The Ethics of Pandemics: An Expert, Interdisciplinary Panel Discussion

Good morning everyone, and uh, welcome to the final session of our 50th anniversary conference on uh, for the Kennedy Institute of Ethics. Um, 50 years we've been in existence, and this uh, has been a great uh, week of learning, I think, for all of us. I'm Dan Solomasi, I'm Andre Heliger's Professor of Biomedical Ethics and Director of the Kennedy Institute of Ethics. Um, and um, our session today is our only live one. Everything else was pre-recorded, but this is a live panel of really outstanding scholars on the ethics of pandemics, what some of us have called pandethics, not the ethics of pandas, but the ethics of of pandemics. And I think one of the reasons that we wanted to conclude this way is that, in some ways, the COVID-19 pandemic has become, for I think many of us, a kind of Rorschach test for uh, for bioethics. It's not that the problems that we're confronting are totally novel, but they've been presented to us, I think, in uh, in new ways and with a new urgency.

So, clinically, we've faced questions like the ethics of triage of intensive care units, the ethics of rationing vaccines, age-based rationing, questions about disability rights, advanced care planning. [Music] In research, there are ethical questions about challenge trials, data sharing, the ethics of gain-of-function research studies. And none of those, again, are new, but presented with a new urgency.

Today, we're going to present a new set of questions that um, are um, uh, these um. One is the question of um, everyday ethics that um, everyone has actually faced, like when to wear a face mask or whether to send your kids to summer camp. We want to talk about the ethics of public health communication, something that I think is important but has been under understudied. Um, you know, are noble lies, for instance, permissible for the greater good? How do we best communicate risk to people?

A third topic we want to take up today is the ethics of racial disparities that um, so sadly, the COVID pandemic has uncovered for us. And are these um, inequalities really the result of racism, systemic or otherwise? And how are they best redressed?

The fourth set of questions will be um, what is a just and fair plan to distribute vaccines globally? I think we're all now very aware of the fact that pandemic means the whole world, and there are large numbers of people in the developing world who don't have access to vaccines. And and so questions arise of whether we ought to selectively lift corporate patent protections. Is the best way to address that? Should be should vaccines be distributed within nations according to particular protocols? And we'll discuss that.

And then finally, we'll conclude with a broad set of issues in public health ethics about how to balance individual freedom and the common good. Um, something that cuts across all the kinds of questions we've had with quarantine and mask wearing and lockdowns and surveillance. And you can ask, you know, who's right, China or Texas? And we'll um, talk about that a little bit uh, today too, not necessarily in those terms.

So, with us today to do this, I mean, that's a large set of tasks. We've got an absolutely stellar group of ethicists: Karen Stohr, Chris Grady, Patrick Smith, Henry Richardson, and Larry Gostin. I'm going to introduce each of them briefly before they give each a 10-minute reflection on these topics. Um, I'll let you know that there are more extensive bios on the website. Um, we're trying to pack all of these scholars into a very short period of time, so I'm not going to spend a lot of time talking to you about what you can learn on the website.

I also want to let you know that if you have questions, we're going to try to field those, and you can send them in via the Q&A function that's in front of you. You don't have access to chat, but in Q&A, you can send the questions in centrally. They'll come to me, and then I will um, forward them to the group. And we'll have about um, 30 minutes for uh, for a discussion at the end.

So, with that, again, welcome to our final live session, our uh, panel on pandemic ethics. Um, and it's my great pleasure to begin uh, today uh, by introducing Karen Stohr, the Ryan Family Associate Professor of Metaphysics and Moral Philosophy and a Senior Research Scholar here in the Kennedy Institute of Ethics at Georgetown. Her research covers topics like practical wisdom, moral imagination, beneficence, friendship, and social conventions. She's written two books on manners, "Minding the Gap," and has a third one on choosing freedom, "Freedom: A Kantian Guide to Life," that will be published next year. She's written um, in the New York Times and other newspapers, gets onto podcasts and uh, and radio. Um, and she split duty with me actually uh, in the spring of last year, writing a little column for the Washingtonian magazine called "Ask a COVID-19 Ethicist." So, Karen's going to speak to us about the ethics of being a good citizen, a spouse, parent, and neighbor during a pandemic. Karen, welcome.

Thank you, Dan. And thank you to everyone for joining us. We are so glad um, to be celebrating this 50th anniversary of the KIE with you. So, my topic is the ethics of citizenship in a pandemic. We can think about citizenship at many different levels. We can think about it globally, nationally, or even locally. And I'm going to focus primarily on local citizenship. And I'm also going to treat it not just as a political category, but as a moral category. So, to think of each other as our fellow citizens is to think of each other as neighbors, members of the same community. And this covers um, obviously political topics, but also sort of mundane, everyday interactions on sidewalks and grocery stores, and those very ordinary uh, moments of our lives. And so, the question that I want to talk about for the next few minutes is, what does it mean to be a good citizen in this sense during a pandemic?

So, the 18th-century Prussian philosopher Immanuel Kant, who's one of my philosophical heroes um, and uses, described a tension that I think is really quite interesting. And the tension, he says um, is between these, what he calls, these two great moral forces: one of love and one of respect. And the tension, he thinks, comes from this fact. Love, he says, instructs us to come closer to people. Um, but respect bids us to keep our distance from them. So, here's an example of what he has in mind. We've all had the experience, probably, of encountering a stranger who seems to be in some kind of emotional distress, either crying or trying to hold back tears. And it's it's a bind, right? Because um, you might want to be concerned, and you might want to see if you can help, but it also seems potentially intrusive or none of your business. And that tension is exactly what Kant is trying to describe. We have moral obligations, moral calls, pulling us in these two different, opposing directions.

So, I think this tension between love and respect is useful in explaining a lot of the ethical challenges in citizenship in our ordinary lives and our ordinary daily interactions. And I think it's also really useful in helping us think through the threats to this kind of citizenship that we see and face during a pandemic. So, obviously, during the pandemic, we've been mostly focused on keeping our distance from people. And there are, of course, compelling moral reasons to do this: public safety, public health concern, and care for others. But we also know that there are costs to keeping this distance, because we lose a lot in human relationships when we're masked and six feet or more from people, and even more um, when we are sort of hunkered down trying to avoid um, close contact. And it's important to continue to see it as a loss, even when we know it's necessary. And we all feel this, of course, in our personal relationships. And we also know that there's only so much the technology, however amazing it is, there's only so much that it can overcome. The the costs of this distance, I think, have been especially apparent in our society's efforts to protect the elderly and the vulnerable from COVID-19.

So, um, distance has of course been essential um, but we also know that it's been devastating in many ways. And this is maybe most obvious in the incredibly difficult choices that nursing home administrators and hospitals have had to make over things like restricting visitor access. Because isolation is bad for us, we all know this. And the distance that's required um, in order to to get ahead of the pandemic makes it very hard to overcome that. I think the same kinds of worries apply not just in our personal relationships with our loved ones, but also in our relationships to other people in our communities as fellow citizens. Because physical distance, I think, has runs the risk of becoming psychological or emotional distance, or what we might call moral distance. And when this is layered on top of the deep political divisions that we of course have here in the United States, the threat it deepens, I think. The distancing is particularly a threat to that what Kant calls the great moral force of love, the one that tells us to draw near to people.

