Covid-19: An Ethical Dilemma for the Ages
The images are striking. The lines of cars miles long waiting for food. The lines of caskets being held in truck trailers because there are so many deaths. The pictures of protestors with guns and signs demanding a return to normalcy. Similar pictures of nurses and doctors with masks and signs asking people to stay home.
And so the tension grows between the providers and the oppressed. What is to be made about the debate pitting the public health against economic insecurity? What’s a society to do for the most vulnerable when “vulnerability” takes many shapes?
The pandemic has put society in the midst of a debate about “rights” — the rights of the individual versus the rights of the many. The challenge becomes one of how to do the best thing.
Often the discussion revolves around how we balance the burdens and benefits of tough decisions so that they do not adversely affect groups in disproportionate ways.
In the case of the pandemic, how do we ensure the safety of our citizens while meeting their basic needs for food clothing and shelter that have been taken away by the shelter in place directives?
Moral Injury
People are being more generous and caring of their friends and neighbors than ever before. We have developed informal families of support through gestures of kindness and support, distanced happy hours and neighborhood concerts and cheering galleries. In the midst of all of this we see the incredible sacrifices on the part of our healthcare professionals and first responders taking a dramatic toll on physical and mental health. They are experiencing a crisis of what Talbot and Dean call “moral injury”^. It is defined as this feeling of depression, hopelessness and exhaustion. It centers on the struggle between idealism and reality — that we could give better care if we had the resources and tools that our government and hospitals are supposed to provide for us. Instead, the guilt of not being able to provide that care because of inadequate resources leads some health care workers to give up.
The Ethical Challenges of the Pandemic
The business of ethics is usually guided by principles and theories that act as a roadmap for making difficult decisions faced by societies and the individuals within it. The ethical principles focus on the individual’s right to decide (autonomy); being a benevolent society (beneficence); doing no harm (nonmaleficence); and treating everyone fairly (justice).
Over the past few weeks we have seen each of the ethical principles at work. We engaged the principle of nonmaleficence by sheltering in place. Then we legislated an unprecedented benefit package (beneficence). Second and third packages were passed to try to provide support to as many people as possible (justice). And now we consider loosening restrictions as a growing number of people are clamoring for an end to the personal restrictions (autonomy).
The theories of ethics which are designed to guide policy and behavior include Utilitarianism (the best course of action for the most people); Deontology (what our duties and obligations are as a society); andConsequentialism (the rightness or wrongness of any action must be viewed in terms of the consequences of that the action).
Some would argue that if people are against the shelter in place order, they do not have to go out when restrictions are lifted. Opponents would argue that if lifting the restrictions allows a few to resume normal activities and the virus proliferates again, it presents a risk to everyone! So how do we proceed? What is the most effective way to honor peoples’ rights?
A Matter of “Rights”
What is a right? A right is a justified claim on others. For example, if I have a right to freedom, then I have a justified claim to be left alone by others.
Immanuel Kant, an eighteenth century philosopher maintained that each of us has a worth or a dignity that must be respected. Valesquez et al** suggest that “this dignity makes it wrong for others to abuse us or to use us against our will and that a right to freedom, then, implies that every human being also has a fundamental right to what is necessary to secure a minimum level of well-being”.
Critics of sheltering in place would argue that these rights ensure that the freedom and well-being of each individual be protected from actions which threaten their freedom and/or economic well-being.
But proponents of the Utilitarian theory of ethics would counter that rights should not be the sole consideration in ethical decision-making. In some instances, the social costs that would result from respecting a right are too great, and “relying exclusively on a rights approach to ethics tends to emphasize the individual at the expense of the community” **. The utilitarian approach invites us to recognize our relatedness—that sense of community, shared values, and the common good which lends itself to an ethics of care, compassion, and concern for others.
Rising to Meet the Challenge
As the debate about a return to “normalcy” continues I fear more about social unrest than the virus itself. Many of us can control our daily activities to insulate against health risks, but what of the social behavior that flies in the face of common sense. Crowded beaches, gatherings in other public places, a rush to establish economic equilibrium? The fear of a loss of livelihood has exceeded many peoples’ fears for their own personal health and that of their families and communities. The fear is a legitimate one and must be addressed through education, information and solid policy. A lack of leadership has exacerbated the problem at all levels of our society and the starting place for us as professionals is at the most local levels in our neighborhoods and community forums.
People want information they can trust. They want to know that our leaders have their well-being in mind, (That is what drove almost universal compliance to the original shelter in place order).
Moving forward we have to support the activities that have served us well since the onset of the pandemic. I would encourage us to think proactively in three areas. First of all, science matters. Our intervention strategies must be based on the scientific knowledge while resisting the culture of politics. Secondly, innovation and collaboration are a must. Over the past couple of months, we have seen wonderful examples of innovators and collaborators working side by side in new and exciting ways. And finally we need to be transparent with our citizens. We are a resilient group and having solid information, even if it is bad, is the key to developing realistic solutions and fostering the type behavior that is required for healthy communities.
Resources
**Issues in Ethics V3 N1, Manuel Velasquez, Claire Andre, Thomas Shanks, S.J., and Michael J. Meyer (Winter 1990)
^^Burnout on the Front Lines Caring for Coronavirus Patients Neesha Nadkarni April 1, 2020 The Mercury News
^Physicians Aren’t ‘Burning Out.’ They’re Suffering From Moral Injury. Simon G. Talbot and Wendy Dean, July 26, 2018, STAT
Back in February, I was walking to a local Tết Festival when I noticed an older adult standing at the corner of a busy intersection who seemed lost. As I approached the crosswalk, he motioned me over and asked if I was going to cross. He quickly explained that he had immigrated to San José from Việt Nam three months ago, and had never crossed a signalized intersection on his own.
