Caution is a strange word to use. On the day they released the statement, about 70,000 new cases of Covid were confirmed in the United States, and about 1,000 people died of it. Is it “cautious” to stop using a vaccine which would almost certainly reduce those numbers, because of an uncertain chance that it might have negative effects in a tiny cohort?

But caution, in this sense, has been rife during the pandemic. The governments of various European countries stopped the use of the AstraZeneca vaccine over similar concerns. Germany, the Guardian reported in March, “was the first country to refuse to allow people over the age of 65 to have the AstraZeneca vaccine because of the absence of evidence of how well it worked in older people, indicating a more cautious approach than most”. 

Over the last two years, again and again, the fears of some possible risk caused by something we might do have outweighed the fears of a thoroughly real, utterly obvious risk which was killing people at the time. And it has, I think, been a failure of the field, or at least the practice, of bioethics.

Bioethics is the study and application of ethical philosophy as it applies to medical and biological research and practice. As a former philosophy student, I have always found the idea very strange – after years spent arguing over the wildly different implications of minor-seeming differences in ethical frameworks, it was amazing to me that you could corral ethicists into things called “ethical review boards” or “independent ethics committees” which would then give you an answer to the question “so is this ethical or not?”

(“We are pleased to inform you, Herr Doktor Kant, that the board rules that you may lie to the murderer for the purpose of concealing your friend’s whereabouts.”)

Drugs continue to be licenced and trials continue to be carried out, so I suppose not every ethics committee gets bogged down for three thousand years in discussions of what we mean by “the good”. And perhaps in normal times, the system works reasonably well, although you do hear some horror stories.

But during the pandemic, something has gone terribly wrong, and I think that the system of ethical approval in medicine has probably cost tens of thousands of lives, at a conservative estimate.

There’s a tweet from 2018 by a California software engineer, about the ethics of self-driving cars. It goes:

Philosophy: so sometimes it goes haywire & ends up-

Me: do the thing that kills fewer people

Philosophy: but it's very salient th-

Me: do the thing that kills fewer people

Philosophy: but the human element of control is-

Me: do the thing

Me: that kills

Me: fewer people

— Mason (@webdevMason) April 2, 2018

I think about it quite a lot. There are interesting questions, sure: if a self-driving car kills someone, who is responsible, the driver or the manufacturer? If you’re designing a safety system for the self-driving car, should it value the life of the occupants more highly than those of people outside?

But they’re quite niche questions. If, in the future, it turns out that a self-driving car will, on average, kill fewer people than a human-driven car, then it would be the ethical thing to do to get a self-driving car. Even if, every so often, the self-driving car does something really weird, like mistake a cyclist for a road marking, or a lorry for the sky, fewer people will be killed in a world where humans don’t drive and robots do. And that is good, so – all else being equal – we should say that self-driving cars are the ethical choice.

You can construct clever scenarios in which that is not true. But they have to be clever. As a starting point, as a reasonable first draft, “Do the thing that kills fewer people” is hard to beat.

In bioethics, though, we’ve overcomplicated things. For instance, early in the pandemic, people were campaigning for “human challenge trials” into Covid vaccines. In normal vaccine trials, people are given the vaccine (or a placebo or other control), and then the researchers observe how many people get the disease naturally. If it’s significantly fewer in the vaccine group, then we say that the vaccine works.

But it can take months for enough people to catch the disease naturally. When I was on the AstraZeneca trial in summer 2020, prevalence was low – there was real concern that it would take many months to get enough data.

With human challenge trials, participants agree not only to be given the vaccine but also the disease. It lets you use far fewer participants, and get your results far quicker, than a traditional vaccine trial.

Suggested reading

Britain's booster plan won't work

By Tom Chivers

A promising vaccine candidate, the Moderna mRNA vaccine, was ready in a lab in January 2020. The hundred or so doses that would have been required to get very solid evidence of effectiveness could have been made at lab scale in a few days. We could have known by February, or March at the latest, whether the vaccines worked. Yes, we’d still have had to scale up production, and that would have taken months. But the whole process would have started earlier. Instead, Moderna’s vaccine was not given emergency use approval in the US until December.

As the philosopher Richard Yetter Chappell points out, there are obvious-seeming objections to human challenge trials. You have to give people a potentially dangerous disease: what if it kills one of them?

But one plausible estimate is that roughly 18 million people have died of Covid during the pandemic – that’s an average of about 28,000 a day. Bringing the end of the pandemic forward by even a single day could easily save thousands of lives. A small risk to a small number of young, healthy volunteers was hugely outweighed by a very likely large reduction in risk to many thousands of old, vulnerable people.