So, um, as I'm sure many of you know um, in 1947, the French philosopher and novelist Albert Camus published um, a work called "The Plague." So, for those of you who don't know the plot, it's the story of an Algerian town that was struck by the bubonic plague. Now, the novel is really about World War II and the Nazi occupation of France, but it applies really well to actual pandemics. So, in the novel, as the plague takes hold of this town, the authorities lock the gates um, of the town, so everybody is trapped inside, and no one can come in um, or leave. And um, something with which we're now more familiar than ever. So, in the novel, not surprisingly, fear, I mean, terror and isolation and loneliness take hold. The town's once bustling life on the town streets become empty. People draw themselves inward, and they detach themselves from their shared life um, in their community. And in the novel, increasingly, their lives become less recognizably human. Friends and neighbors become potential disease vectors. People turn away from each other, and sometimes on each other. So, they they face this communal crisis um, of the plague. But the only way in which they can, as far as they see, to fight it is a way of keeping their distance from people. And in the novel, it leads to tremendous isolation and eventually dehumanization.

So, philosophers and theologians draw a distinction between two forms of evil: natural evil and moral evil. Natural evil includes things like plagues and pandemics and hurricanes, and pretty much everything that insurance companies consider to be acts of God. Moral evil is the evil that human beings inflict on each other, and sometimes also on ourselves. So, in Camus' novel, there are two plagues. There's a natural plague, the bubonic plague, but there's also a moral plague. And the moral plague is the dehumanization that eventually takes hold. As the terrified citizens of the town try to protect themselves from the natural plague, they are largely helpless against the natural plague, against the bubonic plague, but they're not helpless against the moral plague. There's a character in the novel who's a foreigner, a journalist, and he has an um, opportunity to leave the city. He spends a lot of the novel desperately trying to leave because he wants to be reunited um, with the woman he loves who's outside of the city gates um. And as it starts out, he's trying to leave, like anyone would, to avoid the natural plague, the bubonic plague. But he's also, as we come to learn, he's also worried about the moral plague, because his reason for wanting to leave is that he's afraid of losing his capacity to love. He's worried about losing his humanity.

Okay, spoiler alert um, here. He chooses to stay, even when he has a chance to leave. And he chooses to stay because he realizes that he's able to reclaim his humanity and and love and care by coming to love and care for the people trapped with him. So, in choosing to stay, he actually stops becoming a foreigner. He becomes one of them, one of the townspeople. Most of the heroes in Camus' novel, many of them are medical personnel. And one of those heroes, who's the town doctor um, is sort of constantly playing down the heroism. And in one of the more famous lines from the novel, he says um, that really, what's fighting the plague is, he says, as a matter of common decency. In fact, he says, it's the only means of fighting a plague: common decency.

So, like the people in Camus' novel, I think we have two pandemics. We have a natural pandemic caused by COVID-19, and we also have a moral pandemic. The natural one, we fight with the tools of science. The moral one is more difficult um, in part because it has so many different dimensions. The it has, as we've seen, there are obviously disparities to COVID-19 that reflect ongoing injustices and inequalities in our healthcare system and our overall economic structure. We have disparities in access to vaccines. We've seen racism directed at people of Asian American descent. We've seen xenophobia. We've seen a lot of dimensions of moral evil and the moral plague. And common decency is not going to solve all of these, but it does matter.

Very early on in the pandemic, I had an experience in a grocery store before we knew much about COVID-19, where um, an elderly woman who was having some trouble standing up dropped her book of coupons, and her coupons spilled all over the floor in the grocery store. Um, like most people, my first reaction was, of course, to go help her pick them up. But then, of course, I was like, wait, that's a terrible thing to do right now. Um, and so we all had to sort of stand back and watch as this woman struggled to pick up her coupons. This, I think, again, illustrates that tension between love and respect. Our social norms for everyday interaction have been upended. It's going to take a while to get them back, to get back those forms of common decency. But it's really important that we get them back. Because the risk is that we're just going to keep our psychological distance from people, safe in worlds with plentiful vaccines and privilege, because distance is easier. And we can often hide indifference as respect. But if we do that, we're never going to beat the moral plague.

At the end of Camus' novel, people are reunited with their loved ones, but we don't really know which way it's going to go. As Camus reminds us, the plague is always threatening us, not just the natural plague, but the moral plague too. And we can't lose sight of the moral dimension of it, of the importance of maintaining our grip on our capacity to love and our common humanity. Um, and so I hope as we move forward, we'll be able to think about what we need in order to fight that plague too. Thank you.

Thank you, Karen, for that uh, wonderful, wonderful talk, and for being such a good citizen and staying on time. I really appreciate it. Um, our uh, next uh, speaker is Christine Grady, who's a Senior Investigator and the Chief of the Department of Bioethics and Head of the Section on Human Subjects Research at the National Institutes of Health. She's a prolific author, she lectures widely, mostly about research ethics, both domestically and internationally, and some on nursing ethics as well. Um, from 2010 to 2017, she and I both served as commissioners on the U.S. Presidential Commission for the Study of Bioethical Issues. Christine is going to speak to us on the ethics of public health communication during a pandemic, a subject that she's observed up close, since a non-bioethicist named Anthony Fauci has the privilege of being her spouse. So, uh, Christine, thank you.

Thank you, Dan. And thank you for the honor to participate in this illustrious panel for the 50th anniversary of the Kennedy Institute of Ethics. I am going to talk about public health communication and the ethics in a pandemic, and specifically, I thought I'd spend my few minutes saying why public health communication is essential, some of the features of good, effective public health communication, and some of the extraordinary challenges that we face during COVID.

So, why is public health communication essential? As everyone knows, pandemics are crises characterized by urgency, uncertainty, and fear. And providing information about what's going on and what's being done to address the pandemic is vital to to try to stem some of that fear and uncertainty. In the 2015 report on ethics and Ebola that the Presidential Commission for the Study of Bioethical Issues um, wrote, and the commission that Dan and I both had the privilege of serving on, they noted that empowered leadership, strong global health, public health infrastructure, effective communication, and agile ethics expertise are critical to ensuring the capability to respond to a public health crisis. And in that report, there were specific recommendations about the importance of accurate, transparent communication. Specifically, there was a recommendation that said public health officials have a responsibility to support public education and communication, and it has three interrelated purposes: provide the public with useful, clear, accessible, and accurate information about the response, including what communities and individuals can do to protect their own health; provide those most directly affected by public health policies and programs with an appreciation of the values that are reflected in and the reasoning behind the implementation of those policies; and mitigate associated stigmatization and discrimination.

I think everyone is is aware that during a public health emergency, the sort of primary ethical orientation of healthcare and medicine shifts from focusing on individual patients to populations, thus, I think, increasing the responsibility to provide the public with good public health information. And public health communication can educate the public, can reduce fear and mistrust, can increase transparency and accountability about public policy, and can counter stigmatization. But the success of doing those things depends on how effective the strategies of communication have been.

Of course, there's a huge literature, extensive literature on communication, and including on communication about risks and crisis communication, and it talks about how to convey messages effectively. The one thing, of course, is the sort of general standard features of good communication. And there's there's this thing called the Seven Cs, which I'm sure some of you know about, that communication should be clear, concise, concrete, correct, coherent, complete, and courteous. But in addition, in a crisis, communication should not be unidirectional. It has to preferably engage and listen to the public's concerns and the concerns of the communities. And we should not think of the public or the community as a homogeneous entity. For example, different strategies make sense for public health communication to nursing home residents as opposed to children, or to clinicians as opposed to laypersons. Engaging stakeholders and trusted community members as active and respected partners in communication enhances communication and trust.

