The ethical dilemmas presented by COVID-19 with Prof. Steve Gimbel

Steve Gimbel: Hopefully we do come out of this understanding the interconnectedness we have.

President Bob Iuliano: Hi and welcome to Conversations Beneath the Cupola, a Gettysburg College podcast. I’m Bob Iuliano, President of the college and your host. As the global outbreak of COVID-19 continues to progress, we’re all trying to make sense of the significant changes that have been made to the way we live. During this time, we are using this podcast to explore the uncertainty that surrounds some of these changes with the guidance and expertise of Gettysburg faculty. Today, we are joined by Steve Gimbel, Professor of Philosophy at the college, whose teaching and research interests lie in the philosophy of science. He will use this background to help us look critically at the many ethical dilemmas presented by COVID-19, particularly for physicians who are facing very difficult choices under conditions of great uncertainty.

President Bob Iuliano: So Steve, I’m going to jump right in with that old good example that tests some philosophical principles of the trolley car, which you know all too well. But for the people who don’t know it, it’s the example of a trolley heading down a track heading, towards two, three or so people, who for whatever set of reasons, can’t actually get off the track. And there’s an observer, who happens to have a lever, and that observer has a choice, can either let the train continue as it is and three people will be affected, or the observer can pull a lever and that will change the direction of the train. But the bad news is there’s a single person on that track who can’t get out of the way and will therefore be affected. And so this is a good question because it really raises a set of questions about choice, agency and responsibility. And I’m less interested about whether you would pull the lever or not, but rather whether you see a set of principles that should inform how that judgment gets made. And I won’t blindside you, this will ultimately lead us to a conversation about ethical choices being made at this moment in time about the pandemic.

Steve Gimbel: Sure. So what’s wonderful about the trolley example is that on the one hand, it seems so simple, so obvious, right? You have a choice between three people dying or one person dying. What should you do? Well, it’s obvious, right? That you should save two lives by pulling the lever, right? So on the one hand it seems completely, but now until you think a little bit more closely, because what you’re doing is not actually saving two lives. You’re saving three lives, but at the cost of killing a person who wouldn’t have died, but for your actions. So what happens, what’s really interesting is, it seems obvious, yes, of course, pull the lever, less death is better. But empirically, it’s actually not what we do.

Steve Gimbel: If you look at what people actually do in circumstances like that, what we do, we convince ourselves, “Well look, I’m not driving the trolley. I didn’t start the trolley. I’m not the reason these three people are stuck on the track. I’m not really responsible.” It’s the Kitty Genovese problem, right?

President Bob Iuliano: Yep.

Steve Gimbel: That is, if I’m not the cause of this, then I don’t have moral responsibility. There’s a distinction between causing and allowing to happen. Now this is what Bernard Williams called moral luck. So the idea is this, is we usually think that moral obligations are just spread out evenly across humanity. If you’re a person, you have the same moral obligations as every other person. What Williams pointed out is that context matters, is that there are going to be times when you enter situations in your life that you didn’t cause, that you didn’t ask for, that you weren’t seeking, but yet, will endow you with certain moral obligations that other people don’t have, right? So if we have, a person just walking down the street next to the train tracks, they look up, they see the train coming, they see the situation. Now suddenly, it’s a question of moral luck. Right? Now they have no choice, right? What do I do? Do I pull the lever, do I not pull the lever? If you try to play it off as if I’m not involved, that actually is a choice.

President Bob Iuliano: The absence of action is an action, of course. So I began with the trolley example purposely. Whether it has direct bearing on the topic du jour, I don’t know, but let’s see. And that is obviously the pandemic, particularly in the context of the allocation of scarce healthcare resources, is requiring choices to be made. It’s requiring healthcare providers to decide who goes first, who goes second, who gets tested, who doesn’t, who gets access to scarce resources and the like. But what do you see as the principle ethical dilemmas that are being presented by the pandemic? And then, I’d be curious to see how you evaluate who’s deciding those dilemmas and whether there’s a system or whether it’s all local and ad hoc?

