JBI Dialogues

Learning Lessons from COVID-19 Requires Recognizing Moral Failures: Max Smith and Ross Upshur

• Edwina Light

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In this episode of JBI Dialogues, Professor Ross Upshur, one of the co-editors of the journal’s new symposium on the social and ethical implications of the COVID-19 pandemic, talks with Professor Max Smith about their paper "Learning Lessons from COVID-19 Requires Recognizing Moral Failures". 

Max is a bioethicist and Assistant Professor in the Faculty of Health Sciences at Western University, Canada.  Ross is a physician and bioethicist and heads the division of Clinical Public Health at the University of Toronto, Canada.

Article abstract: The most powerful lesson learned from the 2013-2016 outbreak of Ebola in West Africa was that we do not learn our lessons. A common sentiment at the time was that Ebola served as a “wake-up call”—an alarm which signalled that an outbreak of that magnitude should never have occurred and that we are ill-prepared globally to prevent and respond to them when they do. Pledges were made that we must learn from the outbreak before we were faced with another. Nearly five years later the world is in the grips of a pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). It is therefore of no surprise that we are now yet again hearing that the COVID-19 pandemic serves as the “wake-up call” we need and that there are many lessons to be learned to better prepare us for future outbreaks. Will anything be different this time around? We argue that nothing will fundamentally change unless we truly understand and appreciate the nature of the lessons we should learn from these outbreaks. Our past failures must be understood as moral failures that offer moral lessons. Unless we appreciate that we have a defect in our collective moral attitude toward remediating the conditions that precipitate the emergence of outbreaks, we will never truly learn.

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Image: Chapman Chow on Unsplash

Edwina:

Hello, and welcome back to JBI Dialogues, presented by the Journal of Bioethical Inquiry as a multidisciplinary space, connecting contributors, readers and the editorial team, extending the work of the journal with exchanges of ideas about as published research and up and coming issues and practices in bioethics. My name's Edwina Light and I'm the digital content editor at the JBI. In this episode of JBI Dialogues, Professor Ross Upshur, one of the co-editors of the Journal's new symposium on the social and ethical implications of the COVID-19 pandemic, talks with Professor Max Smith about their paper"Learning lessons from COVID-19 requires recognizing moral failures". Max is a bioethicist and assistant professor in the Faculty of Health Sciences at Western University in Canada. Ross is a physician and bioethicist and head of the division of clinical public health at the University of Toronto in Canada.

Ross:

So good afternoon, Professor Smith. Thank you so much for joining me this afternoon. This is part of our Journal of Bioethical Inquiry dialogues on the symposium we recently held on ethical issues raised by this rather complex COVID-19 outbreak. So thanks for joining us.

Max:

Thanks for having me on.

Ross:

So the first question I want to ask you is, you wrote a fascinating paper"Learning lessons from COVID-19 requires recognizing moral failures". In the time that's passed since you first wrote that paper till now, have you changed your mind in any way or how do you think the paper holds up?

Max:

I think the views that I express with my colleague Ross Upshur in that paper have been further entrenched in fact, since writing that paper. The whole idea of the whole argument that we make is that, there's, there's some futility in trying to learn lessons if we don't acknowledge the moral character of the failures that we've had during the pandemic. And I think since we wrote that paper, since that paper was published, we can point to a number of moral failures that have continued to happen that we haven't learned from.

Ross:

You want to give me an example of some of those.

Max:

Yeah. One of the, one of the biggest moral failures really, I think, is failing to learn from our past experiences. So in the paper we, actually, it's a follow-up paper to a paper that Dr Upshur and I wrote in 2015, which identified that ever since SARS, so including H1N1, H5N1 influenza, MERS-coV, Ebola, and, all of these outbreaks that we've experienced in the past 20 years, we continually say that these should serve as a, wake up calls for outbreak preparedness and response in the world. And effectively, we never wake up whenever we received those calls. And so, really I think any additional outbreaks or experiences, if we don't learn from those and we continue to call them, wake up calls and don't do anything different, that just serves as another failure. And so a really good example is a failure not to protect the most vulnerable people in our society. So we know that there are, are just not sufficient investments in things like primary care and public health infrastructure, and in long-term care homes, nursing homes to protect the elderly. And we've known this and we've known this for 20 years and we've seen what outbreaks can do to those populations time and time again. And, what a surprise, this happened again with the COVID-19 pandemic. And so that just represents another moral failing that we need to really appreciate and acknowledge if we're ever going to learn from it.

Ross:

So why is that a specifically moral failure?

