Utilitarianism and the pandemic

Abstract There are no egalitarians in a pandemic. The scale of the challenge for health systems and public policy means that there is an ineluctable need to prioritize the needs of the many. It is impossible to treat all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life. In a pandemic there is a strong ethical need to consider how to do most good overall. Utilitarianism is an influential moral theory that states that the right action is the action that is expected to produce the greatest good. It offers clear operationalizable principles. In this paper we provide a summary of how utilitarianism could inform two challenging questions that have been important in the early phase of the pandemic: (a) Triage: which patients should receive access to a ventilator if there is overwhelming demand outstripping supply? (b) Lockdown: how should countries decide when to implement stringent social restrictions, balancing preventing deaths from COVID‐19 with causing deaths and reductions in well‐being from other causes? Our aim is not to argue that utilitarianism is the only relevant ethical theory, or in favour of a purely utilitarian approach. However, clearly considering which options will do the most good overall will help societies identify and consider the necessary cost of other values. Societies may choose either to embrace or not to embrace the utilitarian course, but with a clear understanding of the values involved and the price they are willing to pay.

Office for Civil Rights (OCR) responded: '… persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person's relative "worth" based on the presence or absence of disabilities or age '. 2 Utilitarianism is now often used as a pejorative term, meaning something like 'using a person as a means to an end', or even worse, akin to some kind of ethical dystopia. 3 Yet utilitarianism was originally conceived as a progressive liberating theory where everyone's well-being counted equally. This was a powerful and radical political theory in the 19th century, when large sections of the population were completely disenfranchised and suffered from institutional discrimination. The theory played a role in antislavery, women's liberation and animal rights movements. Yet utilitarianism remains relevant in the 21st century. As we will discuss, it may be particularly salient and important to consider in the face of global threats to health and well-being.
In this paper, we will summarize what utilitarianism is and how it would apply to the COVID-19 pandemic. Our aim is not to argue that utilitarianism is the only relevant ethical theory, or that a purely utilitarian approach must be adopted. However, it is important to note that whenever a utilitarian solution to a dilemma is adopted, there will be more well-being or happiness in the world. Typically, some people will be better off. Of course, there may be good ethical reasons to deviate from a pure utilitarian approach, for example in order to protect rights or promote equality. However, considering the alternative will help societies to identify and consider the necessary cost of these other ethical values. Utilitarianism is not the end of ethical reflection, but it is a good place to start.

