As Quebec prepares to enter Phase 2 of the pandemic, Premier François Legault faces an ethical dilemma. To avoid another wave of contagion, he will likely have to choose who gets their freedoms back and who must wait.
Quebec Premier François Legault assured the province this week that planning is underway to phase out the societal lockdown that has overturned our idea of normal since it was ordered on March 23.
He wasn’t ready to provide specifics, but along with Dr. Horacio Arruda, the provincial public health director, Legault did offer some hints of what gradually reopening society will entail.
There will be guidelines about wearing masks in public; schools will be reopened gradually, possibly by geographic region and with some kind of physical-distancing policy in place; and widespread coronavirus testing will be necessary.
This process is set to start on May 4.
“The idea is not to rush things,” Legault said Monday. “We’ll go gradually, and our criteria will be the public’s health.”
The virus continues to claim scores of lives each day, most of them seniors in care. Still, public health officials believe the provincewide lockdown is succeeding at limiting the spread of COVID-19 in the population at large.
Quebec appears to have avoided, so far, the surge of COVID-19 patients that has overwhelmed hospitals in other parts of the world. Of the 7,000 hospital beds Quebec set aside at the outset of the pandemic, fewer than 1,300 were in use on Wednesday.
With its capacity at front-line hospitals intact, the government feels it can start moving to the next phase of managing the crisis.
Phase 2, though, poses a different challenge: how to balance the desire to remove restrictions with the fact that the coronavirus will still be circulating, given that no vaccine is likely to be available for at least 12 to 18 months.
Striking this balance has foisted new practical problems on the government, and new ethical ones as well problems that may force all of us to think long and hard about big questions concerning fairness, freedom and our duties to others.
How to allot scarce resources
The ethical choices Quebec will have to make in Phase 2 will be shaped by how it responded to the major ethical challenge that confronted decision-makers in Phase 1: how to distribute front-line health care if supply is outstripped by demand.
This was the nightmare scenario in Italy, where hospitals did not have enough ventilators to treat every patient who needed one.
Doctors were reportedly “weeping in the hospital hallways
” as they had to decide which patients would receive the potentially life-saving treatment, knowing that those who didn’t would likely die.
In a recent article in the New England Journal of Medicine, a group of physicians proposed ethical criteria for making difficult rationing decisions.
Among other things, they outlined when a younger patient should be prioritized over an older one and when someone’s instrumental value to society should determine if they get care before someone else.
“Many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent,” the authors wrote.
As Quebec officials made clear at the outset of the pandemic, they wanted to avoid placing doctors in such a situation.
This guided the decision to devote the bulk of the province’s health-care resources to hospitals, possibly at the expense of already short-staffed long-term care homes.
It was also the justification for swiftly imposing unprecedented restrictions on basic freedoms we may have taken for granted, such as strolling in a park with a friend or heading for a drive in the country.
Whose freedoms first?
The ethical dilemma of how to allocate scarce health-care resources will likely recede in prominence in this next phase of the pandemic.
In its place will be questions about how to ease restrictions while the threat of COVID-19 remains present.
Squaring this circle seems to mean that not everyone will be able to regain their freedoms equally, and some will have to shoulder the burden of avoiding contagion longer than others.
While the Quebec government has yet to decide how it will distribute freedoms and duties in this second phase, examples from other countries illustrate some of the dilemmas at hand.
One option being considered in countries such as the U.S., Italy and the U.K. is issuing an immunity certificate to those who have already had COVID-19 and can prove they have the necessary antibodiesto avoid re-infection.
Those with the certificate would regain the right to work and to move about freely.
A similar practice is in place in parts of China, where a smartphone app determines the likelihood you’re infected based on a questionnaire (and possibly other data as well). If it’s green, for instance, you’re allowed to take public transit.
The advantage of a certificate system is it allows some people to enjoy freedoms and take on jobs deemed too risky for others while reducing the risk of triggering another wave of contagion.
But it also means assigning social privileges based on medical status.
Another option, one that is being discussed by Quebec public health officials, is using the return of schools to generate a degree of herd immunity.
The idea is that once enough people have been infected and develop antibodies, the virus will no longer be able to spread widely.
“Young people who could get the disease with almost no symptoms are like being vaccinated,” Quebec’s public health director, Horacio Arruda, said last week.
“It is natural vaccination that will take hold, and it is important in society that a certain part of the population be vaccinated.”
But COVID-19 poses its greatest threat to the elderly and those with pre-existing health conditions.
If we accept higher transmission rates of COVID-19, the more vulnerable, let’s say, a teacher with severe asthma, may not be able to enjoy the same freedoms as others, such as returning to school or socializing with friends and family.
A moral tragedy?
The first phase of the crisis has involved dramatic reductions in our freedoms, but these applied to all of us equally.
That probably won’t be the case in Phase 2; some of us will get to do things, while others won’t.
“The ethical problem here is one that has to do with fairness,” said Prof. Jocelyn Maclure, a philosopher at Université Laval in Quebec City.
“It’s either none of us enjoy significant freedom, or some of us enjoy more freedom than others.”
There are ways the government can ease the burden on those who will have their freedoms curtailed.
Maclure, who helped draft a government guide to the ethical problems raised by the pandemic, points to Quebec’s welfare net as one way of making the trade-offs more palatable. Those affected could, for example, continue to access financial benefits.
But there can be no mistaking the tragic nature of the dilemma, he said.
On the one hand, there are public health concerns and principles of equality to consider. On the other, there are the social, psychological, economic and moral costs of continued confinement.
“Whatever we decide, there will be a significant ethical cost,” Maclure said in a recent interview.
“So we will lose something in the process. There’s a value commitment that we will not be able to honour because of the decision that we make.”
However, he said, that doesn’t mean we ought to throw up our hands and say, as some existentialists might, that choice is arbitrary.
“I think that there’s a way to reason our way through to a decision that is preferable to the other decision,” he said.
“It won’t be perfect. But the best option is sometimes the one that causes less harm than the others.”