COVID-19
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Do we strife for the moral good?
John Jacobs, 6th March 2021.
The Dutch Red Team decided to stop debating how to fight COVID-19 on TV: "It makes no sense if I explain the rules of chess to people who are busy with checkers." Before that, Bert Slagter told: “The cabinet has opted for mitigation: focusing on intensive care unit (ICU) capacity. That means trying to keep the number of daily infections at a high level. That is very expensive and quite unstable due to poor visibility and uncontrollable factors such as behaviour, the weather and chance. ” “In mitigation, 'space in the hospitals' is the ‘change currency’ that is for the talk show tables. And I don't want to participate in that discussion. ”
Just get ill!
The policy of Rutte (VVD) and De Jonge (CDA) focuses on spreading the disease to as many people as possible, as long as the number remains below the ICU capacity. At the ICU not every patient will survive, in spite of all the hard work by the IC teams. This policy deliberately runs on the edge of what is possible in health care (Figure 1). Subtle mistakes in controlling the uncontrollable virus will have major impact. The virus is carried by the wind in miniscule droplets, and even totalitarian states have trouble controlling all people's behaviour. So it is realistic to assume that the IC will regularly overflow with patients. The triage has been tightened, and a code ‘black’ has been written, that would exclude all people with a less than great prognosis to be admitted at the ICU. Age is an important criterion in the ICU and currently the average ICU patients are working people, not the elderly, as one would expect with a disease like COVID-19. Minister Van Ark (VVD) had some discussion with the physicians on how to deal with ethical choices in medical practice. It should be noted, however, that the necessity of the triage is not due to medical but political choices. Politicians make choices that put human lives at stake.
Early in the epidemic, Van Dissel launched the idea of herd immunity through natural infection. Minister-President Rutte declared it the national policy but later he denied to have done this. Other countries criticized the herd immunity policies from countries like the Netherlands, the United Kingdom and Sweden. The World Health Organization (WHO) has repeatedly spoken out against this pursuit of herd immunity labeling it as unethical and unscientifically. The aim to infect the maximum number of people is unethical. Herd immunity that would arise after an epidemic, would be a natural end point, not something that worthy of pursuing, just the result of failing precautions. Scientifically, it is unlikely that a respiratory virus like SARS-2 will yield herd immunity. Usually, these viruses to not provoke lasting protection against infection - technically: sterilizing immunity. Without sterilizing immunity no herd immunity can be achieved.
Early in the epidemic, Van Dissel launched the idea of herd immunity through natural infection. Minister-President Rutte declared it the national policy but later he denied to have done this. Other countries criticized the herd immunity policies from countries like the Netherlands, the United Kingdom and Sweden. The World Health Organization (WHO) has repeatedly spoken out against this pursuit of herd immunity labeling it as unethical and unscientifically. The aim to infect the maximum number of people is unethical. Herd immunity that would arise after an epidemic, would be a natural end point, not something that worthy of pursuing, just the result of failing precautions. Scientifically, it is unlikely that a respiratory virus like SARS-2 will yield herd immunity. Usually, these viruses to not provoke lasting protection against infection - technically: sterilizing immunity. Without sterilizing immunity no herd immunity can be achieved.
Figure 1. RIVM modeling based on IC capacity. Version from early February 2021
Ethical frameworks
The conflict between the Red Team versus the government with the OMT illustrates different ethical frameworks. Due to my religious vision on life, I’m not neutral in this discussion on the value of life. The ethical framework determines the values, so I’ll discuss these first. I know that everyone wants to do the right thing, but people differ in their value of what is right: “Is it about what is good for me or for everyone?” This is a question through all ages, but times of war or epidemic, ethical choices are blown into full proportions. Choices between right and wrong appear to be more critical when human lives are directly at stake.
Classical thoughts
Aristotle and other ancient Greeks would thank the god Fortuna for three things: (1) being a human and not a beast, (2) being a man and not a woman, and (3) being a Greek, and not a barbarian. Aristotle taught Alexander the Great, the Greek conqueror of the 4th century BC. This Greek thinking formed the values of the Roman culture that conquered Europe and the Mediterranean. However, later this culture was replaced from the inside.
Jewish and Chinese thoughts
In the Roman Empire lived an earlier culture, Judaism, centered around the principle of loving your fellow man like yourself, anchored in the love of God (Lev. 19: 9-18). The double-negative version of this concept had spread east to the Chinese Confucianism, without the belief in a god. Like the Greco-Roman culture, many Eastern philosophers assumed that people were inequal.
Christian thoughts
Jesus focuses to clarify that every human being, male or female, from every culture is worthy as a fellow man (e.g. Luke 10: 25-37). This view is radically different view from the Greek or Chinese that would consider only their only people. Jesus' frame is anchored in the Jewish idea of equal creation of all people, male or female, from every nation (Gen.1: 26-27). The command for charity focuses on the weak and needy in society (Isa. 1:17). This is the basis of both Judaism and Christianity (Prov. 21: 3; Matt. 5: 21-26).
