Prudence in the Pandemic

We do not exercise moral judgment in the same manner in every instance. Broadly, there are three basic situations in the moral life, which require three different ways of thinking. The recent pandemic, and the ensuing reflections on our moral responsibilities as civic leaders and citizens, demonstrate that we’re often confused about these situations. We need to clarify basic principles so that we are better able to make our way when rigorous but nuanced moral judgment is called for.

One kind of demand on moral reason concerns things we are prohibited from doing. In these instances, the moral principle is clear: We are not to murder, steal, lie, or do other wrongful things. But we often need to discern whether a given act qualifies as prohibited. Does my evasive answer to a direct question amount to a lie? When a patient’s death is accelerated by the use of painkillers, is the doctor a murderer? Should we say that charging excessive interest on a loan is a kind of theft?

There are also things I am obliged to do. This is the second basic situation. I have a duty, for instance, to honor my parents and care for my children. Again, the principle is clear—but like prohibitions, obligations require moral judgment. How shall I best honor my parents and properly care for my children? What happens when I think my parents are mistaken about an important matter of principle? What if the individual needs of my children are quite different, even competing?

Important as they are to the moral life, these two types of situations make up a small ­fraction of all the situations that confront us. For the most part, we face situations in which the range of what we are permitted to do is quite large and nothing is strictly obligatory. Our duty is open-­ended: We are asked to discern the best course of action and to take it. Should I increase my weekly donation to my church, or should I put the money into an account to pay college tuition for my children? Should I attend graduate school in philosophy, or should I go to law school? Should we take a camping vacation in the Rocky Mountains, or should we go East to visit family?

The vast majority of decisions facing civic leaders fall into this category, because the general obligation to promote the common good does not issue in definite prescriptions. Should the city spend a budget surplus to refurbish the public park, or to repave the streets? Or to add a musical therapy teacher to the special education program at the school? Or is cutting taxes the best way to spend the surplus? A morally modest person will allow that it’s rarely obvious which course of action is best in these circumstances. The trade-offs are usually too difficult to parse with certainty. But a morally serious person insists that there usually is a best course of action, which is why the duty to promote the common good is a meaningful duty and not an empty one.

The same is true when civic leaders address threats to public health. These situations present a wide range of options, limited only by the obligation to do what is best for the body politic. How much of the public purse should be spent on fighting a disease? To what extent should the normal functions of ­society be suspended? When is it fitting to suspend civil liberties for the sake of policies that may save lives? Neither prohibitions nor positive duties provide much guidance here. Failing to save as many lives as possible is not tantamount to homicide.

Responsible decision-making in pursuit of the common good involves trade-offs. This is true even of decision-making during a crisis. Money spent on public health cannot be spent on the education of children. Shelter-in-place policies mean that weddings and funerals are no longer communal events, and public worship is suspended. Travel restrictions, obligatory quarantines, and the forced closure of businesses run counter to established rights. How are we to navigate those trade-offs? Which way forward sets us on the best course of action?

In spring 2020, many insisted that no trade-off that weighed human life against “economic” values was permissible. This claim suggests several confusions. Value is not “economic” or “non-economic.” When parents pay for their daughter’s wedding reception, they are not engaging in a “merely ­economic” exchange. They are signaling their support of her union with the groom and honoring the institution of marriage. We rightly criticize a mentality that imagines that this support and honoring can be measured by how much is spent, as if a lavish wedding reception certified the moral and spiritual commitments of the parents. But it is equally wrong to think that there is no relation, as if the parents could say to their daughter, “Honey, we’re not going to spend a dime, but you know we’re incredibly happy for you.” We are always weighing the relative value of things, because unless we have infinite resources, we can’t have and do whatever we want, whenever we want.

When, during the COVID-19 pandemic, people insisted that we not “put a price on” human life, what they seem to have meant is that saving human life must, in all instances, trump other considerations. This principle can be ratcheted up to the extreme claim that we must never spare any expense, lest some get the disease and die who otherwise might not. On this logic, we do not face a general obligation to take the best overall course of action, an obligation that entails deciding among competing goods. Instead, the spread of a dangerous disease requires us to follow a clear prohibition: It is always intrinsically evil to act with the knowledge that one is putting another’s life at risk.