Philosophy fans might think that this is a classic utilitarianism problem: is it OK to sacrifice one to save many; can I torture the terrorist in order to find the bomb? But as Chappell notes, in fact it is not. There are willing volunteers offering a (small but real) sacrifice for the greater good. It is an act of altruism, or even heroism, not coercion. “In what other context would the default assumption be to ban heroic acts of immense social value?”, asks Chappell.

There have been other failures. Recently, the drug Paxlovid was shown to be highly effective against severe disease. So effective, in fact, that the trial was stopped midway, because it was deemed unethical to give half of the participants a placebo when it was clear the real drug worked.

But the drug is still not approved in the US. So as Zvi Mowshowitz points out, “It is illegal to give this drug to any patients, because it hasn’t been proven safe and effective,” but also, “It is illegal to continue a trial to study the drug, because it has been proven so safe and effective that it isn’t ethical to not give the drug to half the patients.” 

Suggested reading

There is no spiking epidemic

By Tom Chivers

This is not the only such case. A trial of a drug designed to protect against HIV was stopped last year, because the drug was so effective that it was unethical to give placebo. But the drug was not actually approved by the FDA until … Monday!

There are two important points to make, here. First, while I’m talking about “bioethics”, it’s not clear that it’s actually bioethicists who are the problem. For instance, Peter Singer of Princeton, probably the world’s most famous bioethicist, is on the board of 1DaySooner, the human challenge advocacy group, as is his fellow bioethicist Nir Eyal, of Harvard. Leah Pierson, a Harvard bioethicist who is writing a book about the failings of bioethics during the pandemic, stresses that when the CDC paused the use of the J&J vaccine, lots of the bioethicists she knows were appalled at the decision. But the practice of bioethics as actually carried out in major institutions, such as the FDA and CDC, often leads to these bad decisions. Matt Yglesias makes a good case here that public health agencies tend to follow somewhat rigid rules, rather than the best available science, leading to bad outcomes like a delay in approving fluvoxamine: perhaps I should complain about “institutionalised public health” rather than “bioethics” per se.

Second, as Pierson points out, “When these systems work well you probably don’t hear about it.” No doubt there are lots of drugs that get approved relatively smoothly, and trials which go ahead without much fuss. I don’t know how representative these problems are.

But the problems do exist, and they seem to be exacerbated by the pandemic. Chappell thinks that the main problem is one of status quo bias: that is, that changing things feels like the “risky” option, and keeping things the same feels “safer”. And, he admits, that may (or may not) be true in non-pandemic times. But in the pandemic, the status quo is visibly very dangerous. Throwing some low-but-not-zero-risk options into the mix, like early approval of vaccines or human challenge trials, are almost certainly lower-risk, in terms of the likeliest expected outcomes, than sticking with the status quo. 

There is also an issue that humans instinctively think there’s a difference between bad outcomes caused by our actions, and bad outcomes caused by inaction. It’s hard to make a good philosophical case for this, and what the distinction between an “act” and an “omission” is (Jonathan Bennett had a go), but it’s how we feel. Killing one person by giving them a faulty vaccine feels worse, somehow, than letting a thousand die because we let the vaccines sit in a warehouse for another 24 hours.

And it’s easy to come up with reasons why we need to put more hoops in place for researchers and clinicians to jump through, because the one guy who dies in a botched human challenge trial is very obvious, whereas the thousands of people who would have died if the trial never took place are completely invisible.

Suggested reading

The great climate change fallacy

By Tom Chivers

But whatever the reason is that the hoops are in place, they are in place, and people have to jump through them to get things done. It took until December for the UK to decide to vaccinate the under-12s, despite it being well established that schoolchildren were driving the pandemic, because bioethicists could only take into account direct risk to the patient at the time – not the likelihood that prevalence would go up, or whether the children would rather not put their own relatives at risk. And it’s amazing, with hindsight, to read this approving piece from October last year about how a doctor prevented Donald Trump from forcing through early approval of a Covid vaccine.

It’s rare that academic philosophy can have such a direct impact on people’s lives. But how we apply bioethics really can save or kill thousands, just by changing the speed with which we approve drugs. In peacetime, perhaps, it’s OK to argue the toss and act with caution. But in a pandemic, perhaps we really ought to apply the standard of “Do the thing that kills fewer people”.

