In the early days of the COVID 19 pandemic, news outlets and media pundits were issuing warnings about the increase in demand for personal protective equipment, the need to self-isolate when sick and the terrifying rationing of life-saving medical equipment such as ventilators and ICU hospital beds. This global panic was unprecedented for our time but a reality that many ethicists, medical professionals and policy makers sought to prepare us for way before "Covid" became part of our every day vocabulary.
Professor Iwao Hirose, professor of Philosophy in the Faculty of Arts at McGill, and a joint professor with the Bieler School of Environment, was one of the ethicists and philosophers tasked with answering the ethical questions and dilemmas of pandemic preparedness, when he served on the World Health Organization's 2006 working group on ethical guidelines for pandemic influenza preparedness in Geneva.
How should hospitals administer the distribution of scare resources such as ventilators, antiviral drugs and hospital beds? Can governments restrict our individual freedom for the collective good of citizens? How effectively can we distribute medical resources such as vaccines to socioeconomically challenged communities? These are the questions that Professor Hirose addresses in .
We asked Professor Hirose to speak to us about the importance of ethics and philosophy in policy making and the research and real-life experience that influenced his new book.
Q: Your book “The Ethics of Pandemics” reflects your experience of serving on the World Health Organization’s committee on the ethical guidelines for pandemic preparedness in 2006. What was that experience like? What challenges or discoveries did you make during that time?
The experience was, in one word, daunting. There are several reasons. Firstly, philosophers always disagree with each other when it comes to the matter of life and death. Secondly, there is no “fit-for-all” recommendations simply because the member countries of WHO are so diverse in terms of resources, legal system, public health infrastructure, and enforcement capability. Thirdly, the committee was given only two and half days to write up a full draft of ethical guidelines – in a basement room in a dreary hotel by the Geneva Airport. However, the experience was also highly rewarding.
I learned how we can pragmatically produce a set of practical recommendations while maintaining a high level of analytical rigor. One pragmatic way to consolidate different philosophical views is to identify the recommendations that two or more (if not all) major ethical theories would agree on. In The Ethics of Pandemics, I used this pragmatic method by imposing what I call the common ground restriction.
Q: Your book explores how the Covid-19 pandemic brought a broad range of ethical problems to the forefront, raising questions about the role of government in response to outbreaks and the scarcity and allocation of health care resource, among others. Which main ethical problems does your book discuss and why? 
My book addressed a wide range of topics: from the ethical permissibility of lockdown and curfews to the rational basis of human challenge trials (infecting healthy volunteers with a pandemic disease to gain scientific knowledge). However, half of the book is devoted to the priority-setting of the rationing of scarce medical resources such as ventilators, hospital beds, antiviral drugs, vaccines, and PCR tests.
Priority-setting in the rationing of medical resources is an ethical question nobody wants to talk about. But priority must be set one way or another, no matter how we feel about it. During a pandemic, the method of priority-setting depends on the nature of health care resources. One may give lower priority to elderly adults in the allocation of ventilators but higher priority in the allocation of vaccines. There must be a coherent view about what determines the priority in specific contexts. Philosophers can offer an important perspective on this.
Q: Up until the Covid-19 pandemic, the prospect of the scarcity of health care resources was a distant concept for most privileged Canadians; since then, we’ve been faced with news stories from around the world documenting the shortage of medical staff, and medical resources such as ventilators and personal protective equipment among other things. How do organizations such as the WHO and ethicists such as yourself begin to frame these dilemmas?
Actually, the rationing of health care resources happens under normal circumstances, too. Should our health care system pay for the cost of very expensive drugs to extend a few years of a patient’s life, who would die anyway, instead of using the same amount of resource to reduce the infant mortality rate in deprived neighbourhoods? Insofar as the budget for health care is limited, there always exist many forms of rationing every year. A pandemic, however, poses an extreme form of scarcity. Under such an acute scarcity, it is not possible to meet the needs of all people, and someone must make very difficult decisions.
