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How Far Is Too Far When It Comes To Containing COVID-19, and Can Extreme Measures be Justified?

introduction: who am I? why do I care? what does this project explore?

Hi! My name is Amiya Tiwari. I am a sophomore in high school living in Columbus, Ohio. Through this project, my aim is to explore the specific measures that global governments are taking to mitigate the spread of Covid-19; the video above is an introduction to my project, which is centered around the ethical questions below.


Is it just to change the lives of an entire population to mitigate the spread of disease? How far is too far when it comes to containing a new threat, and can extreme measures be justified?


I also want to see how these respective government’s strategies are justified–or not–by the four main Bioethical principles: Beneficence, Nonmaleficence, Autonomy, and Justice. 

AUTONOMY: rational patients should be independent and able to make their own decisions free of coercion. Patients must consent to a procedure before it occurs.
BENEFICENCE: health care providers should only act in ways that benefit the patient.
NONMALEFICENCE: no decisions made/ treatments undergone should bring harm to the patient.
JUSTICE: resources should be allocated fairly; “fairness” can be defined as according to need, equity, or equality.

This project centers around the mitigation strategies of China, India United Kingdom, & America.


Nation I: China: a brief overview

On January 23, 2020, China shut down Wuhan, China, as the first instance of quarantine on an enormous scale during this crisis. Although many other nations have since “shut down,” none of them have been as swift or intense as China. 

Firstly, according to The Guardian, within hours of the announcement to begin quarantine, “transport into and out of the city was closed, with no exceptions even for personal or medical emergencies.”

Although America, Britain, and India have all implemented stay-at-home orders and lockdowns, none of them have gone as far as Wuhan.

In early February, health workers in the city went door-to-door, visiting 4.21 million households. If a resident displayed symptoms of COVID-19, they were forcibly taken into custody and isolated. While effective in isolating those who could potentially spread the disease, these extreme measures definitely have ethical implications.


One example of a problem that can arise from forced isolation is the story of Yan Cheng, a 17-year old with cerebral palsy. According to the South China Morning Post, the boy’s relatives were all “quarantined on suspicion of having the Wuhan coronavirus,” and the boy died after being “left at home for six days without care.” Cheng’s story raises some questions, for while these measures may be effective, are they ethical?

 


China through a bioethical lens


I will begin exploring these questions by considering how the Chinese government’s decision violates the bioethical principles.

  • Autonomy
    • The Chinese government’s decision to take away the basic right to leave home under any circumstance puts its citizens’ autonomy in jeopardy. 
    • Those who were found to show symptoms of the disease obviously had no choice but to leave their homes and families; they were forcibly quarantined.
    • These decisions were obviously made without the citizens’ consent. 
    • Although one can definitely argue that these decisions were made for the greater good of the city, these extreme measures with no leniency stripped those living in Wuhan of any autonomy they had over their lives. 
  • Beneficence and Nonmaleficence
    • In some instances, those living in Wuhan were not able to leave their homes, even to pick up essential medications and groceries.
    • It is in no way beneficial for those in Wuhan to be without their medications, groceries, or fresh air.
    • In the case of Yan Cheng, we saw that these decisions can bring harm–and even death– to some vulnerable populations, which obviously violates nonmaleficence, the “do no harm” principle. 
  • Justice
    • The situation in Wuhan needed less equality and more equity. Exceptions needed to be made for unique cases like that of Yan Cheng. His case makes it obvious that in a crisis as complex as this one, a sweeping lockdown is not the answer.

China’s decision can also undoubtedly be supported by some of the principles. 

  • Beneficence
    • Although extreme, China’s decision to completely lock down its city resulted in a net positive, as cases fell rapidly.
    • The result was an extremely reduced presence of the disease, which would only be beneficial for Wuhan residents as life returns to a new normal. 
  • Justice
    • Those in Wuhan had a responsibility towards the most vulnerable.
    • According to the principle of justice, it is essential for those who have the potential to spread the disease to stay home to ensure that the elderly and those with pre-existing conditions have access to hospitals.
Post-lockdown, life re-emerges in coronavirus epicentre Wuhan
Wuhan ended its coronavirus lockdown on April 7.

NATION II: INDIA: a brief overview

The push-and-pull between hunger and poverty and flattening the curve of COVID cases is a prevalent issue in India.

India presents a unique situation, for according to Reuters, 120 million workers migrate from their villages to the cities to work in factories or businesses– this is a common practice; my great-grandfather migrated frequently between his village and New Delhi to work as a police officer. According to the New York Times, many of these migrant workers lived and ate where they worked. 

