Scarcity, Justice, and Health Crisis Leadership

Abstract

The COVID-19 pandemic has created or revealed scarcities in many domains: medical, civic, economic, and ideological. Responses to these are analyzed in the framework of a map of justice and an imperative of openness. The main argument is that whatever the view of justice chosen by public health authorities, they should be able and willing to disclose it to the citizens. Objections are considered and qualifications added, but the general conclusion is that in liberal democracies, truth-telling by those in power, although politically hazardous, would be ethically advisable.

1. Introduction

There are two main types of scarcity, theoretically speaking. The first is a not-enough-for-all situation, where the emphasis is on the words “not enough”. For instance, four people have only three oranges to share between them, although “enough” in some sense would require them all to have their own. Perhaps a whole orange would be needed to satisfy their daily vitamin take. One solution to the problem would be to slice out a quarter of each orange and serve everyone three quarters. It may not be enough, strictly speaking, but it is equitable, and everyone gets an equal portion of the scarce resource. The second type of scarcity is also a not-enough-for-all situation, but this time the emphasis is on the words “for all”. The object of scarcity may be indivisible. In the context of health care, if there are only three life-saving machines and four people in need of them, one has to be left without [1].

Scarcities of the second type are especially interesting from the viewpoints of ethics and political morality, because choices have to be made when confronted with them. These are not necessarily the kind of choices that are usually presented in bioethical literature. The first question is not, “Who do we leave out?” but “Why aren’t there four life-saving machines to begin with?” [2] There may, however, be a perfectly reasonable answer to that, if not with four machines, then at least with forty, or four hundred, or four thousand. And then the tough choices will be necessary [3].

At this point, considerations of justice enter the scene [4]. Who indeed should be left without, and, more importantly, why? Is there a reasoned, acceptable way of verbalizing this? Can we find a theory of justice that would support our choice? And is it a theory that we can live with? Is it a theory that we can expect others to accept? If we are leaders in a situation like this, should we not only make sure that we know the ideological presuppositions of our decisions but also make these presuppositions, the basis of our choice, known to those affected by it? This is a demanding view, but I believe we should.

2. Scarcities

What scarcities has the COVID-19 pandemic brought to the fore so far?

The first category is medical. Just alphabetically, there have been shortages of extracorporeal life-support devices, hospital beds, intensive-care-unit beds, medical masks, nurses, oxygen therapy equipment, physicians, protective gloves, sanitizing products, testing equipment, ventilators, and many others. The second category consists of citizens’ concerns: toilet paper, face masks, sanitizers, home tests, berry pickers, farm laborers, consumer goods, fuel, health, security, liberty, normalcy, and equality. Combining these partly we get a “stuff and personnel” grouping. On the medical side, no equipment items stand out particularly. On the citizens side, toilet paper was an early surprise, and the delayed, and partly indirect, impact on consumer goods and—ultimately, it seems—fuel was not initially expected, either.

On the medical side, again, the lack of personnel raises no questions—a shortage of nurses and doctors is a natural consequence of a health crisis. On the citizens’ side, the situation has been more interesting, in a bad kind of way. Using the example of Finland, an allegedly self-sufficient agricultural agent, the pandemic has revealed intriguing arrangements. Contrary to popular belief and national self-image, tens of thousands of farm laborers are needed every summer in Finland to get the work in the fields done. And the living and working conditions of these guest laborers are more often than not suboptimal, approaching illegal. So, equality is an issue, and during the pandemic, global capitalism has shown its exploitive nature more visibly than ever before, also in affluent countries.

Where people have experienced shortages of health, liberty, culture, normalcy, and equality, businesses have been vocal about a decline in innovations, investments, profit, and growth. Together, these form the scarcities in the economy and in civil society.

The final shortages have concerned values such as common sense, proportionality, resilience, sustainability, privacy, freedom, utility, solidarity, caring, and tradition. We know that common sense has, at times, flown out of the window during the pandemic; we have seen how the more responsible public authorities have struggled to find a proportional balance between different measures; and we know that the crisis has shown deficiencies in the resilience of modern societies.

