Jordan Pascoe & Mitch Stripling
[This is an advance copy of an article that will appear in print in September 2020 as part of the KIEJ’s special double issue on Ethics, Pandemics, and COVID-19.]
ABSTRACT. Public discourse about ethics in the COVID-19 pandemic has tended to focus on scarcity of resources and the protection of civil liberties. We show how these preoccupations reflect an established disaster imaginary that orients the ethics of response. In this paper, we argue that pandemic ethics should instead be oriented through a relational account of persons as vulnerable vectors embedded in existing networks of care. We argue for the creation of a new disaster imaginary to shape our own understandings of the interrelated social, political, and economic hardships under conditions of social distancing. We develop a pandemic ethics framework rooted in uBuntu and care ethics that makes visible the underlying multidimensional structural inequities of the pandemic, attending to the problems of resource scarcity and inequities in mortality while insisting on a response that surges existing and emergent forms of solidarity.
1. A Public Health Disaster
When
the disease struck, the new administration determined they must be effective.
Efficient. Do the most good for the greatest number. They built armies of
contact tracers, who knocked on doors to collect symptoms. Neighborhoods with
cases were asked to self-quarantine; a few neighborhoods were cordoned off to
keep the ill from infecting others. But the disease continued to spread,
especially in urban areas inhabited by people of color, where generations lived
together in tight quarters. To better prevent spread, the city moved these
residents a few miles away to isolation camps at full government expense. This
fast, forceful action drove case rates sharply down, saving many lives
(Phillips 2012). The newspapers were supportive—how well prepared the city was!
How fair! It saved lives not just of the wealthy, but the poor of all races,
too!
The
year was 1904; the disease, plague. The isolation camp was named Klipspruit,
later Pimville. Still later, Soweto. The city was named Johannesburg, and, two
years later, still wrestling with plague, it would force all Africans into this
isolation camp. The population’s fear of sickness allowed the white power
structure to take action that would never have been allowed. Not at first,
perhaps, because at first there was sympathy, since most victims were the
domestic workers of white families. But the racialized fear that the city would
descend into chaos proved stronger than the sympathy over time. As a nearby historian
remarked, the plague allowed the town council to achieve what a few had desired
“for the past forty years: to force many African residents in the inner
locations out of town” (Phillips 2012). Thus, apartheid in South Africa sprang
from the seeds of a public health order designed to do the most good for the
greatest number and keep a racialized Hobbesian state of nature at bay.
Systems
that, in better times, prioritize more egalitarian ethical approaches, often
turn to utilitarianism in disasters. This turn tracks our moral intuitions that
in times of great scarcity and competition, sacrifices will be necessary, and
because they will be necessary, they will be acceptable. These choices are
well-intentioned but infected by underlying biases and an “elite panic” (Drabek
2016) that disasters will cause society to descend into a state of nature: the
history of disasters teaches that these events overwhelmingly exacerbate
underlying inequities and that governmental responses tend to reinforce those
inequities, not improve them (Tierney 2014).
As
COVID-19 threatened to overwhelm Italy’s healthcare system, fear of scarcity
took hold. A clinical association issued guidelines for how to allocate
increasingly scarce medical resources. They told doctors to prioritize those
“with a greater likelihood of survival, and second, who have more years of life
left” for ventilators (Mounk 2020), “in order to maximize the benefits for the
largest number of people” (Vergano et al. 2020). Doctors involved in developing
the guidelines called them “soft utilitarian” principles and justified the
choice as consistent with wartime triage and medical ethics in a catastrophe
(Rosenbaum 2020; Ives 2020).
