The coronavirus pandemic has raised countless ethical questions: How do we balance restricting freedoms with protecting others, how do we ethically distribute vaccines, should we force people to get vaccinated—or should we ask healthy people to get infected with COVID-19 in the name of science?
There’s no one better to discuss these dilemmas with than Laurie Zoloth. She’s a Professor of Religion and Ethics at the University of Chicago, one of the leading thinkers on bioethics, and serves on committees and advisory boards with organizations like the CDC and NIH. On this episode, we ask her all our COVID-19 ethical questions—and her answers might surprise you.
(Episode published Feb. 25, 2021)
Paul Rand: In the age of COVID-19, what does it mean to be ethical?
Laurie Zoloth: Everyone’s saying, ‘‘Okay, how do you live within a system that’s essentially unjust?’’ And the only way to do it and still maintain some sort of moral worth and moral compass is over and over to point out the injustice, to fight against it as hard as you can, to demand change.
Paul Rand: That’s Laurie Zoloth. She’s a professor of religion and ethics at the University of Chicago, a former dean of the Divinity School, and one of the leading thinkers on bioethics. And as you can imagine, she’s been incredibly busy in the last year.
Laurie Zoloth: What’s interesting about this, is this is one of the few times in human history where everyone on the planet has actually been affected by the same set of circumstances and has had to face some of the same realities. And it’s an extraordinary moment for humans to figure out, what do we do now? And when you speak to people all over the world, you’ll see the same sorts of questions coming up over and over again.
Paul Rand: How do you balance restricting freedoms with protecting others? How do we distribute a vaccine in an ethical way when there’s so many competing needs? Well, these are all questions that Zoloth has been grappling with.
Laurie Zoloth: The kind of emphasis that likes to live in the practical, tangible world, likes to apply these ideas. So I don’t just present a menu of available options. I like to be the person that recommends, ‘‘Here’s the option that I think is the best course.’’
Paul Rand: From the University of Chicago podcast network, this is Big Brains, a podcast about the pioneering research and pivotal breakthroughs that are reshaping our world. On this episode, ethics in the time of COVID. I’m your host, Paul Rand.
Paul Rand: Laurie Zoloth doesn’t just think and write about the ethical issues around COVID. She’s also in the public policy trenches. She serves on multiple committees and advisory boards with organizations like the CDC, the NIH, and Merck, where these debates are taking place on a daily basis.
Laurie Zoloth: Over and over as human beings, we’re forced to make choices. And the choices are hopefully not just based on feelings or on an aesthetic sense. They’re based on our sense of what it is to be a good human being, what it is to live in a good world. And so over and over again, we’re confronted with this question, ‘‘What is the right thing to do? What is the right act?’’ And then we have to justify it because we’re rational creatures and we have to give each other reasons for how we act. And many, many people in science and in government and in policy with the capacity to enact decisions, do turn to ethics and do turn to us and say, ‘‘What are the ethical implications? Let’s have someone in here who can think through those ideas.’’ And that’s how we end up, not just me, but all of my colleagues end up in places like the CDC and the NIH, thinking about how science is unfolding.
Paul Rand: Before we can discuss something like the ethics of vaccine distribution, Zoloth says we first need to build an ethical framework, an argument to justify one action over another. And as a leading scholar on Jewish studies, one natural place for Zoloth to start is with religion.
Laurie Zoloth: Many, many religions have this notion that we are all fundamentally equal because we are children of a powerful God, a powerful of Allah, or of the God of the Torah, or of the God of Christian scriptures in which we are created beings that are essentially equal. And that essential equality, that essential human dignity and human worth means that we need to share what we have, the abundance of this world, equally and fairly. And with attention to vulnerability, and attention to the poor. So this notion that we have an essential duty comes out of our sense that, it’s what we call bootlegged in from religion, into modern political science.
Laurie Zoloth: But you can turn to Greek philosophy. You can turn to American constitutional law. You can turn to other systems, other stories, other narratives and be a very good ethicist as well. And that cacophony of voices and arguments and sources and traditions is one of the things that gives my discipline its strength, I think. So we talk about a basic decent minimum that societies should be organized to provide. And one of these basic decent minimums is education. Another one is healthcare. Societies should be organized to provide this basic decent minimum for each other, for one another, out of that sense of dignity, out of that sense of duty. And that reciprocity really does annul many of our public policies, and that’s where it comes from. To live outside of the sense of duty to another is sort of a horrifying prospect.