| What is utilitarianism?
Most moral theories imply that there is a (moral) reason to do what is expected to maximize what is good for all, or more precisely, the net surplus of what is good for all over what is bad for them. This might be called a principle of beneficence. Utilitarians hold that maximizing what is good for all is all there is to morality. It makes moral decisions simple by supplying a single measure of rightness: maximization of utility. In many situations this may be enough, along with rules of thumb with the help of which it could be determined what maximizes utility.
According to most moral theories there are, however, other moral reasons. For instance, utilitarianism has often been criticized for ignoring the question of what is a just or fair distribution of what is good for all. The outcome that generates the greatest good overall may be different from the outcome whose distribution of goodness comes closest to being just or fair. Then the principle of beneficence will have to be balanced against the principle of justice. This will most likely have to be done in an intuitive way. It is very controversial what a just or fair distribution consists in, e.g.
whether it consists in getting what is deserved or in more equal shares. This is far too controversial to be settled here. It follows that the issue of balancing justice and beneficence against each other must also be left aside.
Another moral principle is a principle of autonomy, which gives weight to an individual's freedom to choose and to determine, for themselves, how to live their own life. Individual freedoms may conflict with overall good, for example, when individuals choose to flout social distancing laws, or when individuals demand a scarce resource for themselves or their family members. This also brings us to the issue of whether the principle of beneficence should be impartial and accord the same moral weight to the good of all other individuals or whether it should allow greater weight to the good of those who are close to us (and to human over non-human beings).
For the purpose of discussing what policies societies should adopt to deal with pandemics, it is reasonable to assume impartiality.
A further issue is what constitutes goodness and badness for individuals. According to the most familiar theory, hedonism, what is intrinsically good consists in various positive experiences, of pleasure and happiness. What is intrinsically bad consists in negative experiences of pain and unhappiness. Hedonism is, however, frequently criticized for being too narrow in not recognizing that what we are not aware of can be good or bad for us, e.g. that our partners deceive us, or that the state surveys our behaviour, so cleverly that we never notice it. For such reasons a wider conception of what is intrinsically good or bad for us than hedonism will be assumed here, though to determine its precise import would take us too far afield.
Some moral theories imply that there is a stronger or more stringent moral reason to omit doing harm than to benefit. Thus, they imply that there is a stronger reason to avoid making things worse for somebody by killing them, causing them injury or pain, than to benefit them by preventing them from being killed, injured, etc.
With respect to pandemics, considerable moral weight has been attached to harms such as death and disease that can be prevented by various constraints. Therefore, for the present discussion it is better to proceed on the assumption that there is no significant moral difference between harming and omitting to benefit.
Utilitarianism typically accepts that instances of goodness and badness can be aggregated in a quantitative fashion. Thus, consider a very mild pain that is caused by a physical stimulus of one unit and that lasts for 10 min. Now compare 100 instances of such a pain either spread out over 100 lives or over one life lasting many decades with a single instance of excruciating pain caused by 75 units of the physical stimulus lasting for 10 min. According to a standard utilitarian calculus the former outcome is worse than the latter, but this seems implausible. Most of us would prefer 100 instances of mild pain dispersed over our lives than 10 min of excruciating pain. It might be thought that this issue is crucial in the present context, since we will have to balance the deaths of a lower number of people against smaller burdens for a much higher 622 | SAVULESCU Et AL. number of people. We will, however, see that what is morally relevant from a utilitarian perspective isn't death in itself but rather the length and quality of life the deceased would have had if they hadn't died.

It might be said that what matters in the end is what action actually maximizes what is good for all rather than what action is expected
to maximize what is good for all. But our best guide to what will actually happen is what is expected to happen on the best available evidence. So, when we decide what to do, we have to go by what is predicted to be best. This is true in most situations (although in some special cases we know that what is expected to be best is not what will actually be best 4 ). The expected utility of an action is the sum of the products of the probability and value of each of the possible outcomes of that action.

| Act and rule utilitarianism
There are two broad schools of utilitarianism. According to act utilitarianism, the right act is the act that produces the best consequences. According to rule utilitarianism, the right rule is the rule that produces the best consequences. The law is often an instantiation of rule utilitarianism: laws are chosen because they bring about the best consequences.
These versions of utilitarianism can come apart. Sometimes an act will clearly have better consequences, or no adverse consequences but a rule proscribes that act.
Principles or laws around non-discrimination are examples of this. Not considering a person's advanced age or severe disability (e.g. severe dementia) in the allocation of resources, including ventilators, might mean that another person is unable to access those resources who would have gained greater benefit from it, against act utilitarianism. Yet the rule might still overall have better consequences if the non-discrimination rule has over-riding benefits.

