The ethics of the pandemic: life or quality of life?

The pandemic has presented us with some tough ethical choices. Health or freedom? Lives or livelihoods? The greatest good of the greatest number or individual rights? Present or future generations? On reflection, some of these apparently stark choices look more blurred: those waving the banner of freedom, for instance, need to accept that if they ignore masks and social distancing they are limiting the freedom of the vulnerable to go out, while those appealing to health need to appreciate that without some freeing up of the economy there will be no money to pay for care. Nevertheless, the dilemmas are often real, and they are at least partly underpinned by the hardest choice of all, and one of the least discussed. When a pandemic hits, should the overarching aim of governments, and indeed of other bodies and individuals, be to protect life or quality of life, the “good life”?

Despite the stringent restrictions the vast majority of us have accepted this year to protect life, I believe most of us would say our overarching aim is quality of life. If a government were to say to us: “Stay completely locked down in your home for ever; we will bring food, clothing and other necessaries to your door, and you will never catch so much as a cold again, let alone Covid-19,” I do not think many of us would accept. We do not just want life but a life worth living.

Yet concentrating on flourishing need not entail selfishness. Historically, flourishing (a concept which has its roots in Plato and Aristotle) has been conceived in terms of the realisation of various forms of potential—intellectual, emotional, imaginative and physical—and this realisation in turn has been conceived as the exercise of various virtues. I would certainly want to include the practice of care and compassion in any notion of individual or communal flourishing. Making quality of life rather than just life the ultimate goal does not mean letting the virus rip unchecked through care homes, or indeed society at large. People cannot flourish if they are dead. In the first few months of a pandemic, a government needs to target its resources at controlling and mitigating the outbreak. But it also needs to have a clear direction towards a thriving society in mind, and to clearly communicate that direction. If effective test-and-trace systems are in place, it can work towards a careful opening up of the economy and at least some face-to-face education; and then towards a return to the activities which bring delight.

Nor does communal flourishing necessarily have to imply a utilitarian calculation which weighs up the numbers of those who flourish against those who do not (although the concept could be used like this, with “greatest flourishing of the greatest number” replacing Bentham’s “greatest good”). But it does mean being honest about the fact that if we try to work towards the goal of a flourishing society, some people may die of Covid-19 who might otherwise have lived—although other lives will be saved from diseases of poverty or from suicide.

There have in fact been moves towards “good life” notions for a number of years. Quality-adjusted life years (QALYs) are used to inform decisions about medical treatment, although in this case “quality” is seen principally in terms of health, whereas “flourishing” usually implies a richer concept of a full life. Allocating medical resources with an eye to how many years of flourishing (or healthy) life someone might reasonably expect if the treatment were administered does not mean that one person’s life is regarded as more valuable than that of another, only that all should be given equal access to as many flourishing years as medical science will permit.

However, notions of flourishing have also historically proved highly problematic, and we need to be alert to the dangers. Who gets to decide what flourishing (or indeed health) comprises and who is able to achieve it? If authority figures get to decide, there is clearly a serious risk of paternalism and authoritarianism, even if those in authority are benign. In the hands of malign politicians, doctors and scientists, the notion can be perverted into something very dark indeed. Can autonomy be built in? In the case of QALYs, doctors try to ascertain the subjective views of patients, and each year since 2011 the Office for National Statistics has sent out sample questionnaires in its wellbeing survey. But doctors cannot consult with patients who are unconscious or seriously mentally impaired, and the ONS only sends out the questionnaires to private households: those in hospital or care homes are not consulted, even if they are well enough to respond (and many other groups, such as the homeless, or those in detention centres or prisons, also fall outside the survey).

A government faced with a pandemic does not of course—at least initially—have the luxury of time to send out questionnaires; and even if it did, would find no consensus in the responses about particular conceptions of the good life. But it might find agreement on this one crucial point (as Rawls and others have noted): we want to live in a society which, as far as possible, allows us to live out our own individual conceptions of the good life. We want to live in a society which contains live music, theatre and attendance at sporting events for those who enjoy them; where communal dining, drinking and dancing are possible; and from where we can travel to explore other societies and make friends with those from other nations. And this means that a government needs to assist such sectors to survive the crisis. Decisions need always to be informed by a long-term vision of the society we want to emerge from the pandemic. Artists and performers should not simply be advised to retrain, or consider cyber.

It is not only governments who bear this responsibility. NGOs, local groups, individual citizens—we all need to think of what we can do to sustain the sectors which enable us not merely to survive, but also to thrive. It is one of the ironies of a pandemic that amidst all the confusion a few things become clearer: among these are the ethical choices that confront us and, perhaps above all, what we think governments and our own lives are for.