Paul Rand: Living outside our sense of duty to one another is a big part of what we’ve seen in America’s response to the pandemic, choosing not to wear masks for example.
Laurie Zoloth: So I have to become the person who confronts people and says, ‘‘Wear a mask, wear a mask.’’ And often the answers are something like, ‘‘Mind your own business,’’ right? As if they have their own business, quite literally. We share this business of living in a world together, and it is a privilege to live in a world where we have streets and we have lights and we have safe water and all of that working together. This the context in which our choices can be enacted only exists because we live in a social world. Once you’re living in a social world, once you’re accepting that everyone’s business is, in fact, your business, we are responsible in a fundamental way for the health and the welfare of everyone we pass on the street, and it was the refusal to see that that has just been astonishing to me.
Paul Rand: So many of the ethical questions raised by COVID 19 come down to this tension between individual freedom and collective good. And sure, wearing or not wearing a mask isn’t the most difficult ethical question. If you don’t know by now, the answer is wear a mask, but what about the small business owner, the restaurant owner who needs income to survive and feed their family? But by opening back up, they risk harming the public. How should we think about this person’s ethical dilemma?
Laurie Zoloth: We ask people to make choices against their economic interest all the time. I think setting up situations of large congregations without masks is something that we cannot do, at least right now until we figure out how that can happen. But I do think its been terribly difficult for small business owners who have been catastrophically affected by the loss from this economic problem. But it may be rooted in capitalism. A stage in which exchange systems need to be significantly altered.
Paul Rand: So let’s talk about exchange systems. Some people have suggested that one way to distribute vaccines would be through vouchers that could easily be bought and sold. The government might allocate those vouchers based on some equation of equity, but then people would get a voucher, either use it, or simply sell it to the highest bidder.
Laurie Zoloth: There’s something really, quite horrible about that argument that has to do with the fact that money isn’t fairly distributed, that has to do with the fact that some people in fact, in this epidemic, have made millions, millions, and some people don’t have enough food for their children. And look, I live in the market world just like everybody else, right? Everyone has a system of exchanges. I work. I’m awarded. I understand that. I understand the power of capitalism and the power of market exchanges in many, many, many arenas, but not in healthcare. And there’s very powerful forces that argued over and over again for allowing the marketplace to make the decisions for us. And it’s interesting because the market does have its own system of justice. And there’s our quest we know our colleagues think a lot about, how you can make a market system fair and just and rational.
Laurie Zoloth: But we also know that there’s areas that should be and are outside the sphere of the market. And so in healthcare, it’s very hard to use marketplace analogies to get anything successful accomplished. It failed dramatically. And that’s part of the puzzle. Why is it that capitalism is not organized enough to say, ‘‘Oh, human beings need masks in the billions, and we have to make them.’’ And so that’s one of the reasons I think the market has failed us at this very moment. Something similar around the vaccines, I am still puzzled by why large companies that make vaccine for other things, can’t turn some of those productive capacities into making these vaccines. So these are enormous pharmaceutical companies. And why does the market drive an increase in productive capacities? I understand it’s difficult, I understand it’s hard, it’s hard to ramp up, but it’s also possible. And I think we can see here, an example of why market forces are inadequate, why you do need a government intervention to do it.
Laurie Zoloth: And people have made this analogy before me, and this isn’t very original, to notice that people were able to build battleships and airplanes to go fight World War II. And in fact, it was that very activity of warmaking that suddenly ramped up production that suddenly got people out of the depression because there was jobs again, and there was money to be made. But also there was a government that said, "Here’s what we spend our money on. And we can do this." There’s always people who make money off of war, and there’s people who make money off of COVID, many people who make money out of pandemics and wars and other things, need to think carefully about those profits, that wealth that’s being generated by our suffering and our pain, really deserves to be put back into our society. And that’s a moral discussion that companies should be having now, the ones who are profiting.
Paul Rand: Zoloth says we need a new approach to public health, one which emphasizes justice in healthcare.