Public health institutions and scientists and healthcare professionals also have a responsibility to work with the media and also, you know, to help them deliver consistent and scientifically grounded messages that include honesty about uncertainty and the likelihood that new evidence will come to light. And effective communication about public health risks should consider that psychologically and socially mediated understandings of risk include both facts and values. And we also know, of course, that poor communication can result not only in confusion and conflict and error, but also in distrust and harm.

So, what were some of the challenges during COVID? Of course, effective public health communication is challenging when there's rapidly emerging and evolving information, when there's deliberate disinformation and confusion about who to trust and why. So, some of the specific challenges I wanted to highlight: one was just the challenge of emerging information. As we rapidly learned about the virus, about the epidemiology, about the risks, about the clinical manifestations, about treatments, and how to care for people, and about vaccines and everything else, as these data emerged, sometimes the message changed. I would say appropriately, but when it did so, it sometimes caused confusion or a mistrust.

A second challenge is that in the setting of a pandemic and fear and uncertainty, there's a demand for information and explanations. People were desperately searching for answers to lots of things that they were concerned about and often grabbed onto information without necessarily verifying it or contextualizing it. I think especially during the early days of the pandemic, when scientists and health professionals were unable to provide answers for certain things, uh, sources like rumors and conspiracy theories filled that gap to some extent.

A third challenge is just the sheer volume of information. I mean, we all know that there are thousands of news items every day. There's social media, there's word of mouth, there's pre-prints, there's scientific literature. And the just the amount of information is overwhelming and can also be confusing. It's also interesting to me that search engines and social media algorithms work by responding to user input and requests for information. So, they privilege the information that by how many people want access to it. So, even if it's not accurate, and this can drive the distribution of misinformation when it is in demand. We know, for example, I mean, Karen mentioned two pandemics. There are there are two pandemics in terms of information. There's a, you know, the pandemic, and then there's what people call the disinformation pandemic, or the pandemic.

A fourth challenge is health literacy. Um, it's estimated that up to 40% of the U.S. population, for example, is has either a basic or below health literacy and science literacy. And some research shows that Black and Hispanic Americans and people over 65, all of whom are at disproportionate risk from COVID, are also at higher risk of inadequate health literacy. So, communication that attempts to reflect complicated reality and scientific evidence is that therefore not always accessible to people, and sometimes bypassed in favor of simpler messages, but which are possibly inaccurate. Jamie Watson wrote a blog on the BMJ, British Medical Journal, that showed that the reading level of almost all public-facing COVID-related health information was really quite high, much higher than the average reading level of the United States public. And as I mentioned before, public health information should be simple and accessible, acknowledge uncertainty, and take into account both readers' and viewers' concerns. Interestingly, some seemingly unconventional methods like memes and TikTok and Instagram series and rap videos have been quite successful in gaining visibility and getting the message across. Some of those are really good, and some of those are spreading misinformation.

A fifth challenge has been lack of coordination. It's been confusing and at times conflicting information coming from the government, and that was problematic. There was lack of coordination between the national response, the CDC, and the public health agencies at every state. And that lack of coordination sometimes legitimized the view that there that there might be multiple valid interpretations of the threat that was posed by this virus.

All of this leads me to a sixth challenge, which is misinformation and disinformation. Many of us know that misinformation is just not having the right facts, but disinformation is an active campaign. It's when a person or groups of people are knowingly spreading false information with the intent to mislead and deceive people. And in COVID-19, we've had both of those: misinformation and disinformation. The pandemic and the confusion around it provided fertile ground for rumors, disinformation, and conspiracy theories to to spread. And those ranged from bizarre to harmful. It's interesting in the backdrop that, you know, reliable information was already pre-pandemic competing with sort of more sensationalist, easy-to-access content, often algorithmically promoted, and sometimes, and many people were spending time in their sort of online echo chambers receiving information that they wanted to hear and that was polarizing. But the pandemic has exacerbated this. The uncertainty brought by the virus and the worries created by its health threat and economic impact have increased people's vulnerability to misleading information at a time when more reliant when we're when we are more reliant on technology and social media and online channels of information than we ever have been before.

So, on end with a couple of good news changes about communication. Public health communication, I think, one positive thing in my in my estimation is that science and public health have been on the public's minds, in the public's eyes. Everybody's concerned about science and public health. They want to really understand what's going on. Secondly, the the tech giants and social media companies and online platforms have, although long reluctant to to implement anything that looked like censorship, they have been more active, proactive, and taken on some responsibility by removing or restricting posts that have the potential to cause public harm or unrest. And they have been promoting also uh, official resources. The positive aspects of online media and technology have become increasingly apparent as people have been confined, often to their homes. And the third good news piece of information is that there are many, many sources of really great information that are actually quite accessible. I mean, there are websites that are constantly refreshed. The CDC has a lot of great information. The Johns Hopkins University has had a platform that kept everybody up to date on data from COVID. The WHO, the New York Times has these tracker systems that are really incredibly valuable. There's also been a lot of public communication in this in the form of PSAs and news reports. And then there's a lot of creative ways that are that have been and are being developed to reach people. Just one example, I I ran into one recently called Hip Hop Public Health, which has a series of really great rap videos all about COVID and vaccines and stuff, and and it's completely available online. So, I hope that we can learn from these experiences to make public health information more appropriate, more accessible, more effective, and more welcome as we move forward through this pandemic and the next. Thank you.

Thanks, uh, Christine, that was uh, terrific. I'm moving, moving right along. Our next speaker is uh, Patrick Smith, the Director of Bioethics for the Trent Center for Bioethics, Humanities, and History of Medicine, and an Associate Professor in Population Health Sciences and an Associate Research Professor of Theological Ethics and Bioethics at the Divinity School at Duke University. His current research and writing are in the areas of moral philosophy, bioethics, end-of-life care, and the religious and social ethics of Martin Luther King Jr. Patrick is currently a member of the Board of Directors for ASBH. But COVID-19 has turned, I think, some of his scholarly attention from the ethics of care at the end of life and other such topics to an ethical analysis of racial disparities in healthcare outcomes during the pandemic. And he's going to share a bit about that with us today. So, Patrick, welcome, and we're looking forward to what you have to say.

Great. Thank you so much, Dr. Solomasi, for the introduction. It's a pleasure to share the panel with so many distinguished and esteemed uh, scholars here. Pandemics have a way of reminding us of a deep, sort of interconnectivity we have with one another and a kind of vulnerability that we all share. At the beginning of the COVID-19 pandemic, we heard the often-repeated phrase, "We're all in this together." While true, it must be remembered, we're not all in this together in the same way. When crises emerge, the long-term health and economic impact for those who survive is often felt hardest by those who already experience disparities in wealth, overall health outcomes, and in access to and benefits of healthcare. An unqualified use of the expression "We're all in this together" runs the risk of suggesting that suddenly people will now act in ways that reflect in human solidarity, uh, when deep social fragmentation, more important aspects of our collective life together, human tribalism, unfortunately, is not so easily set aside. With the rise of what we see going on in the AAPI community and anti-Semitic uh, actions, this becomes more and more evident.