Steve Gimbel: So this is a question of distributive justice, right? We have a scarce resource, but it’s a resource that’s needed. And the instinct that we all naturally have is an egalitarian one, we want it to be equal, we want it to be fair, and we think of fair as equal to all. Now, a similar situation to what we’re facing simplified might be something like, we have six people who are stranded after an airplane accident in the Arctic, and there’s one parka. If you don’t have the parka, you’re going to freeze to death. Now the egalitarian thing is, “Okay, every hour we’ll rotate.” But if you’re exposed long enough and the rotation would expose everyone, then everyone dies. So the simple egalitarian answer, the simple, let’s just make it equal, doesn’t work, right?

Steve Gimbel: We can’t say, “Okay, there’s one ventilator, there’s eight people who need it, we’ll just alternate.” Well, you do that, you kill all eight. So now we’re faced with the hard moral question, how do we decide who gets the scarce resources? Now we already do it to some degree, right? It’s the wealthy, right, if you’re rich in this country, you’re going to have access to better care. So there already is, in a certain sense, a preexisting system. The question for us is, is it a fair one? How ought we determine who gets it and when? Now we want to think, okay, everyone’s equal. Well, maybe we should have a lottery, right? That seems to be equal. Everyone has equal chance.

Steve Gimbel: The problem there is that when we look at the people, suddenly we start to realize, well, things really aren’t so equal, right? Suppose one person is elderly and another person is young. We’ll think, okay, well if we think of these people, they don’t have an equal amount of life left. So if we think of life as a good thing, then perhaps we ought to prefer quantity. Well, quantity, but then there’s quality. Suppose one of those people is a physician. Now, if we give the ventilator to the physician, we not only save that life, but we now save every life the doctor goes on to save. So the question becomes hard. How ought we, as a society, for the best outcome in the society, allocate these scarce resources?

President Bob Iuliano: At the moment, do you see any common standard or are these all judgements made autonomously at the local level as people, as individual healthcare providers wrestle with the demand that exceeds supply? You may not know the answer to that, but I’m curious, is there a paradigm that begins to inform these judgments?

Steve Gimbel: To some degree there is. Now, every hospital has ethicists on staff, and these ethicists have been wrestling with exactly these questions. So there are certain lives which we do say, in a certain sense, are more valuable than others to the community as a whole. But that question of community value is one that the community itself has to answer, right? You may have a society that values youth because these people have more life left to live. There may be others that value the wisdom of the elders, and so we’d lean that way. There are radically different approaches, all of which could be justified.

Steve Gimbel: Now, the role of the philosophers in this is not the answer the question. Philosophers aren’t the leaders. What we do, we have a specific role. Our job is to clarify the question. Our job is to set out all of the possibilities to look at them hard, to analyze them rigorously and to present them to the larger community. Because there are multiple possible answers to this question, which are mutually exclusive. There are only a fixed number of ventilators and they are going to go to certain people. But that is a sort of community value question. Philosophers need to have a seat at that table so that we can make these questions clear. But it’s not philosophers’ jobs to answer those questions.

President Bob Iuliano: And so implicit in what all of what you’ve said is that there are of course trade-offs. Someone has to make the decision about the trade-offs and those trade-offs may be based upon different cultural norms. And so a judgment made in one community may be different than a judgment made in another community, if the values and the norms of that community may be radically different.

Steve Gimbel: That’s correct. Now that doesn’t mean that anything goes.

President Bob Iuliano: Right.

Steve Gimbel: So there will be certain constraints that are ruled out as morally problematic, but there will be multiple possibilities that are morally acceptable. And from that set of options, the community has to make a call.

President Bob Iuliano: Yep, that makes good sense. So this is also not distinctive to the pandemic at all. It’s a timeworn issue, but it’s put into somewhat sharper relief now, simply because of its volume. I’ve introduced it now, let me actually explain what I’m talking about, and that is how quickly we bring therapeutics to the market. Honestly, we have a situation now where there is a universality to the experience that we’re having about the scope and the reach of the pandemic, and we understand a sense of its lethality. And there are some promising therapeutics bubbling up, no one quite yet knows what’s going to work and what’s not. But we have, for good reasons, long testing processes to make sure that the therapeutics are actually efficacious. Should those rules get waived in this context? How do you think about the ethical questions presented by rushing a product that may not only be ineffective, but could be counter productive versus the certainty of a certain number of deaths anyway? Is this the trolley car again?