In the meantime, privacy, freedom, utility, solidarity, caring, and tradition mark ideological niches that locate theories of justice [5]. Taking a closer look at these shows how understanding them is crucial for public decision making, and especially crisis leadership as morally sustainable ethics communication.

3. Justice

The six ideological niches come in opposing pairs [6].

The first is privacy-solidarity. Some people, including philosophers, are convinced that justice is served when property, especially the means of production, is in private control. This conviction is usually accompanied by the idea that individuals are responsible for their own fates. We get what we deserve, based on our industriousness and efforts, and what we achieve is then ours to make use of in any manner we please. Perhaps I want to give some of my possessions to charity, but this should be entirely voluntary. They are, after all, my possessions to dispense of as I wish [7]. The opposite to this is solidarity. Other people, including philosophers, are convinced that property, and especially the means of production, should be in some kind of public control. They usually also think that individuals should not be held entirely responsible for their fortunes. People should not throw opportunities away, but it is our shared duty to make sure that everyone has those opportunities in the first place. [8,9,10].

The second pair of political moralities is formed by freedom and care. Freedom is seen as essential to justice by most liberal theories, including the privacy view. Here I mean a slightly more specific version. The defenders of privacy usually confine their requirements to what some call “negative liberty”—that is, freedom from the active interference of other people. By the novel category I mean a defence of both “freedom from” and “freedom to” [11]. The latter may include the promotion of people’s opportunities or capacities to reach things that they value in their lives [12,13]. This kind of thinking standardly assumes that moral and political values and norms are, or should be, the same for all—in other words, universal. The opposite view holds that values and norms are positional. They depend on the place of the agent in the network of human relations. The virtues people are supposed to have in one role are not the same as the virtues they are expected to display in others. Similarly, what people are often defines what they are owed by others [14].

The third set of opposing political moralities is defined by faith in either tradition or utility. Tradition here means the practices, social arrangements, and ways of doing things that have emerged organically and historically among smaller or wider populations. Reliance on tradition is closer to the privacy view than to the solidarity view. Time-honored kinships are respected and group cohesion is valued, but these are limited to “us”—one’s own collective. The view is positional like the “care” stance, but with a leaning to a more conservative direction [15]. Care ethics, as a feminist approach, typically finds special relationships between caretakers and dependents and identities in newly found intersectional vulnerabilities [16]. Those who believe in tradition are more likely to emphasize old habits and customs. The opposite to this is a commitment to utility, or to the definition of good as something that can be measured, compared, and calculated [17]. When public decisions aim at optimizing this kind of value—usually wellbeing or preference satisfaction—they are prone to be radical and reformative. The utility view shares with the freedom approach the belief in universal values and norms, and with the solidarity stance the idea of shared responsibility.

The theories based on tradition and care can be further set apart from the approaches leaning on freedom and utility by comparing some of their central background assumptions. The former emphasize spontaneity, immaterial values, collectivism, longstanding practices, and special relations as sources of political nous and moral worth, while the latter stress calculations, material values, individualism, reform, and impartiality. The former recommend a holistic tactic and openness to the involvement of emotion, while the latter prefer analysis and reason. The former establish agency and personhood on intersectional group membership and identity, whereas the latter find similar foundations in cosmopolitanism and individuality. The privacy and solidarity views are divided in these respects, insofar as they take such considerations into account at all.

Figure 1 places views on justice and their assumptions on a conceptual map.

4. Just Responses

All these takes on justice have been clearly identifiable during the COVID-19 pandemic. The privacy view defends multinational pharmaceutical companies and supports the principle that their patent rights are inalienable even in exceptional circumstances like global health crises. On the surface, this looks like a legitimate defense of private property created by private investments. A closer look reveals, however, a different picture. Much of the research needed for the development of new drugs and vaccines comes from public sources, so this turns out to be a redistributive arrangement, taking money from taxpayers to subsidize global businesses. In the meantime, the responsibility for public health is outsourced to individual citizens. The pandemic’s detrimental consequences are not, so the story goes, due to bad crisis management or corporate greed. Instead, the blame is on the people in the street who do not follow orders by washing their hands, wearing masks, and taking vaccinations when they are told to.