Certainly,
these guidelines were lifelines to tearful clinicians faced with two dying
patients and one ventilator.But these cases were rare. In an interview
with the Journal of the American Medical Association, Dr. Maurizio
Cecconi denied that this kind of triage was happening in northern Italy, arguing
instead that the region had created many hundreds of new beds in a few short
weeks that were shared by hospitals across Lombardy. In fact, hospitals in
northern Italy joined together in an ICU network to share resources. They
committed jointly to giving an intensive care bed and ventilator, to anyone who
needed it. The Italian government sent additional resources to fulfill this
promise. Doctors improvised, finding new pathways of care that both used fewer
ventilators and were more effective (AMA Ed Hub 2020; Grasselli, Pesenti, and Cecconi
2020; Begley 2020).
But
this wasn’t the story that captured the world’s attention: “Italians over 80
‘left to die’” read a Telegraph headline (di Blasi 2020). In the US
articles about how utilitarian guidelines should be applied in ventilator
shortages proliferated (Wikler 2020). In hospitals, these resource allocation
guidelines are just one element of what is known as Crisis Standards of Care
planning, which is itself only entertained once a healthcare system has reached
the limits of its ability to surge care (Hick et al. 2020) But in the
public imagination they loomed large, as hospital guidelines justifying limited
care for those over 80 became public calls to sacrifice the elderly to keep
unemployment numbers down. The lieutenant governor of Texas, Dan Patrick,
argued that older people like himself should volunteer to die to save the
economy (Levin 2020). Meanwhile, a utilitarian emphasis on “acceptable
sacrifice” seemed to lead President Trump to suggest that sacrificing human
life was warranted in order to keep the economy functioning (Haberman and
Sanger 2020).Our existing moral frameworks for disaster and
response shaped a set of moral dilemmas that pitted us against each other. In
doing so, they undermined our perception of a wider set of moral hardships
emerging as the pandemic unfolded.
In
this paper, we argue that we need a more diverse set of moral frameworks to
guide public health and economic policy in a pandemic and to shape our own
understandings of the interrelated social, political, and economic hardships
under conditions of radical social distancing. As we write, the moral dilemmas
of COVID-19 are still unfolding around us. We focus, therefore, on how the
collective narratives that shape our experience of this disaster inform what kinds
of moral problems we see. These narratives, we argue, are disaster
imaginaries, which orient our identification of moral dilemmas, shape the
premises and priorities of planning and response, and ground moral motivation
in disasters. They may harness or hamper the perceptual shifts that disasters
produce, and they may warp or enrich the moral frameworks that guide response.
We
understand this global pandemic as a peculiar kind of public health disaster
in which persons are characterized by their vulnerability to and their status
as vectors of contagion. As vulnerable vectors, persons are embedded in
multidimensional networks of caregiving that produce new dimensions of
vulnerability over time. To understand this context, we need new disaster
imaginaries that understand human beings as interconnected in an unfolding
public health and economic crisis, where our hardships are often the result not
of scarcity, but of undermining or overburdening existing networks of care.
The
basic structure of the argument is as follows. In §2, we unpack our existing
disaster imaginary and ethical frameworks, arguing that utilitarian-driven
disaster ethics, though helpful for distinct problems of resource scarcity,
ultimately conceive of emergencies in terms of competition, deploying a “second
state of nature” narrative that both racializes response and fails to capture
the emergent nature of a pandemic. In §3, we argue that this ethics is
ultimately not grounded in the sociology of public health disasters, and we draw
on recent developments in feminist bioethics to reconceptualize autonomy
through our relational account of vulnerable vectors. We then develop a new
disaster imaginary in §4, drawing on the ethics of uBuntu to show how
attentiveness to our interconnected vulnerability can help us reconceptualize
the moral dilemmas and hardships of the pandemic through solidarity. With this
moral orientation in place, in §5, we examine the problems of interdependency,
vulnerability, and risk that arise in a pandemic where everyone is, in effect,
both a vector and a caregiver, and reframe the moral labor of response using a care
ethics framework. Finally, in §6 we argue that the totality of these ideas
makes possible a pandemic response that surges and sustains existing and
emergent forms of solidarity which would otherwise collapse. We conclude by
exploring how the moral challenges of vulnerable vectors are not unique to
pandemics, but instead we argue that disaster ethics more broadly should
reorient its understanding of how disasters unfold in time, producing new
dimensions of vulnerability along existing axes of marginalization.