But what we learned from the SARS-CoV outbreak in 2002-2004 was that no country was prepared to make such a difficult decision. What happened was that we dispersed the process of decision-making by passing the buck to each other so that no particular person can be held liable to the decision of priority-setting. Of course, nobody wants to think about the rationing of health care resources. But since the rationing happens anyway, we thought it is desirable to make it explicit, discuss it publicly, and think about the ultimate ethical problem of life and death openly.
Q: What has the pandemic and its ensuing restrictions on social and professional lives taught us about our society? Have the last two years made us more aware of ethical dilemmas?
This pandemic taught us how we should balance short-term and long-term effects. When the pandemic started in early 2020, I thought this pandemic would be very long and painful because it would take three or four years to develop vaccines, produce a huge number of vaccines, and vaccinate a large portion of the global population. Fortunately, my initial belief proved too pessimistic, partly because of game-changing mRNA technology, more than half of global population received at least one dose of vaccine within a year and half from the beginning of the pandemic.
Unlike many countries in the world, Sweden and Japan chose not to enforce highly restrictive measures such as lockdowns, curfews, school closures, and travel bans because it was believed that those measures were unsustainable, and would negatively impact the economy, social integration, and mental health. These countries were criticized during the pandemic for not taking radical measures. Whether this criticism was reasonable is yet to be known as we do not know the full extent of long-term effects. But what we do know is that we need to balance the short-term and long-term effects in a subsequent epidemic.
Q: Why is philosophy an important area of study for students of public policy and medicine? What questions and discourse are you hoping to raise for a new generation of policy makers, doctors, and philosophers?
The reason is simple -- no public policy can make everyone happy. Every public policy requires us to weigh up the gains for some people and the losses for other people. Philosophers can offer a perspective on whose interest should count, whose interest should count more or less, and how the interests of different people should be aggregated. The question I want to raise for future policy makers and philosophers is the moral importance of statistical victims. Statistical victims refer to a difference in the statistical frequency of death within a population. It is widely known that there exists cognitive, legal, and arguably ethical bias against statistical victims. That is, we tend to value future victims, whose identity is yet to be known, less than the identified victims, whose identity is already known. However, it seems obvious that the moral value must be the same. The voice of identified victims can be heard by people and politicians whereas statistical victims are a silent mass. We should try to listen to the voice of those silent victims. An example of statistical victims are future people who would not die prematurely if climate change did not happen. It seems that many people pretend to care about climate change but in fact undervalue the value of future victims.
Q: You spent May – August 2022 at the Institute of Social Science at the University of Tokyo. Can you tell us a bit about the work and research you were doing during that time?
Last year, the Institute of Social Sciences launched a large interdisciplinary research project, “measurement in practice”, which gathers more than 20 researchers in social sciences. I am very excited to join this project in the next few years and work on a series of articles on the measurement in public policy with an economist and political theorist there. I like working with researchers from different disciplines because I learn a lot from them. Our collaborative project will explore philosophical and formal methods of measuring the value of statistical lives. The results of our research are expected to provide analytical foundations for many areas of public policy such as health policy, environmental policy, and international development policy. The Institute offers a relaxed research environment in the leafy campus, which enables us to forget that we are in the heart of bustling Tokyo.
Q: Throughout your career, you’ve held professorships and fellowships at various universities around the world, such as the United Kingdom, France, Israel, Sweden and Japan. How has that experience influenced your research?
Philosophy is one of few disciplines that require only paper and pencil. Philosophical inspirations often emerge from random conversations with others. I am privileged to spend an extended period at leading universities and institutions all around the world and have a lot of inspiring conversations with amazing scholars. I often coauthor papers with those scholars, based on the idea which emerged from our discussion in the café and pub, which is a fun part of philosophical life.
Iwao Hirose is Professor and Tier 1 Canada Research Chair in Value Theory and the Philosophy of Public Policy, jointly appointed to the Philosophy Department and the Bieler School of Environment. He is the author of The Ethics of Health Care Rationing (2014, 2022), Moral Aggregation (2015), Egalitarianism (2015, 2023), and The Ethics of Pandemics (2022) as well as the editor of Oxford Handbook of Value Theory (2015) and Weighing and Reasoning (2015). He was awarded the Kitty Newman Memorial Award by the Royal Society of Canada in 2018.