Steve Gimbel: So if you look at the situation as we have it, right, we have a virus. Now, a successful virus, counter-intuitively, isn’t that deadly. If the virus is too deadly, then it’s going to kill the carrier before the carrier has a chance to spread it, and the virus itself is going to die. The idea is it wants the host to live long enough and to be asymptomatic long enough to be able to spread it far and wide because that’s how the virus makes its living. And so, we don’t have the time bomb situation in which, if we don’t try what ever Hail Mary pass we have, then we have certain death. The human immune system is quite powerful and the majority of people will recover from this. Now, there will be lasting effects in a number, right, but the point is that we don’t have an all or nothing situation.

Steve Gimbel: And so what we see in the case of, certain highly hyped possible solutions that have been tried in certain trials, is that the cure might be worse than the disease. That is what might happen, like in the trolley case, is that innocent people who wouldn’t have died, now by pulling this lever, are going to die. And it may be the case that you had three people on the original track, but now you have 27 who have signed up to be part of the trials for this medication. So the question is, how can we be sure or how can we have good reason to believe that this cure is likely to have a better cure rate than the human immune system?

President Bob Iuliano: So how do you think about questions of individual choice in that scenario though, that is, who gets to make the judgment about the risk? And this is going to bear on the question I’m going to ask you after this, that, why can’t the patient decide, “You know what? I think I’m prepared to take the risk because I don’t like the odds of where this is heading.”

Steve Gimbel: And to some degree, that’s absolutely the case. So I have served twice as the college’s IRB Chair. And every institution has an organizational structure that oversees testing in human beings. And part of that process is to guarantee that there is a sense of agency in the people who volunteer. So it’s absolutely true that people who want to be part of these studies should have access to them. Now they have to know that there’s a 50% chance they’ll be in the control group, right? Testing is a very touchy situation, especially in the case of medical testing, right? So we’ve got to go through a couple of steps. The first is in vitro, we have to look at how this thing works, set off in the laboratory, where we can screen off everything else from reality, just look at this particular virus and test this on it and see if it’s effective or not in the Petri dish.

Steve Gimbel: If it is, then we go in vivo, that is we go to living things. There, it gets much more complicated for several reasons. One is, we’re not just walking Petri dishes. We are interconnected systems and those systems might interfere with each other. And so what worked in the Petri dish, now may not work in the person, in part, because there are other structures in the body that are interfering, or that are bolstering, or that are tweaking it in a strange way. You have genetic differences between individuals that have to be accounted for, and you have environmental factors. So does sunlight on the skin now suddenly counteract something?

Steve Gimbel: So the idea that we have good reason to think this is a possibility means that we should go towards testing. If there’s circumstantial evidence, if there’s anecdotal evidence, all right, you know what? Let’s test it, let’s really see. And this takes us to the context of justification, which is the ultimate step we want, which is having good reason to believe something is probably true, right? Science doesn’t prove anything. Mathematicians prove, scientists give you good reason to believe, based on evidence. And now in the case of medical evidence, we need it tested in the Petri dish, we need it tested in populations, we need it tested widely in populations to see how effective it is, what the side effects are, and what the results are relative to not treating them at all or treating them with some other treatment that we’ve already looked at.

President Bob Iuliano: Very interesting. In a related vein, I think, is something we’ve seen growing over the last couple of weeks, where there has been a strain of argument that the government is inappropriately restricting individual autonomy by virtue of the constraints it’s placing on our ability to work, on our ability to leave our houses indeed. I mean, we’re still under a stay at home order in Pennsylvania, that just today was extended until I think early May. So first, this seems like, my training is one of law. This seems like a very distinctively American concept of individual versus collective rights, with a bit of an emphasis on the individualism. Do you agree or disagree with that? But more broadly, how do you think about these trade-offs between the individual and the collective, in this instance?

