Health & Health Care Feed

Pandemic Philosophy

Cross posted from my church column.

Back in March the Italian philosopher, Giorgio Agamben criticized the approach to the virus then taking hold.  He wrote,

The first thing that the wave of panic that has paralyzed the country obviously shows is that our society no longer believes in anything but bare life. It is obvious that Italians are disposed to sacrifice practically everything — the normal conditions of life, social relationships, work, even friendships, affections, and religious and political convictions — to the danger of getting sick. Bare life — and the danger of losing it — is not something that unites people, but blinds and separates them.

His was one of the first philosophical writings on the pandemic, but since then philosophers have been very busy commenting on the metaphysical, epistemological, and ethical implications of this crisis.  Some have also been involved practically—for example a group of philosophical ethicists in Sweden helped to devise that nation’s triage criteria for ventilators. 

Let me draw attention to three of the ethical writings I’ve found provocative and worthy of consideration as we all do our best to think well and wisely during this crisis.

First is an article from May by Dalia Nassar, Senior Lecturer in Philosophy at the University of Sydney, that developed Agamben’s ideas and responded to some of his many critics.  Nassar points out that

the COVID-19 shutdown infringes on every aspect of our selves: not only our biological lives, but also our psychological or emotional lives, our social and political lives, our intellectual lives, and so on. That the shutdown affects every aspect of our lives should mean that every aspect of our lives should be taken into consideration when decisions about restrictions or easing restrictions are being made. It means, in other words, that ethicists, psychologists, sociologists, political scientists, economists, philosophers and theologians should be part of the decision-making process concerning the right response to the crisis.

I agree with Nassar that trying to reduce the human person to biological health is wrong and that the full richness of the human person and human life must be weighed when we are making individual and communal decisions during this crisis.  She goes on to encourage democratic processes of decision-making:

The ideal response to a crisis must be capacious, context sensitive and democratic. It must take account of the complexity and many-sidedness of life and of the concrete lives of all living beings. It must consider differences across regions and cultures. Only in this way can we develop an adequate response to the . . . crisis: one that aims not to neglect, leave out, or put in harm’s way any of the beings that share this planet.

In June I read “Surging Solidarity: Reorienting Ethics for Pandemics” by Jordan Pascoe & Mitch Stripling, in which they argued that our ethical frameworks must be revised in response to the pandemic.  They offered their alternative:

We develop a pandemic ethics framework rooted in uBuntu and care ethics that makes visible the underlying multidimensional structural inequities of the pandemic, attending to the problems of resource scarcity and inequities in mortality while insisting on a response that surges existing and emergent forms of solidarity.

I thought their paper provided the most robust, interesting ethical analysis I’ve read.  They emphasized relational approaches rooted in the South African concept of Ubuntu and feminist care ethics.  I liked this claim, “Our framework understands disasters as producing networks of interlinked people who need care and are giving it; the ethics we propose will help to surge and sustain that entire network, not force us to break it apart and choose between the pieces.” 

They too were advocating a more holistic approach to the human person, not settling for reductionist accounts.  And by doing so were able to explain in one theory the importance of public health measures while also criticizing how they violate core aspects of our humanity:

The tragedy of our dangerously overwhelmed health care system is not only that there are not enough ventilators to go around. It is also that people must suffer alone, must die alone, must give birth alone; it is that our system is so broken that even a basic right to human company must be surrendered (Goldstein and Weiser 2020). Many of us fear not just getting sick, not just dying, but dying alone. Many who are grieving are grieving because they could not be present for a person essential to them, for birth or for death or for suffering. We are grieving not just the inevitable moral failures that will come from lack of resources, but from the lack of humanness, of being human with and through one another. These, too, are moral failures.

Yes.  That people were not able to be with their sick and dying loved ones was one of the most cruel and inhumane aspects of this year.  Which should compel us to imagine and develop different approaches in the future so that such inhumane burdens can be prevented.

A final essay from July with the very academic title “Virus interruptus: An Arendtian exploration of political world‐building in pandemic times” by Rita A. Gardner and Katy Fulfer develops from the philosophy of the ever-more-essential Hannah Arendt.  In their abstract they describe their project:

We explore the ways in which we can engage in political world‐building during pandemic times through the work of Hannah Arendt. Following Arendt’s notion of the world as the space for human togetherness, we ask: how can we respond to COVID‐19’s interruptions to the familiarity of daily life and our relationship to public space? By extending relational accounts of public health and organizational ethics, we critique a narrow view of solidarity that focuses on individual compliance with public health directives. Instead, we argue that solidarity involves addressing structural inequities, both within public health and our wider community. Finally, we suggest possibilities for political world‐building by considering how new forms of human togetherness might emerge as we forge a collective ‘new normal’.