2.
Disaster Ethics and Imaginaries
At Memorial Hospital in New Orleans in
the days after Hurricane Katrina, doctors euthanized as many as two dozen
patients in the face of an uncertain evacuation and a lack of resources (Fink
2009). Hospital staff directed an ad hoc effort to triage patients;
having decided which patients had the greatest likelihood of survival, they
determined that euthanizing those least likely to survive would increase the
chances of the greater number—a utilitarian moral principle similar to those
used by doctors to prioritize ventilator allocation in COVID-19. Frightened of
what waited outside the hospital, they looked at a lobby full of very sick
patients and saw a trolley problem.
But this was still New Orleans, after all.
There were Coast Guard crews and radiocommunication. Evacuation was happening
consistently. Why did the staff at Memorial fail to look beyond their own
walls? As in the Italian example, why do so many people in disasters imagine
they are trapped within a trolley problem when, by connecting or sharing, they
could escape from it? To understand why, we have to unpack the ethical
frameworks of utilitarianism and autonomy that structure much disaster decision
making, including during pandemics, and the “state of nature” disaster
imaginary that grounds them.
At Memorial, doctors’ prioritization of
care was the inverse of what happens in “normal” times, when emergency room
triage takes the most severe cases first, sometimes leaving those with minor
ailments waiting for hours as they work to save all those who can be saved. Is
this inversion justified? In Ethics for Disaster, Naomi Zack
argues that disaster ethics should remain committed to the moral principles of
ordinary times. She warns against a shift from the rule-utilitarian commitment
to saving all who can be saved (SALL) towards the more limited saving the
greatest number (SGN), noting that this shift often rests on a faulty fixation
on scarcity and stress. Instead, we have a moral duty before disasters to
prepare for them in ways that will limit these hard choices.
The choices doctors faced at Memorial
were the result of failures at every level of management, from within the
hospital, from its management and parent companies, and from local, state, and
federal officials (Fink 2009). Clearly, failures of preparedness can produce
impossible moral choices (Tessman 2017, 3). Yet Memorial was not significantly
less prepared than other hospitals in New Orleans. The decisions made there
show that the ethical tools we have to shape our formulation of these moral
choices, in moments of crisis, matter. In this case, we see the limitations of
utilitarianism as a guiding framework when resource scarcity is assumed. The
urgency that drove the decision to euthanize patients was first, a failure of
moral imagination: an expectation that in disasters, scarcity makes moral
failure inevitable. Second, it was a flawed moral framework: once failure is
inevitable, utilitarian frameworks move the question to which failures are most
acceptable, a question ripe for bias.
These failures are rooted in a deeper moral narrative that shapes our understanding not just of disasters, but of human communities in rupture. Naomi Zack argues that in the popular imagination—and often, in government policy—disasters trigger a kind of “second state of nature,” a condition in which our institutions and protections dissolve or are flooded into ineffectiveness, in which we find ourselves in some kind of Hobbesian war of every person against every person (Zack 2009, 74–79). The second state of nature story operates in disaster as what Bruce Jennings and Angus Dawson have called a “shaping sensibility—a vantage point that informs other normative principles and ideals rather than supplementing or competing with them” (2015a, 32). When our disaster imaginary leads us to expect a Hobbesian state of scarcity and competition, our orientation towards our ordinary moral commitments shifts based on that perceived threat.
