COVID-19 and the moral failure to protect the most vulnerable

Abstract

The USA’s COVID-19 pandemic experience is an example of privileged thinking that what generally works for those in power ought to be the standard for what makes medical interventions, research, treatments, and policy ethical. As a result of not focusing on doing whatever was required for vulnerable or susceptible populations or their members to achieve their health and flourishing, there are a disproportionate numbers of COVID-19 infections and deaths in Black, Hispanic, and indigenous communities. Future studies will likely show even more harm and larger health failure than known of now.

Instead of using the language of privilege and power in their thinking, public health organizations should focus far more on the language of diversity and meaningful inclusion. If we truly are interested in the vulnerable and susceptible communities flourishing as individuals and populations within our society, as well as the society’s flourishing, then those terms have to be defined in the language of the vulnerable and susceptible. It is only by using this approach that we can make pragmatic plans that work to the advantage of those who are vulnerable or susceptible.

Introduction

The USA’s COVID-19 pandemic response has been illicitly affected by public health officials, scientists, and politicians’ unconscious, social privilege. Both groups assumed that what generally works for them and their constituents ought to be the standard for federal and state pandemic actions for all communities. Their privilege blindness created guidance and policy that did not focus on doing whatever enabled vulnerable or susceptible sub-populations or their members to achieve their health and flourishing, therefore, it is not surprising that there are now disproportionate numbers of COVID-19 infections and deaths in Black, Hispanic, American Indian, and elderly communities. When a fuller damage assessment of these communities’ social, economic, and professional disparities is performed, it will be recognized that far greater and worse harm was done than currently believed.

Instead of using the powerful language of privilege, those in charge of managing the pandemic should have focused on the language of diversity and inclusion in their planning and implementation. A variation of Community-based Participatory Research (CBPR) (Warren et al, 2011) would have pragmatically designed pandemic responses, since CBPR’s are democratically created by all stakeholders as equal partners with equal say in the enterprise. If we truly are interested in the vulnerable and susceptible communities flourishing as individuals and populations, as well as overall society’s flourishing, then we need to implement something like CBPR, perhaps Community-based Participation Planning (CBPP). That approach requires us to think about what reality actually is, which makes planning and implementation far more likely to be practically and ethically successful.

What does it mean to be a vulnerable or susceptible population?

There are an infinite number of ways in which people and communities are vulnerable, although vulnerabilities can be categorized roughly in the following six groups, each with its own object: cognitive, juridic, deferential, medical, allocational, and infrastructural (Kipnis 2006). Cognitive and deferential vulnerabilities are about mental and emotional competences, whereas infrastructural addresses a lack of resources that might put a person at greater risk than she otherwise would have been. The remaining three involve duress of some form that will limit free will or freedom of choice.

For intrinsically valuable beings, vulnerability and susceptibility matters only when there is severe or significant impact to their thriving as communities or individuals within communities. Formally put:

An intrinsically valuable being, X, is morally vulnerable to Y’s power over X = df.

1. X has an aspect, such as a status, ability, potential, interest, desire, need, or relationship that is capable of being altered in that environment over that time period,

2. X has insufficient power to stop Y’s use of power to alter that aspect,

3. Y’s use of power will objectively or subjectively harm X’s ability to flourish, and

4. X is unable to fully mitigate the harm that could be inflicted on X by the attacks on X’s aspect.

An essential definitional element to vulnerability must be power, or more specifically, the lack of power. And that power has to be understood in its environmental context, including the people in their socio-biotic communities involved and their environments. For vulnerable people and communities, the power to avoid or to heal is less than required to avoid or mitigate all injury. Every person and community, therefore, is vulnerable in some way, and that they are vulnerable to various degrees (Rogers 1997).

Michael Kottow (2002 and 2004) makes a plausible distinction between vulnerability and susceptibility. Susceptibility occurs after someone has been harmed or has deficiencies that have created a “vulnerated state of susceptibility that…indicates a process of actual destitution and increased liability to additional harm” (Kottow 2004, p. 283). A person or community might be vulnerable in the moment or over a period of time to some force being wielded against it. Neither named time period may cause susceptibility in a particular case, although each is essential to doing so in certain circumstances.