Steve Gimbel: So every culture has a founding mythology, and by mythology, I don’t mean false stories of the gods. What I mean in the Jungian sense is a sort of narrative that helps us make sense of the world. And in America, that narrative really is that of the rugged individual, right? We are Adams, we are individuals out there and we engage, unhindered by anyone else, embracing our own freedom in order to find our own happiness. Now, that myth is based on a word you just used, which is rights, it’s a rights-based ethic. And there are absolutely certain elements of truth to that picture, right? That is the idea behind ethics is to determine how to create a situation of human flourishing.

President Bob Iuliano: I suppose the challenge is that in an interconnected society, there are inherently line drawing exercises that have to be drawn and the question is, who gets to make those calls? Because every exercise of right has an impact on others.

Steve Gimbel: I think that’s exactly right and the idea is that you’re right, these individual liberties are being taken. And at times, these individual liberties ought to be protected and protected vigorously. But there are other contexts in which the public good is so weighty, that sometimes we need to give up certain individual rights for the overall good. And this just does seem to be one of those instances

President Bob Iuliano: And that ends up being, again, it’s a community conversation that is, it’s not in any individual’s ability to make that call. And if in this particular instance, 90% of the population said that we had this wrong or that we feel like the intrusion outweighs the benefit, my guess is we’d be having a different conversation. So philosophers may not be able to answer all the questions, but as you say, you can frame the questions more acutely, what sense should we be making? It’s maybe too early to tell, but what sense do you make of this pandemic? Are there lessons here that we should be taking? How do you predict its longterm impact on us as a society? Do you have any sense of that?

Steve Gimbel: Well, I have at least two hopes. One is shallow and the other is a little bit more profound. The shallow one is, one of the things I hope we do take out of this experience is that pajamas become acceptable where, in all social and professional situations, which is a joke, but what it also means is we see life a little bit differently now. I think things that we used to think were so important, now we see in a little bit better perspective. Some of the things that we had been socialized to think were crucial, maybe they’re really not as important as having your family around you, having time to be with those you care about.

Steve Gimbel: And there are certain things we really do miss that we ought to miss. And hopefully it’ll help us reorient our priorities. The other one, that I think is the little more profound one, harkens back to the question we just discussed, which is, hopefully we do come out of this understanding the interconnectedness we have, that you can’t go to the store without having somebody ring up your groceries. That person is putting themselves at risk for you, right? You are connected to them and we see each other, our and our wellbeing, connected with the health and wellbeing of other people. We see ourselves, not only financially, but socially interconnected now in ways we may not have appreciated before. So that deep sense of inner connectedness hopefully is something that stays with us.

President Bob Iuliano: So when I was talking with Bruce Larson of the Political Science Department, one of the conversations we had was, will this be a moment where some of the hyperpartisanship that exists in today’s world begins to break down because we understand that we have more in common than we do not, and that there are interests in acting, as you were saying, through a sense of connectedness. Two final questions. One is, in a conversation with the Religion Department the other day, the faculty observed that the students were approaching the course with a different level of intensity and engagement because the questions seemed more immediately relevant than perhaps they might have in a more ordinary time. Are you seeing that with your students or what you’re hearing from the fellow members of the Philosophy Department? Has this moment in time and some of the existential questions it’s raising, causing students to see their academic work and philosophy through a different prism?

Steve Gimbel: Oh, how could it not? So the most profound part of the job is that my coworkers, the students, have an unbelievably important job, right? Their job is not to write my papers or to take this physics test. Really, their job is to build a human being, right? They show up on the first day and we hand them a high school student and we say, “You have four years to turn this into an adult.” And they have to spend those next four years thinking about what constitutes human flourishing? How can I build this adult in such a way that they’re not going to be isolated, not going to be alienated, that they’re going to have a fulfilling life, that they’re going to be able to enter into a capitalist structure with all the tools needed to survive?

Steve Gimbel: These are hard existential questions and this really is the work of college. These students are creating a human being. What, up until now, they’ve had the advantage of, is they could look out the other side and see what that world looks like and that would help them construct this person to be one who could succeed in that world that they see out there. And so yeah, these seemingly abstract puzzles that philosophers love to play with, now suddenly have a slightly more urgent feel to them because we need to figure out what is human flourishing, especially if we don’t know what that’s going to look like.