The challenges resulting from COVID-19 as a reminder of something that has always been true ethically and sociologically: people are deeply interconnected, and yet our societies are often structured so that we lose sight of this reality. Moreover, there is a deep interconnection between people, health, and how we arrange our social and political life. Most societies, if not all, reflect a social hierarchy within them. These societies also have corresponding hierarchies of health status and outcomes directly associated with those social arrangements. Donald Barr has summarized the general findings of a growing body of research that suggests uh, the health of an individual will be affected by both their place in the social hierarchy of their own society, along the lines of race, as well as by the level of economic inequality that exists between the best off and the worst off within society. The problem is not solely that inequalities in health exist. The primary issue in view is when those health differences become disparities, when those inequalities become inequities. Evaluations such as these are largely correlated with the amount of control a person has over the conditions that is causing the disparity. A socio-historical understanding of the formation of poor suburbs, low-income towns, and ghettos reveals the role of systemic, legal, financial, and racial exploitation in directly contributing to the creation of such conditions and the maintenance of unfair social hierarchies. The general direction of the evidence suggests that both racism, not race, and lower socioeconomic status often work together in mutually reinforcing ways to perpetuate disparities in health. Nazarew and Williams suggest that social and economic inequalities, as well as the effects of racism, both can be viewed as significant contributing factors of ethnic inequities in health.

Now, to appreciate how this connects to questions of health, pandemics, and ethics, it is important to understand the notion of race as a socio-political construct. At least in the context of my remarks, I employ the term socio-political construct to denote an idea developed around a social imagination, a set of political practices that appear to be natural, but is the development of a given society. Race, then, is an invented socio-political category that divides human beings into hierarchical groups based on differences in physical appearance, geographical origin, and ethnic backgrounds. Historically speaking, as philosopher Alyssa Nay points out, the system of racial classification is designed to enforce a social hierarchy with those who are considered white people at the top. This is just what it meant to be white, in addition to one's ethnic heritage, be it Polish, Germanic, Scottish, and so forth. The concept of race developed alongside the transatlantic slave trade to justify the accumulation of wealth and the political economy built upon the exploitation and dehumanizing treatment of people. The intermingling of skin color and economic exploitation has been linked to some of the most insidious social arrangements of our body politic, the legacy of slavery, colonialism, and ongoing tribalisms. To be racialized, then, is to be systematically subordinated or privileged in virtue of being perceived as appropriately occupying certain kinds of social position. In this sense, all people in a given context are actually racialized, whether or not it is acknowledged. Race as a socio-political construct both reflects and reinforces a racialized imagination with respect to how people view, encounter, embrace, include, and exclude one another, and how we configure our social, economic, and political arrangements. Is this framing of the issue that makes sense out of the claim by Dorothy Roberts, when she writes, "Race is the product of racism; racism is not the product of race." Understanding race as a social construct rejects a notion that it somehow refers to or picks out objective categories inherent to the biological nature of distinct human communities. This distinction is crucial to keep in mind. For Dorothy Roberts rightly notes, if race is a natural division, it is easy to dismiss the glaring differences in people's welfare as fair and even insurmountable, which leaves huge gaps between white and non-white well-being. Therefore, the observed health disparities in places like the United States cannot be explained by appeal to an inferior biological status of entire groups of human beings.

COVID-19 is a reminder that we cannot easily, nor without consequence, separate our particular community's well-being from that of others. Responding ethically in times of pandemics requires a commitment to a robust notion of human solidarity. Solidarity is a unity among people within a social organization to have a firm commitment to the common good of all people, especially to those on the margins. It is the realization that all inhabitants of this great world house, to use the words of Martin Luther King Jr., are now and will continue to be neighbors, brought into being largely as a result of the modern scientific and technological revolutions. Thus, people have obligations to work on behalf of one another. Solidarity is the realization that Martin Luther King Jr. admonished half a century ago that "together we must learn to live as neighbors, or together we will be forced to perish as fools."

A commitment to solidarity requires both individual and communal introspection and action. Individually, solidarity invites us to consider whether our own behaviors and mentalities demonstrate concern with those on society's margins. There is personal work to be done in terms of our own character formation, our own professional formation, and cultivating dispositions that are committed to the common good, environmental well-being, and concrete forms of justice, or rectifying injustice through principles of redress, particularly applied communally. Solidarity challenges us to ask whether the social organizations and political processes of which we are a part strengthen the bonds of human friendship, especially the bonds between those with and those without sufficient resources. If our societies are not doing this well, like for example, in parts of the United States, given the data on health disparities along racializing socioeconomic lines, then we must seek systemic changes as to how these may be improved to enable such relationships.

Widespread public health crises exacerbate problems of disparities between groups of people, thus undermining a notion of genuine solidarity. Pandemics like COVID-19 signify challenges to health and human well-being, both in our physical bodies as well as in our body politic. In other words, they display the effects of an underlying socio-political pathology just as much as diseases like COVID-19 present pathologically in people's bodies. Ethics, then, must attend to both of these categories simultaneously, while recognizing that each one is multifaceted. This dual emphasis, or as a subset of the uh, twin pandemics of this moral evil and natural evil, this dual emphasis is especially important to keep in mind. The negative consequences of pandemics for all people in a society can be mitigated more effectively when people work collectively and together, and through policy, for more racially just social arrangements. By focusing on the margins during non-pandemic times, the title of Martin Luther King Jr.'s last book is "Where Do We Go From Here: Community or Chaos?" In some ways, this is our question: where do we go from here in the collective work of bioethics? And hopefully, we can flesh some of this out as we chat further throughout this panel session. Thank you.

Thank you very much, Patrick, for some um, very carefully crafted and a sobering message um, for uh, for all of us. Um, continuing the theme in some ways of of justice, our next speaker is um, Henry Richardson, who's a Professor of Philosophy at Georgetown University and a Senior Research Scholar here at the Kennedy Institute of Ethics. His books include "Moral Entanglements: The Ancillary Care Obligations of Medical Researchers" and "Articulating the Moral Community: Toward a Constructive Ethical Pragmatism." He also edited the journal "Ethics" from 2008 to 2018. The COVID-19 pandemic diverted some of his attention from his Guggenheim fellowship to work on the issue of fair international allocation of any eventual COVID-19 vaccine. And he, along with others, published a paper on this topic in the journal "Science" that's been downloaded 24,000 times. Henry's going to speak to us about that work uh, today. Welcome, Henry.

Thank you, Dan. And I will, though I'm a philosopher, I will be sharing uh, slides. So, my title of my talk gives my thesis: that we must now prioritize getting COVID-19 vaccines to other countries that urgently need them. I'll be making a moral case for that, and I'll be building on themes that all my previous panelists have mentioned. We must not hide behind our distance, as Karen Stohr said, and we must not do that globally. Christine Grady mentioned the importance of urgency, and I'll be unpacking that a bit. And Professor Smith talked about the importance of not adding disadvantage to the people who were already disadvantaged, which is also important globally.

This is the paper that Dan so kindly mentioned. I had 18 co-authors. Zeke Emanuel put it together. And this is where I got, I'll be building on this paper, and where we invoked three principles for fair vaccine allocation globally. Uh, one principle we didn't so much uh, develop, but just presumed, is the principle of justice or fairness, because that was the problem we took: is how to allocate this vaccine fairly on a global basis. And then the two principles that we spelled out further are the kind of principles that Marcus Rensen would call an informational basis for implementing justice, things to pay attention to when trying to be just. The first one, crucial in this setting, is benefiting people as much as you can and limiting harms as much as you can. And then the principle, which we all agreed on, of you must not further disadvantage people who are already disadvantaged through no fault of their own.