| Two level utilitarianism
The two different schools of utilitarianism can be combined. The father of modern utilitarianism, Richard Hare, argued that moral thinking occurs at two levels: intuitive and critical, and that we should move between these depending on the circumstances. 5 At the intuitive level, we have many rough rules of thumb that can be rapidly deployed without protracted and demanding reflection: don't kill, don't steal, be honest, etc. These enable us to act efficiently in everyday life. During a pandemic, doctors and other decision-makers require rules of thumb. For example, when faced with multiple simultaneous patients in the emergency department it is important to have a way of reaching a decision quickly about which patient to attend to first. Triage rules are potentially justified by a form of rule utilitarianism that enables rapid intuitive decisions.
'Critical level' utilitarianism requires choosing the action that will maximize the good when we are thinking in the 'cool, calm hour', with all the facts at hand. Hare imagined a decision-maker who had perfect knowledge of the outcomes of all available options (he called them a 'utilitarian archangel'). In complex situations, where there is time to do so, we must try to rise to the more reflective and deliberative critical level and ask what action we should endorse. What really is the right answer? Hare argues that in such situations we should employ act utilitarianism (this corresponds to system 1 and 2 thinking in psychology 6 ).  We will explore some of the implications of critical level utilitarianism for the current COVID-19 pandemic. We will also describe plausible rules of thumb that would tend to maximize utility and would be useful in emergency and urgent situations. Box 1 illustrates two questions that have been prominent in the early phase of this pandemic.

| Utilitarian rules of thumb
There are several rules of thumb that can guide rapid decision-making about these kinds of cases.

Number
One utilitarian rule of thumb is to save the greatest number (other things being equal). This rule could be applied to the lockdown question by assessing how many lives would be lost if lockdown is applied, or not applied. It could also be used for the triage question: in practice, this would mean considering the following variables:

A. Probability
If Jason has a 90% chance of recovery and Alessandro has a 10% chance, other things being equal, you should use your ventilator for Jason. Indeed, if you treat people like Jason rather than people like Alessandro, you will save nine people instead of one for every 10 treated. That is why probability is a relevant consideration. 8

B. Duration of treatment
In a setting of scarcity, duration of time on a ventilator has implications for the numbers of lives saved. The longer one person will be on a ventilator, the more people who potentially die because they cannot get access to breathing support. If Alessandro needs a ventilator for 4 weeks, and four others (including Jason) need it for 1 week, the choice is between saving one person or four people. So doctors should take duration of use into account.

C. Resources
When resources are limited, resources equate to numbers of lives. The more resources a treatment or a person uses, the fewer are available for others. Imagine that Alessandro and Jason had identical chances of survival, but Alessandro needed a treatment that required three staff to administer the treatment (e.g. extracorporeal membrane oxygenation [ECMO]-essentially cardiac bypass) and Jason needed a treatment that required only one staff member (e.g. mechanical ventilation). We can potentially save three people with ventilation for every patient we save with ECMO. ECMO should be a lower priority than ventilation.

Length of life
According to utilitarianism, how long a benefit will be enjoyed matters-it affects the amount of good produced. Thus for life-saving treatment, treatment that saves people's lives for longer is to be preferred over treatments that save life for shorter periods.
According to this criterion, priority should be given to the younger Jason rather than the older Alessandro, because Alessandro is expected to live less long if successfully treated. If it were Jason who was expected to die sooner, utilitarianism would support treating Alessandro, even though he is older.
Age is thus a de facto measure of length. Because older people tend to die sooner than younger people, utilitarianism tends to favour saving the lives of the younger. However, age itself does not matter: it is the expected length of the benefit. This is why utilitarianism is not unfairly discriminatory, and not 'ageist' in an ethically problematic sense (we will discuss discrimination further below).
Length of life is also relevant for the lockdown question. It is the length of life extended that matters. This has implications for evaluation of current policy. In the UK, the decision to implement national lockdown at the end of March was influenced by modelling produced by Imperial College (Figure 1).
The UK Government opted to try to reduce deaths to 20,000. While interventions to prevent COVID-19 may be cost-effective (though this seems perhaps unlikely), they are unlikely to be the most cost-effective actions that we could take. There are likely to be better investments for utilitarians. As an example, The Gates Foundation has estimated that global eradication of malaria by the year 2040 would cost up to $120 billion. 13 Such an initiative (costing only 1/15th as much as the US pandemic stimulus package) 14 would potentially save 11 million lives.