The
state of nature disaster imaginary, with its accompanying utilitarian emphasis
on scarcity, competition, and anxieties over the suspension of “ordinary” rules
has informed the priorities of pandemic planning for the COVID-19 pandemic. The
CDC’s Ethical Guidelines for Pandemic Planning, for example, reflect this
concern with scarcity and resource allocation, in the form of ventilators and
vaccines (2015). These guidelines, however, reject pure utilitarianism as
morally inadequate and offer three correctives meant to prevent a pandemic
response of “saving all who can be saved” from harming the few in its quest to
protect the many. These correctives, briefly, are that any response must
refrain from harm, provide equal opportunity to resources within defined
priority groups and, crucially, respect autonomy. Much of the guidance focuses
on justifying the limited circumstances under which autonomy may be restricted
in the interests of public health (Kinlaw and Levine 2007, 6–7).
This
emphasis on autonomy and individual rights reflects the degree to which the
state of nature disaster imaginary is also a narrative that frames response as
a kind of social contract, restricting the state’s authority to infringe rights
and liberties (Kessler 2020; Zack 2009, 76–77). But as we will argue,
conditions of contagion undermine “normal” conceptions of individual autonomy,
making it impossible to distinguish when one is choosing for oneself or
unwittingly choosing for others and, thereby, creating risk for them (Francis
et al. 2005, 321). In this way, Leslie Francis and Margaret Battin argue that the
threat posed by infectious disease may be analogous to the threat posed by
concealed weapons: both concern our rights to pose unseen threats to one
another in public spaces (Francis et al. 2005, 316). In the US, where gun
rights differ from state to state, our “ordinary” conceptions of the risks we
are entitled to pose to one another also vary. Thus, while public acceptance of
social distancing and lockdown protocols have broken down along existing
political and economic divides (Cunningham 2020; Brewster 2020), they have also
tracked attitudes about gun rights and our right to pose threats to one another
without government restriction. And, as Charlie Warzel argued in The New
York Times, our failure to respond to the epidemic of gun violence sets a
troubling precedent for our willingness to accept preventable death on a mass
scale rather than accept collective responsibility and restrict civil liberties
accordingly (2020).
Our disaster imaginaries, then, shape
both what we identify as moral dilemmas in disaster and the moral premises and
priorities of response (Solnit 2010, 90–93). As Charles Mills has argued, the
state of nature narrative itself, which emerges through Europe’s colonization
of the New World, races both bodies and spaces, constructing non-white bodies
and non-white spaces as embodiments of the state of nature, the medium through
which the threat of the state of nature looms even in civilized society (1997).
The image of Black neighborhoods and Black bodies as always already potential
states of nature does a great deal of symbolic work in disaster narratives,
where predominantly Black areas are assumed to “inevitably” slide into chaos,
while the rights of white people, and white property owners in particular, must
be protected (Mills 1997, 87; Solnit 2010, 248–54). At Memorial, fear of the
“crazy Black people” outside in the streets is part of what drove doctors to
euthanize patients, rather than waiting for aid (Fink 2009).
This racialized disaster imaginary has
shaped the impact of the COVID-19 pandemic; in New York City, enforcement of
social distancing was heavily racialized, with only 7% of those arrested being
white, even as people of color are disproportionately contracting and dying of
the virus (Southall 2020). Racialized law enforcement and health care
inequities are not emergent effects of the pandemic: they are well-entrenched
patterns of inequality and vulnerability produced by our “ordinary” moral
commitments in “normal” times, weaponized by the policies and pressures produced
by the pandemic.
This racialization of disaster narratives
and response reflect the ways that the pre-disaster moral order is already
deeply flawed, often feeding a disaster imaginary oblivious to the assumptions
of utilitarianism, autonomy, and social contract theory. Zack and others argue
that greater preparation before can ease the dilemmas we find within them. Zack
bases our moral duty on the framing “Save All Who Can Be Saved, With the Best
Preparation.” In current Crisis Standards of Care guidance for COVID-19, this
is expressed as a “Duty to Plan,” a framework which charges healthcare systems
and society, generally, with an ethical obligation to think proactively before
the full impact of a pandemic or other hazard is upon them.