Reformation and Humanism
The Reformers protested the perversion of the Roman Catholic Church, an example followed by the Mother Church, albeit a century later recognized by the Mother Church. During progression of the Reformation, various humanist thoughts emerged, considering man from a social, liberal and / or evolutionary perspective. Social coherency is central in the social concept translating this to the communist system. Freedom was central in the liberal idea, which was translated into the capitalist market system. The evolutionary doctrine does not start at biological evolution but aims help or redirect by a political ideology that selects for strong people destroying the weak. It is a regression to classical thought of ‘us’ being better and more important than other people.
Council of Europe
Technology is embedded in European ethics to serve all people. About vaccination, this is reflected in the appeal of the Council of Europe: “Everyone has the right to a safe and effective vaccine. Given the shortage of vaccines, priority should be given to groups with the aim of reducing mortality, serious illness and spread. However, it is necessary that everyone in every group is vaccinated. " Several European churches are encouraging people to get vaccinated because of the importance of vaccination (1,2,3,4), illustrating the dominant Christian line of thinking in Europe.
Human nature
Man is naturally prone to selfishness and shortsightedness. Our own short-term interest easily outweighs the long-term interest of everyone else. We are aware of our dark side and like to dress ourselves up, by quoting beautiful thoughts that do not live in our hearts. I’m fully human, also in this respect. In my own eyes I always choose the right way, but God tests what moves me inwardly (Prov. 21: 2). We do not always practice what we preach. Reality is like a Zoom meeting with a beautiful background. The image suggests that we sit alone on a beautiful beach, but we are in a crowded cluttered room with many others. The still image might not be very clear about this discrepancy, but occasionally something pops up to illustrate that we are somewhere else. Ethics requires complex considerations which cannot be simply derived from the conclusions of our thinking – the arguments are critical to understand someone’s heart.
Conspiring
Conspiracy thinkers deny scientific consensus and take their reasoning to the extreme with theories that all but touching reality or evidence. For example PCR gate of Peter Borger ignores evidence at different levels: (i) the objective to detect SARS-1 related viruses, (ii) the molecular biological validation of RT-PCR, (iii) the verification by sequence analysis, (iv) samples of infections with other corona infections, (v) RT-PCR data with other protocols, (vi) source and contact research on virus transmission, (vii) the relative increases in positive tests during epidemic waves, (viii) the number of cases at population level and (ix) excess mortality during the epidemic. A multilevel list of facts that would falsify Borger's inductive thinking, and thus is carefully ignored by him.
Loving the truth
Science is grounded on progressive insight, by testing ideas. Ethical progress would depend on recognition of one's own mistakes. Nobody likes to be criticized or to admit that he was wrong. People prefer to ignore, downplay the mistake, say they cannot remember, or the infamous “wir haben es nicht gewusst” (we did not know). However, without admitting mistakes, we cannot learn from them and are likely to repeat the same mistakes over again. This also happens sometimes to famous scientists on their cherished theories. Healthy science is important to its value, but it cannot be taken for granted.
Falsification
Admitting your mistakes might be easier if one honestly believes that the truth exists, and it will become known anyway. Faith in forgiveness has helped many men to admit their mistakes. In the last millennium, the foundations of modern science have been laid based on Judeo-Christian philosophy. Much knowledge, technology and insights were already developed in other regions and cultures (China, India, and the Arab world). However, the collective philosophy was devoid of this great love for the wisdom (Sophia, Logos) in the Judeo-Christian culture, which forms the basis of science.
To exemplify proper falsification. My hypothesis is that iron is drawn to a magnet. Then I can come up with several experiments, like having the magnet on the floor and releasing the iron above or having the magnet on the ceiling and the iron underneath. The first experiment is not suitable for falsification, because iron falling downwards would be expected as well by other laws of nature, i.e., gravity. The magnet on the ceiling and iron falling upwards would be suitable to falsify the magnetic forces.
Good science aims to falsify its own beloved theory by finding as much evidence as possible against it. A fellow scientist misused Williams Faulkner's quote: "Kill your darlings" to say try to debunk your beloved theories.
To exemplify proper falsification. My hypothesis is that iron is drawn to a magnet. Then I can come up with several experiments, like having the magnet on the floor and releasing the iron above or having the magnet on the ceiling and the iron underneath. The first experiment is not suitable for falsification, because iron falling downwards would be expected as well by other laws of nature, i.e., gravity. The magnet on the ceiling and iron falling upwards would be suitable to falsify the magnetic forces.
Good science aims to falsify its own beloved theory by finding as much evidence as possible against it. A fellow scientist misused Williams Faulkner's quote: "Kill your darlings" to say try to debunk your beloved theories.