Laurie Zoloth: We have to pull back and create a different sort of movement for public health, and it might seem impossible, but we saw this happen with AIDS. In the midst of the AIDS epidemic, in the midst of the initial chaos and the great grief of the AIDS epidemic, AIDS activists did not accept what was given to them, fought back and demanded changes in healthcare that are enduring changes in research and enduring changes in healthcare. And the same thing is true for previous epidemics. We don’t even think about the restrictions imposed on us because of cholera. We understand water has to be purified, we pay for the water being purified. We just accept that. So there will be changes that get built into our system in the same way that seem now to us like enormous restrictions on our own freedoms and enormous acts of duty that will just become a part of the fabric of what it is to live in this social world.
Laurie Zoloth: I think we’re going to enter a world in which people have masks on hand at all times. I’m very impressed with how the flu is not a problem this year. There’s almost no flu. And how nice is that? We could have done that. My goodness, if you all had been masked and understood this, we wouldn’t have ever had flu. I mean, I am stunned by how I used to behave. I used to be one of these people that would march off to work with a cold, as a sign of my toughness, and that’s going to stop me. And it was valorized. That behavior was valorized, and we can absolutely change some of these behaviors to be healthier.
Paul Rand: After the break, the ethics of vaccine distribution. Challenge trials and making difficult personal choices.
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Paul Rand: When you think about an ethical framework for distribution of the COVID vaccine, what do you think that ethical framework is? And how do you think that we, let’s start with, as a country, are dealing with that?
Laurie Zoloth: You can see what we’re trying. You can see, especially since the new administration has taken over, the careful attention that people have spent on this issue. And in fact, to some extent, that’s meant that we spend a lot of time figuring out elaborate schemes and ignored a central fact of this epidemic, which is, it’s not like a disease that affects everyone equally. It’s a disease where 80%, upwards of 80% of the deaths have been concentrated on people over 65, particularly over 75. If you get the disease and if you’re over 75, you have a 40% chance of dying. And that’s a very terrible case fatality rate. And the fact that the case fatality rate is different based on age is a significant part of how we have to think about the justice system.
Laurie Zoloth: In the same way that if it was a pediatric disease, we would have to favor the children. This is a disease that disproportionately affects elderly people, and suddenly I’m in that category. People over 65 are just in that category. And it’s a disease where that has to be taken seriously. And that should center our attention on giving the vaccine to people in that age category. And that’s where our systems have to start. So normally, we would think about the poor. We would think about the vulnerable. We would always foreground them first, but in this particular case, with this particular disease, an age based distribution system has worked most effectively and has brought the death rate down. We see this in Israel and in the UAE and in England, where they have done that strategy, the most straightforward strategy. And you can begin to see it changing the death rate in those countries.
Laurie Zoloth: Now, in addition to that things that potentiate the disease and make you more likely to die, have to do with your social economic status, like all diseases. And we shouldn’t be surprised by that. That’s true for breast cancer. That’s true for cardiovascular disease. If you are poor, if you are socially marginalized, if you don’t have access to healthcare, if you don’t have access to adequate fresh food and nutrition, if your park is dangerous and not a place of rest and joy, then you’re sicker, then the disease tends to affect you more deeply. And that’s potentiated the epidemic in black communities and brown communities around this country.
Paul Rand: Okay. And so how do you feel if we’re looking at this ethical framework of keeping in mind age, primarily, as a framework in this country for dealing with vaccine distribution, how do you feel like we’re doing on that path?
Laurie Zoloth: Slowly but surely, we’re getting there. Most of the healthcare workers have been offered the vaccine, and more and more people in nursing homes have been offered the vaccine. There’s a somewhat alarming trend about people not taking it, about healthcare workers themselves refusing it, in numbers that are concerning at this point. And we have to spend some time thinking about that, about the ethical implications of that for people who have no other choice but to be in prisons or in nursing homes.
Laurie Zoloth: And it is shocking to me that these things weren’t thought about in advance in the previous administration, and no one had sat down and said, "How is it? What’s the national distribution scheme? How are we going to do this? How much can you get per week?" And numbers were tossed out that just had no basis in facts, no basis in reality.