Their discussion focuses on togetherness as essential for responding to a crisis and yet the paradox of our traditional modes of togetherness being impossible.  They are critical of judging those who are non-compliant with public health measures, arguing that individual compliance is not the true crisis of solidarity revealed this year, but rather the larger systemic inequities.  Our frustration and anger should be directed at those concerns.  One reason they resist too much judgment of individual behavior is that the only way out of this crisis is to develop greater trust in one another:

Indeed, it seems as if many societies are at a serious juncture where we have the potential for making new choices about how we want to live together. The COVID‐19 crisis has also shown us that we too have a choice in that we can live our lives in fear and isolation, or we can start to trust one another again as we move back to our public spaces. Establishing trust will be important in helping people learn to adapt to the new normal in organizational spaces and other public places.

They conclude that the virus creates an opportunity to rethink human social and political relationships and to address the inequities and lack of trust we’ve seen: “An Arendtian politics is concerned with how we share the world in such a way that it becomes a place of belonging, not just for a few, but for humanity.”

These essays all share a robust vision of the human person which leads to an emphasis on relationships of solidarity, care, and trust and the opportunity to create new and better institutions and systems. 

This crisis does compel us into deep, visionary, and careful thinking as we use our best judgment to make wise and good decisions for ourselves, our families, our institutions, and our society.  We don’t want “bare life;” we want to belong to a flourishing humanity.


The Basic Question of the Moment

I feel as if the most basic question of our worldwide moment remains unclear.  And how one answers that basic question implies radically different behaviors.

That basic question is:  Is the coronavirus an infection we should all/most anticipate getting at some point or is it an infection that can be avoided?

Back in February I read that Atlantic article that said option A, which has been my underlying assumption all along.  But it became obvious in April that many people were under the impression that number two was true.  In recent weeks I've seen very little that clarifies this basic question, and even the public health experts I've asked have largely been unable to answer it satisfactorily.

Let's call Option A the one where everyone or most everyone can expect to be infected.  That means this is largely an event in the natural history of our species that we have to get through.  Five percent of humanity may die.  A significant number will be seriously ill, some with lasting lifetime effects.  While a large percentage (according to the best data currently available) will have no or few symptoms.

Back in the first quarter of the year you read and heard debate about two approaches to Option A--either spike early and get it over with or flatten the curve so the medical system doesn't crash and has time to prepare.  Most nations chose the latter public health approach.

On Option A the purpose of the public health measures is to manage the crisis.  Manage it so we can prepare.  Or so health systems don't crash.  Or to try to delay most infections until a time we have a better treatment or better yet develop a vaccine.  Or try to manage so that the most vulnerable aren't impacted unjustly. 

On Option A  the recent lockdowns could be understood as temporary measures in order to prepare the health care system for the inevitable and are not justified once those preparations are in place.  Or another version of Option A is that they are justified until treatment is available.  But a common feature of Option A is the measures must be weighed significantly with other factors.

On Option B the purpose of the public health measures is to avoid getting the virus all together.  So the lockdowns would be justified in being longer.

A goal of Option B would be to keep as many people alive a possible.  That might also be a goal of Option A, but with the larger goal of maintaining a social order that can see us through a horrible event.

The two options suggest different behaviors as well, at least for some.  For example, if you can avoid the virus all together (Option B), and particularly if you are vulnerable, then you should minimize your risk. 

But, if you can't avoid the virus and will eventually get it no matter what you do unless you live permanently as a hermit (Option A), then you might engage in more risk.  Some might go so far as to try to get it and get past the crisis, some of those because they are taking the chance of being in the large percentage that is asymptomatic and some for other reasons.   Some might conclude that if they have a good chance of getting sick and dying, then they will want to enjoy their life and not be stuck at home.  I've had a 95 year old say as much to me acknowledging that they don't have that much longer to live regardless.

In some of the classic pandemic literature you see that the worse the crisis became that  some people began to live more openly, enjoying life precisely because the times were grim and there was risk that they would not survive.