In order for a vulnerability to become moral susceptibility or excess vulnerability that justifies outsiders acting paternalistically or otherwise, then certain conditions must obtain. One vulnerability definition includes a prescriptive element that is absent in mine but which works in these cases: “vulnerability as a claim to special protection should be understood as an identifiably increased likelihood of incurring additional or greater wrong” (Hurst 2008, p. 195). This definition fits with the notion that vulnerability is limited to those populations having a special need for protection because they are unable to protect their interests and they face calamities that justify intervention (Weisser-Lohmann 2012). Let us call this condition moral susceptibility:

X is morally susceptible to Y’s use of power on X in X’s environment over a period = df.

1. X is morally vulnerable to Y,

2. X’s moral vulnerability is the result of a process of actual destitution, and

3. X and the feature(s) making X intrinsically valuable has increased liability to additional harm by Y in X’s environment that cannot be accounted for merely by X’s vulnerability alone.

Once again, moral susceptibility establishes a right or entitlement to be protected by others from this danger, all things considered (Weisser-Lohmann 2012). Relevant groups as used here means those class memberships that help to identify her as a person in general and as an individual. The former involves objective membership in groups, such as being a certain age, whereas the latter are subjectively chosen, such as one’s career. Both occur within a socio-historical context that helps define the person and community. A benefit of this definition is that it sets a practical standard in a pragmatic way. Instead of idealized or impractical rule, the person’s real situation in her context is taken into account in the decision procedure.

A duty to protect the vulnerable and the greater obligation to protect the susceptible

Vulnerability and susceptibility relevant to bioethics and ethics in general have a normative component to them that requires at least a prima facie obligation by moral agents to protect those relevant things that have that feature. David Thomasma (2000) argues that this potential duty depends on power disparities. Those with more power have a duty to respect, protect, and not exploit the vulnerable. In the case of susceptibility, there is likely a prima facie obligation to mitigate, if not eliminate the weakness status altogether, especially if the agent is undeservedly privileged with power to change reality. That is, if one has unmerited power whereas the vulnerable/susceptible do not, then there is good reason that the former should do something to help enable the latter to be able to better compete and collaborate to achieve their flourishing in that environment. It makes the individual, communities, society, and environment better by improving all four’s thriving, whilst reducing the imbalance of power between society members. That reasoning becomes far more plausible and persuasive in most cases of susceptibility, where there is an extreme form of vulnerability.

Five inclusive goals or criteria are a useful guide in what to do in a pandemic, when there is an insufficient supply of personal protective equipment and other relevant goods to satisfy all needs. What does exist should be distributed for:

1. Protection of the most vulnerable, [especially the susceptible];

2. Protection of key personnel in healthcare, public health and safety, and crisis response infrastructures;

3. Protection of key social functions, including transportation, fire and police departments, food production, utilities, and undertakers;

4. Maximization of economic benefits; and

5. Provision of “fair innings” (Arras 2009, pp. 287–8).

The most important two goals/criteria for the vulnerable/susceptible are one and five. The fifth criterion most aptly applies to what has happened to racial/ethnic minorities in the federal and state COVID-19 response failures. There are those who have lived long, flourishing lives, whereas other society members are merely starting out. The older people have had their fair innings, according to Arras, and it would be unfair to make those who have not had such benefit bear the costs of not receiving a vaccine or goods that will save their lives. Based on fairness, those who have already received their fair share cannot receive even more benefit whilst others who are already lack just deserts are required to bear the costs of the others excess.

I will leave to the side qualms about ageism that Arras’ argument raises, to focus on a less controversial, far more morally plausible fairness claim that can be drawn from it. In pandemics:

[T]he inequities normally attendant upon such differences [capital wealth, racial, and/or perceived sexual superiority] must be intentionally offset by the dissemination of a fair and reasonable set of social goods (Warren et al 2011, p. 7).

Some groups have far greater privilege when it comes to surviving, recovering, and eventually thriving than do others. Part of that privilege may be earned through the work of the privileged group members, but a great deal of it is unmerited. It is the result of being part of socio-biotic communities and environments that favor morally irrelevant social and genetic characteristics. It is simply sheer luck to be born into that community, and that community may have procured or maintained their advantages through illicit behavior, exploiting more vulnerable individuals or communities, cultural practices, legal institution, and social conventions and mores. Other communities and groups did not have that moral luck, and they have been illicitly handicapped from fair competition and access to resources by the social, cultural, economic, and political structures and misuse of power to create or maintain vulnerability/susceptibility. Therefore, they are at social, economic, cultural, and other opportunity disadvantage through no fault of their own. Fair innings in pandemic situations, therefore, require that those made more vulnerable by illicit forces acting against them, especially those who are susceptible, receive benefits invested to nurture their flourishing, whilst those who have already had their fair innings go without or do with less than they want, or even need. That was and is the duty of politicians and health officials in the COVID-19 pandemic.