Paul Rand: So let’s bring this down right to the individual level of our listeners at this point. And you’ve heard plenty of stories of somebody that may not see themselves as vulnerable, but they have the opportunity for the vaccine. Should they take it, or should they pass it on to somebody else who may be perceived as more vulnerable?
Laurie Zoloth: So in situations where you not taking the vaccine, you could actually give it to some person who needed it more, then of course, that’s the ethical thing to do, right? And that’s a very old problem in ethics and in the early sources, in the Jewish tradition, a story reappears that if two travelers are in the desert, and reappears in Jewish and in Christian and in Islamic texts, if it’s two travelers in the desert, and there’s only one water, who gets the water? If they both drink it, they’ll die. If one drinks it, then they’ll live, but the other one will die. And so it’s a very early story. Clearly this is something people about. And the text is unresolved, as in many texts in the tome, it’s not really solved. It’s not a finished text. It’s an open text. So clearly people have wondered about this. And we wonder about it now.
Laurie Zoloth: My own very own 24-year-old graduate student, who’s been working at home since March, and has had no patient contact, nor would have patient contact, and yet, she was offered the vaccine. This, we were not unique in this. Pretty much every medical center had struggled with that same problem of giving a vaccine to their own, and not really thinking that through. And to be sure, courageous people stepped forward and said, ‘‘This isn’t fair,’’ went to the press in city after city and said, ‘‘We have to change this.’’ I mean, you have to understand that this is a disease that can kill you, and so the temptations to take it and to step ahead is extraordinarily strong.
Laurie Zoloth: And also because people did not see another person standing next to them, whose life they could save by not taking the vaccine. And my poor 24 year old graduate student, who heard me go on and on about this, in her case, I felt that it was actually legitimate licit for her to take the vaccine, given the severity of the disease as a deadly disease. But then you have to create a movement to fight against that injustice. If you take it, you have an obligation to go beyond that action and into the public arena and fight against that system, and to say to the people in charge of the system, ‘‘This isn’t fair, change this system now,’’ right? So it doesn’t relieve you of the obligation to dismantle the system of injustice.
Paul Rand: In essence, Zoloth is saying that under our current distribution, if you happen to become eligible to take the vaccine, even though you’re not in a vulnerable group, you can make an ethical choice to take it. But that’s only if you’re willing to also advocate for a better system in which the vaccine will get to the vulnerable as quickly as possible. ‘‘When we’re forced to make unethical decisions,’’ she says, ‘‘we have to demand better of the people in power.’’
Laurie Zoloth: And we have an example of this because of the Vietnam war, as white middle-class men in great numbers, my husband was able to get out of the draft because he knew a doctor who could say this and that about him. That happened all the time. People found ways to get out of the draft. They joined graduate school, they joined the revenant, they joined the clergy, they did other things. And every time you took an out, somebody else went to Vietnam. A poor person went to Vietnam, a person of color went to Vietnam. It was a very, very similar, and it was a life and death decision. Your not being there meant that some poorer person would be there. And the only way that that kind of choice is legitimate is to create a mass movement against the war in Vietnam that eventually brought everybody home and stopped the draft cold in its tracks.
Laurie Zoloth: And so that’s the kind of answer I think we could create. So people are spending a lot of time. And I know, our family, we went through the same exact story with all of us who were 65 and older in our family, what were we going to do? How are we going to work it out? What sort of system would be fair? Could we sign up? And everyone’s saying, ‘‘Okay, how do you live within a system that’s essentially unjust?’’ And the only way to do it and still maintain some sort of moral worth and moral compass is over and over decree to point out the injustice, to fight against it as hard as you can, to demand change.
Laurie Zoloth: A lot of that energy went into changing the administration, and you can see how that’s meant that this is how justice has been changed, but it doesn’t mean we relaxed. It means we keep paying attention to what’s going on and writing about it and thinking about it and doing whatever we can to create a movement for justice and healthcare, which is a lifelong determination of mine, and should be for everyone. And now we can see how an unjust system of healthcare really makes a difference when there’s a crisis, but it makes a difference always, actually,
Paul Rand: So far, the issues raised around vaccine distributions have been due to scarcity, but some think they have a way to speed up vaccine trials to get more vaccine in this system. They’re called challenge trials.