Scientific transparency
Arguments for a certain decision provide insight into someone's motives. Analogous to the zoom meeting, a person's motives show what moves him or her. So is someone’s background real or is it an old holiday picture. After all, the argument not to eradicate the virus or the argument to vaccinate healthcare personnel can be tested theoretically. Open science would add transparency by illustrating how meaningful and suitable a method is for the given purpose (Figure 2). It might also show that that the chosen method should not be the method of choice but is chosen due to a hidden agenda. Transparency is crucial to make good choices. Without transparency, we are led by blind signposts (Mat.23: 16-36), or worse, by signposts leading deliberately to the wrong destination.
Figuur 2. Hanlons scheermes. Denk niet aan kwaadaardige opzet als dommigheid een goede verklaring geeft.
Ethical considerations
The same ethical principles could lead to opposite choices in an altered context, because of differences between the situations. This is especially true in cases where interests between various groups conflict with each other. For vaccination, the greatest interest is for people whom ae most vulnerable to disease, like the elderly and people with comorbidities such as cardiovascular disease. In ICU placement, the greatest importance lies with people who have the best chance of survival, so the younger, previously healthy people. In pursuing shared interests, it is crucial to understand what is most important. Ideally an option is chosen that serves everyone’s interest. Everyone will fair better in the long-term interest if we keep the epidemic as small as possible, preferably Zero Covid, but individual interests can be different in the short term.
Shared interest
The collective ethical interest is to limit the damage to health, society and economy from the COVID-19 epidemic. These interests focus at preventing disease spreading. After all, the more people become infected, the more people become (chronically) ill and die, the more the loss of labor productivity and the costs of medical care. Covid care is displacing other medical care. Reducing the measures to limit epidemic growth would cause an exponential increase in the number of cases. The example of the single grain of rice at the first field of the chessboard is famous. Doubling to 2 at the second, 4 at the third, 8 at the fourth, 16 for fifth, 32 at sixth, >1000 at eleventh, >1.000.000 at twenty-first, > 1.000.000.000 at thirty-first. As the epidemic grows, the problem for society and the economy grows exponentially, making it uncontrollable. COVID-19 has the potential to cause the death of ~ 1% of the population and cause a multitude of illness and chronic illness. It should be evidently that this will have major consequences for society and the economy. Letting the disease spread is not an option. Action is needed, but what would be the best and most efficient action?
Fighting the virus together.
Epidemics of contagious respiratory infections have been controlled successfully with test, trace and isolate (TTI). Many European countries have shown this in the previous century for tuberculosis, and countries in East Asia and Australia show that it can be done with SARS-2 too. While the infection rate still is low, TTI can keep the epidemic completely under control, avoiding the need of a lockdown to get the R0 <1. The limitation of TTI is the capacity needed to trace and test every case. A well-supported TTI system can keep track of all contacts of 10 people per 1 million every day for testing and possibly isolate them. However, when it comes to 1000 people per 1 million, quickly detecting all infections becomes a very big challenge. The larger the TTI capacity, the more likely it is that a lockdown can be prevented.
A lockdown is not an intelligent, but a necessary emergency break of the epidemic. A lockdown should be as powerful as possible to be as short as possible. The aim should be to reduce the control the epidemic, so that it could be controlled with TTI. Lockdown measures are about equally effective for low or high infections, because they affect the relative number of infections (the average number of people infecting everyone; R0 or Rt). TTI affects the absolute number of infections, but not the relative number. With a low infection rate, the epidemic can be controlled by TTI, with a high one not.
It is crucial to limit the number of infections so that TTI could control spreading the disease and a lockdown becomes superfluous. This is where health (fewer sick people) and society (more freedom) share their purpose. The economy is hit harder by the virus than by the measures against it. The earlier the epidemic is stopped, the smaller the damage and the less effort it takes, because TTI has relatively few unpleasant consequences compared to a general lockdown.
A lockdown is not an intelligent, but a necessary emergency break of the epidemic. A lockdown should be as powerful as possible to be as short as possible. The aim should be to reduce the control the epidemic, so that it could be controlled with TTI. Lockdown measures are about equally effective for low or high infections, because they affect the relative number of infections (the average number of people infecting everyone; R0 or Rt). TTI affects the absolute number of infections, but not the relative number. With a low infection rate, the epidemic can be controlled by TTI, with a high one not.
It is crucial to limit the number of infections so that TTI could control spreading the disease and a lockdown becomes superfluous. This is where health (fewer sick people) and society (more freedom) share their purpose. The economy is hit harder by the virus than by the measures against it. The earlier the epidemic is stopped, the smaller the damage and the less effort it takes, because TTI has relatively few unpleasant consequences compared to a general lockdown.