Did government agencies and politicians fulfil their duty to protect the racial/ethnic vulnerable and susceptible?

At the beginning of COVID-19’s spread in the United States, health officials knew from China’s experiences that the elderly and those with certain preexisting conditions were especially susceptible to becoming seriously ill, whereas healthy people under the age of 65 suffered little ill-effect, if they even caught it (Zimmer 2020). But even though government agencies were armed with that knowledge, state and federal responses where not designed to protect the most vulnerable groups. Instead, general lockdowns and other measures that treated all people as equally at risk were instituted. Given current data indicating disproportionate older age (Robinson, Barchenger, and Powers 2020) and race/ethnicity representation for cases and morbidity, there are serious questions that need to be asked about how those in charge of the federal and state level measures to deal with COVID-19 performed, and unfortunately in some cases, continue to adversely affect the elderly and certain racial minorities.

COVID-19 is more dangerous and deadly to those with existing health conditions, such as immunosenescence, obesity, hypertension, higher blood clot risk, diabetes mellitus, cardiovascular disease (Shikha et al 2020), respiratory diseases, and a number of other co-morbidities. There were also very strong links to vulnerability caused by long term exposure to pollution. For example, 78% of Italian and Spanish fatalities were from only five regions, and those regions had extremely high concentrations of nitrogen dioxide (Ogen 2020).

Environmental racism, which degrades the environment of vulnerable populations through pollution and environmental hazards in part, because those groups are vulnerable, increases health and environmental problems (Bullard 2004). Although poverty is a contributor, race has an impact, for example, poor Blacks bear a greater burden of particulate matter emissions than poor Whites (Mikati et al 2017). Dillion and Young characterize the moral problem as “The deliberate siting of hazardous waste sites, landfills, incinerators, and polluting industries in communities inhabited by First Nations [Canada] communities represent a social justice issue of considerable magnitude” (Dillion and Young 2010, p. 23). The same problem can be found in the United States (Collins-Chobanian 2017).

It has also been understood for a very long time that certain racial/ethnic groups have far greater representation in COVID-19’s comorbidity areas than in the general population or other racial/ethnic groups. The Centers for Disease Control and Prevention’s (CDC) report on diabetes, for example, states that Whites have the lowest percentages of diabetes, with Hispanic, Blacks, and American Indians sometimes doubling that number (CDC 2017; OMH 4). Blacks, American Indians, and Hispanics are far more likely than Whites to have kidney failure, and Hispanics suffer higher rates of liver disease and deaths than non-Hispanic Whites (National Kidney Foundation 2020; OMH 3). For heart disease, black people are more than 20% more likely to die than Whites, and black women are 60% more at risk to have high blood pressure than white women (OMH 5). The Office of Minority Health (OMH), Department of Health and Human Services stated, in 2014, that Blacks were almost three times more likely to die from asthma related deaths than Whites, and in 2015, that black children’s death rates from asthma related conditions were 10 times higher than that of white children (OMH 1). OMH also knows that Blacks have the highest mortality rate for all cancers combined and for most major cancers in general (OMH 2). The CDC’s CDC Health Disparities and Inequalities Report – United States, 2013 reiterates these and other health disparities. So, although there is always a need for more research, it was never a mystery which racial/ethnic populations were at higher risk for COVID-19 than others.

It was also well known that environmental, economic, cultural, and other factors can contribute to how vulnerable a group is in public health emergencies. The CDC states that “Where we live, learn, work, and play affects our health” and then points out that the living conditions, work circumstances, underlying health conditions, and lower access to medical care can help explain the disproportionate number of minority group members represented in overall hospitalizations and mortality (CDC 2020). In New York City, a COVID-19 outbreak epicenter/hotspot, Blacks are 18% of the population, for example, but made up 33% of hospitalizations and 92.3/100,000 deaths. Whites, on the other hand are 59% of the population, 45% of hospitalizations, and have 45.2/100,000 deaths. Only Hispanics had lower hospitalizations than their representation in the population – 8% and 14%, respectively - but they suffered 74.3/100,000 deaths (NYC Health 2020).