With businesses shut down, these workers are now without food and shelter, which is a very significant problem when ¼ of India’s population lives below the poverty line.

The problem with a total lockdown in India means that these migrant workers are now stranded in cities with no connections. The workers obviously want to return to their home villages, but Prime Minister Narendra Modi banned travel between states after there was a mass exodus of workers trying to return home.  

Before public transport was shut down, this mass exodus caused passenger trains to be stuffed with Indians trying to return home. The video below shows a scene from a bus station on March 28. 

 

After the Indian government shut down most modes of transport, workers had two options: remain stranded in the cities without food or a roof over their heads, or brave the walk home, which could be up to hundreds of miles. 

The quote below from a Maharashtrian taxi driver highlights and humanizes this battle between mitigating the spread of the disease and battling hunger and poverty. 

Some people will die of the virus. The rest of us will die of hunger.

– Sanjay Sharma, taxi driver in Mumbai, Maharashtra, India

India Through a Bioethical Lens

How does India’s decision go against the bioethical principles?

  • Autonomy
    • The Indian government’s restrictions on their population are inverse to those in Wuhan; Chinese citizens were kept inside their homes, while those living in India have been kept out. 
    • Despite this difference, my reasoning is the same: by prohibiting migrant workers from returning to their home states and villages, the Indian government is not allowing their population to have jurisdiction over their actions, which violates the principle of Autonomy. 
  • Beneficence and Nonmaleficence
    • By preventing one public health crisis, the Indian government is facilitating another: homelessness and starvation. It is simply not beneficial for migrant workers to be stranded in cities without sources of food or shelter.
    • Some Indian governments–such as the state authorities in Gujurat–have ordered the closures of public parks, meaning that the now-homeless migrant workers have one less place to get through the night.
    • The decision to prohibit migrant workers from leaving cities results in harm to those stranded without a home, which clearly violates the principle of nonmaleficence. 
  • Justice
    • Like Wuhan, there needs to be some equity inserted into the lockdown in India.
    • Not all Indian citizens’ living situations are made equal, and exceptions need to be made for the millions stuck inside cities that do not have the opportunity to socially distance safety.
    • The fact that these workers are stranded on the streets seems to me like it would increase the spread of disease, not flatten the curve.  

Modi’s decision to close state borders also has some benefits. 

  • Beneficence
    • If migrant workers were to return to their villages after working in the city, it is likely that they would bring COVID-19 home with them.
    • Villages have significantly lowered access to medical care compared to big Indian cities. Therefore, it would be beneficial to keep the potentially infected within state lines to prevent spread of disease to areas with less resources.
    • Public transport is a major vector for disease, and the exodus of millions of migrant workers could result in a high concentration of people using public transport.
Now-homeless migrant workers in New Delhi.

NATION III: The United Kingdom: a brief overview

In early March, Boris Johnson presented a novel strategy for dealing with COVID-19: the herd immunity strategy.

Although the government has since moved to a social distancing model similar to America, important ethical implications arise from the herd immunity strategy.

The UK’S initial strategy relied on people getting the disease and becoming immune as a result. This strategy fascinates me. It is exactly the opposite of China and India’s response: people were able to remain independent.

Johnson’s primary motivation in proposing the herd immunity strategy was to curb “behavioral fatigue” in which people stop complying with social distancing orders, becoming less vigilant as the disease begins to peak.

The government also feared that when quarantine measures were lifted, the virus would return without some type of immunity present in the population– this strategy was meant to reduce the rate of transmission in the case of a resurgence.

Even though it is at the complete opposite end of the spectrum compared to responses by other nations, this initial strategy still changes lives. In this situation, the UK had initially planned to change the lives of their population by allowing them to contract the illness for the greater good of the population.

Boris Johnson stresses the importance of immunity and acknowledges the fact that the herd immunity strategy will result in the death of loved ones.

The United Kingdom Through a Bioethical Lens

Britain’s herd immunity strategy definitely goes against some bioethical principles.

  • Beneficence and Nonmaleficence
    • In terms of the health of the individual, this strategy seems backwards, for it is relying on the fact that citizens would contract the disease, suffer through it, and eventually obtain immunity.
    • In terms of the individual, it is not beneficial to be subjected to disease.
    • This strategy could also result in harm, for hospitals could become inundated with patients, meaning that care would not go to those who need it the most. This reason was the primary motivation behind the government’s decision to switch to a social distancing model in mid-March. 
  • Justice
    • The British government was completely aware that many people would die as a result of this approach.
    • Justice is tricky in terms of the United Kingdom, for this principle really raises the question: does the death of the few justify the death of the many?