Those earnest promoters of the work ethic, Dominic Raab and Priti Patel, must be a bit worried. Are we actually enjoying lockdown? Are we enjoying doing less? Are we enjoying being masters of our own time? Maybe we won’t want to go back to work.

The government was expecting an outcry from the people when it extended lockdown. Please, open the factory gates and let me get back in there! Let me rise early again, and scrape the ice from the windscreen! Let me plod through the rain with my enormous jug of coffee and let me buy meal deals at lunchtime! Let me spend my hard-earned cash on after-work drinks with colleagues I hate! Let me never see my children and let me spend long hours standing on buses and trains!

Tories have long pushed the Puritan ideal of hard work for other people. Raab and Patel were among the five authors of a dismal Gradgrindian manifesto in 2012, pompously entitled Britannia Unchained:

The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.

Football and pop music indeed! Around this time, some bright spark in the Tory party came up with the depressing notion of “hard-working families”, enthusiastically taken up by David Cameron, who, as has been noted many times, singularly fails to distinguish himself in that respect in his own daily life.

Suggested reading

Lockdown is just a holiday from modernity

By Niall Gooch

Then there is former MP for Grantham, Nick Boles. Boles, like many MPs, studied PPE at Oxford, training ground for utilitarians. He is an enthusiastic opponent of the universal basic income, believing that if left alone, Brits will vegetate, or, worse, write poetry:

The main objection to the idea of a universal basic income is not practical but moral.

Its enthusiasts suggest that when intelligent machines make most of us redundant, we will all dispense with the idea of earning a living and find true fulfilment in writing poetry, playing music and nurturing plants. That is dangerous nonsense.

Mankind is hard-wired to work. We gain satisfaction from it.

This sort of thing, as Jeremy Bentham might have said, is nonsense on stilts. If mankind were hard-wired to work, then we would not be enjoying the autonomy of lockdown. Most people don’t gain satisfaction from work, they gain money from it. That’s why they do it.

In fact mankind is hard-wired to write poetry, play music and nurture plants — which is exactly what we have been doing in lockdown. The other day I found myself writing a short poem about the folk singer Sam Lee and his love for nightingales. And I sowed some seeds in a pot. That’s the sort of thing that happens when you have a bit more time.

Suggested reading

Coronavirus will change nothing

By Ben Gummer

At the Idler we’ve seen take-up of our online courses quintupling over the past few weeks. When left alone, it appears, people do not do nothing. They take exercise, they read and they listen to learned lectures on Jane Austen and Plato.

PC Plod famously ticked off sunbathers that lockdown was not a holiday. But in some senses, it is a holiday. And the distinguishing characteristic of holidays is not that you do nothing. It is that you are in control of your own time. Holidays can be quite busy. So it is with lockdown. To a far greater extent than normal, we call the shots. We are not slaves. We take responsibility.

At this point the middle-class communists will pipe up: it’s all very well for you, with your 19^th-century novels and volumes of Keats’s letters. What about the key workers? Are they enjoying lockdown?

No one is saying that being a nurse is not a difficult and important job — now and at all times. And I am more grateful than ever that the dustmen come and take away our rubbish. But we cannot ignore the people for whom the crisis has led to a questioning of what a good life is all about. And a little less work all round would be good for key workers too.

Suggested reading

What do post-liberals really want?

By Peter Franklin

It is instructive as to the mutable nature of morality, that a few weeks ago, being very busy was considered morally good, and now we are being told to indulge in its precise opposite. Do nothing, save lives. This shows you that Nietzsche was right: morality, so-called, is merely a tool of control.

The truth is, as Chesterton said about lying in bed, there is nothing morally good about hard work, or bad about being lazy.

Instead of being regarded, as it ought to be, as a matter of personal convenience and adjustment, it has come to be regarded by many as if it were a part of essential morals to get up early in the morning.
It is upon the whole part of practical wisdom; but there is nothing good about it or bad about its opposite.

After all, what could be more harmless than lying in bed? When lying in bed you are doing nothing to harm the planet. You are consuming nothing. You are bothering no one. And you are doing yourself a lot of good by giving yourself a rest.

Suggested reading

Why Schitt's Creek is a parable for the good life

By Libby Emmons

For many, many people, lockdown will beat working. My neighbour is using his furloughed time and the lovely weather to paint the outside of his house and spend some time in the garden. He says he is not particularly relishing the prospect of going back to work.