Quality of life
Utilitarians consider not just how long someone will live after treatment but how well they will live. They consider quality of life important.
This could be relevant to the triage question (as suggested in the quote from the Office for Civil Rights at the start of this paper).
Consider an extreme example. The end point of dementia is unconsciousness. Imagine that of our two patients with respiratory failure Alessandro is still working, in possession of all of his faculties.
Jason, by contrast (in this version of the case) has end stage dementia. According to utilitarians, we should treat Alessandro if we cannot treat both. Jason would derive zero benefit from being kept alive in an unconscious state. Indeed, this would apply potentially even if Jason (with dementia) had a higher chance of survival, or were going to survive for longer.
What about lesser degrees of cognitive impairment or other disabilities? According to utilitarians, these would also be con- As a heuristic for triage, it may be that in developed countries a threshold is set at a level where overall well-being is certain to be low. 16 One practical cut off would be unconsciousness or severe disorders of consciousness, such as being in a minimally conscious state. It is highly unlikely to be cost-effective to provide intensive care for a patient who is permanently minimally conscious. 17 Lines could be drawn where there is more uncertainty, and may need to be in countries with more limited resources, or if the demand were much greater. For example, the threshold might be set at the ability to recognize and respond meaningfully with other people. So, on this approach, cognitive impairments that reduced the capacity to have minimal human relationships would reduce priority for treatment as a proxy for believed reduced well-being. 18 Quality of life may also be relevant to the lockdown question. If the life years saved by lockdown were likely to be of reduced quality that would influence how much benefit overall is gained, and therefore what economic cost would be worth incurring.

Equivalence of acts and omissions, withdrawing and withholding
For utilitarians, how an outcome arises is morally irrelevant. It makes no difference if it is the result of an act, or an omission.
Doctors, patients and families, however, hold that there is a moral difference between acts and omissions. Many people hold a causal account of responsibility: they tend to think that we are responsible for the consequences of our acts but not for our omissions. Thus people tend to believe that withdrawal of life-sustaining treatment is morally worse than withholding life-sustaining treatment.
This folk commitment to a causal sense of responsibility and the acts/omission distinction has a number of bad consequences. prognosis is often thought to be ethically acceptable. However, some apparently poor prognosis patients will do well and a trial of treatment might provide more accurate prognostic information.
Thus, under conditions of uncertainty, a trial of treatment with the possibility of withdrawal would be preferable to withholding treatment. 19 Utilitarianism would reject the idea of employing any form of 'first come, first served' to decide about treatment. The timing of when a patient arrives needing treatment is morally irrelevant to whether or not they should receive treatment. This is a principle that we have elsewhere labelled the principle of temporal neutrality.
According to utilitarianism, doctors should be prepared to withdraw treatment from poor prognosis patients in order to enable the treatment of better prognosis patients if they arrive later.

Social benefit
According to utilitarianism, all the consequences of actions, both short and long term, direct and indirect are relevant to decisions.
Thus it may be relevant to consider not only the benefit to the person directly affected by an action (for example, by being placed on a ventilator), but also others. This can be called 'social benefit' or social worth.
In pandemics, one rule of thumb likely to maximize utility would be to give priority to health care workers, those providing key services and others who are necessary to provide essential benefits to others. This has been applied in many countries, including the UK, to testing for coronavirus. However, it might also apply to access to ventilators or other medical treatments. A reason given for this is that it will potentially mean that they can also return to work sooner. 20 What about the social worth of others? Should criminals have a lower priority in accessing limited resources? What about scientists working on a vaccine? Related to social benefits is the issue of dependents. Should pregnant women and parents of dependent children be given greater priority for health care? Developing rules of thumb for assessing social worth is ethically and epistemically complex, liable to abuse and difficult to enforce fairly. Critical level utilitarianism would likely not endorse such priority rules, perhaps beyond prioritizing critical essential services workers (which is relatively clear cut and easy to enforce and has wide social acceptance).
Utilitarianism is sensitive to the potential for abuse of its operationalized principles. If there is a risk that a principle will be abused, this should be taken into account in deciding whether to operationalize it or not. For example, social worth is easily abused by the powerful to claim privilege and priority.