It is not that we think this is wrong or
unhelpful. Certainly, not thinking about these issues before a crisis can lead
to “wasted resources, inadvertent loss of life, loss of trust, and
triage/rationing decisions being made unnecessarily” (Hick et al. 2020).
However, disaster ethics cannot rely on “preparedness” to fully address these
inequalities precisely because preparedness frameworks remain committed to
“ordinary” moral commitments and established disaster imaginaries. In Ebola
and Learning Lessons from Moral Failures: Who Cares about Ethics?, Smith
and Upshur (2015) chronicle dozens of failures from the 2014 global Ebola
response, critiquing the health preparedness frame as “myopic” (7) when dealing
with complex issues such as health systems fragility. These problems, they
argue, are deep moral failures created by lapses in global values, which can
only be addressed by new systems. Similarly, Sheri Fink argues that Memorial’s
staff failed, in part, because of a “lack of situational awareness” (Fink 2013,
338) driven by biased or false narratives of events. Healing perception is not
an act of preparation—it requires new ways to understand the moral challenges
of disaster.
3.
Vulnerable Vectors: Rethinking Pandemics
Pandemic
planning has largely emphasized that “ordinary” moral principles can be adapted
to emergent contexts and relied on to mitigate harms. We’ve seen how this can
be problematic; it also assumes that a disaster is fundamentally a rational
expansion of an everyday crisis or moral choice. Larger in scale, perhaps, but
fundamentally the same as a car accident, say, or a fire (Zack 2009, 4–7).
Disaster literature, however, teaches us that at the scale of a public health
disaster (such as a pandemic), these events are much different, in three
relevant ways: They alter perception, require imagination, and enhance
community.
First,
disasters alter perception. Saundra Schnieder (2014) argues that disasters
break old societal norms and immediately create new ones to help adaptation.
Second, catastrophic response requires imagination, as E. L. Quarantelli, the
father of disaster sociology, makes clear (2005). Paradoxically, if a situation
doesn’t break day-to-day systems and procedures, it is not a disaster, meaning
that any disaster response will have to be partially improvised. Full
preparedness is therefore not only ethically problematic but not possible.
Since we can’t properly perceive disasters beforehand and must respond to them
with imagination, the appropriate decisions can’t be made beforehand. The key
question is the following: what moral grounding can we provide to that
imagination to keep us away from problems of scarcity?
A
partial answer lies in the third feature of disasters: They enhance community—unless
people are redirected toward apathy by the response itself. Rebecca Solnit
argues:
In the aftermath of 9/11, people had not a good time, but a deep, profound, rousing time, woke up from their ennui and isolation and trivialization to feel engaged, connected, purposeful, ready to give, to engage, to care, to learn. There was a tremendous opening in which the country could have gone in other directions, an opening in which people wanted to understand Islam and foreign policy, wanted to sacrifice and engage. I saw the Bush Administration wrestling these forces back into insignificance and urging people to fear, to shop, and to withdraw instead. (Vishwanathan 2017)
By rapidly shifting our imaginative horizons in a context in which we are
deeply dependent on one another for survival, disasters tend to open up new
moral possibilities and to drive communal innovation. In short, the history of
disasters tells us that, for the most part, people are not worse moral actors
during a disaster; they are better (Drabek 2016). Instead of looting and arming
themselves, most people in disasters work together in existing and emergent
communities to share resources and care for one another. In natural disasters,
they jumpstart ad hoc search-and-rescue units and evacuation teams. In
pandemics, they knit masks and design new treatments.