It became clear to us as we were working on this global fair allocation problem that this is really not your usual distributive justice problem. Why not? Well, because there's, for one thing, there's only one commodity being distributed. People are either going to get it or they won't get it in the near term. And over the near term, or if we think of that as a couple of years, anyway, as supplies ramped up, we can hope that everyone will have been offered it in due course, whether they accept it or not. Um, but everyone is in quotes there, because some people, many people, will die before the vaccine can save them. So, the key aspect of this problem of distributive justice is the timing. The key question is, who gets the vaccine when? And this is a question of urgency, which we can think of as a kind of amalgam of seriousness and time sensitivity. And we argue there are three tiers of urgency relevant to this problem. There's one devastating, irreversible, and non-commensable and non-compensable harm. You can probably guess what it is, right? It's death. So, death is devastating, it's irreversible, and as far as I can think, it's the one harm that you can't compensate anybody for. You can't compensate someone for having died. You can send compensation to the family, but that's not the same thing. There are, of course, other devastating and irreversible harms flowing from this pandemic: incurable organ damage, or setbacks to education and employment that will outlast the lives of those now living. Count as irreversible for them. There are other still devastating harms that are not irreversible but really quite terrible. But we argue that given the focus on urgency, we really must give first priority to averting death.

And this is still very much our problem. So, in the United States, things are somewhat under control. It's not terrible the way it was in terms of the deaths, but in the world, it's getting worse. And I think going to continue to get worse. We have, on average, right now, over 11,000 deaths per day worldwide. And so, we've got to continue to prioritize averting deaths around the world. And again, we're doing pretty well on this in the United States. This is now looking at deaths per capita per million people. And it's, some comments on this: India looks like it's only doing a little bit worse than the United States per capita in deaths right now, but everything you read about India says that the deaths are way underreported there, which is not the case here. And then I've highlighted these five countries in South America that right now are really being hard hit by the virus, and lots and lots of people are dying if you look at it on a per capita basis. And that's the kind of place where they really need the vaccine. And we in the United States, I think we, using "we" for we Americans, I should steer vaccine doses there, as as should COVAX, the international facility that deals with the low and middle-income countries getting them vaccine. That's where the vaccine should go.

And again, another way to look at the U.S. being in good shape is that our reproduction rate of the virus is reasonably low. In the paper, we said any country that gets its reproduction rate below one should start giving doses uh, to other nations that need it more. We got below one uh, in mid-April, and now comfortably sitting quite far below one. And I've picked these other countries where the reproduction rate is going low, which is a harbinger of terrible things to come. And particularly worrisome to me here are the two countries in Africa, the Democratic Republic of Congo and Uganda, especially where those are shooting up. And it's going, it's really an indication that things are going to need to be handled there with vaccine. So, we've put our oxygen masks on for ourselves, well enough, and it's time for us to now attend to those in serious danger.

I also, looking at that from the point of view of how much vaccine we've directed to ourselves, uh, we're way more vaccinated than the other parts of the world, although there are countries that are uh, exceptionally exceptional to this. But and it's, it's the least advantaged parts of the world, especially if you look at Africa, that are the least vaccinated. Almost no vaccine yet administered in Africa. So, you might say, given the time scale, we've already used more than our fair share of COVID vaccine, and it's time to help the world's most disadvantaged countries. And one more point about not further disadvantaging the disadvantaged. So, the poorest countries in the world experience the lowest life expectancy at birth. This graph shows data that, it's preliminary data, but suggested that that in the poorest countries of the world, uh, younger cohorts are much more likely to be dying of COVID-19 than in Europe or North America. So, if if they don't get the vaccine, you're going to get a compounding of this disadvantage that already exists, and it's undeserved disadvantage in terms of life expectancy.

It's amazing that we have all the vaccines that we have. It's amazing that two million, two billion doses of vaccine, where thereabouts, have been administered around the world. In the United States, that rate is tailing off because, you know, Americans are the Americans who aren't vaccinated haven't aren't that interested. But the problem is huge, right? So, I applaud President Biden's donation of 80 million doses. That's a start. But if we have the goal of vaccinating 70% of the world's population, which we should really try to aim at, that that will take 9 billion more doses of vaccine, and that needs to be spread around the world. And the world will just need lots of help from the United States on that.

So, just to recap, fair allocation of COVID-19 vaccine calls for giving first priority to averting deaths. The problem is one of the shape that this justice problem has means that the urgency is what matters. Things that are not only irreversible but non-compensable, we must do. We, the United States, and COVAX must do all we can to get vaccines where they will avert the most deaths. And I recognize that is hardly an easy job. It's a very complicated job. But we in the U.S. can well afford to do this now, and we have the know-how to help out with this now and to figure out what must be done. And to fail to do this, and this was my last point, was would be to unjustly further disadvantage the world's already least advantaged, who were people who were disadvantaged through no fault of their own. And I haven't even mentioned that in this case, what morality demands goes together with what's in our self-best interest. But you've all heard this, that that by failing to stop big surges from happening abroad, we're just opening up opening the world to dangerous variants being bred, and then we'll be in bad shape because of that. So, thank you.

Thank you, uh, thank you, Henry, another um, sobering talk with um, a tall task for us, as uh, Patrick had before you. Um, continuing on our sort of public health ethics approach to this, we're going to have our next speaker is Larry Gostin, a University Professor and Founding O'Neill Chair in Global Health Law here at Georgetown. He directs the WHO Center on National and Global Health Law and he's a Professor of Medicine here at Georgetown and a Professor of Public Health at Johns Hopkins. Um, he's served in high-level positions for the WHO um, on topics including global health equity, pandemic influenza, genomic sequencing, migrant health. And he served as a Senior Advisor to the UN Secretary-General's Post-Ebola Commission. His book on global health law has been translated into many languages and read throughout the world. And Larry is going to talk to us about a sort of cross-cutting issue in public health ethics, which is the balance between individual freedom and common good in public health ethics, particularly as it's played out in the COVID pandemic. So, Larry, thanks for joining us. The floor is yours.

Thanks very much, uh, Dan. And also, just congratulations to you and the Kennedy Institute of Ethics. You know, to have a half-century of excellence is really quite something. And um, so

I just tipped my hat to you, and it's just been in a fantastic panel. And I don't feel like I, you know, measure up to the, uh, to the standards that that we've had. But I've worked on all the areas we've talked about. Um, and I've been very deeply involved in the the pandemic. You know, we're now about a year and a half into it. Um, the, when, uh, almost every aspect of COVID-19 has been kind of an exemplar or even amplifying all the kind of major ethical themes that the Kennedy Institute of Ethics has been working on for all these many years.

And so, you know, let's just begin at the beginning. You know, where, when, um, China reported, um, a cluster of cases to the World Health Organization. In fact, what actually did happen was China didn't report, but WHO found out those reports from unofficial sources within China. China then belatedly, um, uh, confirmed those cases. Um, but soon afterward, um, the world faced something that the world has never faced before. It was the lockdown of 20 million people in in Wuhan and 20 million people in in Hubei province. And I remember at the time that I said that that this could never happen, um, in a liberal Western democracy. But of course, it happened in London, Paris, Milan, uh, it happened in New York, uh, and throughout the United States. Um, and the biggest shutdown in the history of the world, probably was India, including Delhi. And so we've seen, um, in at one point in the pandemic, over 60% of the population literally locked down. I mean, you couldn't possibly imagine, um, a more thorough deprivation of of of mass and individual liberty.

And so you've had the tension between public health in a crisis and liberty. Um, you've also had, um, uh, you know, deep questions of autonomy. You know, should I wear a mask? Must I? Must I be forced to be vaccinated? Do I really have to stay at home? All these kind of individual choices, again, pitted against the common good. We've seen, um, in America and throughout the world, um, struggles between traditional freedoms like religious freedom and public health, with the Supreme Court, you know, hearing, uh, COVID in religion cases, I think at least three, maybe four times, and shifting its view from, uh, the time when it became, uh, before it became a firmly conservative majority, and, and before that.