Of course, even on Option A, some will try to hold off on running the risks of being exposed till a better treatment is available. 

Note: John Rawls developed the veil of ignorance to be a thought experiment, but here we are in a real life version.

On Option B many normal social functions would be curtailed for a longer period of time.  On Option A they would not, as they would be needed to help through the crisis.  On Option A  you will want more social solidarity in order to help with the care and grieving.  For example, I think of my institution--the church.  If a great deal of illness and death is inevitable, then you will want the church engaging in all of its functions of care and support and performing its rituals of grief and consolation.  

Another example, some of the leading choral music organizations last week recommended that choral singing largely be avoided until this is a vaccine in order to minimize infection.  But that approach only makes sense if you are confident that Option B is correct.  If Option A is correct, then singing together will be an important part of human solidarity helping the grieving through the crisis.

On Option A you will want to do your best to try to minimize the other traumas and disruptions (including but not only economic) brought about by the virus.  Whereas on Option B you will tolerate more disruption to society.

On Option B you would trade even some long term damages to society, the economy, child development, mental health, other health factors, etc. in order to minimize the death toll.  Whereas on Option A you would want to minimize all those long term damages in order to help humanity to more quickly recover from the horror of the crisis.

So, it really seems that this most basic question is the uncertainty we most need to figure out if we are to know collectively what we are to do and individually what risks we should take.


Philosophical Follow Ups

A couple of new links to follow-up on previous posts about the pandemic and philosophy.

Last Sunday I posted Alex Broadbent's article "Thinking Rationally About Coronavirus COVID-19," which generated some vigorous discussion on my Facebook timeline.  He's out with two more articles, becoming something of an indispensable voice in this crisis (he is a "philosopher of epidemiology").  The article "Why a one-size-fits-all approach to COVID-19 could have lethal consequences" discusses why the measures taken in other parts of the world might have a higher mortality rate than the virus if they were taken in Africa. 

His other new post in a broader article at Daily Nous entitled "The Role of Philosophy & Philosophers In The Coronavirus Pandemic."  I particularly liked the final paragraph labeled as "Call to arms:"

The skill of philosophers, and the value in philosophy, does not lie in our knowledge of debates that we have had with each other. It lies in our ability to think fruitfully about the unfamiliar, the disturbing, the challenging, and even the abhorrent. The coronavirus pandemic is all these things. Let’s get stuck in.

One of the commentors, a Tom Cochrane, writes about how aesthetics intersects with the pandemic:

Aesthetics won’t help to combat the disease, but it will point out that there is considerable final value to be found in simply observing what is happening, for its own sake. Whatever else it is, the coronavirus is incredibly interesting. A great big rock has been dropped into the pool of human society and we are witnessing a million different effects that even the best fiction writers would have found hard to anticipate (who would have anticipated the creative response of putting different song lyrics to hand-washing instructions? and also how this is now *so* last week?)

So all I’m saying is that, like everything else, there is intense drama, and beauty, and sublimity and tragedy and comedy in this event. And it will no doubt stimulate the creative responses of human beings for years to come. And perhaps in recognizing- and embracing this, we can be less fearful or depressed.


At Home: "It is Moral"

“'Marguerite Derrida has just left us, a whole world is leaving,' announced the Institute of Advanced Studies in Psychoanalysis (IHEP) in a press release dated March 21, 2020." The widow of the acclaimed French philosopher has died of COVID-19.  

In Italy the moral, social, and human cost of no funerals is mounting.

A criticism of Giorgio Agamben published in the Chronicle of Higher Education (unfortunately behind a paywall) rightly points out that writings on the pandemic have focused on the moral crisis:

Agamben correctly observes that the question of the proportionality of the response is not a scientific one; it is moral. And the answer is not obvious. Here, at least, Agamben arrives at a serious question. This is exactly the kind of question we had hoped the humanist could help us answer.

Note, if you've missed the discussion of Agamben, I've been tracking it in my recent blog posts on the pandemic.

This author zeroes in on some appropriate criticisms, but I feel as if her essay is just the beginning of a response.  I was left wanting more from the final section.  Also wanting her to grapple more fully with the story out of Italy about lack of funerals, for instance.

The intellectual response is growing this week.  Here at The Point, one can read plague journals from around the world, including a shortened version of that Chronicle of Higher Education article not behind a paywall.