“So I push this button and just wait for the white figure to appear? How much time do I get? What does the red hand mean?”
As we walked together, I explained how to safely cross the street and he confided how scared he was to walk because of the speed of drivers.
“It’s so different from home where traffic flows around you.”
Before this chance encounter, I had been thinking about how different it is to cross a street in San José than in Hà Nội (pictured above), particularly for newly arrived immigrants and the elderly. And now, as we continue to shelter-in-place, I worry about the lack of safety nets in place to meet the needs of older adults who are disproportionately affected by COVID-19.
Back in February, I wanted to hear from my Vietnamese elders about how they were getting around the City and how the physical layout influences their walking habits. So I reached out to Hoang, the Vietnamese American Cultural Center (VACC) Senior Recreation Leader, who helped me facilitate a discussion with a group of 25 older Vietnamese adults. Hoang began the conversation by sharing an experience where he fell while walking because a tree had over sprouted and cracked the sidewalk. His story struck a chord with the elders and immediately lit the room up in conversation—mostly of how frustrated they were with San José’s sidewalk repair ordinance, which places the responsibility of fixing sidewalks on property owners.
“Do you all remember Chị Han? The City expected her, as the homeowner, to fix the sidewalk in front of her house. When she complained that the sidewalk is a public space, they added that she needed to pay for a permit and hire a contractor to fix the sidewalk!”
Without missing a beat, several others cried out, “That’s ridiculous! That’s the city’s responsibility.”
Then, the conversation shifted to how dangerous it is to walk on certain streets, such as Senter Road, a Vision Zero priority safety corridor located in the Little Saigon neighborhood. One elder brought up the 85-year-old Vietnamese woman who was killed last December while crossing Senter Road. She suggested that while she doesn’t know the solution to stopping these fatalities, the City needs to do something to keep people safer.
Before our conversation ended, I wanted to lighten the mood by asking one last question: what encourages you to walk? There was a brief moment of silence before the room exploded in chatter.
“I don’t like to walk!”
“Sức khỏe! Health. I walk for my health.”
As Hoang asked for final comments, one elder simply stated, “If it was safer, then more people would walk; if more people are walking, then it would feel safer.”
While so much has changed since that conversation we had in February, the valid concerns these elders shared who scoffed at the idea of walking around in their own city still resonates. The struggles to walk in their communities have worsened since COVID-19 because older adults are especially vulnerable to the coronavirus, and are also more likely to be socially and physically isolated. Many senior wellness programs have been cancelled and community centers are closed throughout the City. Older adults still need to get to medical appointments and grocery stores, but are struggling because bus and light rail service has been reduced and other services, including parks, are limited. And as most of our lives shift online, many older adults do not have access to the necessary devices or have support to teach them to use online tools like Zoom.
Now, the state is beginning to reopen without a robust plan for where older adults fit into re-entry, and what safety measures will be enacted to protect 1.2 million older Californians as they transition out of shelter-in-place. The harsh reality is that older adults will not be able to go back to “normal” at the same pace as healthy, able-bodied, young people. While Governor Newsom and the state’s Department of Aging have introduced harm reduction measures such as Friendship Line California and Social Bridging Project, we need long-term planning around the explicit needs of older adults in a world that will endure long-term impacts from COVID-19.
Without guidelines or contingencies for how older adults should safely transition out of shelter-in-place, our older population will continue to suffer disproportionately from the impacts of COVID-19, especially those who are food insecure, low-income, and/or experiencing houselessness. The state has postponed planning of the California Master Plan for Aging, but there is an immediate need for discussion on the impacts of COVID-19 on our aging population and how to effectively address this public health concern.
Since so many resources are no longer options for seniors, it’s important that we all continue to check-in with the older adults in our lives, express support, and raise awareness of programs that are available. The Center for Disease Control and Prevention’s website provides guidance for older adults, with information available in multiple languages, and AARP outlines advice for specific, daily scenarios given by top infectious disease experts. In San José, the Senior Nutrition Program has transitioned to providing boxed meals to-go at most locations and San José Public Library’s (SJPL) Family Learning Center (FLC) Coordinators have created the Community Connection Hour, a virtual community chat-room on Thursdays at 1 p.m. where residents can ask questions in English, Spanish, or Vietnamese and get reliable information in a safe, secure space. Lastly, at Walk San José, we’re working with the San José Department of Transportation on adapting our Senior Pedestrian Safety outreach series into an online format to address safe walking tips during this pandemic.
In these uncertain times, we need to strengthen our commitment to creating safe, healthy, walkable communities. We need streets and public spaces that work for everyone, that are designed with people at the forefront as more are out walking and biking. People of all races, ages, identities, and abilities deserve to live in a community that is safe, healthy, and welcoming. As the elders said, we need to continue to demand more of our elected officials and co-create a future where everyone feels safe and comfortable moving under their own power.
To attend a webinar on older adult safe walking practices, please check out our Facebook Page with event information.
If you’re interested in learning more about our work or getting involved with Vision Zero, please contact me at theresa@calwalks.org.
