Why lockdown of the elderly is not ageist and why levelling down equality is wrong

The pandemic body: the lived body during the COVID-19 pandemic

In this study, we conduct a detailed analysis of qualitative survey data focusing on adult populations in the UK, Japan and Mexico to address the following question: How has the COVID-19 pandemic changed people's lived experience of their bodies, other people's bodies and the world? We identify five themes: (i) fear and danger, (ii) bodily doubt and hypervigilance, (iii) risk and trust, (iv) adapting and enduring and (v) changes in perspective. We use two theoretical frameworks: first, Mary Douglas' anthropological work on purity, risk, danger and symbolism is applied to understand how social and cultural meanings attached to the body have changed during the pandemic. Second, we use the concept of bodily doubt developed by Havi Carel to interpret how people experience their bodies and other people's bodies differently during the pandemic. While we recognise the significant variation in people's embodied experience of the pandemic, our findings suggest there are commonalities that span different countries and cultures. Specifically, we look at responses to COVID-19 protective countermeasures such as national lockdowns and physical distancing which we suggest have reduced people's ability to put faith in their own bodies, trust other people and trust the political leadership. We conclude by proposing that the changes to our lived experience during the COVID-19 pandemic have prompted changes in perspective and a renewed focus on what people consider important in life from a social, moral, cultural and political point of view.

Reelin' In The Years: Age and Selective Restriction of Liberty in the COVID-19 Pandemic

During the COVID-19 pandemic, focused protection strategies including selective lockdowns of the elderly were proposed as alternatives to general lockdowns. These selective restrictions would consist of isolating only those most at risk of COVID-19 hospitalization and subsequent use of healthcare resources. The proposal seems to have troubling implications, including the permissibility of selective lockdown on the basis of characteristics such as ethnicity, sex, disability, or BMI. Like age, these factors also correlated with an increased risk of hospitalization from COVID-19. In this paper, we argue that age has meaningful differences as a morally relevant characteristic in the justification for selective restrictions of liberty. Thus, it might justify selective freedom restrictions in a way in which other factors might not. We offer four moral domains that separate age from other proxies: empiricism, operationality, discrimination, and disparity.

Civil Liberties in a Lockdown: The Case of COVID-19

In response to the spread of COVID-19, governments across the world, with very few exceptions, have enacted sweeping restrictive lockdown policies that impede citizens' freedom to move, work, and assemble. This paper critically responds to the central arguments for restrictive lockdown legislation. We build our critique on the following assumption: public policy that enjoys virtually unanimous support worldwide should be justified by uncontroversial moral principles. We argue that the virtually unanimous support in favor of restrictive lockdowns is not adequately justified by the arguments given in favor of them. Importantly, this is not to say that states ought not impose restrictive lockdown measures, but rather that the extent of the acceptance of these measures is not proportionate to the strength of the arguments for lockdowns.

A Millian Case for Censoring Vaccine Misinformation

The spread of vaccine misinformation may contribute to vaccine refusal/hesitancy and consequent harms. Nonetheless, censorship is often rejected on the grounds of free expression. This article examines John Stuart Mill's influential defence of free expression but finds that his arguments for freedom apply only to normal, reasonably favourable circumstances. In other cases, it may be permissible to restrict freedom, including freedom of speech. Thus, while Mill would ordinarily defend the right to express false views, such as that vaccines cause autism, he might have accepted restrictions on anti-vaccine misinformation during the present pandemic. This illustrates that even the staunchest defenders of free speech can permit temporary restrictions in exceptional circumstances.

How low can you go? Justified hesitancy and the ethics of childhood vaccination against COVID-19

This paper explores some of the ethical issues around offering COVID-19 vaccines to children. My main conclusion is rather paradoxical: the younger we go, the stronger the grounds for justified parental hesitancy and, as such, the stronger the arguments for enforcing vaccination. I suggest that this is not the reductio ad absurdum it appears, but does point to difficult questions about the nature of parental authority in vaccination cases. The first section sketches the disagreement over vaccinating teenagers, arguing that the UK policy was permissible. The second section outlines a problem for this policy, that it faces justified vaccine hesitancy. The third section discusses three strategies for responding to this problem, arguing that there may be no simple way of overcoming parents' reasons to resist vaccinations.