President Bob Iuliano: Well, I don’t mean to make this reductionist, but as I talk about the importance of the work that we do and the sort of education that we provide our students, part of the point that I make is that our graduates have the greatest chance of thriving in uncertainty because what we’ve equipped them with is the capacity, I hope, of adaptability, of flexibility, of the ability to see across disciplinary boundaries and make sense of uncertainty. And so I think the work takes on heightened importance precisely at this moment. And we give our students the greatest opportunity to find their way in an uncertain world, by virtue of the breadth of the education that we’re affording them. And I said much to the incoming students, just the other day, at Get Acquainted Day, was part of the point I was making when asked about why us and why the education that we provide.

Steve Gimbel: Amen.

President Bob Iuliano: So I leave you with one last question. I know you are both a humorist, but for this purpose, perhaps someone who studies the philosophy of humor. This may be obvious, but what role does humor play in a moment like this? How does it help us make sense of the world?

Steve Gimbel: Tremendously. I think humor, right now, does three very important things for us. So the first one is, if you think about how a joke works, right? It has two parts, it has a setup and it has a punchline, right? Knock, knock.

President Bob Iuliano: Who’s there?

Steve Gimbel: To.

President Bob Iuliano: To who?

Steve Gimbel: No, to whom. The point of the setup is to force you to think in one direction and then the punchline makes you realize, “Oh, I needed to be thinking of this differently.” And so a joke inherently forces multiple perspectives, right? And so humor, especially humor about a situation you’re in, allows you to see it from multiple different ways, and that sort of depth can be helpful. The second thing is that humor creates a sort of connection amongst people. So University of Chicago, a professor who passed away, Ted Cohen, who wrote a wonderful book called, Jokes, coined the term, joke intimacy. When you share a laugh with someone, it’s like sharing a meal. You’re not exactly friends, but you’re more than just strangers. There’s something human about sharing a laugh, and at times when we’re spatially so isolated from each other, any sort of additional intimacy is just a good thing.

Steve Gimbel: And the last thing is that humor just does wonderful things for you as a person. And if you think of it just on a physiological level, right? Stress, which we are all under constantly, we’re hearing the numbers, we’re hearing the politics and you can’t not be stressed. Are we still going to have a job? Are we going to have students? What’s going to happen here? Stress does horrible things to the body, right? The brain releases cortisol and adrenaline in ways that biologically, we’re meant to be held until there’s a tiger chasing us. So if this is a constant state of being, it leads to all sorts of negative medical outcomes. Humor has wonderful effects on the body. It not only brings little shots of happiness, but it helps the brain just reorient itself in a normal way. So anything from standup specials to funny movies, to just cheesy dad jokes, anything that’s out there can only help.

President Bob Iuliano: Well, Steve, let us leave it at that. I can see why your students so enjoy your classes and get so much from them. Thank you for spending the time with me this afternoon and thank you for helping me make a little bit of sense of this uncertain world.

Steve Gimbel: Thank you very much.

President Bob Iuliano: Let me conclude with a Slice of Life, from Gettysburg College. As we have all experienced, the pandemic has resulted in changes to the way we do things. One such change relates to our wonderful tradition of Get Acquainted Day, where we invite admitted students to campus to get a sense of the special nature of this community. This year, we had our first virtual Get Acquainted Day, which gave the admissions team the chance to show its creativity and to show off, through new means, why the admitted students would thrive at Gettysburg College. It also gave alums and current students the chance to reflect on their Get Acquainted Days. As C.J. Rauch Said, “I remember my Get Acquainted Day at Gettysburg College back in 2006, the campus was electric. It was the start of being part of an amazing community of students, faculty, staff, and alumni. I now live in the UK and can attest that the community extends around the globe.” Let us hear your stories about your Get Acquainted Day and introduction to our college. For admitted students, congratulations and I look forward to welcome you to the class of 2024 in the fall.

President Bob Iuliano: Thanks for listening. If you’ve enjoyed this conversation and want to be notified of future episodes, please subscribe to Conversations Beneath the Cupola by visiting gettysburg.edu or wherever you get your podcasts. If you have a topic or suggestion for a future podcast, please email news@gettysburg.edu. Thank you, and until next time.