And we've also seen, um, clashes on religion in South Korea and a whole, whole range of other places. Another big area between the common good and individual freedoms was privacy. We've seen things that we hardly ever see in public health, for example, contact tracing applications, which have not been particularly well used or populized, popularized in the United States, but had huge impacts around the world, particularly in in East Asia, but also in Europe, where one can track our ability and where we are now.

Of course, um, the, the thing that all of the panelists, you know, um, uh, have talked about, Henry with vaccination, Patrick with race, and, and, and others, was equity. Um, I always believed that even before COVID-19, that the prevailing global narrative, um, was a narrative of inequity. Inequity based upon race, socioeconomic class, poverty, whole range of other things. And that before the pandemic, and this has changed since the pandemic, we had had ever-rising rates of global health. And you'd hear many of the the great and the good in in global health, you know, the Bill Gates at the time, Margaret Chan, head of the WHO, um, Joe Mike Bloomberg, all of them saying that we've really done extraordinarily well in global health. In many ways, we have. If you, if you track the MDGs, for example, or even many of the SDGs, you find, um, huge advantages in humankind with numbers of people in absolute poverty plummeting, child maternal deaths plummeting, people in sub-Saharan Africa on antiretroviral medications for AIDS making enormous progress with malaria and tuberculosis, um, uh, child survival, you name it. Um, we were doing really well with it before COVID. But even before COVID, there were huge gaps between, um, those who had the advantages of health and those that didn't. And this was only amplified in enormous, um, ways, um, during the COVID-19 pandemic.

Of course, Patrick is right. You know, we, you know, in one way, we're all in this together, but in another way, we're not in this anywhere near the same. Um, certainly not in the United States, and, um, doubly, triply so, um, globally. Um, you know, I, I, I tweeted out something that just really kind of struck me. Um, it was just a little, um, uh, notice on the front page of the New York Times, which basically said, you know, now, now that we're getting back to normal in the United States, we're going to tuck the COVID coverage, uh, in beyond the front pages into the back pages. And it just was jaw-dropping, just as the world is not even at the peak of COVID illness and death, where it's really moving, um, uh, to the Indian subcontinent, um, where there's a resurgence in in East Asia, where Latin America is on fire, where sub-Saharan Africa, as it is, is an extreme risk, and where, uh, vaccine inequities, um, have become, in the words of of Tedros, uh, in the greatest moral catastrophe of our modern age.

And I remember that after Ebola in West Africa, when the last case left the United States, literally the media stopped on day one covering it, uh, entirely. And yet, uh, it was still raging on in in West Africa. And, you know, this is, you know, I, sadly, typical of the United States, where we're a country that that in some ways has great compassion for the world, but in some ways is very ignorant to the world and only looks to ourselves. And so, you know, I'm writing a paper right now, um, on risk, risk trade-offs in in the COVID-19 pandemic. You know, how do we, how do we make sense out of the idea that, you know, we want to save COVID lives, but at what cost? Um, in some cases, you know, I think that there's some synergy between, um, the common good and individual liberties. Um, for example, with, with, um, business closures or masks, um, you actually can get the economy back moving more quickly if you can, if you can lower COVID rates. But in so many areas, we've struggled. We've closed our schools and, and, and we've had kids, uh, losing a generation of education. We've seen it much more so in black and brown and poor populations. Many of us can learn remotely, but many of us cannot. We don't even have reliable internet access.

And so as we kind of look forward, uh, it'll be very interesting to see what we've learned, if anything, from the COVID-19 pandemic. What we've learned in terms of our ability to embed equity into the future of pandemic preparedness and response. Whether we will invest in in the kinds of pandemic response that will actually be effective. Will we have a pandemic treaty? Will we have a, um, a relaxation of intellectual property rights at the World, um, Trade Organization? Um, there's so much at stake. And, you know, and I, I keep thinking, um, what will the world be in the next year, two, three, or four? We might go one path where we all kind of go back into our silos and our selfishness, or we might take another path, and we might choose to work together, both for global health, but also for justice and equity. And I'm not sure exactly where we'll come out. If history's any guide, we'll lurch from panic to complacency and we'll go back to things the way they were, normal. But sometimes you can get opportunity out of a crisis. And, and I don't think any of us in this world have experienced the kind of a crisis that we have now, certainly not since the 1918 pandemic of influenza, and of course the two World Wars. Um, but we do face a choice going forward as a planet about whether or not we're going to, you know, choose justice, equity, preparedness, um, whether we're going to be affirming on the value of of science and, and the common good, uh, or whether we'll go back to our tribes and in our selfishness. Um, and that still remains to be seen.

And so again, congratulations, Dan, and the Kennedy Institute of Ethics on a great run and a hope for 50 years more. Uh, thank you very much, uh, Larry, um, for your, um, words of kindness for the Kennedy Institute and also for an excellent talk. And I think many of us share your hope that we might really learn something as a, as a world community from this, but particularly as Americans. So we have 25 minutes now for questions, which is good. So, um, maybe, uh, first one, we'll go all the way back to, um, to Karen, if we could. Um, you know, one question that arises, I guess, is whether respect is ever love. So what do you do with the woman who drops the coupons? And if you are standing there, do you, are you standing there because you, um, respect her or because you love her? That's a tough one to start with.

I, both, I think. I mean, I still remember this, right? Because it goes against all your instincts. Like, but, you know, I didn't want to disturb her or worry her about coming closer, I mean, physically coming or touching her coupons and all of that. And I think you could describe it either as respect or as love. And I don't think they're always clearly separable, um, in this case. And I think the physical distancing of COVID is interesting because it does combine both. It combines respect for someone's space and, you know, the freedom, but also caring concern for them. Um, yeah, so I think they come, they come together sometimes. But I think they're also, there still is that tension though.

In that, no, I agree. I'm, I also want to remind, um, folks, I'm reading some of the questions that have come in, but if you have more, you can put them in through the Q&A function. And, and then I'll be able to relate them to, um, either all the panelists or if you have a question for, uh, a particular panelist. Uh, one that came in for, uh, for you, Christine, I think is an interesting one was sort of the, the ethics of communication about ethics in the public arena during, during this. What do you think? Did we do a good job of talking about, you know, the ethics of vaccine allocation, the ethics of ventilator triage, and all those kinds of decisions? Or did we just drop the ball on that? And how do we best, best have a public conversation in the crisis?

A great question. I do think that bioethics has become more visible during the COVID pandemic for reasons that you just stated, Dan. I mean, there were bioethicists, uh, visibly involved in developing allocation guidelines and crisis standards of care and vaccine allocation policies and, you know, policies at institutions as well. And I think that there was a recognition, at least on the part of some people, that bioethics had something very important to contribute to those discussions and decisions. I think it's an interesting question, and it follows with some of the things that have been said. You know, what, how will that be sustained if it will going forward? I mean, I think the, the question will be asked, did we do a good enough job as bioethicists? Were we, you know, we were there, but were we effective? That's one thing to ask. And how do we going forward maintain involvement in a way that makes sense to people? And I mean, by makes sense to people like at organizational levels, but also the public. You know, if the public is, um, on board with some of those decisions in terms of vaccine allocation or, you know, crisis standards of care, that would make more sense to say bioethics did a good job. So I think we have some evaluation to do, uh, going forward.