Lockdown support, trust and COVID-19 conspiracy beliefs: Insights from the second national lockdown in France

Due to the COVID-19 pandemic, restrictive sanitary measures such as lockdowns have been implemented all around the world. Based on a representative sample of the population collected through an online cross-sectional survey, the goal of the study was to investigate the factors associated with lockdown agreement in France during the second general lockdown of fall 2020. More specifically, we aimed to investigate how trust in the government and COVID-19 conspiracy beliefs influenced lockdown agreement. Trust in the authorities and low adherence to conspiracy beliefs appeared as strong predictors of lockdown acceptance among our sample. Using a mediation analysis, we highlighted a significant indirect effect of trust in the authorities on lockdown agreement through the adherence to conspiracy beliefs: low level of trust translated into higher odds to believe in COVID-19 misinformation which in turn decreased lockdown support. The double effect of trust on lockdown agreement, both directly and indirectly, underlines the importance of careful communication from the government around decisions related to COVID-19 mitigation measures in order not to deteriorate even more the low level of trust in the health action of the government. The fight against false information also appears of the utmost importance to increase the population adherence to public authorities’ recommendations.

Costa, cancer and coronavirus: contractualism as a guide to the ethics of lockdown

Lockdown measures in response to the COVID-19 pandemic involve placing huge burdens on some members of society for the sake of benefiting other members of society. How should we decide when these policies are permissible? Many writers propose we should address this question using cost-benefit analysis (CBA), a broadly consequentialist approach. We argue for an alternative non-consequentialist approach, grounded in contractualist moral theorising. The first section sets up key issues in the ethics of lockdown, and sketches the apparent appeal of addressing these problems in a CBA frame. The second section argues that CBA fundamentally distorts the normative landscape in two ways: first, in principle, it allows very many morally trivial preferences-say, for a coffee-might outweigh morally weighty life-and-death concerns; second, it is insensitive to the core moral distinction between victims and vectors of disease. The third section sketches our non-consequentialist alternative, grounded in Thomas Scanlon's contractualist moral theory. On this account, the ethics of self-defence implies a strong default presumption in favour of a highly restrictive, universal lockdown policy: we then ask whether there are alternatives to such a policy which are justifiable to all affected parties, paying particular attention to the complaints of those most burdened by policy. In the fourth section, we defend our contractualist approach against the charge that it is impractical or counterintuitive, noting that actual CBAs face similar, or worse, challenges.

Respecting Older Adults: Lessons from the COVID-19 Pandemic

The COVID-19 pandemic has exacerbated many social problems and put the already vulnerable, such as racial minorities, low-income communities, and older individuals, at an even greater risk than before. In this paper we focus on older adults' well-being during the COVID-19 pandemic and show that the risk-mitigation measures presumed to protect them, alongside the generalization of an ageist public discourse, exacerbated the pre-existing marginalization of older adults, disproportionately affecting their well-being. This paper shows that states have duties to adopt and put into practice redress measures to compensate for the negative consequences of COVID-19 public health policies on older adults' overall well-being. These duties flow from the minimal ethical requirement of respect for persons. We show that respect is a morally basic attitude that presupposes taking the others' interests into account, with the aim of advancing their well-being. This duty is not limited to kinship, relatives, and friends but it extends to states and the rest of the civil society. In the conclusion, we draw lessons from the COVID-19 pandemic and sketch some redress measures that could compensate for the decrease in older adults' well-being as a result of the adoption of measures to contain the spread of the virus.

Psychosocial status of older adults aged 65 years and over during lockdown in Turkey and their perspectives on the outbreak

Older adults over the age of 65 were announced as a high-risk group in the COVID-19 outbreak and had to be placed on lockdown for a long time. The research was conducted to identify the psychosocial status, attitudes, and experiences of individuals aged 65 and over who were in-home lockdown during the COVID-19 outbreak in Turkey. In the study, 51 older adults were reached using the snowball sampling method. The research data were collected through qualitative interviews from older adults who were in house restrictions during the pandemic period, and thematic analysis was performed. As a result of the interviews, four main themes revealed as (a) Growing old is like a crime: The public perception of the older adults regarding the stigma associated with aging, (b) The inevitable course: Potential possibilities arising as a result of the pandemic period, (c) The cost of lockdown at home: Risk factors arising due to staying at home for a long time, (d) The desire for equality: The developing resistance against lockdown and demands for equality. The lockdown applied exclusively to older adults forced them to create new routines and made them aware of some values; however, they asserted that they were stigmatized and lonely, that their concerns about death/catching COVID-19 increased, and they were treated unfairly. Measures should be taken to prevent mental problems in older adults. In addition, public health nurses are advised to provide preventive care services and counselling for early intervention.

