of Oxford, and Department of Government at Harvard University, I aim to provide a framework for how to respond to the spread of contagious diseases that is grounded in individuals' moral responsibilities. I advance three core hypotheses: The first is that, during epidemics of infectious disease, individuals have more demanding obligations not to take part in the spreading of disease than standard accounts of moral responsibility would suggest. The second hypothesis is that, public health emergencies give rise to very demanding individual obligations to accept coercive measures aimed at restoring the situation back to normal. The third is that whereas some market responses to epidemics are wrongful (e.g. price gouging), it can, under certain conditions, be justifiable to reward participants who take part in high-risk drug trials. My overall aim is to help advance the urgently needed, yet underdeveloped, field of ethics of infectious diseases, and to propose a way forward that cuts across disciplinary boundaries and that can be accepted by deontologists, consequentialists, and virtue ethicists alike.