And this evening I listened to a good podcast interview with the always interesting Anne Applebaum about authoritarian opportunism during the crisis and how the USA should learn from this to modernize its bureaucracy.  

Yesterday I encountered the Philosophers on Medicine podcast, which has yet to grapple fully with this crisis, but they do address some of the concerns that it raises.

An interesting Midlands Voice in our local paper wondered if the luck of the Boomers has finally come to an end as they now face their biggest challenge as a generation.

My long planned sermon theme for this coming Sunday is "To Be More . . . Hopeful."  What seemed like a serious challenge at the start of the week quickly took shape, as I will be exploring some of the things I've preached about hope before and testing them against the current crisis.

And just because this post lacked any cute Sebastian photos, here is a previously unshared one from a few days ago.

In a tree


A Journal of the Plague Year

A Journal of the Plague YearA Journal of the Plague Year by Daniel Defoe
My rating: 4 of 5 stars

"A plague is a formidable enemy, and is armed with terrors that every man is not sufficiently fortified to resist or prepared to stand the shock against."

I had actually been contemplating reading this book of Defoe's sometime this year anyway. I had picked up my copy at the church's used book sale last year. A few weeks ago I decided it was timely.

The historical perspective helps to break us out of the fierce urgency of the now, reminding us of what remains the same and also that this too shall pass.

What Defoe describes is far more frightening than what we are currently encountering, at least here in Nebraska. And in this book about the 1665 London plague you encounter all the same issues we are in 2020.

I particularly liked reading his discussions of churches and clergy and how they ministered through the devastation. He is very severe on those ministers who ran away to avoid it all.

There's wisdom here as well, such as "Nobody can account for the possession of fear when it takes hold of the mind."

Also sobering. In the last few days I've read some article predicting we will be better after this crisis. Defoe writes about how the people of London were actually worse because they had been "hardened by the danger they had been in."

And I intend to begin using the phrase he does on the final page of the book, "This calamitous year."

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At Home: Labyrinths

Defoe

Daniel Defoe, in A Journal of the Plague Year, which I'm currently reading having intended to read this year even before the pandemic, writes this key paragraph:

Now let any man judge from a case like this if it is possible for the regulations of magistrates, either by shutting up the sick or removing them, to stop an infection which spreads itself from man to man, even while they are perfectly well and insensible of its approach, and may be so for many days.

To that end, I recommend Thomas Pueyo's "The Hammer and the Dance," which does the best job of anything I've recently read about the best current steps and what comes next.  

Even so, there are other voices.  As with any scientific question, there are unknowns.  There's this piece I read on Towleroad entitled "What's the Best Path Forward?"

Part of the value of reading Defoe, or any of the other classic works of plague literature, is that we so often live in the fierce urgency of the now, and historical perspective gives us some sense of what has always been case and the ways our time is not unique.  Also that this too shall pass.

One of my main worries last week was that I saw so much focusing only on one dimension of the problem--the medical questions of the virus (or secondarily the economy) but less about all the other well-being and moral issues implicated.  This week there does seem to be more of that, including more articles about mental health impacts of social isolation, the rise in domestic violence that has already occurred after only one week, and this article in The Atlantic "The Kids Aren’t All Right" about the lasting effects this trauma will have upon a generation of children.  I also had an engaging conversation with a professor of gerontology on Saturday who thought that nursing homes should be providing residents a choice instead of placing them unilaterally in lockdown.  Her reasons were that lack of visits from family and friends are proven to shorten life expectancy, so residents should be offered the choice of whether they want to run the risk of the virus and still be with family and friends.  This is vividly brought to light in my own congregation by a member who was already in hospice and yet now doesn't have those visits, at a time when she would normally be surrounded by people loving her into death.

Defoe has this (among other things) to say about churches in the midst of the 1665 epidemic in London, "Indeed nothing was more strange than to see with what courage the people went to the publick service of God even at that time, when they were afraid to stir out of their own houses upon any other occasion."  He writes about the courage of ministers staying in town and ministering to the citizens.  We are, of course, doing it differently in 2020.  Most of our connections these days are virtual.  This week's staff meeting was inspiring as we now are getting a little more used to everything and are beginning to come up with more innovative and interesting ideas for what to do.  Also this week we will be rolling out more of our programming.  The staff meeting was one of the things that yesterday helped to lift my mood.