Canadian perspective on ageism and selective lockdown: a response to Savulescu and Cameron

In a recent article, 'Why lockdown of the elderly is not ageist and why levelling down equality is wrong', Savulescu and Cameron argue that a selective lockdown of older people is not ageist because it would treat people unequally based on morally relevant differences. This response argues that a selective lockdown of older people living in long-term care homes would be unjust because it would allow the expansive liberties of the general public to undermine the basic liberties of older people, and because it would discriminate on the basis of extrinsic disadvantages.

Lockdown strictness and mental health effects among older populations in Europe

This paper investigates whether lockdown policies aggravated mental health problems of older populations (50 and over) in Europe during the first COVID-19 wave. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE COVID-19 questionnaire) and from the Oxford COVID-19 Government Response Tracker for 17 countries, we estimate the causal effect of lockdown policies on mental health by combining cross-country variability in the strictness of the policies with cross-individual variability in face-to-face contacts prior to the pandemic. We find that lockdown policies worsened insomnia, anxiety, and depression by 5, 7.2 and 5.1 percentage points, respectively. This effect was stronger for women and those aged between 50 and 65. Interestingly, lockdown policies notably damaged the mental health of healthy populations. We close with a discussion of lockdown policies targeted at individuals above 65 and/or with pre-existing conditions.

The Ethics of Selective Mandatory Vaccination for COVID-19

With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for those at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk–benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers.

Red herrings, circuit-breakers and ageism in the COVID-19 debate

In their recent paper 'Why lockdown of the elderly is not ageist and why levelling down equality is wrong' Savulescu and Cameron attempt to argue the case for subjecting the 'elderly' to limits not imposed on other generations. We argue that selective lockdown of the elderly is unnecessary and cruel, as well as discriminatory, and that this group may suffer more than others in similar circumstances. Further, it constitutes an unjustifiable deprivation of liberty.

Determinants for hospitalisations, intensive care unit admission and death among 20,293 reported COVID-19 cases in Portugal, March to April 2020

Background

Determinants of hospitalisation, intensive care unit (ICU) admission and death are still unclear for COVID-19. Few studies have adjusted for confounding for different clinical outcomes including all reported cases within a country.

Aim

We used routine surveillance data from Portugal to identify risk factors for severe COVID-19 outcomes, and to support risk stratification, public health interventions, and planning of healthcare resources.

Methods

We conducted a retrospective cohort study including 20,293 laboratory-confirmed cases of COVID-19 reported between 1 March and 28 April 2020 through the national epidemiological surveillance system. We calculated absolute risk, relative risk (RR) and adjusted relative risk (aRR) to identify demographic and clinical factors associated with hospitalisation, ICU admission and death using Poisson regressions.

Results

Increasing age (≥ 60 years) was the major determinant for all outcomes. Age ≥ 90 years was the strongest determinant of hospital admission (aRR: 6.1), and 70–79 years for ICU (aRR: 10.4). Comorbidities of cardiovascular, immunodeficiency, kidney and lung disease (aRR: 4.3, 2.8, 2.4, 2.0, respectively) had stronger associations with ICU admission, while for death they were kidney, cardiovascular and chronic neurological disease (aRR: 2.9, 2.6, 2.0).

Conclusions

Older age was the strongest risk factor for all severe outcomes. These findings from the early stages of the COVID-19 pandemic support risk-stratified public health measures that should prioritise protecting older people. Epidemiological scenarios and clinical guidelines should consider this, even though under-ascertainment should also be considered.

Ethics of selective restriction of liberty in a pandemic

Liberty-restricting measures have been implemented for centuries to limit the spread of infectious diseases. This article considers if and when it may be ethically acceptable to impose selective liberty-restricting measures in order to reduce the negative impacts of a pandemic by preventing particularly vulnerable groups of the community from contracting the disease. We argue that the commonly accepted explanation-that liberty restrictions may be justified to prevent harm to others when this is the least restrictive option-fails to adequately accommodate the complexity of the issue or the difficult choices that must be made, as illustrated by the COVID-19 pandemic. We introduce a dualist consequentialist approach, weighing utility at both a population and individual level, which may provide a better framework for considering the justification for liberty restrictions. While liberty-restricting measures may be justified on the basis of significant benefits to the population and small costs for overall utility to individuals, the question of whether it is acceptable to discriminate should be considered separately. This is because the consequentialist approach does not adequately account for the value of equality. This value may be protected through the application of an additional proportionality test. An algorithm for making decisions is proposed. Ultimately whether selective liberty-restricting measures are imposed will depend on a range of factors, including how widespread infection is in the community, the level of risk and harm a society is willing to accept, and the efficacy and cost of other mitigation options.