Responsibility
For utilitarians, we are morally responsible to the extent that the effects of our acts or omissions are foreseeable and we have control

Avoid psychological biases, intuitions and heuristics
Utilitarianism seeks to avoid biases, emotions, intuitions or heuristics that prevent the most good being realized.
For example, humans are insensitive or numb to large numbers. 24 They are also more moved by a single identifiable individual suffering than by large numbers of anonymous individuals suffering each to the same extent (this is the so-called 'rule of rescue' 25 ). Thus they will be motivated to alleviate the suffering of a single highly publicized individual, rather than taking action that prevents suffering of a larger amount of unknown or unidentifiable individuals. To some extent, national responses to COVID-19 might represent a massive form of the 'rule of rescue'.
Probably most relevant to political decision-making is bias towards the near future. The desire to avoid deaths now is stronger than the desire to avoid deaths in the future. It is psychologically easier to impose severe lockdown now in the name of saving lives These future and non-identifiable deaths might be greater than or less than those prevented by lockdown. They are hard to predict and even to confidently assign, which is one reason that they are difficult to take into account. However, they are just as ethically relevant as the deaths caused by COVID-19. We should not ignore them because they are less psychologically real and motivating.
Utilitarianism aims to the maximize the good, impartially conceived. Statistical lives matter as much as identifiable lives.
Another bias is to one's family and friends. According to utilitarianism, we should give equal weight to the lives of strangers, even those in other countries. The effects on the pandemic in Africa are yet to be documented or manifest. Given that there are fewer advanced life support systems, the mortality is likely to be greater.
Utilitarianism would favour diverting resources there if the effects would be greater.

Much of ordinary decision-making is driven by emotion, biases
and heuristics. Thus, much of utilitarianism will strike ordinary people as counterintuitive.

| The lockdown question
While the triage question lends itself to heuristics, and the devel-

| Evidence sensitivity
Utilitarianism is highly dependent on accurate information about the world. It requires good evidence. Without good evidence, it is less likely that we would choose means that will bring about the most good.
Utilitarianism is thus complementary to science-it requires science. Thus utilitarianism will urge more research to get better estimates of consequences and probabilities from a wide range of possible courses of action. Utilitarianism invites scientific inquiry.
The Swedish approach to lockdown has been informed by epidemiological models of the impact of coronavirus that were lower and less dramatic than some of the models used elsewhere (for example in the UK). 28 Any modelling or data that is used to inform decision-making should be openly available and subject to peer review. If the evidence changes, or the modelling needs to be revised, policy should also change. This means that countries might need to change their policy. That could mean relaxing lockdown, or implementing stricter lockdown. The UK government changed tack in its response to coronavirus in late March in response to revised modelling. 29 That does necessarily mean that the previous policy was mistaken. As noted, utilitarianism directs decisions on the basis of expected utility.
Where our expectations change, decisions should change too.
For example, in order to get better estimates of true mortality, utilitarianism would support random population testing to see the incidence of COVID-19 in asymptomatic or minimally symptomatic community members.
Sometimes the opportunity costs of gathering more information or evidence will be prohibitive when urgent action is needed. In these cases, it is important that beliefs are as rational as possible.
They should result from wide expert dialogue, embracing the possibility of dissensus. 30 April) suggest that the UK has had a large increase in all-cause mortality-the highest in Europe, and that this rate has not been decreasing even as reported deaths from COVID-19 have fallen. 31 There is an urgent need to identify and quantify deaths (and more importantly loss of years of well-being) from all causes in order to inform decisions. Deaths or illness from COVID-19 might be greater in number than other causes (or they might not), but they are not ethically more important than those from other causes.