The freedom view is more prone to side with ordinary citizens and their reasonable concerns for liberty and normalcy (whoever and whatever these are). The demand for negative “freedom-from” means that restrictions should ideally be kept to a minimum; while the requirement of positive “freedom-to” means that people’s abilities should be promoted, so that once they have opportunities, they are capable of making use of them. However, the promotion of abilities, capacities, and capabilities is a long-term project, and perhaps it is unrealistic to expect too much of that during health and other crises. Sweden, with its exceptionally permissive corona policy, has provided an example of this kind of thinking during the COVID-19 pandemic [18].

The solidarity view offers a diametrically opposed alternative to privacy thinking. It calls for international aid for less affluent regions, including vaccinations in third-world countries. Despite early rhetoric to the contrary, the global North has responded poorly to this call, both in prudential and in moral terms. It is, theoretically, understood that the pandemic is not in control until it is in control all over the world. In practice, however, dumping unwanted and leftover vaccines to developing countries has been the best that Europe and North America have managed. This does not show great acumen, and it is morally deplorable. In the meantime, acting from clearly propagandist motives, totalitarian governments provided medical knowhow to other countries during the first few months of the crisis. Otherwise, solidarity has been limited to clapping hands to our brave nurses and doctors in the streets [19,20].

The care view extends the concern for the vulnerable to oppressed groups everywhere—women, minorities, the disabled, and so on. Where the universalism of the freedom approach demands fair opportunities to atomistic, self-standing individuals, care ethics points out the collective and intersectional nature of our agency and identity. Group membership, rather than contentless individuality, should be the basis of our recognition as human beings. And going further than that, recognition can also be extended to nonhuman animals and the natural environment [21]. Their vulnerabilities to human activity are obvious. And they can, figuratively speaking, strike back, although this is not the core message of care ethics. Examples include the probable animal-human genesis of the current pandemic and, of course, climate change. Be that as it may, the human concerns raised are a reminder of the shortcomings of some of the other tactics, notably a Sweden-type advocacy of freedom for the young-and-healthy. That success came with the price of formidable loss of life among the elderly and the frail.

The utility view has, in one form or another, figured in the pandemic policies of almost all liberal democracies in the West and the Global North. Especially in the beginning, this came in the form of short-term health utilitarianism, often with a side constraint of precaution. The pandemic was first contained with restrictions and advice, and then controlled by testing, tracking, and isolating people who had been exposed to SARS-CoV-2. Some countries have also attempted to suppress the spread of contagions in their own jurisdiction, but this tactic has proven to be less and less feasible with the emergence of new variants of the virus. The precautionary approach was evident in endeavors to protect the vulnerable, that is, the elderly and those with a heightened risk of death and serious illness. In time, however, other utilitarian considerations came to the fore. The restrictions were seen to pose a threat to longer-term public health, to the economy, and to the “normal” conduct of social life [22,23].

The tradition view automatically opposes any utilitarian policies simply because they are based on calculations and fail to respect local ways as intrinsic sources of value. Some mainstream interpretations of the view seek compromises with the freedom and utility approaches, but conservative versions of communitarianism can also support less amenable tactics. These have included demonstrations and social media campaigns promoting denialism (“There is no actual pandemic”) and conspiracy theories (“Elites are trying to poison us with vaccinations”). In some public protests, traditionalists have temporarily joined forces with the care people who see restrictions and vaccinations as a threat to some vulnerable groups. The alliance is strained, but it is, theoretically, a more than feasible partnership between two positional worldviews.

5. Mixed Messages

None of these views is particularly difficult to communicate to citizens. The positive messages are clear. Public decision makers rooting for the privacy view can say: “We are securing the free operation of businesses.” Freedom advocates can say: “We are protecting the freedom of our citizens.” Utility people can say: “We are safeguarding public health and wellbeing.” Solidarity promoters can say: “We are emphasizing the need for global considerations.” Care ethicists can say: “We are caring for the vulnerable in our society.” And traditionalists can say: “We are defending ordinary folks against elites.” This way, representatives of all six views have a positive message, convincing to their own supporters but not completely unacceptable to others, either.