Laurie Zoloth: So challenge trials are a very interesting way to think about this, and they came up in the beginning of the epidemic as an idea, I found this trial put forward, actually, by my colleague Mark Lipschitz, who’s on that CDC committee with me and who has given a lot of thought to epidemiology, and very, very skillful and thoughtful scientist. The idea is that in some cases where you need to know the answer quickly, you can take a certain population and challenge and give them your intervention, and give them the disease and see if your intervention prevents them from getting sick.
Paul Rand: This approach, giving patients a vaccine of unknown efficacy, then infecting them with COVID, is obviously hugely controversial, and most bioethicists are against it. But we now know that Moderna had its COVID vaccine developed all the way back in January, 2020. So it’s possible that challenge trials that risk the lives of volunteers could have helped us get the vaccine faster, but would it have been worth it? And would it have been ethical?
Laurie Zoloth: And that’s been done in the past. There is a history of using a challenge trial, but never in a disease where we knew so little and we didn’t know how to stop its ravages, and we didn’t know who it would sicken. And so the two problems with challenge trials was normally they’re given, for instance, in malaria, where you had something, if someone got sick, you could treat them and they would not die, and they wouldn’t be seriously harmed. You would just want to know, does this prevent infection or not? Oh, and if you had a fail-safe system. In this case, if someone got sick, the implications of that were terrible, and we were not willing. It was unethical to subject people to such an unknown disease, such an unknown story.
Laurie Zoloth: The other thing that was wrong was, as we began to understand that this was a disease where the case fatality rate in the elderly was so different, that doesn’t make any sense to have challenge trials on young people, because it wouldn’t have told us anything important or useful about this actual disease. And you weren’t going to ask elderly people who had these case fatality rates of 40% to engage in a challenge trial. It just didn’t make any sense. It was much too risky. And that level of risk was seen as unethical. Now, when there is vaccine and there is treatments, somewhat effective treatments, it makes the calculus a little bit different. And you might engage in a challenge trial to test a certain vaccine against another vaccine. Is this vaccine better than that vaccine?
Laurie Zoloth: And you’re going to have to use something like that in situations where mostly people are getting vaccinated, but you might have a better vaccine come along. How would you do that? And you might want to think about that. Now the trouble is, is that the epidemic is so fierce and raging so intensely. There was no need to do a challenge trial because you got your results really quickly anyway. And challenge trials are typically used in places where the rate of infection is very, very, very slow and would take years to show any effect. And so you’d have to give it deliberately to show the effect you wanted, and that the situation of COVID actually rapidly changed. And so many people got sick. It was very easy to test any disease you want, any intervention you wanted against a disease that was that common.
Laurie Zoloth: So that’s the trouble. You’re always measuring lives and you’re always asking people to take some degree of risk. When it becomes unethical is when the risk is unacceptable, right? Asking people to take a risk to test an intervention is a very common part of practice. It’s just the essential tragedy of first use in humans. There’s a deep tragedy involved in research. Because we try it on animals first and you give people consent, but ultimately you are trying interventions on human bodies, and it’s always a risk.
Paul Rand: In the UK, health officials have decided that the risk of challenge trials are acceptable. The country will be launching trials this month that expose healthy volunteers to the virus to try and answer a key question. How much virus does it take to cause an infection? Eventually, the UK trials challenge will also test new vaccines to see which are most effective.
Laurie Zoloth: Now the ethical issue in vaccination is scarcity, and demand way exceeding supply, but that’s going to change. The supply issue will be dealt with. There is an answer to the supply issue. And then as more and more people who demanded and who wanted have those needs satisfied, then it will shift to the 30% of Americans that don’t want it. And what do we do about that? And what’s the limits of the state action there? And we’ll shift our ethical concerns to the opposite problem. We’ll have supply. And what do we do to get people through to understanding how critical it is for everyone? And the people who aren’t taking the vaccines currently are a funny mix of people. They’re sort of hippy, left-wing natural, a sense that natural is better. There’s always that argument. There’s a right-wing argument about states and hating states and not wanting microchips and all of the right wing conspiracy theories about states, too invasive.