| Global, impartial equality
Lockdown measures themselves will have direct morbidity and mortality (through denial or delay of medical treatment), as well as indirect effects through economic recession. One estimate is that 25 million jobs will be lost worldwide 32 with associated loss of well-being and death.
According to utilitarianism, the right policy is the one that maximizes well-being overall, across all people across all countries. It has been questioned whether isolation will work in Africa or whether it will kill more young people through its economic effects and subsequent malnutrition. 36 For utilitarians, policy will need to be sensitive to context and facts about individuals and local communities. The policy that is best for one country may be worst for another.
Utilitarianism is a theory with no national boundaries.

| Well-being matters more than rights and liberty
For utilitarianism, well-being is all that matters. Liberty and rights are only important insofar as they secure well-being. Thus a utilitarian approach to the lockdown question may be prepared to override the right to privacy or liberty to protect well-being.
Vietnam, Singapore, Taiwan and China have used methods such as tracing contacts and enforcing self-isolation using mobile phone data, with severe penalties for failure to comply (in Singapore, it is up to 6 months gaol). 37 These countries have been highly effective at containing COVID-19, more so than liberal Western countries with greater emphasis on rights and liberties. Utilitarians support the East Asian approach of constraining liberty and privacy to promote security and well-being. This approach also appears cost-effective while delayed response may not be.
One recent suggestion has been an app that facilitates contract tracing. 38   liberty based approach is less effective, it will necessarily come at the cost of additional cases of COVID-19 and additional deaths.
Importantly, the extent of the liberty restriction or rights violation should be commensurate with the effect on well-being.
Utilitarianism would support isolating certain groups if the benefit to them was greater or the benefit to others was greater. Thus a utilitarian approach to lockdown might favour selective isolation of the elderly and other vulnerable groups if that was the most cost-effective way to secure overall well-being.
Likewise, the restriction of liberty of low risk groups may also be necessary to secure large collective benefits. This justifies, for exam- It is often objected that utilitarianism leads to discrimination against those in 'protected' categories, 40 such as the elderly, disabled, women, ethnic minority groups, etc. 41 For example, in COVID-19, it appears that elderly, male, obese, and BAME patients have a worse prognosis than other groups (to varying degrees). Utilitarians, it is argued, will give lower priority to some or all of these groups for access to limited resources and/ or a higher priority to isolating these groups, which is discrimination.
The first issue at hand is the accuracy of the information. For example, apparent differences in mortality between groups may be mere proxy correlations, that arise from unrelated factors such as faster spread amongst different groups in the community meaning there is uneven distribution of cases in the first place (we still do not know the true number of cases due to testing shortages in nearly all countries), the presence or absence of different groups in high-risk occupations (in addition to uneven distribution of cases, there may be a 'dose-dependent' effect of the viral load on the severity of illness making some workers more vulnerable), existing comorbidities that are correlated with different groups, but unrelated to them and should be considered separately, or poorer care due to bias or lack of access. Moreover, identification and analysis of these factors may lead to the ability to apply effective focussed measures such as equipping care homes with better testing and protective equipment, or focussed testing measures. Utilitarianism fails if it is applied unscientifically, without finegrained information, or if it fails to consider the best policy responses.
If the evidence associating a group of people with higher mortality is indeed both accurate and predictive of a higher mortality, and the association is of sufficient strength, and the proposed policy is both necessary and effective, then assigning resources or burdens such as lockdown selectively is no more discriminatory than other policies, such as the selective isolation of people on the basis of a proxy risk factor for infection, such as travel history or contact with someone who has COVID-19 (this was the early strategy 42 ).
Nevertheless, there would still be utilitarian reasons to reject policies that give lower priorities to these groups. In particular, these groups (with the exception of males) have already been disadvantaged, and indeed this disadvantage may even be the direct cause of vulnerability to COVID-19. Justice requires that they not be further disadvantaged. Accepting the validity of justice need not mean rejecting utilitarianism. Utilitarians must consider all the effects of their policies and actions. If some policy will perpetuate or exacerbate discrimination or injustice with concomitant effects on well-being, these must be considered. Loss of short-term utility is justified by the larger long-term gains of a more just society.
In any case, as we outlined at the beginning of this paper, utilitarianism is not necessarily a complete answer: one can sacrifice utility for other values. Thus, there might be straightforwardly utilitarian reasons for treating different groups in the same way: the resulting fractures in society arising from a policy that did not do so would ultimately cause a greater loss of well-being. Or there might be pure justice reasons: upholding central values such as justice is more important than the net difference in expected health outcomes.
A key aspect of the law on discrimination is proportionality. In a pandemic, very large numbers of lives are at stake. Equality, even for those opposed to utilitarianism, is only one value amongst others.
Discrimination may be proportionate if the stakes are high enough and alternative measures are not available. 43

