By Neil Pickering

An ethical tension that COVID-19 highlights is between saving lives and acting equitably.  Bluntly, in the current circumstances, it may be that any weight given to equity will potentially cost lives.  This need not always be the case, of course.  The two can both be realised at one and the same time in any number of actual situations.  But in the current pandemic, situations have arisen where they are in tension with one another.  In New Zealand this tension has become bitingly evident, given the extent of inequity related to the Māori population, the colonised indigenous population of New Zealand.  It is worth trying to analyse the problem.  When we do, I believe a reason emerges for placing significant additional weight on the equity considerations.

Imagine the following scenario.  Two households, one impoverished the other rich.  The impoverished household has been reduced to penury through a manifestly unjust process by which the rich household has tricked, forced and lawyered its way into ownership of more and better land, which at one time was equally divided between them.  That said, the current members of the rich household were not involved in this historical injustice.  Nonetheless, the members of poor household are relatively unhealthy because they live in poor accommodation and are not well-nourished.  The members of the rich household are relatively healthy because they live in good accommodation and are well-nourished.  An infectious disease arrives in the area:  it is worse for those who are unhealthy, but for all it threatens death if untreated.  There are limited health resources.  It is predicted that if the resources are used for the rich household, two lives will be saved.  If the same resources are used for the poor household, one life will be saved.  Where should we put our resources?  I shall suggest that there is a strong case for giving them the poor household.

First, the notion of equity needs to be clearly defined.  Braveman and Gruskin choose to define inequity in health in terms of unjust social arrangements which systematically disadvantage some groups socio-economically with a resulting impact on their health.  Disadvantage is defined relatively – that is to say, it is basically a form of inequality, broadly speaking socio-economic inequality.  Not all inequality is inequitable.  Some inequalities result from things which are not unjust.  For example, COVID-19 seems to affect those with respiratory comorbidities worse than others.  But this is not in itself unjust – it is the way the virus happens to affect people.

However, if the existing health conditions which exacerbate the impact of COVID-19 are unequally distributed, then the question may arise as to whether the unequal distribution of these conditions is itself inequitable.  There is a clear case that these comorbidities are unequally distributed around the world:  that on these health indicators, as on many others, indigenous and other often (but not always) minority groups are more likely to be disadvantaged, and that COVID-19 and responses to it impact them unequally.  Moreover, this is because these populations have been subject to unjust processes in the course of colonisation, conquest, war and other events, so that the unequal health status is a result of being unjustly disadvantaged socially and economically.  These groups are somewhat like the poor household in our imaginary scenario.

As a result, these populations are relatively less likely to benefit from equal health provision, and are more burdened by universal public health measures.  An example of the former would be ICU provision which relatively unhealthy populations are less likely to benefit from because (for example) they are more likely to have comorbidities which contraindicate treatment or make treatment less likely to be successful.  An example of the latter is the loss of income from loss of work, which hits those in already straitened circumstances harder.

In short, indigenous and other unjustly poorly off populations are disadvantaged twice:  they are unjustly disadvantaged by the social arrangements which impact their health status, and those disadvantages in health status and in social status make the impact of the pandemic harder.

On the basis of this, I want to reframe the relationship between equity and the cost in lives of COVID-19.  It is less easy to save the lives of affected disadvantaged groups, and this is because their health status is worse to start with.  In other words, one reason why there is a clash between equity on the one hand and saving lives on the other is because of the inequity of the system.

The unjust, socially-created, disadvantages cannot themselves be put right by anything one does in a pandemic.  In our imaginary scenario, saving the life of one family member of the poorer household will not magically reverse the inequality in the socio-economic standings of the two households.  However, the non-indigenous, colonising population are, like it or not, relatively the benefactors of the social arrangements which disadvantage the indigenous and other groups.   When dangerous infectious diseases come to call, this existing advantage confers a secondary advantage on them.   Thus the challenge for those who are as a group better off is to recognise the injustice of the history and the concomitant justice of the claims which equity represents.  Even though the unequal distribution of the burden of COVID-19 is simply a reflection of the disease’s nature, the distribution of the existing comorbidities is the result of social and historical forces.  Equity is the principle that recognises this, and makes the case that those who are unjustly disadvantaged should have relatively greater resources allocated in their interests.

I think it should be recognised that the demands of equity are not a small thing to challenge anyone with.  It would be tough to ask the rich household in our initial example to give up their chances of saving two lives from amongst their members.  This is not only a theoretical debate (despite the use of terms such as utility and maximisation, and indeed equity itself to try and frame it).  Rather, I suspect that anyone can sense the issues internally.  Most people have a sense of the equal importance of each life, and would prefer to save more lives than fewer; and most people have a sense of justice, recognising where an allocation of resources both replicates and feeds off an existing injustice.

The point is this:  the existence of a strong tension between saving lives and equity in the course of the current pandemic is in some cases itself the result of un-righted wrongs.  This provides a reason that equity should be given additional weight in considerations about how to respond to the COVID-19 crisis in New Zealand, and wherever in the world there are similar circumstances.

Author:  Neil Pickering

Affiliation:  Associate Professor, Bioethics Centre, University of Otago, New Zealand

Competing interests:  None

Acknowledgements: Thanks to Lynley Anderson and Mike King for helpful discussion and comments.