Dien Ho is a professor of philosophy at Massachusetts College of Pharmacy and Health Sciences (MCPHS) and his research focuses on reproductive ethics, philosophy of medicine, clinical ethics, theoretical reasoning, and philosophy of pharmaceutics. He is the director of the Center for Health Humanities.
Abstraction is a necessary component of public health. In crafting effective policies, epidemiologists and policy makers must balance the demand that the policies accommodate differing local and individual needs against the applicability of the policies. During the early days of the COVID-19 vaccine distribution in the United States, priority was given to essential workers and residents of long-term care facilities. The definition of “essential workers” however was mapped onto categories of industries and this led to some counter-intuitive results. For instance, a contractor who maintains the electronic health records of patients in a dentist office over weekends would likely qualify as someone who “have the potential for direct or indirect exposure to patients or infectious materials. This includes persons not directly involved in patient care…” (National Center for Immunization and Respiratory Diseases, 2021) On the other hand, a bus driver who was exposed to hundreds of passengers daily was excluded from the initial vaccine rollout. In terms of sheer risks of infection, the odds were likely higher for the bus driver than the IT assistant. The prioritization policy could have been more nuanced. For example, rather than mapping it onto industries, we could have mapped it onto everyone’s respective risks. Yet, public health leaders chose not to do that. The rationale was simple: a more nuanced policy might maximize “fit” but it would also render the policy more cumbersome to deploy. In the end, the net good done by a coarse grain policy that contained pockets of counter-intuitive prioritizations might be greater than a complex policy that required more resources to implement properly.
The abstraction (i.e., trading fit for applicability) that epidemiologists must undertake poses a challenge, especially for those who dig a bit deeper and examine the reasoning behind policy decisions. Consider the high-risk bus driver again. He understands and agrees that vaccines should go to workers that provide critical infrastructural support and are most at risks. He also understands that the necessary abstraction in health policies entails some less-than-ideal compromises in fit. The prioritization policy, as it stands, assigns the bus driver a lower priority even though the rationale for preferring frontline health workers applies equally to the bus driver. Indeed, as the bus driver learns of the IT assistant’s access to the vaccine, complying with the vaccine distribution policy (e.g., don’t lie about your occupation, wait your turn) appears not only senseless, it requires the bus driver to adhere to a policy that seems obviously unfair.
Public health abstraction creates these “pockets of tension” where a particular individual might have no rational or even moral reasons to follow the policy. Paradoxically, the more one learns of a policy and its rationale, the better one is able to identify pockets of tension. And, of course, if all stakeholders feel justified in skirting a policy that they believe is irrational or unfair, the policy would likely implode on the count of low compliance. After all, a line is only as effective as folks’ willingness to stand in line.
We might be tempted to address these pockets of tension by striving for greater transparency. Perhaps if public health professionals do a better job of explaining the deliberative process that goes into a policy decision, it would generate greater buy-ins from all stakeholders. The hope is that when one encounters an instance where following a policy strikes one as irrational and unfair, the temptation to skirt the rule would diminish when one gains a better understanding of why the rule is the way that it is. Although there is much to say in favor of transparency, it is doubtful that it can maintain compliance. Consider a parent whose child is just a few months shy of the age cutoff for vaccination. She faces the unpleasant possibility of her child being infected with COVID-19 and bringing the virus home where an immunocompromised grandparent resides. What reason would she have not to lie about the child’s age, especially when there exists a surplus of vaccines? The coarseness of the prioritization policy entails that, in some situations, those who ought to be vaccinated are not and those who ought not be vaccinated are. It is extraordinarily difficult to convince parents that they should wait their turn when a distribution protocol strikes them as irrational and unjust.
Increasing transparency to improve buy-ins tacitly assumes that the rate of compliance depends on our trust in policymakers and public health agencies. But, trust is the not the main issue here. Parents who consider skirting the vaccine prioritization rules need not have a lack of trust in the regulatory agencies; their faith that policymakers are doing what they believe will advance the common good can be high. The problem is that upon the briefest examination, stakeholders can easily see that following rules can make little epidemiological and moral sense when they are in these pockets of tension. Instead of trust, the force that can nudge folks towards compliance is solidarity; that is, shouldering burden as an act to demonstrate support for a shared goal. Mistreated workers of a large coffee chain might go on strike as a way to improve their conditions. Although I do not work for the same employer, I might refrain from the chain’s coffee as a way to show my solidarity with the striking workers. My personal boycott is obviously not as costly to me as the risks a striking worker undertakes. Moreover, I can plainly see that the profit of the coffee chain is unlikely to be affected by my decision not to do business with them. Standing in solidarity is not about the wisdom of one’s action; it is about voluntarily assuming a cost as a way to recognize the plight of those fighting.
Solidarity is a reaffirmation of our commonality. We undertake unnecessary suffering to demonstrate to ourselves and to others that the misfortune that has befallen on the striking workers is a matter of luck: I too could have been on the receiving end of mistreatment by heartless employers (1). To assume some degree of voluntary suffering is to acknowledge that misfortune can be arbitrary. My self-induced pain neither lessen the pain of the striking workers nor likely harm the employer enough to cause them to change their behaviors. From the point of view of effecting change, it is largely inert. Yet, the moral impetus to stand in solidarity with the striking workers is powerful and it is this desire to demonstrate our commonality and compassion that ultimately drive us to do what is essentially irrational.
Our commitment to following public health policies is likewise grounded in a sense of solidarity. This is so even if we recognize that, in pockets of tension, it makes little rational or moral sense for an individual to follow the rules. We do so because we realize that the misfortune that befalls on some of us during a public health crisis can be arbitrary. There are often no obvious explanations for why one person as opposed to another becomes infected and bears the heavy burden of COVID-19. Deciding not to skirt the rules even when doing so entails greater risks to myself and my family reaffirms our commonality and desire to lessen the arbitrariness of suffering. To be sure, the normativity of solidarity is but one of many factors when deciding what one ought to do. Our obligations to those we love, the use of our limited resources to effect positive change, the desire to maximize other intrinsically valuable things such as self-determination, and so on all come into play when deliberating one’s proper course of action. There are obviously moments when solidarity takes a backseat to other normative demands.
The recognition that solidarity is a powerful moral impetus might help us understand how to craft more effective public health policies. For starter, compliance is not just about trusting policy makers; it is also about our sense of commonality and compassion. To ensure that policies of common good are effective, building trust will not be enough. Given the coarseness of any workable public health policy, there will always be pockets of tension in which a stakeholder recognizes the irrationality or unfairness of following rules (while having a high degree of trust in policy makers). Explaining the deliberate process of policy makers does not lessen these concerns. Indeed, in some way, the concerns are more salient as one understands the necessary tradeoffs between fit and applicability. Cultivating a sense of solidarity by, for instance, stressing our shared humanity, the arbitrariness of misfortune, and the value of compassion can go a long way in preparing ourselves for the next collective crisis. In this sense, ethics might be our best tool in our quest for a better world.
- Garfinkel, A. (1981). Forms of Explanation: Rethinking the Questions in Social Theory: Yale University Press.
- National Center for Immunization and Respiratory Diseases. (2021). Interim List of Categories of Essential Workers Mapped to Standardized Industry Codes and Titles. Retrieved from https://www.cdc.gov/vaccines/covid-19/categories-essential-workers.html.
(1) Alan Garfinkel’s Forms of Explanation: Rethinking the Questions in Social Theory (1981) is a hidden gem. Drawing from theories of explanation, Garfinkel argues that social theories are at best able to explain why certain segment of a population occupies their specific socioeconomic stratus but they cannot explain why a particular person ends up where they do.