| Separateness of persons
One prominent objection to utilitarianism is that it fails to respect the separateness of persons. 44 One instantiation of this problem that is relevant to pandemic management is that utilitarianism can favour very small risk reductions spread over very large numbers of persons rather than the saving of one long life. Small goods can be summed to outweigh one large good.
Insofar as this is a problem, it can be avoided in practice by only comparing and summing comparable goods, for example lives.

| Conclusion
Utilitarianism is a demanding and counterintuitive theory. Why should we consider it? If the utilitarian course of action is not adopted, someone (often many) people will suffer or die avoidably. There may be good reasons (such as the preservation of liberty) to sacrifice wellbeing or lives. But such choices need to be made transparently and in full awareness of their ethical cost. One must have good reasons to deliberately choose a course of action that will be worst overall.
Policy is often driven by politics or popular opinion, not ethics. This is morally wrong. Much of ethics in the public sphere involves social signalling, moralism and sometimes wishful thinking (for example, trying to wish away difficult ethical dilemmas). Careful consideration of the consequences of our actions requires us to face the facts and our values. A utilitarian approach is not simple, or easy. It requires that we choose the course of action that will benefit most people to the greatest degree, however difficult or counterintuitive that is.
There is some support for utilitarianism. In one survey investigating the public's views on how to allocate intensive care beds amongst critically ill infants, we found the general public widely supported utilitarian allocations. 45 They supported allocating the intensive care bed to save the infant with a greater chance of survival, who would have a longer life or less disability. They also supported saving the greater number. This suggests that there may be public support for the algorithm that we have proposed for the triage question. When people understand that there is an unavoidable need to choose between patients, they appear to recognize that securing the most benefit overall is both logical and ethical.
One of the psychological biases that dominates decision-making is loss aversion. Losses loom larger than gains. And when we evaluate a policy we are liable to focus on the negatives, rather than the positives. Thus governments, such as East Asian governments, who radically curtail liberty and protect health and security are criticized for being overly authoritarian. Liberal governments that protect liberty and incur greater infection risks (such as the UK and Australia) are criticized for failing to protect the vulnerable and secure public health. There is no win the in the court of public opinion.
That is why we need, in the cool, calm hour, to set our policy objectives and priorities. Utilitarianism gives a clear framework for that. And it gives criteria to judge success.
The universal common ethical currency is well-being. What matters to each of us is how well our lives go. This is the very heart and basis of utilitarianism: it takes an impartial approach to everyone's well-being. While people may argue other things matter (autonomy, privacy, dignity), everyone can agree that well-being matters.
It is doubtful that any of the policies currently being adopted by any governments worldwide are purely or simply utilitarian.
However, some are potentially reflecting more clearly and carefully about the costs and benefits of different courses of action and policy. The fundamental difficulty facing all of us during this pandemic is that we cannot know for certain which action will be best overall. We do not know what a utilitarian 'archangel' would choose: it would require a detailed understanding of the science and facts, the nature of well-being and an exhaustive understanding of the consequences of our choices. But that is what we should be aspiring to.