The UK’s decision can also undoubtedly be supported by some of the principles. 

  • Autonomy
    • Unlike China and India, the British government’s first plan to address this crisis was to uphold respect for their citizen’s autonomy.
    • If citizens wanted to self-quarantine, they were still permitted. The British government did not force them outside like China and India forced their populations inside. 
  • Beneficence
    • In terms of the health of the population, this strategy is beneficial.
    • The reasoning behind this strategy is similar to that of vaccines; the more people who are immune, the less likely the disease is to spread.
    • This strategy cuts off the disease at the source, which is beneficial for the population. Britons would have potentially been “safe” from another surge of the disease, unlike countries who participated in social distancing, who would have to return to quarantine. 

An Interview with Amit Tiwari: Londoner, Coronavirus patient, and my uncle

While working on this project, I called my uncle to speak with him about Britain’s herd immunity strategy, the current climate in London, and his experience recovering fron COVID-19. 

Q: How did the government communicate this strategy to the population? 

A: I thought the herd immunity strategy made a lot of sense, despite its differences from other countries. The direction from the government was a bit unclear, as I was still going to work when I began showing symptoms of coronavirus. The government was mainly putting on a brave face; they acknowledged that many people needed to die and 95% of the population would likely contract the disease after 14-16 weeks of the herd immunity strategy. To me, the reasoning behind this strategy was sort of like the “Keep Calm and Carry On” posters of WWII; they wanted us to get on with our lives to lower the economic impacts of the crisis. Their intention was to flatten the curve during the peak, so instead of 14-16 weeks of quarantine, it would be a 2-3 week period near the peak. 

Q: The government was worried about “behavioral fatigue,” or that people may tire of quarantine and begin breaking protocol even as the disease becomes more serious. Do you see this happening in your community after the shift to a social distancing model? 

A: When I went into London to turn in my coronavirus test, I was one of two people on the train. I was surprised when I was walking along the streets. I saw three people walking in London, and I walked about 2.5 miles from the station to the medical clinic and back. I usually see hundreds and hundreds of people. In the suburbs, people are more relaxed, taking walks with their families. But in London, everyone I saw was wearing a mask. 

Q: What was your experience with contracting COVID-19? 

A: I really think this disease affects everyone differently. For me, I had a wet cough, and my lungs were very clogged. I was still working in the office when I first started feeling sick; my cough started in February. I never had a fever or dry cough. I lost my sense of taste and smell in late March, and my wife lost hers around that time as well. She had a dry cough and had trouble breathing, but her symptoms mainly lasted for one week. My two young daughters have had headaches and itchy throats, but that was it. My case was confirmed through a blood test. 

My Uncle, Amit, his wife, Lorraine, and their two girls, Aryana and Arabella.

NATION IV: America: a brief overview

America has adopted the fairly common social-distancing strategy, but there has been some disparity in the response on federal and state levels. 

For example, my state, Ohio, has responded aggressively to coronavirus. Over the week of March 13, schools, followed by gyms, restaurants, and public parks were all closed.

Although I am very lucky to live in a state with proactive state officials, I think it is interesting that my school closed 6 days before my cousins’ did in New York City, the current American epicenter for the disease. 

In the 6 days in which New York schools were still in session and Ohio’s were not, many people were exposed to infection that could have been prevented if the country had locked down all at once. 

In order for the social distancing strategy to be equal and ethical for a nation with different levels of government such as America, there must be some type of uniformity in terms of measures taken to mitigate the spread. This does not mean that every state needs to take measures as extreme as New York; rather, each level of government in each state should take this crisis seriously. 


America Through a Bioethical Lens

America’s fragmented response can be justified bioethically. 

  • Autonomy
    • While the principle of autonomy is typically used in the context of a specific patient, the autonomy of states should still be upheld amidst this crisis, as the COVID-19 situation looks different in every community.
    • South Dakota’s governor used this same reasoning when she justified her state’s lack of a stay at home order, saying, “South Dakota is not New York City.” 
  • Beneficence
    • When considering the health of the individual, it is not beneficial for those living in less densely populated states with lower case rates to be following the same guidelines as those in big cities.
    • Unnecessarily strict measures could result in mental strain for many reasons; for example, prolonged closures of businesses result in financial stress.
    • Closing down life for an unnecessary period of time could do more harm than good in situations like this.
  • Justice
    •  America is currently using a model that prioritizes equity and need– which are both theories of justice.
    • Depending on the concentration of cases in the state, differing measures have been implemented to insure that the “input” of cases does not outweigh the “output” in severity of response. 