Laurie Zoloth: And then there’s an argument that a state run by white people has been harsh and unfair and untruthful to persons of color. And there’s that separate refusal that we call Tuskegee refusal, but it’s not only the Tuskegee experiment. There was a history of other bad action and centuries of distrust. And those three are a very powerful mix of resistance. And that’s going to be, in three months from now, when you and I talk again, it will be, that’s the ethical question. Now, what do we do? We have plenty of vaccine. We have most people vaccinated, but it’s not going to be herd immunity, unless we get everybody vaccinated. And in that unvaccinated population will be the location for the development of the variants in very powerful ways, so don’t threaten everyone. So that’s a new sort of problem, and we can see it coming, and approaching us actually rather rapidly.
Paul Rand: Which now raises the question of whether it would be ethical to force people to get the vaccine.
Laurie Zoloth: Let’s just move back just one step from force. Is it ethical to demand that people get the vaccine to participate in certain actions? So you can say to someone, ‘‘I don’t want to get the vaccine,’’ and you can say, ‘‘Fine, the state can’t force you to get it, but we can say you can’t get on an airplane. You can’t get on the L. You can’t take a class at the University of Chicago.’’ There’ll be a mix of public and private action. Much of the private action will be self-protective, right? We don’t want our students to sicken, we don’t want our faculty to sicken, we don’t want our workers to sicken, so we’re going to keep people who make that choice out of our space to do it. And that, I think, is completely permissible.
Laurie Zoloth: Now, these are emergency use authorizations. They’re not theoretically approved. That’s never really been challenged in court. And that’s a legal question about the limits of state. I think there’s no question morally and ethically that it’s fair to do that, to say, ‘‘No, you have the freedom not to be vaccinated, but you don’t have the freedom to walk around unvaccinated as a little vector spreading your choice to everyone else.’’ And especially the people who can’t, for whom the vaccine is impotent, like people who have a weakened immune system or people on immunotherapy or some people with AIDS. So all of those people need us to surround them with protection. And that was done with smallpox. And that certainly was done with polio. During the smallpox, when smallpox was around, we didn’t let people not get vaccinated for smallpox. People had to be vaccinated. You had to not have smallpox.
Laurie Zoloth: And in some states, it will come to that. In the United States, I think it will be the power. Then we’ll use the power of the marketplace to force behavior, acceptable behavior. We thought it with smoking. People can choose to smoke, but they have to do it in very constrained areas. They can’t bring their feelings and their choice and their freedoms into the collective space, because our feelings don’t match our sort of rational action and justifying action all the time. What if someone doesn’t feel they want to take a vaccine? And it’s like, ‘‘I don’t care what you feel. I’m an ethicist, not a psychiatrist.’’ Right? And as an ethicist, I’m interested in the reason, what makes the right act, and how do you justify it? What makes it so? Why do you have feelings? What’s behind these feelings?
Laurie Zoloth: But we don’t act on our feelings in any rational society, in any society that works well. We don’t act on feelings. My golden retriever acts on her feelings, but human beings, adults, need to have justifying reasons for their action and not just do what makes them feel good. In 1,000 ways, to live in a social world means turning away from gratifying feelings, towards some sort of social norm, some sort of duties to others, doing things that don’t feel good, or feel hard, or feel difficult for you, or make you restrain what your desire would be. In some sense, much of religion is about restraining that, those feelings and those desires, and understanding that your feelings, or maybe the wrong guide may lead you astray in terrible ways.
Laurie Zoloth: So my mom turned 100 on July 7th of this year. And I said, we did this chart. There’s a chart in The New York Times about where you would stand. And to my horror, she was way down the list. Even though that she was 100, she has pre-existing conditions and everything else, she wasn’t at the top of the list. She’s not essential. She’s staying at home.
Laurie Zoloth: And she handed it with a real equanimity of spirit. She said, ‘‘Well, of course, those old sick people should get the vaccine before me. Those poor sick people in nursing homes, of course they needed before I get it.’’ And that’s the kind of attitude that I told my students, that that’s what I wanted to see all of you have. You had the capacity to wait. The patience was also something that you could come up with and that other people would be more in need than you, and that you should allow that process to play out. So I was very proud that she did it. And she has now gotten both vaccines, both the shots of the Pfizer vaccine. And I hope to see her at some point, haven’t seen her in over a year, hope to see her at some point, as soon as we can.
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