Thanks. One, uh, one question for, uh, for Patrick. Um, you seem to talk, um, mostly about, um, the hope, which maybe is Larry's hope that we would have a better sense of solidarity coming out of the, uh, the pandemic and, and a commitment to addressing the, the kinds of inequities that led to the disparities in healthcare outcomes, um, along racial, ethnic, and socioeconomic lines. But you really didn't say much about what could or, or can be done now in terms of very practical, immediate responses. Do you think that, um, sort of, for instance, the way in which we distribute vaccines ought to be affected by the ways in which there's been a disparity in outcomes? Or do you think that the real task before us is to address the underlying structural questions that led to the disparities in the first place?

Uh, yeah, thanks, Dan, for that question. And the answer is yes, right, uh, all the way around. I mean, it's interesting because I do, when you use the word hope, I was thinking to myself, yeah, hope versus this notion of what's needed, right? Um, right now. I don't use the term optimism, right, as a kind of inevitability that things are going to work themselves out. Uh, hope, I will say, at least my connotation of hope is built into this kind of African-American religious ethic that I kind of have. In other words, it's a way of looking at where things are right now, envisioning a future that can be different, and working to that end, not knowing whether or not those efforts are going to ultimately come to fruition, right? So it's not, uh, optimism as an inevitability. It is something that requires a very, uh, long-term, sustained, disciplined, uh, work. And so when I kind of end it with with King's, uh, you know, the question of the toughest book, where do we go from here? Right? Community or chaos? Right? That is the question, I think, in many ways, uh, that's before us. So, yes, I do think we have to look at these larger, you know, kind of structural issues. I, I use this phrase, racialized imagination, because I do think that, uh, this connects to, I hate to use a 25-cent term in this space, right, the kind of the epistemic frame of reference with the ethical life, right? In some ways, how we imagine, how we do life together, and the potential for us to be able to reimagine, uh, how we could do life together, that there's not any kind of inevitability with the way our social relationships, um, um, come together now. And so in that sense, the emphasis is looking at how do we arrange our social life, being aware of how policies are playing out, uh, now, and how they have historically, yes, uh, but then also in terms of a concrete level, which I didn't get into, I was trying to be, uh, judicious with what I wanted to say, uh, in terms of just, you know, kind of giving me steps. I do think if we're thinking in terms of the issue of bioethics, right, uh, a colleague of mine, Charlene Gallarno, I think he's done really good work talking about bringing community back into bioethics, right? We often make these dichotomies between, like, clinical bioethics with a set of ethical principles, public health ethics with a particular set of principles, but the reality is is that we're not just individuals, right? We're individuals in particular communities, or as King would say, uh, persons in community, so to speak, which brings these things together in ways that, uh, sometimes are, are hard, right, for us to try to navigate. But it does put a very different equation on how we think about, um, uh, principles of like maximizing benefit, utilitarian calculus for particular populations, right? Or having kind of individualistic ways of thinking, you know, in terms of dealing with the autonomy and so forth with, with particular, uh, particular patients, right? So in this sense, when we think about the racialized imagination and how it has played out in communities, I think that should go into our calculations as we think about these various policies. So instead of having it saying, being attentive to these issues means this is the policy that we implement, it means factoring that into the calculation of how you begin to think about these issues. Because the last thing I'll say here, Dan, is that all, uh, forms of justice, I want to say that that's okay to have some abstract ideal theories of justice, but those justice principles of justice have to be implemented in particular concrete situations, and the context determines exactly how that works out. And I do, along with many other folks, think that we have made moves in bioethics, and we can do more about learning about the history of racism in this country, how it plays itself out in terms of clinical ethics encounters, and the connection, social determinants of health, uh, and how it plays out in terms of clinical realities as well.

I also, um, hear, hear within your voice a little bit of, uh, Reverend King saying, I might not live to get there. Oh, Lord, I certainly, uh, hope so. But, but not optimistic. Yeah, right. Um, that, um, uh, take, go, switching back to the global, um, uh, um, perspective again, a set of questions that I think can be posed to both Larry, um, and Henry. And maybe the first one more to Larry, and the second one more to, um, Henry. One person just simply asked, and that's maybe more for Larry, why do you think the world was so late to even think about, um, the justice questions about distributing vaccines? And then a question for, um, for Henry, is whether waiting until your, uh, R factor is less than one, is that a concession to just sort of practical, uh, self-interest that you think is in countries, or is there some more sort of principled view of justice that that underlies that?

Right. Um, I mean, I'm tempted to answer the question that was posed to Henry as well, because, but, um, on on why we were late with equity, you know, we really weren't very, very late with equity. Um, the, the WHO formed the ACT Accelerator, which was really the global mechanism for, um, uh, promoting, uh, COVID-19 medical technologies, including vaccines. COVAX is the, um, is the, is the vaccine arm of the, of the ACT Accelerator. You know, that that came quite early, and it got a lot of nominal, um, support from governments around the world. You know, the equity problem was really, you could probably narrow the equity problem down to 10 countries around the world, or probably less. You know, the US, the UK, Canada, even though it hasn't done all that well, and part of the European Union, although it was late, basically pre-purchased the vast bulk of the vaccine supply. And that which left COVAX, um, with, um, a chronic and, and now exacerbated, um, supply problems, particularly, um, now that the Serum Institute of India is, is under an export ban, and they were going to be the engine for, uh, AstraZeneca vaccine for, um, COVAX. So, you know, the, the equity problem has really been caused almost wholly by a handful of, in, in high-income countries. And because it was caused by those high-income countries, the vast burden, the ethical burden, um, uh, and also the, the burden in terms of the capacity to, to actually do it, falls on the, on these high-income countries. I, I think President Biden has made a nice start, um, but it's going to take a lot more, um, for us to be able to, to, to get beyond this. Many of us have written, and I certainly have, about very concrete ways that one could, um, quickly get to much more equitable vaccine distribution in the world. Um, and if we, so we have the capacity to do it, um, and the question is, is whether we have the will. You know, the capacity has to do with, you know, waiving IP, technology transfers, transferring the know-how, building manufacturing capacity in particularly a number of high-performing middle-income countries, and then massive donations. Um, donations of, we've, we've tended to look at as the most immediate, um, and most pressing way to get to equity, and that's absolutely true. But if you, if you donate a dose, you save a life. If you, if you, um, transfer the technology to make a vaccine, you save a country, and ultimately the world. And how we're going to get to equity, um, in the next pandemic won't be just from philanthropy and donating doses. It will actually be an equitable distribution of, of the capacity to manufacture COVID medical technologies, or pandemic medical technologies, um, around the world, so that people can save themselves and they don't look to other countries to save them.

Henry. Yeah, I second everything Larry has just said. And just to comment on the focus on equity, sort of from the global point of view, those dealing with the ACT Accelerator and COVAX had their eyes on equity from the very beginning. Uh, and Prime Minister Trudeau and Canada and other supporters were very vocal about that. But unfortunately, they, at least initially, went to a kind of knee-jerk idea of equity, which is sort of equal per capita, pro rata basis to cover the first 30% of each country's population, is not taking account of the urgency, which I've tried to argue with the key thing. And that gives me sort of a pivot back to the US situation because, you know, the, the US was really hard hit for various complicated reasons. You know, the, the pandemic in the US spun out of control, there were lots of people dying. So, so we would have been, you know, pretty urgently in need, and it was certainly hard, would have been hard in the throes of that to be sending vaccine doses abroad. We could have sent a lot of money abroad, but we didn't do that, unfortunately. But the, the our number getting below one was basically just a concession to vaccine nationalism. But let me explain a little bit more why I, I pitched my remarks to us to we, my remarks were pitched to we, the people of the United States, because the main moral argument for vaccine nationalism is that the elected politicians have a responsibility to look out after their own citizens. But in a democracy like ours, we citizens have a responsibility, as Karen was looking to, to think for ourselves and to tell our government what we want. And so partly I'm trying to convince you all is we need to get this message out to the citizens that we, the citizens should want now our government to be sending the vaccines abroad because that's the right thing to do and that will save lives and that will also, by the way, you know, reduce these dangerous variants coming at us.