How about the negative side of the message, though? If the requirement is transparency and openness—in the sense “the truth, the whole truth, and nothing but the truth”—then these public decision makers should make the unpalatable dimensions known as well. The privacy advocate should then add: “And we are making the precariat and the otherwise vulnerable pay for it, if necessary.” The champions of freedom should say approximately the same thing. The vulnerable are the ones paying for the liberty of the young and the healthy. For the utility people, it is the opposite. They should own up that they will restrict the citizens’ freedom—and sometimes quite severely—to reach their health-and-wellbeing aims. For solidarity, the “other side of the coin” is that to make a difference, affluent countries and regions should be prepared for a substantial redistribution of wealth. Care ethicists want more attention for the vulnerable, but on grounds that are hostile to the universalist vocabulary of liberty, utility, and rights. And the defense of local communities comes with the cost of ignoring the more general common good both nationally and globally. These are all bitter pills to swallow, and this is why public decision makers tend not to include them in their communications. But should they? And if yes, why?

6. Ethics Communication

This is where the idea of health crisis leadership as ethics communication comes in. Its starting point is an imperative:

Always make your spontaneous-health-crisis leadership decisions based on causes that you can and will make known to all those affected by the decisions!

The formulation has certain hidden depths that are worth mentioning.

But first a disclaimer. The imperative cannot be applied to all public decision making. Being open and honest is probably plausible in the cases of COVID-19 and the climate change. But if a foreign government infests us with a deadly virus, it would be wise to hide some things for tactical reasons. Anyway, there is more to the formula. Let us take a look at the wording detail by detail.

I use in the imperative the expression “based on causes”. This may raise some eyebrows. In ethics, it is more customary to talk about reasons. Why should we be interested in the causal chain that leads to our decision? Is it not more important to know the reasons, the justifications?

Well, yes and no. I will get to the reasons momentarily, but here are some causes of important public decisions: hunger, thirst, lack of sleep, the need to snap at irritating opponents, fear of adverse media responses. Decisions based on these may be good or bad, but the factors by themselves do not contribute to the goodness of choices in any way. This is why they should be recognized and their impact, where possible, eliminated or at least mitigated.

Which brings me to the first real-life implication of the imperative. I propose an autophilanthrophic approach to leadership and management. Self-friendly, in other words. It would be embarrassing to tell the public that an important decision was made because we forgot our morning porridge, quarreled with a fellow negotiator, or worried about the media reaction. Which is why it would be important to know one’s own limits and, against the grain, not to be the no-food-no-sleep hero leader. In a recent TV program in Finland, past Prime Ministers confessed, with some pride, that they had been at the end of their tether more or less all through their tenure. This is not advisable, and the popular image of the self-sacrificing commander-in-chief should be reversed. This is, of course, also an organizational and managerial matter. Resources and arrangements are needed for a proper amount of stand-ins and deputies.

So causes in the imperative mean both causes (that threaten good choices and have to be counteracted) and reasons. The reasons, or justifications, in terms of justice, include the views that I already presented—libertarian, liberal, utilitarian, socialist, care ethical, and communitarian. There are others, but these will suffice for now.

Moving on to other expressions in need of clarification in the imperative, the word “can” refers to knowledge and understanding. Leaders should be able to describe what is being done, explain why it is being done, and justify it to all those affected. Or is this unrealistic? Can we expect our leaders to know exactly what they have ordered or authorized? And, especially, they are not philosophers or ethicists. How could they know about the ideologies? And why should they? My response to this is that these are inadequate excuses. Of course the people in charge must know what they decide. And of course they must be aware of the grounds of their decisions. If they have difficulties with this, they should let philosophers guide them.

The word “will” in the imperative means wanting and daring. An apt point of comparison could be the traditional rule: “At work, do only things that you can tell your children about when you get home.” To illustrate, parents could get themselves in trouble by reporting, “I make mice blind to …”. The horrified offspring is more than likely to interrupt before the sentence is finished, “What!?! You make mice blind!?! You monster!” The parent could, of course, try to complete the sentence, but the probable response is that no excuse will be enough. Unless the point is to save Earth from an immediate and fatal collision with an asteroid, explanations and justifications remain ineffective.

