MCPHS Professor Dien Ho on the Ethics of Confronting COVID-19

Dien Ho, PhD, wants to explain that, with COVID-19 raging across America, we need to think critically about the ethics the unfortunate situation poses. The stakes of this moral dilemma are higher than ever for the MCPHS Professor of Philosophy and Healthcare Ethics, whose talk, “The Ethics and Rationality of Saving the World: Some Basic Problems in Confronting a Pandemic,” on July 7th, helped viewers come to grips with some of the ethical implications of the pandemic which has so wildly distorted our world.

Ho has been thinking about potential disasters since long before COVID-19 struck. “I’d like to begin by talking a little about existential threats,” Ho began his lecture. He quickly sketched out the scale upon which philosophers and ethicists classify threats. The scale runs along two axes: one of scope, from personal to global, and one of intensity, from endurable to terminal. Having one’s car stolen represents the low end of the scale: while deeply inconvenient and perhaps even life-altering, the loss is personal and endurable. By contrast, Ho explained, “an existential threat is one which would result in a dramatic and sustained lowering of quality of life for most, if not all, humans and other sentient creatures on Earth.” Existential threats include the collapse of the global ecosystem, shortages of fresh water, global warming, and rising food insecurity, among others. You could certainly look at the COVID-19 pandemic as one.

So why aren’t we better at preparing for and dealing with existential threats? For one, Ho says, “Market solutions usually fail, as we see exemplified when we consider the numbers of new antibiotics being developed. Antibiotics don’t make money and are expensive to develop. They’re high risk, low reward, and are prescribed episodically”—the exact opposite of a profitable drug. That said, Ho cautioned, it is important not to ascribe malicious intent to the actors contributing to existential threats. “Often, threats come from unforeseen consequences of well-intended actions, like using growth hormones on cattle to cheapen protein for people, extending their lives and improving their nutrition,” Ho said. “That strategy actually worked. Global absolute poverty is currently at the lowest level in all human history—only 10 or 15 percent of all people on earth live in poverty. 100 years ago, about 80 percent did.”

Most threats are also easy to ignore: as an example, Ho proposed that Boston residents consider the Alewife dam, an aging piece of infrastructure that keeps brackish water from flooding the Boston subway system. The dam is predicted to fail by 2040; prudence would dictate that it be replaced right away. However, the replacement would cost many millions of dollars, and, even if implemented immediately, the affected residents would never sense any difference, let alone improvement, in their daily commutes—making the replacement project extremely difficult to motivate politically.

Unfortunately, pandemic preparation and deflection falls into much the same chasm of inaction as “invisible” improvements like the Alewife dam. “COVID-19 is a good rehearsal in that sense; even though it doesn’t rise to the level of a catastrophic threat, we can see how much of a disruption it’s posed,” Ho said. “Pandemic responses have one very basic strategy: prepare, because time is of the essence.” That preparatory work is daunting, including stockpiling PPE and hospital equipment like ventilators; developing the infrastructure for vaccine development and manufacturing; fostering education, mobilization, and overflow capacity. Unfortunately, because the costs to individual constituencies is high and the benefits either invisible or strictly long-term, the global budget allotted to this preparatory work is miniscule. “The budget for the World Health Organization is about half the budget of the Mayo Clinic, and most of the member states are behind on their dues,” says Ho. “All these preparations require political foresight and will, cross-political and international collaborations, and above all, empathy. All of these things face systemic obstacles: the way we have structured our nation-states, economies, and cultures, make these responses difficult, and until we change those structures, we are going to have a hell of a time fighting pandemics.”

Take also the Prisoner’s Dilemma. A classic problem in the world of philosophy, the Prisoner’s Dilemma seeks to find the best possible outcome for players locked within a ruthlessly competitive system. Here’s how it works: imagine that you are one of two partners in an alleged crime, locked in separate interrogation rooms. The police offer you a deal: inform on your partner and go free today, while your partner will receive ten years’ punishment. However, your partner is being offered an identical deal: he can inform on you, going free while you receive ten years in jail. There are two other possibilities: you can both stay silent and receive a sentence of two years each, or you can both inform on each other and get eight years each. “If your partner stays silent, you are better off ratting. If your partner rats, you are better off ratting. No matter what your partner does, you are better off ratting,” Ho points out. “However, if both people reach that same conclusion, you both end up serving eight years, which is a worse outcome for everyone than if they both cooperate by remaining silent.

So if all individuals behave in a rationally self-interested manner, we end up with a much worse outcome collectively. Politics is the art of moving large groups of people from the eight-year box, to the two-year box.” In the case of any large-scale disaster, especially an existential threat, the challenge becomes to convince large numbers of people to behave in a non-self-interested manner, for the benefit of generations of humans around the world whom they will never meet. “We are playing Prisoner’s Dilemma with people in the future—a trans-temporal prisoner’s dilemma,” Ho said.

Interestingly, those living in liberal democracies may actually have a harder fight ahead of them than those living under more authoritarian regimes; as Ho pointed out, the measures taken by authoritarian governments to curb the virus’s spread would be completely unacceptable to Americans. “China dealt with COVID by locking down one sixth of their population in a particularly strict and aggressive lockdown,” Ho pointed out. “The trains stopped moving; there was strict information censorship, paired with a crackdown on disinformation; heavy penalties were levied against people who violated stay-at-home orders; private industries appropriated to produce PPE; and massive pivots made to build support systems, such as the building of two massive hospitals in Wuhan in ten days. We couldn’t do that here—ignore zoning laws, claim eminent domain, ignore environmental rules and simply mobilize the construction crews to build two gigantic hospitals in very little time. So, we’re confronted with a philosophical difference: in a liberal democracy, we are better at information transparency, but we are not as good at a unified response to disaster.”

So, what is possible? Can we Americans have a healthy response to a pandemic while maintaining values such as privacy and freedom of movement? How do we stop a pandemic in a way that is consistent with the values that we hold?

Ho’s solution? Myth. “We solve a lot of Prisoner’s Dilemmas with myths,” the professor pointed out. “We propagate the myth of civic duty to promote voting and reinforce it with a sticker. We’ve attached a sense of shame to littering, to promote civic cleanliness.” Spreading myths (or, in a more modern take, memes) that attach positive values to the actions that help prevent future disaster is, Ho cautioned, “very unlikely to work, but it’s probably going to be a better shot than anything else we can do in combatting rationally self-interested thought.” In a world in which many prominent scholars believe that humanity’s chances of surviving the coming century hovers between 16% and 50%, Ho’s idea feels a lot like hope. Existential threats may be terrifying, but most of them are manmade, and, as Ho puts it, “These are social problems that require social solutions.”