This moral position is impossible to maintain with consistency. Commanding troops in battle is a particularly clear instance of wittingly putting the lives of others at risk. A crew boss knows that workplace accidents occur, sometimes fatal ones. Hospital administrators know that healthcare workers sometimes catch dangerous diseases from patients. Driving a car always entails the witting acceptance of the statistical risk of causing a fatal accident. Traveling to exotic locations means accepting the marginal risk of bringing home a tropical disease. The list is long, perhaps endless. Given the fragility of our condition as mortal beings, very nearly every human activity puts the lives of others at risk. Childbirth is exemplary: It poses a risk to the life of the mother, and the child’s entrance into the world invites the peril of death.

This hard fact about the human condition puts us in what seems an impossible dilemma. If we affirm the infinite value of all human life, then we seem committed to ruling out all trade-offs—and life becomes a series of tortured and impossible demands to avoid any risk to the life of another.

In practice, most people adopt what I’ll call the sentimentalist position. The sentimentalist affirms the infinite value of life. He deplores compromise with the unavoidable practical demands of social life, promising that sincerity of commitment will somehow compensate for them. He abandons logical consistency. Though he insists that we have a duty to save lives “at any cost,” he capitulates to the limits of what we are willing to sacrifice—even as he denounces those limits as “heartless.”

If we placed only a finite value on each human life, we would preserve logical consistency. But when we say that saving lives is worth only a certain amount, we seem to surrender key components of our proper affirmation of human dignity. In the most extreme instance, the absolute prohibition on intentional killing falls by the wayside. If life is merely one value among others and we can assign it a finite value, why not allow a person to be killed if a greater good can come of it? Why not toss a passenger overboard if it will prevent the ship from sinking? In more routine circumstances, placing a particular value on life can underwrite invidious distinctions among people based on their quality of life. Whether it takes extreme or moderate form, I call this the calculorist approach.

The sentimentalist and the calculorist approaches seem to be at odds with each other. But both assume the same account of practical rationality, one exemplified in the philosophical work of Adam Smith and David Hume. Most (but not all) economic models of rational decision-making assume this account of practical reason. I will call it the Hume-Smith model. It evaluates an action based on the difference the action makes to the world.

Difference-making is subtly but importantly different from the consequences of an action. Let me illustrate. Suppose we stipulate that minimizing murder should be our highest priority. Now suppose I have to choose between committing or not committing a murder. Let us suppose, further, that by the murder I choose to commit (or not), I will prevent the commission of three other murders (for example, by killing a person certain to begin a murder spree). Given the supreme value of preventing murders, I should (according to the Hume-Smith model) commit the murder, ensuring a world-state in which one murder occurs rather than a world-state in which three occur. This conclusion follows because the Hume-Smith model takes into account all of the differences that an action makes, not merely its consequences, which in this scenario are limited to the death of the person I decide to kill. Thus, it is misleading to call the calculorist approach simply consequentialism.

The Hume-Smith model relies on what Thomas Nagel calls the “view from nowhere.” The choice-worthiness of an action is reducible entirely to the difference the action makes to the world, and we can know that difference only by evaluating the total state of the world from the perspective of a detached, ideal observer. This observer is charged with ­evaluating the net gains or losses to the total value of the state of a world. He does so without reference to the acting person or to the nature of the acts by which total value declines or rises. From this perspective, I am obliged to commit murder if I thereby minimize the total number of murders.

We are rightly troubled by this approach to moral reason, for it paradoxically abstracts from the values we cherish in order to arrive at a view of “total value.” The sentimentalist is right to say that life is of infinite value, if by that he means something precious in itself and not merely a component in a greater “total value.” But sentimentalists accede to the reduction of practical rationality to the Hume-Smith model. They are thus forced to abandon rationality altogether and resort to emotion.

Fortunately, there is an older model of practical reason, one grounded in the works of Socrates, Plato, Aristotle, and the later Stoics, and passed down to us through the works of Cicero, Augustine, and Thomas Aquinas. This model does not pretend to ascend to the view from nowhere and assess the “total value.” Instead, it asks which action is most worthy of choice here and now. It judges the goodness and badness of actions, not the goodness and badness of an entire world-state. From this perspective, the value of an action’s outcome exhibits path-dependency: How we reach the destination can be as important as the destination itself.