Of additional concern is the lack of urgency to use the best science. Although the data is vital to saving lives and preventing suffering, it is difficult to have any definitive idea of how greatly COVID-19 will affect racial/ethnic minorities, in part, because state and federal agencies have not been collecting it in full - or at all - in some cases. The fact that 52% of reported COVID-19 cases are missing that information now (Barron-Lopez et al 2020) entails that the CDC does not know the actual impact of the disease on vulnerable communities. Federal guidance issued in June 2020 mandates that race and ethnicity be recorded, but leaves it until August 2020 to take effect, which is well over 6 months after the outbreak began. One could reasonably question how this late collection will help those whose lives could have avoided severe health issues caused by infection or have been saved.

Although 48 states report on race and ethnicity for death, only 45 do so for both cases and deaths from the disease, which means these data cannot give a complete picture of what is happening. Even if the states report for both, many of them are missing significant amounts of data required to get an accurate picture, which is needed to help government health officials and politicians to design more effective responses for what people are undergoing. What we see from sources such as the COVID Tracking Project is morally appalling, to say the least. In Wisconsin, for example, Blacks make up 6% of the population but 21% of cases and 25% of deaths, over four times what their numbers should be if this disease was killing people equitably. Whites, on the other hand, have 86% of the population, but only 59% of cases and 70% of deaths (COVID Tracking Project 2020). In Arizona, American Indians are overrepresented in cases and death – 18% and 20%, respectively, when they comprise only 4% of the state’s population (Ibid.).

Given the above, there is already a prima facie case that there is a problem of privilege: those in power believe that what works for them works equally as well for everyone else, without taking into account that not everyone in US society has that same privilege. Take, in addition, the mandate to shelter in place for residents in under-resourced communities (Cabildo et al 2020). Shelter in place and other lockdown strategies favor those who can work or be schooled from home, have access to medical professionals, ability to have food delivered to the residence, and so on to maintain their lifestyle and fulfill their needs and wants. Only 16.2% of Hispanic and 19.7% of black workers can work from home, for example, compared to 29.9% of white workers (Bridges 2020, p. 44).

Not everyone is as fortunate. Among other factors that cause inequities are health disparities caused by a lack of adequate access to quality food, healthy lifestyles, and access to medical care, housing density is much higher on average, for employment, many people of colour are deemed essential workers and they cannot afford to stay at home, and there is a lack of adequate testing because of lack of healthcare and jobs that do not supply it (Zimmerman 2020). The current crisis standard of COVID-19 care guidelines privilege certain people to the unfair detriment of others who are more vulnerable because of their comorbidities (Tartak and Khider 2020). The conditions that make people far more susceptible than the general population to infection and developing serious, life-threatening conditions, therefore, were known early by US health officials and others, therefore, vulnerable groups should have been targeted for special protection.

The privilege asserted might have darker roots than mere negligence. Intentional or unintentional racism might be a cause: “The COVID-19 crisis shows the one of the deadliest underlying conditions in America is systematic racism” (Cabildo et al 2020). Others identify institutional racism and decades of its effects on these homo sapiens sub-populations (Zimmerman 2020, p. 40; Williams, Lawrence, and Davis 2019; Hardeman et al 2018).

Whatever the cause(s) of why certain groups have greater numbers of their members who are vulnerable or susceptible, the fact is that these issues where fully understood long before COVID-19 began in earnest in the US. Given the actual and morally reprehensibly incomplete data on morbidity and mortality for racial/ethnic groups alone, public health authorities, politicians, and others who were responsible for federal and state responses to this pandemic too often failed in their professional and personal moral duties to save lives and prevent unnecessary suffering.