This raises two interesting questions. First, parents mostly continue in their mouse-blinding jobs despite their children’s objections. If this is justified, could the same justification be available to public decision makers in health crisis leadership? And secondly, it is sometimes just a fact of life that even good decisions have bad side effects. Is there a way to explain and justify this systematically?

7. Justifying Non-Communication

Parents can override their children’s objections on paternalistic [24] and republican [25] grounds. They are adults, and they know what is good for the child and for the family as a functioning unit. The adults need to have jobs to earn a living, and it is up to them to judge what kind of work they do. It is all for the children’s best interest, they are not hurt, and they have no say in the matter. If they could understand the situation in its entirety, they would join the family’s general will and accept parental decisions.

This cluster of justifications may or may not stand scrutiny in family situations. But to see how they fare in the context of the COVID-19 pandemic, let us remind ourselves what we are talking about. As an example, to observe the imperative of openness or truth-telling, public authorities in many countries should at some point have said: “Our aim is to protect the freedom of the young and healthy at the expense of the old and frail.” The appeals to paternalism, the common good, and the general will suggest that dispensing the information is unnecessary. Citizens, like children in the mouse-blinding example, fail to see the wider ramifications and are prone to object. For the smooth management of the crisis, it is better to leave them uninformed. Rough times call for tough measures, and it is the job of public authorities to administer them.

This is a questionable stance. Out of solidarity, even young and healthy people may not want to sacrifice the old and frail. In this case, the decision is not unproblematically in their interest, as the paternalistic justification would have it. The concept of the common good, in its turn, can be criticized for unduly emphasizing the aggregate wellbeing of the majority. Special needs can all too easily be ignored in such a lump definition of value. And liberal democracies do stand by the principles of transparency and openness, at least ideally. For them to have meaning, we should do better than evoke indistinct and opaque ideas of a general will.

There is a qualification to this. In exceptional and immediately threatening circumstances, it is sometimes, at least temporarily, best that public decision makers act firmly without thinking too much about ethics communication. Especially, crises created by the nation’s adversaries should probably be handled like this, as I said before. But this does not apply particularly well to the COVID-19 pandemic. Conspiracy theorists aside, what we have here is a spontaneous natural crisis, to be dealt with by using procedures that are as normal as possible.

8. Inclusive Communication

So I tend to think that public decision makers cannot justify strategic lying or concealing their true ethics any more than they can hide behind their ignorance on it. The problem still is, however, that they would have to say nasty things to be open and honest—things such as “we are sacrificing the elderly for the good of others”. Not in those exact terms, necessarily, but nonetheless in words to that effect. The choices will have good and bad effects, and these will almost always be unequally distributed, regardless of the theory of justice they are based on. How could this be expressed in a palatable way?

Views on ethics and justice have their answers, of course. The utilitarian response is that the good of the many outweighs the good of the few. It is a civilized government’s task to aim at the greatest happiness of the greatest number, and this end justifies the collateral damage inflicted on the smaller numbers. The solution is, in theory, well in line with the principles of democracy, and should not, if executed to the letter, cause political upheavals. This is what we did; you, our voters, benefited; now please vote for us again. Minorities may object, but that cannot be helped.

The attitude toward minorities has drawn negative attention to utilitarianism, and several remedies have been offered. My own partial solution (some time ago) was to use a nonstandard account of value, based on hierarchical needs [26,27,28,29]. Trade-offs are accepted only when the need satisfaction that is sacrificed is relatively unimportant and the need satisfaction aimed at is uncontroversially important. The government is allowed to snip away some of our smaller pleasures to secure the health and safety of even a few. Initially, this produces results that go against the freedom solution in the COVID-19 case. Although citizens are normally entitled to frequent pubs and sing Karaoke, this entitlement can be postponed in the name of protecting the elderly. And this is what was done in many countries quite successfully and without major objections. Initially, that is. As the pandemic dragged on, people began to complain, and the complaints seem to show a weakness in my view. In the long run, frequenting pubs and singing Karaoke may, after all, be essential for a good life in our societies, and if so, protecting the good life of the elderly ceases to be such a good defense of wider restrictions.