In the Summa Theologica I-II, question 18, ­Aquinas identifies four reasons why an action is choice-worthy. The first rests in the value an act shares with all human acts. The second concerns the essential nature or species of the act. The third is the intended end of the act. The fourth is found in assessing the relevant circumstances.

All human acts engage our freedom and reason, and for this reason it is more choice-worthy to engage in human action than to decline into a passive or vegetative existence. But we can set aside the superiority of a life of action to one of inaction, since it is not relevant to the choice among alternative actions.

This brings us to the second element: the essential nature of an action. It is determined by the immediate “object” of the action, that is to say what is done, most properly speaking. In 2012, Matthew O’Brien and I argued in the American Catholic Philosophical Quarterly that “what is done” can be identified with the specific powers of the human being that are being exercised—the capacities and skills that are employed in making the action happen—and the objects upon which those capacities are directly applied. If I make change for a customer, I use my powers of reason to calculate the proper amount to give him, and in so doing ensure I select the proper bills and coins to give him.

Correct change-making is a choice-worthy action insofar as it serves the proper end of a just exchange, the third element. But some actions cannot be directed toward proper ends. These are intrinsically evil acts, such as lying or cheating. I may not use my power of reason deliberately to miscalculate the change due to a customer so that I can pay the store’s rent, nor even so that I can make donations to charity. Such actions are intrinsically evil because they are a misuse of our human powers. Other actions are intrinsically evil because a morally neutral capacity is exercised upon a morally inappropriate object. We may kill an unjust aggressor, for example, but not an innocent person. A man may have sexual relations with his wife, but not with anyone who is not his wife. In both instances, evil actions are not to be done, regardless of the supposed good that might come from doing them.

In much the same way, there are intrinsically meritorious acts. Worshipping God and taking religious vows are good things to do, even if they don’t improve the conditions of life for ourselves or others. Acts of charity are intrinsically meritorious. It is not necessary to ensure that the homeless person you give money to will not use it to get drunk. The act of giving it is in itself meritorious, no matter the outcome.

The third source of choice-worthiness arises from the intended end, the goal or purpose for which the action is chosen. If I choose to act so as to avoid saving a man’s life, and I do so for the reason that I prefer that he should die, I am guilty of a grave evil, even if I do not cause the death. The man who sees his enemy drowning and refrains from extending a hand because he’s happy to see the man die is certainly culpable.

Conversely, if a death is a foreseeable but unwanted consequence of my action, the action does not thereby partake of moral evil. A doctor who removes a cancerous tumor from a pregnant woman’s uterus foresees the death of the unborn child, but he does not intend it, and if God’s providence permits the child miraculously to survive, he is deeply grateful. The Catholic tradition has developed the principle of double effect to explain the moral logic of situations like this. The doctor foresees (one effect) but does not intend the death of the unborn child. His object is to save the mother’s life (the other effect).

We can apply this line of thinking to debates during the pandemic. At minimum, we should say that it is not necessarily evil merely to forgo the opportunity to save lives for the sake of some other good (including economic well-being). For example, it’s obvious that if a country is under attack, political leaders may rightly give priority to civil defense over public health, even during a disease outbreak. It’s less obvious but nevertheless morally reasonable for civic leaders to have as their object the protection of the livelihoods of citizens, foreseeing that this will require them to forego certain public health policies that might save lives. Indeed, they do this all the time, recognizing that driving fatal workplace accidents to zero would require putting a halt to many economic activities.

The fourth element, that of circumstance, is something like a catch-all for all the other features of an action that contribute to its choice-worthiness. Circumstance includes the unwanted or unintended differences that an action might make. The Thomistic model does not ignore this dimension. But it differs from the Hume-Smith model by taking into account aspects of these differences that are related to the agent and to the action itself. These include what the philosopher Bernard Williams termed agent-relative considerations. The Thomistic model does not insist on the perspective of the detached observer but retains the perspective of the actor himself as he engages in action.

The agent-relative considerations are best assessed in terms of what Aquinas calls the order of charity (see Summa Theologica II-II, questions 26 and 32). An action that benefits someone closely related to me (myself, my family, my benefactors) is more choice-worthy than an action that benefits an unrelated person to the same degree. By analogy, a governmental action that benefits members of the civic community is a better action than one that benefits to an equal degree those for whom the government is not responsible. This is a matter of degree and not an absolute priority—an action benefiting strangers might be better, if the benefit or the need is much greater.