Max:

It's a moral failure for a couple of reasons. First of all, I think if there are lessons that we have extensively seen in the past, then we have a moral obligation to learn those lessons. If we can avert morbidity and mortality based on our prior experience, then there's a moral imperative to actually do something and cultivate those lessons and translate that into practice. So I'd say that's one of the reasons why it's a moral failure. The second reason that it's a moral failure is because it suggests that we haven't been able to reorient our, our moral attitude and practice towards things like justice and solidarity. That there's populations that are disproportionately burdened by infectious diseases, like homeless populations or institutionalized populations or refugee migrant populations, and failing to, seeing and knowing that these populations will be disproportionately burdened and not doing anything to stop that from happening reflects a failure of justice and it reflects a failure of solidarity, which we would argue are moral failures.

Ross:

I agree. So this notion that this was predictable, avertable, yet somehow seemed as a surprise and a need for a wake up call, what do you think that says about our collective consciousness when it comes to ethical issues and pandemics?

Max:

Yeah, I think it's, I actually don't think it's a problem of learning. Right? I think that if we go all the way, all the way back to SARS and before, we know that these are important experiences, important lessons. So I don't think it's a matter of just learning this for the first time with the COVID-19 pandemic. I think it fundamentally reflects the failure of shifting our values and attitudes towards the protection of these populations and intervening to promote their interests and needs. So that's why I think it's fundamentally moral. These aren't things that require technological innovations or, or experiences or lessons that we simply haven't experienced yet. But the things that we know well and just simply have chosen not to. We don't have the political will or even the public will to address those failures.

Ross:

So reflecting broadly on ethics and the current COVID-19 SARS-coV2 pandemic, what are the other sort of major ethical issues that you see require a concerted attention from the bioethics community?

Max:

Yeah, I think there's a number, and the good thing is that the bioethics community over the past 20 or so years have actually paid good attention to some of these ethical issues because of the experience with SARS and H1N1 and other infectious disease outbreaks. And so some of the, some of the ethical issues that we've identified in the past are emerging again in the COVID-19 pandemic and still remain important to address here. So, first and foremost, I think if you look at the ethics literature, you'll appreciate that the vast majority, I would say, regards ethical issues and resource allocation. So what's the fair way to allocate resources like vaccines, like personal protective equipment, and, and other sorts of resources, like critical care resources and ventilators and that sort of thing. So I think the allocation of resources continues to be one of those major ethical issues that deserves attention and certainly receives attention. Two others that I've mentioned regard the ethical issues that emerge in the context of using respected public health measures and the trade offs between individual liberties and the public good. And another is the obligation of healthcare workers to provide care in the context of contagion, where there are increased risks for our health healthcare workers.

Ross:

Thank you. So looking forward, with your crystal ball, what do you envision emerging from our experience with this pandemic will be the big issues that we'll have to collectively struggle with.

Max:

Yeah. And there's so many different things that we can look to. I suppose, one of the things that really worries me is the, the tremendous amount of money that we're spending to respond to this pandemic. So in Canada, for instance, we have a benefit that's provided to those who aren't able to work or have lost their job even temporarily because of the pandemic. And so the government quite rightly I think has, has tried to find funds to support Canadians. And we've seen this in many other parts of the world. And so I think this is an important thing, but what I worry is that in the years to come, we'll shift to an austere sort of mindset. We'll see an era of austerity where, because of all the money that we've invested in, in the pandemic response, we'll be very tight in how we spend money. And you'll see clawbacks of how we spend money in social programming and health and education and other areas. And so I think if we don't explicitly think about protecting and recognizing that those investments actually can help to prevent panedmics in the future, or help us to respond to pandemics in a more effective way in the future, and we'll see those programs either be limited or we'll lose all sorts of financial support for them. So, I think that's one of the biggest ethical issues that I can see that as a society, we need to collectively really try to prevent happening.

Ross:

Great. Well, thank you for your time today, Max, it's been a wonderful discussion and I do hope that you will consider submitting more of your very thoughtful work, and incisive work, to the Journal of Bioethical Inquiry.

Max:

Thank you.

Edwina:

Thank you for joining us for JBI Dialogues. The transcript of this audio resource is available on our website, bioethicalinquiry.com, where you'll also find links to the article discussed today, as well as other JBI articles and issues. For JBI updates, subscribe on the website to our email newsletter or follow us on Twitter@bioethicinquiry. The Journal of Bioethical Inquiry is the official journal of the Australasian Association of Bioethics and Health Law, and the University of Otago's Bioethics Centre. It's published by Springer Nature.