Moral dilemmas and trust in leaders during a global health crisis

Trust in leaders is central to citizen compliance with public policies. One potential determinant of trust is how leaders resolve conflicts between utilitarian and non-utilitarian ethical principles in moral dilemmas. Past research suggests that utilitarian responses to dilemmas can both erode and enhance trust in leaders: sacrificing some people to save many others ('instrumental harm') reduces trust, while maximizing the welfare of everyone equally ('impartial beneficence') may increase trust. In a multi-site experiment spanning 22 countries on six continents, participants (N = 23,929) completed self-report (N = 17,591) and behavioural (N = 12,638) measures of trust in leaders who endorsed utilitarian or non-utilitarian principles in dilemmas concerning the COVID-19 pandemic. Across both the self-report and behavioural measures, endorsement of instrumental harm decreased trust, while endorsement of impartial beneficence increased trust. These results show how support for different ethical principles can impact trust in leaders, and inform effective public communication during times of global crisis. PROTOCOL REGISTRATION STATEMENT: The Stage 1 protocol for this Registered Report was accepted in principle on 13 November 2020. The protocol, as accepted by the journal, can be found at https://doi.org/10.6084/m9.figshare.13247315.v1 .

Covid-19: a call for mobilizing geriatric expertise

Aim

Covid-19 is a true gerontological pandemic, with frailty, multimorbidity and geriatric syndromes being of great importance.

Finding

There has been a lack of geriatrician involvement in planning and delivery of care for older people with Covid-19 in many arenas. Lack of mobilisation of geriatric expertise has led to inconsistent policy responses and ageism. The pandemic has shown that medical education and health systems have failed to align training, resources, and systems with current demographic and health usage realities.

Messages

We must take the specific needs of older people into account to position ourselves to provide better care for this group during Covid-19 and beyond.

[On the ethics of corona apps]

Zu Beginn der Pandemie im Frühjahr 2020, und nach einem weitreichenden Lockdown, ruhten große Erwartungen auf Corona-Warn-Apps, um einen erneuten Lockdown zu verhindern. Diese Erwartungen haben sich nicht erfüllt; stattdessen wurden in Deutschland als Reaktion auf erneute Wellen von COVID-19 weitere Kontaktbeschränkungen verordnet. Wie hätte die digitale Kontaktverfolgung wirksamer gestaltet werden können? Wir argumentieren, dass es ein Spannungsfeld zwischen der Datensparsamkeit und einer wirksamen Bekämpfung der Pandemie besteht. Im Gegensatz zur deutschen Corona-Warn-App wäre eine Variante der App, in der pseudonymisierte Kennungen zentral gespeichert werden, in der Lage gewesen, die Effektivität der Kontaktverfolgung entscheidend zu erhöhen. Schließlich argumentieren wir, dass das Spannungsfeld zwischen Datensparsamkeit und einer wirksamen Pandemiebekämpfung sich jedoch nicht in einen Wertekonflikt übersetzt, weil zentrale Systeme uns trotz ihrer erhöhten Wirksamkeit nicht vor deutlich gravierendere Probleme beim Datenschutz stellen als dezentrale Systeme. Zentrale Möglichkeiten der digitalen Kontaktverfolgung wären daher ethisch gerechtfertigt, um auf weitere Wellen von COVID-19 oder auf zukünftige Epidemien effektiv zu reagieren.

Privacy versus Public Health? A Reassessment of Centralised and Decentralised Digital Contact Tracing

At the beginning of the COVID-19 pandemic, high hopes were placed on digital contact tracing. Digital contact tracing apps can now be downloaded in many countries, but as further waves of COVID-19 tear through much of the northern hemisphere, these apps are playing a less important role in interrupting chains of infection than anticipated. We argue that one of the reasons for this is that most countries have opted for decentralised apps, which cannot provide a means of rapidly informing users of likely infections while avoiding too many false positive reports. Centralised apps, in contrast, have the potential to do this. But policy making was influenced by public debates about the right app configuration, which have tended to focus heavily on privacy, and are driven by the assumption that decentralised apps are "privacy preserving by design". We show that both types of apps are in fact vulnerable to privacy breaches, and, drawing on principles from safety engineering and risk analysis, compare the risks of centralised and decentralised systems along two dimensions, namely the probability of possible breaches and their severity. We conclude that a centralised app may in fact minimise overall ethical risk, and contend that we must reassess our approach to digital contact tracing, and should, more generally, be cautious about a myopic focus on privacy when conducting ethical assessments of data technologies.