Thus, a community has a special reason to promote its own common good. The common good of a community is not the aggregate of the individual or private goods of its members—it concerns the flourishing of the civil society as such. This is an important consideration, for my life is a private good, just as the life of another is a private good. As a consequence, saving the most lives does not automatically correspond to promoting the common good.

At the outset of the pandemic, civic leaders emphasized the need to prevent hospitals from being overwhelmed. This made good sense. A functional health system is a common good. It serves our shared interest in ensuring that citizens receive good care should they fall sick. But then, the emphasis shifted to saving lives. This is surely important. A well-functioning society acts with benevolence toward its members. The state does so primarily by enforcing the rule of law and through the consequent moral education of the younger generation (S. Th. I-II, q. 95, a. 1). But civil authority also has a role to play through the regulation of commercial and social activities. This ­regulation can rightly be ordered to the end of promoting public health, one goal of which is to prevent deaths when possible. But the constraints of the possible are not in this context technical. The common good of public health no more requires that every death be prevented than the common good of economic security requires that every bankruptcy be prevented.

Aquinas, following Aristotle and Cicero, is explicit that a society’s common good takes priority for the governors of that society over all individual temporal goods, and that those temporal private goods include physical survival. This is why it is reasonable for the state to ask individuals to give their lives in the defense of their country. It is why we honor policemen and firemen who risk their lives to serve the public. If some individual lives (even a great many, as has been the case in major wars) must be lost in order to sustain a well-functioning society ordered toward the common good, then their deaths are not signs of an immoral political order. A sentimentalism that says otherwise is a sign of moral confusion.

Once we set aside the false, sentimentalist view that failing to prevent deaths invariably damages the common good and is a sign of a morally disordered society, we can address the challenges of public health and the importance of saving lives in a morally informed way.

A number of considerations come into play. To begin, the value of saving a human life can depend on the condition of the recipient. This is a point on which the Thomistic and Hume-Smith models agree. It is of greater importance to save the life of a young and healthy person than to save the life of a person with few expected years of life. To measure social actions by years of added human life rather than simply by the number of lives saved is reasonable, since those with more years to live receive a proportionately greater benefit than do those with fewer. This distinction must be justified publicly in the right way: We are not supposing that older people are by virtue of their age less worthy of solicitude, nor are we treating health itself as a marker of intrinsic worth. It is simply a question of the magnitude of the benefit received. This accords with our common sense: In cases of triage, a reasonable person would save the life of a young child rather than that of an elderly person.

There is, in addition, the question of scarcity. If we are able to extend the life of either of two people by one year, then it is of greater value to extend the life of the person with the lower life expectancy. In other words, it is more important to prevent imminent death than to extend a person’s life in the remote future, even when the same number of years would be added. This is why we should have emergency rooms, even if someone were to make the convincing argument that we could better extend life-expectancy for the population as a whole by directing the money we spend on emergency care to primary care or some other means of ensuring that healthy people stay healthy. During a pandemic, marshaling resources and taking social measures to meet the emergency needs of those whose lives are in immediate danger is justified, even if most such people are elderly and have low life expectancy as compared to the general population.

We must also consider adverse effects. Other things being equal, we prefer added years of life without additional disability, and so the benefit of adding life without adding disability is greater than the benefit of adding life with disability. Using the Hume-Smith model, the World Health Organization and many other organizations rely on the disability-adjusted human year to assess the benefit of various measures. This has the unacceptable consequence of treating the lives of disabled people as intrinsically less valuable than the lives of those without those disabilities. The Thomistic model takes into account the relation between disability and action in a more satisfactory way. If an action is associated with a state containing more disability than existed in the status quo, that diminishes the value of the action. We intuitively follow this logic when we deem treatments worse than their cures. If we can save a life, but only by putting the person on life support for an indefinite period of time, then the value in doing so is very low.

The certainty of loss is another consideration. Suppose I have two alternative actions, each of which has a 10 percent probability of saving a human life. In one case, I can reduce a person’s odds of death from 100 percent to 90 percent, and in the other case, I can reduce the odds of death from 20 percent to 10 percent. From an expected difference-making point of view, the two actions are equivalent. But it seems clear that the action that gives a chance of life to someone who would otherwise face certain death is of much greater value than making a mostly healthy person safer still. Here again, we see why we allocate resources to emergency care and affirm large expenditures for ICUs and other means of increasing the odds that those on the brink of death will survive.

