{"id":3816,"date":"2020-05-13T22:07:56","date_gmt":"2020-05-13T21:07:56","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3816"},"modified":"2020-05-13T22:07:56","modified_gmt":"2020-05-13T21:07:56","slug":"lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/05\/13\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\/","title":{"rendered":"Lives vs equity \u2013 analysing the dilemma in the COVID-19 response"},"content":{"rendered":"

By Neil Pickering<\/p>\n

An ethical tension that COVID-19 highlights is between saving lives and acting equitably<\/a>.\u00a0 Bluntly, in the current circumstances, it may be that any weight given to equity will potentially cost lives<\/a>.\u00a0 This need not always be the case, of course.\u00a0 The two can both be realised at one and the same time in any number of actual situations.\u00a0 But in the current pandemic, situations have arisen where they are in tension with one another.\u00a0 In New Zealand this tension has become bitingly evident, given the extent of inequity related to the M\u0101ori population, the colonised indigenous population of New Zealand.\u00a0 It is worth trying to analyse the problem.\u00a0 When we do, I believe a reason emerges for placing significant additional weight on the equity considerations.<\/p>\n

Imagine the following scenario.\u00a0 Two households, one impoverished the other rich.\u00a0 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.\u00a0 That said, the current members of the rich household were not involved in this historical injustice.\u00a0 Nonetheless, the members of poor household are relatively unhealthy because they live in poor accommodation and are not well-nourished.\u00a0 The members of the rich household are relatively healthy because they live in good accommodation and are well-nourished.\u00a0 An infectious disease arrives in the area:\u00a0 it is worse for those who are unhealthy, but for all it threatens death if untreated.\u00a0 There are limited health resources.\u00a0 It is predicted that if the resources are used for the rich household, two lives will be saved.\u00a0 If the same resources are used for the poor household, one life will be saved. \u00a0Where should we put our resources?\u00a0 I shall suggest that there is a strong case for giving them the poor household.<\/p>\n

First, the notion of equity needs to be clearly defined.\u00a0 Braveman and Gruskin<\/a> 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.\u00a0 Disadvantage is defined relatively \u2013 that is to say, it is basically a form of inequality, broadly speaking socio-economic inequality.\u00a0 Not all inequality is inequitable.\u00a0 Some inequalities result from things which are not unjust.\u00a0 For example, COVID-19 seems to affect those with respiratory comorbidities worse than others.\u00a0 But this is not in itself unjust \u2013 it is the way the virus happens to affect people.<\/p>\n

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.\u00a0 There is a clear case that these comorbidities are unequally distributed around the world:\u00a0 that on these health indicators, as on many others, indigenous and other often (but not always) minority groups are more likely to be disadvantaged<\/a>, and that COVID-19 and responses to it impact them unequally<\/a>.\u00a0 Moreover, this is because these populations have been subject to unjust processes in the course of colonisation, conquest, war and other events<\/a>, so that the unequal health status is a result of being unjustly disadvantaged socially and economically.\u00a0 These groups are somewhat like the poor household in our imaginary scenario.<\/p>\n

As a result, these populations are relatively less likely to benefit from equal health provision, and are more burdened by universal public health measures.\u00a0 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.\u00a0 An example of the latter is the loss of income from loss of work, which hits those in already straitened circumstances harder.<\/p>\n

In short, indigenous and other unjustly poorly off populations are disadvantaged twice:\u00a0 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.<\/p>\n

On the basis of this, I want to reframe the relationship between equity and the cost in lives of COVID-19.\u00a0 It is less easy to save the lives of affected disadvantaged groups, and this is because their health status is worse to start with.\u00a0 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.<\/p>\n

The unjust, socially-created, disadvantages cannot themselves be put right by anything one does in a pandemic.\u00a0 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.\u00a0 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. \u00a0\u00a0When dangerous infectious diseases come to call, this existing advantage confers a secondary advantage on them.\u00a0 \u00a0Thus 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.\u00a0 Even though the unequal distribution of the burden of COVID-19 is simply a reflection of the disease\u2019s nature, the distribution of the existing comorbidities is the result of social and historical forces.\u00a0 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.<\/p>\n

I think it should be recognised that the demands of equity are not a small thing to challenge anyone with.\u00a0 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.\u00a0 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).\u00a0 Rather, I suspect that anyone can sense the issues internally.\u00a0 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.<\/p>\n

The point is this:\u00a0 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.\u00a0 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.<\/p>\n

 <\/p>\n

Author:<\/strong>\u00a0 Neil Pickering<\/p>\n

Affiliation:<\/strong>\u00a0 Associate Professor, Bioethics Centre, University of Otago, New Zealand<\/p>\n

Competing interests:<\/strong>\u00a0 None<\/p>\n

Acknowledgements:<\/strong> Thanks to Lynley Anderson and Mike King for helpful discussion and comments.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

By Neil Pickering An ethical tension that COVID-19 highlights is between saving lives and acting equitably.\u00a0 Bluntly, in the current circumstances, it may be that any weight given to equity will potentially cost lives.\u00a0 This need not always be the case, of course.\u00a0 The two can both be realised at one and the same time […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":353,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2143,8070],"tags":[],"class_list":["post-3816","post","type-post","status-publish","format-standard","hentry","category-distributive-justice","category-pandemic"],"yoast_head":"\nLives vs equity \u2013 analysing the dilemma in the COVID-19 response - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/05\/13\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Lives vs equity \u2013 analysing the dilemma in the COVID-19 response - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Neil Pickering An ethical tension that COVID-19 highlights is between saving lives and acting equitably.\u00a0 Bluntly, in the current circumstances, it may be that any weight given to equity will potentially cost lives.\u00a0 This need not always be the case, of course.\u00a0 The two can both be realised at one and the same time [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/05\/13\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\/\" \/>\n<meta property=\"og:site_name\" content=\"Journal of Medical Ethics blog\" \/>\n<meta property=\"article:published_time\" content=\"2020-05-13T21:07:56+00:00\" \/>\n<meta name=\"author\" content=\"Mike King\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Mike King\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"6 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/\"},\"author\":{\"name\":\"Mike King\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/b107957622bc42b2097d15e5e02a112c\"},\"headline\":\"Lives vs equity \u2013 analysing the dilemma in the COVID-19 response\",\"datePublished\":\"2020-05-13T21:07:56+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/\"},\"wordCount\":1154,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"articleSection\":[\"Distributive justice\",\"Pandemic\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2020\\\/05\\\/13\\\/lives-vs-equity-analysing-the-dilemma-in-the-covid-19-response\\\/\",\"name\":\"Lives vs equity \u2013 analysing the dilemma in the COVID-19 response - 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