And on my daily bicycle rides around west London, an alien observer would be forgiven for thinking he’d landed in some sort of William Morrisesque utopia. There are no cars, the air is clean, birds sing, and smiling family groups cycle along the river.

The main issue here is the people actually enjoy the freedom. The right-wing view is that, left to our own devices, we’d just sit around in our underpants watching daytime TV, and I’m sure there are a few who do that.

But in fact, when people are left to their own devices, and have more free time, they get creative. They help each other. They form community groups. They do things not just for profit. We are seeing the anarchist principles of mutual aid in action, and we are disproving the old proverb, “the devil finds work for idle hands to do”. In fact, idle hands get on with a lot of fun stuff — it’s just not working for the boss.

Suggested reading

What's wellbeing worth?

By Tom Chivers

And maybe we won’t want to go back to work. Maybe the leisure society dreamed of by people like William Morris and later Bertrand Russell and John Maynard Keynes will start to materialise. Morris believed in what he called “useful work” versus “useless toil”. Russell said that a civilised society would gradually reduce the hours of work, leaving time for poetry, nurturing plants and studying philosophy. And Keynes of course reckoned that technology would usher in a 15-hour working week.

I called my pal Professor Brendan Burchell of Magdalene College, Cambridge. He has been studying working habits for over 30 years.

“I think lots of people are enjoying lockdown though they are afraid to say it for fear of being seen as lacking compassion,” he said.

He reckons that some people will undoubtedly want to work less when the crisis passes. “Whether that’s 1% or 10% or 30%, we don’t know.”

He also predicts that the crisis will lead people to question that other great pillar of contemporary society: consumerism.

“Empty nesters who are used to spending money are realising that they can be perfectly happy without expensive holidays and consumer objects. And if consumerism weakens its hold, so will the work ethic, because people cite ‘money’ as the main reason for working.”

Suggested reading

The rise of the hippie conservatives

By Freddie Sayers

It’s not that Professor Burchell is against work. “Work is good — in small doses,” he says.

The work ethic is a relative recent invention. It has its roots in the Protestant Reformation — the Tudor authorities were, like Raab, hostile to idlers. Monks were considered to be lazy. It gathered force in the Industrial Revolution when the mill owners required a docile and punctual workforce to toil in the dark satanic mills. That’s when punctuality became a matter of essential morals. And most recently Silicon Valley has invented its own version: unless your side hustle has a side hustle, then you are going to fail in life.

Earlier societies, though, were not so work-oriented. The ancient Greek philosophers insisted on the ideal of “schole” or cultivated leisure, for a happy life, and even the brutal Romans believed that civilised people should enjoy a decent portion of otium. Life was not all about business: they called that negotium.

In the Middle Ages, the great creative projects of the cathedrals were carried out voluntarily in people’s spare time. Guilds were against overwork as it might give you an unfair advantage over your brother in the guild. And there were multiple holy days and feast days when working was prohibited.

Some are born idle, some achieve idleness and right now, a lot of people are having idleness thrust upon them. And many of them rather like it.

It is time to revisit Mill’s central philosophy: that it is possible to both support and protect individual liberty through the free-market system, while at the same time addressing social injustices. It is possible to create a freer and fairer capitalist society.

More from this series

John Milton: smug liberal and free-speech warrior

By Polly Mackenzie

Almost impossible to place on the political spectrum, Mill’s inability to fit neatly into any of the usual political pigeon holes has, sadly, meant that his work (some of it written with his wife, Harriet Taylor Mill) has been neglected. Writing at a time of immense poverty and inequality, and yet also restrictive Victorian moralism, Mill sought to make capitalism work better, rather than to replace it.

Mill believed in the power of the market – in the benefits of competition and the individual liberties it helped to uphold – and was skeptical of the state, along with revolutionaries who, in his words, had “serene confidence in their own wisdom on the one hand and a recklessness of other people’s sufferings on the other”. Today’s relevance is clear.

Mill’s agenda for improving capitalism was two-pronged. The first and best known was increasing personal liberty, as set out in his book On Liberty. He believed that social injustice could in part be addressed by making sure that people were freer to take advantage of the opportunities of life. The second (and lesser known) prong was Mill’s theory of the mind: his recognition that we sometimes go along with things without properly thinking about them, but that through education and reason we have the potential to change our mind, and in a way that enables greater individual liberty alongside greater social justice. Central to this was how we could reconcile our own individual self-interest – that desire to be free to do our own thing – with the interests of society.