Trust and Compliance with COVID-19 Preventive Behaviors during the Pandemic

This study examined the role of trust in lay people's health behaviors related to the current pandemic. A total of 376 Israelis completed an online questionnaire during the second lockdown. A latent profile analysis was conducted to identify profiles of individuals based on their levels of trust in the various institutions and stakeholders examined in this study. A three-profile solution was deemed most appropriate. The largest profile (N = 178) was characterized by low levels of trust in the government, but high levels of trust in science and one's primary care provider. Next, was the generally low trust profile (N = 108), characterized by low levels of trust directed towards all stakeholders and institutes. The third profile (N = 79) was characterized by high levels of trust. Results are discussed in relation to the important role of trust in determining people's response to the current pandemic and the unique features of Israeli society.

Good reasons to vaccinate: mandatory or payment for risk?

Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. Penalties or costs could include withholding of benefits, imposition of fines, provision of community service or loss of freedoms. I argue that under conditions of risk or perceived risk of a novel vaccination, a system of payment for risk in vaccination may be superior. I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service.

Lockdown and levelling down: why Savulescu and Cameron are mistaken about selective isolation of the elderly

In their recent article, 'Why lockdown of the elderly is not ageist and why levelling down equality is wrong', Savulescu and Cameron argue for selective isolation of the elderly as an alternative to general lockdown. An important part of their argument is the claim that the latter amounts to 'levelling down equality' and that this is 'unethical' or even 'morally repugnant'. This response argues that they fail to justify either part of this claim: the claim that levelling down is always morally wrong is subject to challenges that Savulescu and Cameron do not consider; and a policy of maintaining general lockdown does not constitute levelling down, as it provides absolute benefits to those who would be worse off under selective isolation.

How to overcome lockdown: selective isolation versus contact tracing

At this stage of the COVID-19 pandemic, two policy aims are imperative: avoiding the need for a general lockdown of the population, with all its economic, social and health costs, and preventing the healthcare system from being overwhelmed by the unchecked spread of infection. Achieving these two aims requires the consideration of unpalatable measures. Julian Savulescu and James Cameron argue that mandatory isolation of the elderly is justified under these circumstances, as they are at increased risk of becoming severely ill from COVID-19, and are thus likely to put disproportionate strain on limited healthcare resources. However, their arguments for this strategy are contingent on the lack of viable alternatives. We suggest that there is a possible alternative: a mandatory, centralised contact-tracing app. We argue that this strategy is ethically preferable to the selective isolation of the elderly, because it does not target members of a certain group, relying instead on the movements of each individual, and because it avoids the extended isolation of certain members of the society. Although this type of contact-tracing app has its drawbacks, we contend that this measure warrants serious consideration.

Chronological quarantine and ageism: COVID-19 and gerontology's relationship with age categorisation

In March 2020, the government of the United Kingdom advised all people aged 70 and above to self-isolate stringently for a minimum of 12 weeks in response to COVID-19. The British Society of Gerontology criticised the government for ignoring individual differences, deeming the approach ageist. Former British Geriatrics Society president David Oliver contested accusations of ageism, arguing that the approach was pragmatic discrimination based on epidemiological evidence. This debate catalyses core gerontological tensions regarding ageism, discrimination, categorisation and heterogeneity. A critical realist perspective reveals that both the government and gerontology are struggling to negotiate these irresolvable tensions. Contrary to the binary debate, age-based isolation simultaneously represents pragmatic discrimination and value-driven ageism. However, it does so partly because it relies on a chronologic epistemology that positions age as a potent biosocial axis of meaningful difference, thereby reflecting gerontology's own ageism. The ethical purism of gerontological accusations of ageism is thus somewhat misplaced, potentially obscuring an opportunity for reflection on value-laden engagements with age in social research.

Passport to freedom? Immunity passports for COVID-19

The COVID-19 pandemic has led a number of countries to introduce restrictive 'lockdown' policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people's civil liberties. We make tentative recommendations for the ethical introduction of immunity passports.