Once we have jettisoned the fallacious inference from the infinite value of human life to the obligation to save lives at any cost, the question of how we should allocate care can be dauntingly complex. It is for this reason that morally serious people who must make these difficult decisions often measure the value of life in monetary terms. The point is not to put a “price” on life. Instead, the goal is to develop a fungible, sliding metric for processing the multiple factors that go into our moral reasoning about ­saving lives.

In what sense, then, can we still affirm the ­infinite value of human life? The Hume-Smith model cannot, which is why the sentimentalist rebels against the calculorist mentality. Once we have fixed society’s stock of wealth, an absolute price can be assigned to each human life, based on the number of expected disability-adjusted human years at stake. This unacceptable reduction of human life to a specific price leads the sentimentalist to ­assert that we must put no limits on what we will do in order to save lives—a seemingly noble position that is unworkable in reality. By contrast, the Thomistic model both affirms the infinite value of life and acknowledges the limitations we face in saving lives. Even if the stock of wealth in a society is finite (as it always is), there is no absolute maximum to the value of saving any particular human life. A billionaire who spends his net worth trying to find the miracle cure to save the life of his child need not be judged to be acting immorally, given the order of charity. We can never say that saving a particular human life is worth a set sum and no more. Instead, the value of saving each life will be highly contextual, without an absolute maximum. In addition, in the Thomistic approach, the intentional taking of innocent human life is always wrong. In these two senses, therefore, the infinite value of human life is honored.

These considerations can be applied to the question of choosing between an expensive lockdown and running the risk of additional COVID deaths. The COVID virus seems to strike hardest those with a lower life expectancy, so the number of human years involved is smaller. At the same time, we are talking about imminent deaths from the virus and not merely loss of future life expectancy, so the order of scarcity would increase the value of adding those years. Certainty of death would count on the opposite side of the ledger. Most of those vulnerable to the disease have a considerable probability of either avoiding infection altogether or surviving the infection. On the whole, the dangers posed by the disease suggest a mixed judgment, not a clear imperative. But this is almost always the case in public health emergencies, which rarely affect the entire population in the same way and to the same degree.

There is great wisdom in the precautionary principle. When we cannot estimate probabilities on the basis of objective data, and when the worst-case scenario is catastrophic and irreversible, it makes sense to take extreme measures to ensure against extreme threats, even when those threats seem unlikely. The precautionary principle applies in both directions, however. A prolonged lockdown is an unprecedented experiment in social engineering on a massive scale. We cannot calculate with any confidence the impact it will have on our social and political institutions.

The factors are complex, and good judgment in matters of public health can seem dauntingly difficult to attain. We are tempted to fall back on platitudes. For most of us, the preciousness of every human life is a given. Indeed, every human life, no matter how humble, has infinite value. It is natural to attribute such value to the act of saving a human life. How could we compare the value of saving a human life with, say, the value of making a hamburger or a widget? The question seems absurd: The value of human life will always exceed merely “economic” values.

And yet, despite the apparent absurdity of the question, we are being bewitched by words. The infinite value of human life is not the same as the value of saving a life, any more than the infinite value of the body and blood of our Lord in the Blessed Sacrament is the same as the value of protecting it from desecration. Every time I drive to a restaurant or a movie or make any other trip, I am putting human lives (my own and those of others) at risk. The same thing happens when I buy products that put workers at risk in making them. We do these things, despite the cost in human life, because we place greater value on the activities involved. The virtue of prudence allows us to judge when that greater value is justified, and I have tried to lay out some of the considerations that should inform the proper use of our practical reason when we think about our obligation to save lives.

Clarity about these matters is of vital importance as we look back on our approaches to the pandemic and ahead to measures that may be necessary in the future. There is a danger that the voice of sentiment will predominate, demanding that we sacrifice everything to minimize the number killed by the virus. The voice of calculation points to the self-contradictions into which sentiment casts us, but in attaining consistency it sacrifices our humanity, forcing us to make invidious distinctions among persons and to lose any conception of the incalculable value of life itself. We must attune our hearing instead to the still, small voice of prudence. 

Robert C. Koons is professor of philosophy at the University of Texas at Austin.