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BioEdge: Is seeking ‘herd immunity’ ethical?

Bioedge

Is seeking ‘herd immunity’ ethical?

by Xavier Symons | 9 May 2020 | 1 comment

Several health experts have proposed a “herd immunity” strategy for managing the coronavirus pandemic. This would involve allowing the virus to spread in a controlled way so as to achieve population immunity — even though this may expose vulnerable members of the community to an increased risk of infection.

While Australia has managed so far to control the spread of the virus, the number of new infections may increase as state and territory government move to ease social distancing and self-isolation measures. The situation in other regions such as North America and Europe is much worse, and initial strategies of strict containment have in some cases been abandoned in favour of mitigation policies.

In light of this, many commentators argue that governments should officially make herd immunity — rather than containment or virus suppression — the end goal of their COVID-19 policies. Harvard Medical School Professor Martin Kulldorff, for example, recently argued that we have no choice but to allow the virus to spread through the community rather than seeking to suppress it:

Because of its virulence, wide spread and the many asymptomatic cases it causes, Covid-19 cannot be contained in the long run … To think otherwise is naive and dangerous.

Governments must inevitably make a judgement about the levels of morbidity and mortality that they are willing to accept to manage the COVID-19 threat. They must, in other words, determine how high a risk of infection we can permissibly allow for older people, people with chronic illness and people with serious disabilities.

Yet, we should be wary of herd immunity proposals that trade off the interests of the community at large with those of older members of the population and at-risk groups. There is a sinister subtext to the rhetoric of policy proposals that focus purely on economic productivity and that give insufficient importance to the lives of vulnerable persons. Intentionally allowing the virus to spread is a very different proposal to easing social distancing measures, and involves a deliberate decision to expose vulnerable people to a potentially deadly disease. At the very least, we must wait for better data on the COVID-19 mortality rate before risking devastatingly high rates of morbidity and mortality among vulnerable members of the population.

The pandemic dilemma

Some commentators believe that the interests of younger generations are of paramount importance in a pandemic. This position might be operationalised in policies such as a complete abandonment of physical distancing measures and a decision by health authorities to allow the virus to spread throughout the community in a controlled manner. Texas lieutenant governor Dan Patrick, for example, recently answered a question about social distancing measures by saying:

Let’s get back to living ... Let’s be smart about it. And those of us who are 70-plus, we’ll take care of ourselves, but don’t sacrifice the country.

Similarly, Australian economist Sam Lovick argued in favour of letting the virus “wash through” the community, while imposing protracted isolation measures on vulnerable populations (particularly people over 70). Writing in the Australian Financial Review, Lovick stated:

The people most likely to need intensive care and most likely to die are identifiable. Strict, very strict, isolation of that cohort is key so that they have a low likelihood of infection.

Such a strategy would allow for greater economic productivity, and would restore freedom of movement and other basic liberties to the majority of Australians. Vulnerable populations would themselves be at less risk of catching the virus once a sufficient portion of the population (some estimate around 60 to 70 per cent) had been infected.

While UK Prime Minister Boris Johnson and his advisers sparked an uproar when they bluntly proposed a herd immunity strategy — and later, at least formally, backtracked — this is actually something approved by politicians and public health experts in Sweden, the Netherlands and Norway as well.

The prima facie case for abandoning a containment strategy in favour of the pursuit of herd immunity is strong. COVID-19 is more than just a public health problem. The pandemic has crippled economies around the world, and the situation has only been exacerbated by social distancing and lock-down measures around the globe. The government’s response to a public health crisis can have radical implications for the economy, as has become painfully clear in recent days.

And the economy matters. Without a functional economy, jobs will be lost, businesses will collapse and younger generations will spend decades paying off the debt accumulated by government stimulus measures during the protracted lockdown. Recent Australian Government estimates suggest that Australia’s unemployment rate will exceed 10 per cent by the end of the June quarter. Several major Australian corporations — most notably Virgin Australia — have recently gone into voluntary administration.

COVID-19 has far reaching social implications, too. Rates of domestic violence have increased sharply in jurisdictions that are in lockdown, and community mental health has taken a hit. A recent study in The Lancet found that people who are quarantined or isolated are very likely to develop a wide range of symptoms of psychological stress and disorder, including low mood, insomnia, stress, anxiety, anger, irritability, emotional exhaustion, depression and post-traumatic stress symptoms.

Criticisms of a herd immunity approach

There are, however, many practical problems involved in abandoning restrictions on movement, commerce and assembly for “low-risk” members of the population. First, health experts argue that it is impossible to isolate older members of the population from younger people — something that many herd immunity strategies suggest. University of Sydney epidemiologist Fiona Stanaway, for example, recently told reporters that, “It would be really hard to actually just restrict the virus to one part of the community and not have that rollover … Young people aren’t without risks and also increasing the prevalence of disease in the younger population is likely to increase the risk in the older population.”

Second, rates of hospitalisation and death, even among younger persons, would likely be high. In a country like the UK, herd immunity would require that upwards of 40 million people be infected. Generous estimates suggest that COVID-19 has a 2.3 per cent case-fatality rate and a 19 per cent rate of severe disease. If correct, this means that achieving herd immunity to COVID-19 in the UK would result in the deaths of roughly a million people or more, with a further eight million severe infections requiring critical care.

Important data has emerged in recent days suggesting that the fatality rate from coronavirus is in fact radically lower than originally thought. A groundbreaking study released by American researchers late April suggests that 13.9 per cent of residents in New York State (or 2.6 million) have contracted the virus — a figure that is remarkably higher than the 329,405 confirmed COVID-19 cases in the state (as of Thursday, 7 May). With a cumulative total of 25,720 fatalities recorded by that date, the fatality rate based on New York State data would appear to be closer to 0.05 percent, rather than the 5.9 per cent suggested by official statistics.