A similar precautionary approach could perhaps be supported by justice as fairness, the idea immortalized by John Rawls [30]. He argued that anything governments do should eventually serve those who are worst off in a society. Potential shortcomings in this model are related to the expressions “eventually” and “in a society”. Rawls believed that the disadvantaged will be best protected indirectly, by primarily safeguarding the economic freedom of those who produce the wellbeing. We must first bake the cake and only then start sharing it. Unfortunately, the sharing seems to be left to a trickle-down effect. The prosperity of the stronger will, by a mechanism that has never been proven to exist, benefit all in the end. And even this applies only to our society, whatever that is taken to mean, because Rawls had difficulties in extending the idea across national borders. Replacing the worst off by the vulnerable and tending to their needs first would possibly be a solution, and care ethics advocates this. But it may run into the reverse problem. How do we support the vulnerable if we do not have the resources?

Immanuel Kant’s categorical imperative offers yet another answer to the question of justification. “Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means, but always at the same time as an end” [31]. Authorities could admit that they are using people as a means by restricting the freedom of the young and putting the old to some danger. But since it’s a part of the humanity of the young to be concerned for the old and a part of the humanity of the old to allow normalcy to the young, the humanity of both groups is also treated as an end. This could be too complicated, though.

9. Double Effect

Another version of related thinking is provided by the doctrine of double effect [32]. The doctrine states that an action which has two effects, one good, the other bad, can be allowed on four conditions. First, the action is in itself morally good or neutral (meaning that it doesn’t belong to the class of intrinsically wrong actions). Secondly, the bad effect is not directly willed (meaning that although it is foreseen, it would be avoided, if possible). Thirdly, the good effect is not caused by the bad (it is caused by the action itself). And fourthly, the good effect is proportional to the bad (meaning that it is sufficiently desirable and important to compensate the harm).

Lethal self-defense provides a natural example of using the principle. An agent is allowed to shoot an aggressor to death to save one’s own life, provided that the death is not intended, because protecting one’s own survival is crucial and justifies the death. Here shooting is interpreted as neutral in itself. The death of the aggressor is bad and the survival of the agent is good. The death is caused by the shooting, not by the survival, and if the aggressor lives, there are no complaints or further lethal action. Saving the agent’s life is proportional to the loss of the aggressor’s life.

Applied to the freedom approach to the COVID-19 pandemic, the situation can be sketched as follows. A government is allowed to take measures (taking measures is in itself neutral) that put the vulnerable to lethal risk (this is the bad caused by the measures) to protect economic activity and normalcy (these are the good effects and they have no causal connection with the bad effect), provided that the risk is not intended (if the vulnerable survive, no one tries to kill them deliberately), as protecting economic activity and normalcy justifies this (because it is proportional to the bad).

I wonder how verbal acrobatics like this would fare in public communications. For instance, is “shooting” a neutral action? Perhaps it is, if we think about “firing a gun as target practice”. But a more accurate description here could be “firing a loaded gun at another person knowing that the shot can be lethal”. With this interpretation, the moral neutrality seems to vanish. The same applies to the COVID-19 case. It is one thing to “take measures” but arguably quite another to “take measures that put the vulnerable to lethal risk”. Where’s the neutrality in the latter?

In the COVID-19 response, another challenge is proportionality. Are economic activity and normalcy as such so important that they justify risking the lives of the vulnerable? To be sure, they affect a wider range of people, but the doctrine of double effect is anti-utilitarian and cannot rely on numbers [33].

It is not my intention here to name the best ethical theory or view on justice in health crises—they all have their pros and cons. My emphasis is on more basic elements. The authorities, if the imperative of openness is anything to go by, should grasp (know and understand) what they are doing; accept their responsibility for the consequences; and have the humility to confess the challenges of their solutions. Figure 2 summarizes my message.

By following the path of autophilanthrophy and openness, public decisions makers could manage scarcity in spontaneous health crises in the spirit of justice and morality. The key, I suggest, would be self-awareness and honesty.