While many economic and politic thinkers suppose that our own selfish interests are fixed and unchangeable, Mill disagreed. For Mill, reconciling individual and social interests can in part be achieved by getting people to think and question, rather than leaving it to the state to force people to do things for the “good of society” that they feel are against their own interests. This, he believed, resulted in an unnecessary trade-off between individual liberty and society.

More from this series

Aristotle's answer to identity politics

By Henry Olsen

Born into and educated in the “utilitarian” tradition – one that sought the greatest utility (or happiness) for the greatest number – Mill had an epiphany moment in his early twenties that triggered a six-month period of depression. Asking himself whether the ultimate achievement of a utilitarian reorganisation of the world could make him personally happy, his answer was ‘no’.

While utilitarians focused on rearranging the outside world, Mill argued that we also need to think about the world inside our minds. Bringing romanticism to bear on utilitarianism, and no fan of Victorian moralism, he adopted the idea that the human mind is embedded in culture and history – that much of what we do, think and value is shaped by something other than reason, and can, as a result, be reshaped by its application, making us happier as individuals and as a society. Perhaps the best example is his argument that women’s subservience was not “natural” but was instead the result of unequal liberties (e.g. unequal voting rights, property rights and education) that were blindly accepted because of societal conditioning. Mill believed that “[t]he despotism of custom is everywhere the standing hindrance to human advancement”.

In The Subjection of Women Mill reasons that fighting the attitudes and laws that render women second class citizens is not only good for women, but is in the best interests of everyone – that men will have more personal fulfilment when they associate with women as educated equals, and that equality in the home conditions us to be democratic rather than autocratic. He also suggested that equal liberties for women would help reduce population growth, thereby increasing wages and helping to achieve greater equality (he was, in fact, arrested as a young man for helping women access birth control).

Further reading

Capitalism is the best guarantee of individual freedom

By Victoria Bateman

This is an example of his two-prongs at work: how supporting individual liberty alongside encouraging reasoned argument can help deliver a world in which there is both greater individual freedom and lower levels of inequality. For Mill, the “emancipation of women and cooperative production, are…the two great changes that will regenerate society”. We have made great strides towards the former, but what of the latter?

This brings us to the third part of Mill’s agenda for reforming capitalism, one that receives even less attention than his theory of the mind, yet has particular relevance to today. Mill was a big fan of the competition, experimentation and diversity that free markets supported, and crucially believed this extended to the form of business organisation itself. He did not see the future as being one of capitalists versus workers: firms in which workers receive wages and capitalists the associated profits. Instead, he anticipated a future that involved an “association of labourers with the capitalist”, or an “association of labourers among themselves” in the form of worker cooperatives.

While communist revolutionaries (then and now) suggest that a fairer future hangs on the expropriation of property from private hands – the nationalisation of “the means of production” – Mill offered an alternative. His was a model that avoided expropriation, where new firms would instead develop to challenge older style firms – new firms in which workers were given shares, or firms that were composed entirely of workers working together in the form of cooperatives. For Mill, such firms had the possibility of being even more successful than traditional capitalist firms, as they would motivate workers (who would now receive a share of profits) and would result in better labour relations, avoiding the angst associated with more traditional firms. As a result, the advantages of the market are maintained, but with a more equal distribution of private property: individual liberty with greater social justice.

More from this author

Capitalists – not socialists – are killing capitalism

By Victoria Bateman

For Mill, capitalism would naturally evolve in a way that made this new style of firm inevitable: as wages rose, on the back of women’s liberation (which would slow population growth), he believed profits would fall, reducing the prospects for the older style firm and giving workers more savings to invest in new style enterprises. So far, history hasn’t exactly borne this out – despite, at least in the UK, politicians championing cooperative and mutual business models. And yet with the share of income going to capital increasing at the expense of labour, the idea of workers sharing in the profits should be an attractive one to those seeking to rebuild public faith in capitalism.

Why, then, has Mill’s idea not taken off? Was he wrong that share ownership for workers (or full-scale worker cooperatives) results in better companies, ones that outcompete older style ones and so naturally become the future? Or, are there stumbling blocks in the way of alternative models of business, such as the hold of existing business forms, together with inadequate human and physical capital for challengers? Today, if we are serious about maintaining markets, but at the same time having a fairer distribution of private property, these are questions we should be considering.

In the charged, post-crash era we are living through it is easy to blame capitalism for our ills. But abandoning the free-market model means enabling greater state intervention, and history shows us that leads to less individual freedom – to a “recklessness of other people’s sufferings on the other”. Mill understood this, and provided a middle way.