One, uh, question that's come in that I think it could be from anybody or all of us on the panel is that a question that wasn't on my list of ones that everybody else has asked, nor the ones that we're asking today, but more question about the ethics of contingent, uh, issues and some ancillary issues, like the ethics of visitation restrictions and people dying alone, sometimes even having clergy kept out of the rooms, or the ethics of postponing elective or urgent, sometimes urgent medical procedures in order to facilitate caring for patients with, uh, with COVID at the peak of the crisis. Um, anyone have comments, um, on, uh, on those issues?

I'd say something about the visitation policies. I think, you know, it reminded me of some of the things that Karen was talking about. You know, the visitation policies were put into place in an urgent setting to reduce the number of people that were being, you know, gathered together and reduce exposure to vulnerable people. So it made sense. There was some scientific rationale for making visitor policies restrictive. However, I don't think in the very beginning, people thought through carefully enough the full consequences of such policies and the, um, the isolation of patients who were dying, in many cases, without having family members nearby at all, or having them only on a screen, and the isolation of those family members who couldn't see their loved ones at the end. And the, the incredible moral distress that the healthcare providers experienced having to make that connection happen with very little, um, both time but also resources. And so I think the, I don't think the visitation policies were wrong. I'm not saying they were wrong, but I think they should have been more fluid. People should have, and some institutions did spend some time thinking about, you know, where can we make exceptions? How should we make exceptions? How should we change this as community patterns of disease change? How do we think about the consequences of these kinds of policies that go way beyond protecting people from infection? And, and I think again, it's something that we're hopefully we've learned from and will, um, be more thoughtful about the next time.

Anyone else want to make a comment on that? Uh, yes, I would like to speak to the other question about postponing urgent procedures, which the why that was done was much for the kind of reason Christine was just alluding to, that it was a terrible emergency, and you had to pull all the doctors in the hospital to deal with COVID patients. And in many cases, where things got terrible, and in in countries like what certainly was happening in India, where the, the hospitals are completely overwhelmed, you know, nobody wants to go to the hospital in those conditions. But from, from the ethical point of view, and just to amplify on the position I was putting out about the importance of averting death using vaccines, a key way to avert death using vaccines is to get the outbreaks under control enough that the health system doesn't break down. And that means that people can go and get their urgent procedures in the hospitals. So I, I would count in our paper, we were counting as deaths avertable by vaccine, the deaths that are caused because people don't get the urgent care they need for their heart or whatever it may be. Uh, so we shouldn't just look at averting deaths from COVID itself as the cause of death, uh, on that, on the coroner's form, but using vaccine to avert deaths from also these knock-on and direct causes that that terrible outbreaks can lead to.

One, uh, more question because we're running out of, out of time, and of course, this is a big one. Um, somebody wants to know what all of our panelists think about vaccine passports. Who wants to go first?

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Um, well, I've got an article coming out, uh, Monday morning in JAMA on that. Um, what do I think about vaccine passports? You know, I think that, um, I think that the, the arguments in favor, arguments against vaccine passports based upon autonomy, um, or privacy are, are weak arguments because I think individuals have a right to make whatever decision that they want about their own health and well-being, but they don't have the right to be maskless and unvaccinated in a crowded space. But I think equity is is the large issue, as I think you've learned from all the rest of our conversations. Um, and so as long as everyone who wants a vaccine can get a vaccine, um, I think that, uh, so-called vaccine passports, really proof of vaccination systems, are a better way of terming it. We can get us back to more normal life more quickly, and that's happened, and it's going to happen, um, in many parts of the world. But equity, I think, is the huge issue. And, and certainly with international travel, um, the idea of conferring more privilege on the already privileged and, and, and making it more difficult, um, for, uh, people who don't have access to vaccines to, to do ordinary things, I think is an unspeakable injustice. And so for me, the key issue for, um, vaccine passports are equity. And if equity has to come front and center, unfortunately, we're really out of, out of time.

Um, the conversation has been incredible, and I'm sure that, um, the audience shares my enthusiasm. Could probably go on for another, uh, hour here. But I think that, um, all of you have been very generous in giving your time on a Saturday morning to us. But it's really been, from my perspective, a superlative end to five wonderful days of bioethics. I'm deeply grateful to, uh, to all of you, to Karen, to Chris, Patrick, to Henry, and to Larry. I'm really, most, most of you, I work with pretty regularly, and I'm really blessed to have wonderful colleagues like you. Um, and especially those who are here at, uh, Georgetown, at the, uh, at the Law School, at the Kennedy Institute, at the Pellegrino Center. Just a chance to reflect, uh, for a few seconds on 50 amazing years for the Kennedy Institute. You know, I'm, I'm part of the second generation, I guess, of bioethicists. I first met Ed Pellegrino in 1987, and I couldn't imagine that there wasn't already bioethics happening for a thousand years. I didn't realize, really realize how new it was at the time. And sort of look at us, look at us now. I think we have to thank the Kennedy Foundation for the vision to start this over 50 years ago. Um, I want to also thank our many other benefactors, people currently like Kathy Eugen, who've been very supportive, Fran Buckley, who supported, uh, all the costs for this program so we could send it out to the world. And I think there are over 300 people who've registered for this program to be able to do this to you for free. We look to them and to others of you out there to help support us to make the next 50 years even better. Um, I certainly want to thank our president, Jack DeGioia, Provost Bob Rose, for their support and encouragement and their willingness to give of their busy time during graduation to give us some welcoming remarks. Um, to all of our speakers over the last, um, five days, um, mostly from the Kennedy Institute, Pellegrino Center, but some like on today who also come outside and donated their time to, uh, to us. I certainly need to thank John Keown, who took the lead in organizing this event, which I think has been really splendid. Our staff, especially, um, people you don't see behind the scenes, like Lucas Chandler and Laura Bishop, who've done countless tasks that none of us know about, but make this all work smoothly. Mike and Sydney Lucan, who assisted them. Our librarians, particularly Roxy Friends and Written, who prepared the online bibliographic resources. Optimum Audio, I think they've done a great job with recording and editing and streaming. But most of all, to thank, um, all of you who joined us daily, those who will join us, uh, asynchronously, perhaps in the, um, in the future. We hope you share our passion for bioethics, a passion that we think is going to ensure a bright and really exciting future for the Kennedy Institute as we navigate the next 50 years in partnership with the Pellegrino Center, the Program Environmental Justice, and the Center for Digital Ethics, as we try to build out our emergent ethics network. My motto has become, it takes a network to solve an ethical problem today. Um, we started with an approximation of a network with a panel today, and I think we did a pretty good job. And so I want to thank you, um, for listening in, um, for your questions, um, for your support over the years. And, um, don't forget your evaluations. I'm remiss if I don't say that. Thank you all very, very much, and we look forward to continuing to work with you in the future. Thank you all.