Making sure diversity and inclusion are central

Different vulnerabilities and susceptibilities require tailored approaches based on the historical, social, physical, psychological, economic, cultural, and all other relevant realties to address those needs. Firstly, this means that those involved in the process must speak the language of diversity and inclusion, which must include culturally appropriate public education programs Cabildo et al 2020) for all relevant stakeholders and decision makers. For a possible pandemic flu, there is a need to motivate “health professionals and faith leaders to rethink what is meant by terms such as community, vulnerability, and greatest need” (Warren et al 2011, p. 5). To accomplish this essential task, they must have “knowledge of the community in the broadest sense of the term,” including the social, economic, political, and ethical dimensions (Walker, Mays, and Warren 2004, p. 2), so that they can have a shared understanding of what the relevant terms mean (Warren et al 2011, p. 5). Knowledge of the interrelated, interdependent complexity of the situation and its values will help form pragmatic, effective social policy with its multiple objectives.

Secondly, to begin the process of rectifying these problems required addressing them based on their root causes and how they affected the groups discriminated against. For Blacks, Vine Deloria states that the problem is “one of culture and social and economic mobility” (Deloria 1989). For American Indians, “it is the adjustment of the legal relationship between the Indian tribes and the federal government, between the true owners of the land and the usurpers” (Ibid.). Responsively designed solutions would provide the relevant mobility and adjust the relationship, respectively, to efficiently, pragmatically address the needs.

Thirdly, those with privilege need to understand what their privilege is and how it may bias their decisions and actions. Returning to Deloria, a commonality between the problems faced by blacks and Indians is the cause, viz. whites. Deloria states that each white person

[M]ust examine his past. He must face the problems he created within himself and others. The white man must no longer project his fears and insecurities onto other groups, races, and countries. Before the white man can relate to others he must forego the pleasure of defining them (Deloria 1989).

The root cause agent is the same in both cases, which is why whites must be part of the solution to the problems caused by that group’s actions. Moreover, effective ways to achieve reconciliation, restorative justice, social justice, or whatever the desired and desirable outcome is all pass through a critical understanding of the causal group’s identity as a product of its history, experiences, its interdependent, interconnected relationships to others, and its place within its environment.

Fourthly, one of the largest challenges for some racial/ethnic groups is mistrust in the public health system to the detriment of these groups’ health equity and health outcomes (Ramos et al 2019). For instance, David Hodge points out the “Black Americans visceral distrust of white institutions, white systems, and indeed white people” which resulted, in part, from the morally repugnant historical treatments of Blacks in the United States (Hodge 2018, p. 65). Mistrust comes from being ignored, exploited, exposed to micro-aggressive behaviors, “derogatory, invalidating snubs in research and health care services,” (Ramos et al 2019, p. 2) and political/social incivility. Public health officials have to publicly, empathically identify all of the values involved in the crisis, acknowledge and show care for the vulnerable and susceptible in regard to these values, speak about it knowledgeably and in a form that communicates that everyone is being validated as the intrinsically valuable beings they are individually and as a community, and then formulate and implement a response built on these foundations. Performing as a trustworthy partner in this manner will eventually create trust because these actions carry far greater evidential weight than lofty ideals spoken in press conferences and interviews.

Finally, epidemic and pandemic planning would benefit from following a variation of Community-based Participatory Research approach. CBPR:

focuses on the social, structural, and physical environmental inequities through active involvement of community members, organization representatives, and researchers in all aspects of the research process (Warren et al 2011, p. 10).

With each participant being an equal partner with equal weight in designing and making decisions, the outcome is a collaboration all can buy into. Instead of solutions being forced by those privileged with power and other relevant resources onto those who are vulnerable or susceptible, whatever is decided is acceptable because it uses diverse and inclusive language to produce community solutions. The same approach works for pandemic and epidemic planning. Perhaps it could be called Community-based Participation Planning or Community-based Participatory Health Engagement, so that its charge is all health care issues. This broadness of charge would be more useful than limiting it to pandemic, because as we have seen above, the reason that certain groups are vulnerable or susceptible is because of far more factors than merely being able to catch a certain virus. The relevant causes include social, cultural, economic, environmental, and other influential sources, so any planning and implementation have to address those as foundational issues for decreasing vulnerability and pursuing individual and group flourishing.

At the very least, the moral duties of public health officials, politicians, and others involved in pandemic planning and responses can no longer treat all communities as if they are equal, when it is more than clear that some are more vulnerable than others. At times, far, far more vulnerable to a degree that creates susceptibility. If they do not, then any assertion they make that they are doing everything they can do to save every life, no matter the cost, will be seen as the empty claim it was.