However, the principles support a uniform response to this crisis as well. 

  • Beneficence
    • A uniform strategy makes a lot of sense when one considers the health of the population.
    •  If one state has less intense measures than another and individuals travel across state lines, those coming from the less-strict states could potentially bring the disease with them, like the crisis in India.
    • A uniform strategy would prove beneficial for the country as a whole, for each citizen would be experiencing the same level of security and regulation regardless of their state of residence.
  • Nonmaleficence
    • We see the decision to regulate more states heavily than others resulting in harm in the case of Sioux Falls, South Dakota.
    • The current governor of South Dakota, Kristi Noem, refused to issue a stay-at-home order, saying that “the people themselves are. . . responsible for their safety.”
    • Smithfield Foods, a meat processing plant in Sioux falls that remained open until April 12, was the source of 600+ coronavirus cases. At least one employee has since died from the governor’s decision to allow businesses to decide for themselves when to close.
Coronavirus hotspots in the United States

My response and opinion on the American response to the coronavirus

My research on India, China, and the United Kingdom has shaped my strongest opinion concerning the response to COVID-19: my opinion on the American response to this virus. 

After researching China, a country with total lockdown, I can say that I think this strategy strips citizens of too much of their autonomy. Although direction is needed during this time, I do not think it is just to strip citizens of their fundamental rights such as leaving the home for solitary exercise or grocery shopping. 

I do not agree with the herd immunity strategy either. I think granting too much autonomy in times like these results in confusion amongst the public, which benefits no one.  Additionally, I think it is important that we focus on protecting the public as much as possible until a vaccine becomes available. 

Therefore, I believe that the best way to attack this crisis is how most of the world is handling it: through social distancing. 

However, I think America is handling this crisis in a way that is confusing for citizens. How can we say our country is taking this crisis seriously when 7 states have yet to issue a stay-at-home order? 

I believe that there should be a baseline response for each state; every state in America should have the same bare-minimum guidelines in place.

However, I do concede that these guidelines should vary in intensity based on the state. For example, both New York and Wyoming should have stay-at-home orders in place at this point in time, even though there is a large difference in the number of cases. The intensity and duration of these orders will definitely vary, but as our nation approaches its peak, we need to ensure that our nation has a message that is clear, which will provide reassurance to the population. 


What are your thoughts?

The fact that this conference gives me access to a global community is very exciting, for this crisis is ever-changing and is different in every city, state, and country. I have really enjoyed learning about the ways that different countries have responsed to this crisis, and I would love to hear your thoughts. 

It would mean a lot to me if you could respond in the comments to the following questions!


Works Cited and Consulted

https://docs.google.com/document/d/1mZPo9o-SXcgchxbkfhRFTRPLOZwLXfw1iVN4lEZbcEA/edit?usp=sharing

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COMMENTS: 3
  1. April 24, 2020 by lucas

    This is a great example of looking at an issue from a global perspective. I am also interested in how the social determinants of health impact different countries choices. For example, Sweden appears to be continuing toward the herd immunity strategy but what societal factors are in play that help them make that choice and how is it different than in China or the USA? Are these worth considering country by country or should we (ideally) pursue a global policy.

  2. April 25, 2020 by Artemisia

    Hi Amiya, I really liked how you focused on four separate countries and clearly broke down their policies into concise sections. In my community in California, people are being pretty good at following social distancing protocol, and a lot of the people I see when I go outside are wearing some type of mask. I don’t think there is one correct response to this global pandemic, but I think the best solution so far that I know of would be Taiwan’s response to the coronavirus. Since Taiwan is so close to China, it was predicted that the coronavirus would have a severe impact on the country, but with Taiwan’s quick response to the pandemic, the numbers of infected and dead are some of the lowest in the world. With everyone wearing masks, intensive screening in airports, and heat monitors in restaurants, Taiwan has actually been able to donate millions of masks to various countries in need of them, including the US. It shows what the situation in the US could have been if the correct actions had been taken at a much earlier date.

  3. April 26, 2020 by Seva Kelly

    Hi Amiya, This is a really informative presentation. I like how you clearly broke down the stay at home orders for each state and how the orders related to bioethics. Good job!

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