Neptune painting

At Dadda's Preschool today was about the planet Neptune, which included painting our papier mache planet.  We also spent a good hour outside with Sebastian riding his bike and walking the church's labyrinth (which I recommend if you can get over there some day on your own).  While walking and biking the labyrinth, Sebastian kept asking, "Is this the right path?"  

I kept answering, "It is.  But it tricks you."

Sebastian biking the labyrinth

I also seemed to have a lot more work to do today.  I didn't come near to completing my to do for church or here at home.

Yesterday's paper in Omaha reported that our citizens are doing a good job of following the guidelines.  Fingers crossed.

 


A couple of philosophical responses

Finally had some time this morning to catch up on philosophical reading.  Among the philosophers responding to COVID-19, I thought these two article were interesting..

This one is somewhat predictable--Peter Singer encouraging ending forever "wet markets" like the one that passed this disease (and others to humans). Read his arguments here.

And this article by Alex Broadbent lays out the various principles and ideas involved in a rational, cost-benefit analysis of the virus and responses to it.  Most interesting are these two considerations (two of a handful he includes):

Identification of losers and winners, and weighing of their rights. Older people and those with pulmonary conditions are at greater risk of developing serious illness from COVID-19 infection. The protection of these groups must be weighed against the good of the whole. Closing schools, for example, will surely reduce rates of infection; but it may harm the children’s education, to which they arguably have an important right, for the probable benefit of their grandparents. Such trade-offs are generally considered permissible, as in taxation to pay for a public service, but not unrestrictedly so. I am not commenting on any particular measure here; school closure is merely an example and may in fact benefit children significantly. I am merely trying to structure the cost-benefit analysis by pointing out that those who suffer most from the measures may not always be those who benefit the most, and their respective rights and interests must be weighed.

 Assessment of quantity of life. Delicate though it may be, the public health response needs to take seriously the extent to which those who die are sick and elderly. This is not because their lives matter less, intrinsically. It is because they have less life left. We may imagine that if COVID-19 had not killed someone this week, they would have died of some other ailment next week, or even on the same day. Such imaginary cases are the subject of study by philosophers who think about causation, but in this case they have an evaluative import. Life is a quantity rather than a binary variable, and disease reduces its quantity, both for individuals and populations. The quantity of this reduction is less for people who are going to die sooner: the sick and elderly, in other words. If the cost of a disease to a population is the quantity of life that it takes, then this can only be measured in time, because all life is a quantity of time.

Some of us have more life left than others. Thus the cost of COVID-19 to population health is not simply a function of how many it kills, but whom. This is surely not the only factor in assessing the cost of a disease or benefit of a public health measure, but, given that life comes in a finite quantity, the quantitative effect must be taken into account in assessing the benefit offered by a public health measure against the cost of the disease.

 


My Mother's Curse: A Journey Beyond Childhood Trauma

My Mother's Curse: A Journey Beyond Childhood TraumaMy Mother's Curse: A Journey Beyond Childhood Trauma by Christine Nicolette-Gonzalez
My rating: 4 of 5 stars

I met Christine in 2003 during my first week as a youth minister at Royal Lane Baptist Church. She was a parent with two children in my youth group. I vividly remember the first time I met her, she was excited for my arrival, and greeted me with a big smile, warmth, and curiosity. She was a devoted and proud mother. As a teacher she set for herself high professional expectations, and I felt she expected the same of others who worked with teenagers and kids. I remember when she praised a program I had created, and I received it as a great stamp of approval.

And of course I had no clue of the childhood trauma she was carrying. As a pastor I have learned that everyone is carrying some pain, often privately, which is one reason we should be kind and charitable to one another.

In this brave memoir, Christine provides details of her mother's severe mental illness and how it deeply affected her childhood. But the memoir also contains the story of how Christine built a different life as an adult, as a wife, mother, and school teacher, and the emotional and spiritual work of dealing with her own anxiety.

I recommend the book to everyone developing resilience in the face of trauma. Or those trying to better to relate to those who are.

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Brave Woman

The Guardian today published a story on Julie Burkhart who has bravely worked to maintain access to abortion in Kansas after the assassination of Dr. George Tiller.  

I met Julie in 2011 at a reproductive justice conference at Oklahoma State University.  She was one of the main featured speakers and I was an invited panelist and participant.  All of us invited guests hung out socially after the academic events.  Julie was then still deeply grieving Dr. Tiller but bravely organizing a response.