This data, however, is provisional, as the authors of the study admit. It is based on tests of 3,000 people who visited supermarkets and other essential services in 19 boroughs in New York State earlier in the month. It is by no means a representative sample of the whole population of the state. The actual number of deaths from coronavirus in New York State is also thought to be higher than official statistics.

More to the point, the New York biomarker study suggests that the COVID-19 virus is much more contagious than we initially thought. As such, if social distancing measures were eased and a herd immunity strategy adopted, it is hard to see how this would allow the virus to spread in a “controlled” fashion — indeed, with limited social distancing measures in place, it is hard to see how the spread of coronavirus could be controlled at all.

Underlying philosophical arguments

For argument’s sake, however, let us leave aside these practical considerations and consider the philosophical arguments for and against a policy that pursues herd immunity rather than disease prevention.

There are several utilitarian arguments in favour of prioritising the needs of the economy and the community over the lives of people who are likely to die from COVID-19 if we allow the virus to spread. To put it crudely, young and healthy people make up the majority of a population. And this group stands to lose their livelihood if the strict economic and social shutdown continues in response to the COVID-19 threat. Recent estimates from economists in the United States, for example, suggest that the coronavirus economic freeze could cost 47 million jobs and send the unemployment rate past 32 per cent.

The interests of vulnerable populations are relevant on a utilitarian calculus. But it could be argued that they are outweighed by the needs of the rest of the population who stand to suffer dire economic consequences if the government continues to pursue a virus suppression strategy. If indeed the death rate from COVID-19 is low, the raw number of deaths from widespread infection may be less than initially anticipated. And surely some level of mortality is acceptable where this is necessary to continue or restart basic economic activity in a jurisdiction.

Furthermore, it may be the case that lockdown measures inadvertently cause avoidable deaths — that is, a full lockdown involves restrictions that over time may cause an increase in population mortality. Social isolation has a negative effect on people’s mental health, and some experts say we may see an increase in suicides if current restrictions continue. People are also more reluctant to see their GP or present at hospital during a pandemic, even when they are suffering from a serious illness. As such, some serious conditions may present too late for effective treatment. The mortality rate as a result of COVID-19 restrictions, then, may itself be very high.

Importantly, it is not the case that all arguments against virus suppression boil down to a crude utilitarian calculus. On the contrary, some communitarian thinkers suggest that it is a virtue for older people to forfeit their wellbeing and security for the sake of younger generations — which is to say, older people should put the interests of younger generations before their own, at least when it comes to situations like a public health crisis.

This is, in effect, the argument made by Republican Dan Patrick (as quoted earlier). He said that older people have a civic duty to accept risks to their health for the sake of younger generations. “No one reached out to me and said, ‘As a senior citizen, are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren?’” Patrick said on Fox News. “And if that’s the exchange, I’m all in.” In this telling, it is the patriotic duty of the elderly not to force privations on their country, and make life worse for their grandchildren. Such a communitarian ethic would resonate within countries such as the United States, and can claim a philosophical pedigree in the writings of Alexis de Tocqueville, among others.

The problem with a trade-off between lives and the economy

The trade-off between lives and the economy is, however, a major source of ethical concern. A herd immunity strategy may result in a higher death rate among older members of the community than other strategies — unless our isolation policies were fail-proof. Even if the overall death rate from COVID-19 is lower than initially thought, the contagiousness of the virus would still likely mean a high number of fatalities especially among older and risk members of the population. Utilitarian proponents of a herd immunity strategy would claim that this is acceptable — it is preferable that the elderly and the sick can die in numbers as an alternative to widespread economic damage caused by more stringent suppression measures.

In the end, this argument is based on a highly controversial economic rationalism. Instead of showing solidarity with society’s most vulnerable members, the claim is that we should protect the market in order to avoid widespread and extensive economic damage. Market interference is dangerous. But the coronavirus is an undeniably devastating virus. The real question we must ask is whether the prevention of a catastrophic COVID-19 mortality rate is more important than returning immediately to normal economic conditions?

Amid the public rhetoric surrounding COVID-19, the real danger is that vulnerable members of the population become construed as a separate group that somehow counts for less in our calculus about outcomes. As commentators have warned, “In the perverse eugenics of the market, the elderly and the sick have become the ‘others’ of the pandemic.”

If, however, we take the lives of vulnerable members of the community to have an equal (or even greater) value than the lives of ordinary people, the moral equation looks very different. Indeed, some varieties of communitarian political thought suggest that the way we care for vulnerable people is an indication of the moral character of a society. In a COVID-19 specific context, the way we protect vulnerable populations becomes an indicator of how we have managed the ethical challenges of the pandemic. The death of an older person is no longer just collateral in a broader public health response, but rather becomes a cause for deep concern.

Analysing the philosophical logic more deeply, there seems to be an ageist and ableist prejudice implicit in the way people assess the importance of protecting older members of the population from infection. The argument seems to be that the needs of older people are less important because older people are nearing the end of their lives. Alternatively, one might say that the interests of people with chronic illnesses do not matter as much because they are very sick already. But what does it say about our society when one’s health or life expectancy becomes the indicator of whether preserving one’s life is of moral importance? One could argue that individuals with chronic health conditions or a life limiting illness have less to lose from an early death. But it begs the question to presume that factors like health and life expectancy are the sorts of things that determine the value of a person’s life.

Xavier Symons is deputy editor of BioEdge. This article has been republished from ABC Religion & Ethics with permission

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