If
we take seriously the idea that much of what we believe about the moral
breakdown of society during disasters is wrong, then new ethical possibilities
emerge. We need philosophical interventions in disaster response that
complement the sociological findings that community is the primary source of
aid and support in disasters. While the CDC’s pandemic planning guidelines call
for a suspension of some dimensions of autonomy to slow the transmission of a
virus (Kinlaw and Levine 2007, 4), feminist bioethicists argue that a
relational account of autonomy attunes us not to the suspension of liberties
enacted in a pandemic, but to the transformations of relationships and rights
required to keep us collectively safe (Bayliss, Kenny, and Sherwin 2008, 6;
Sherwin and Stockdale 2017). By emphasizing the political dimension of
our social locations and relationships, relational autonomy understands persons
as inherently interconnected, attending to the ways that the options available
to individuals are shaped by existing relationships, institutions, and axes of
marginalization and risk (Sherwin and Stockdale 2017; Bayliss, Kenny, and Sherwin 2008, 6–7).
Relational approaches to
autonomy are well-suited to the moral challenges of a pandemic, challenging standard
accounts of bioethics developed in an era when many experts assumed that
infectious diseases had been conquered by modern medicine. While standard accounts
of autonomy in bioethics have assumed that it is possible to make choices for
oneself without harming others, a relational approach can make sense of the
ways that highly infectious diseases make this distinction untenable (Francis
et al. 2005, 307; Selgelid 2005, 274). Accordingly, Margaret Battin and Leslie
Francis urge bioethicists to understand patients of infectious disease as
bearing both the rights of victims and the responsibilities of vectors (Battin
et al. 2005). They distinguish their account of the relational autonomy of
contagion from feminist formulations, attending to physical (rather than social)
location and tracking collective responsibility in accidental encounters among
strangers, rather than in intimate, dependent, and chosen relationships (Battin
et al. 2008, 79).
In a public health disaster shaping a global economic emergency, however, we argue that the ethical commitments of response must be grounded in an account of agents as vulnerable vectors who are embedded in relationships—specifically, relationships of caregiving. This account shifts the focus of any pandemic response from the rights of those who are infected to our universal but unevenly distributed vulnerability to the disease, directing our attention to the systemic and institutional structures that unevenly produce vulnerability and resilience (Bayliss, Kenny, and Sherwin 2008; Fineman 2010).
Our emphasis on vulnerability both aligns with and challenges new social vulnerability models for prioritizing “at risk groups” in disaster preparedness and response (Jennings and Arras 2008). The CDC’s Social Vulnerability Index uses demographics to categorize, rank, and map populations who share characteristics ranging from oxygen dependency, to advanced age, to poverty in an effort to help planners locate and assist them as they may be “disproportionately impacted by an incident or event” (CDC 2015). But, as critics have argued, indices such as these fail to capture the complex interdepencies of disaster vulnerability (Rufat et al. 2019). In COVID-19, as both the virus and fear of contagion “infect” people and lead to behavioral change, vulnerability is complex and fluid, spreading through existing and emergent matrices of inequality (Hynes et al. 2020).
Our collective status as vectors requires us to do more than identify “at risk” populations and the burdens of health care workers, but to track the ways that wealth and privilege were themselves vectors of the virus, spreading contagion around the world through travel, moving it from urban centers to rural communities via second homes (Peterson 2020), and in several notable cases, spreading it across communities through drunken, “coronavirus themed” parties (Waldrop and Gallman 2020; Williamson and Hussey 2020). Minimizing vulnerability and vectorhood through social distancing and telecommuting was itself an act of privilege, while acquiring everyday necessities like groceries made an already precarious class of “essential workers” shoulder the risks of infection. In doing so, they became vectors of contagion in their own families and communities. Thus, vulnerability analysis must be embedded into pandemic planning, understanding it not as a static characteristic of populations but something produced through the pandemic and the response itself. We can track how agents operate as vulnerable vectors only through a multidimensional account of the complex systems through which vulnerability produces vectors of both contagion and dependency in the ongoing public health, social, and economic fallout of pandemic (Fineman 2008; Hynes et al. 2020; May 2015).
Our
account of agents in a pandemic as vulnerable vectors, therefore, calls us to
shift both the moral frameworks that organize response and the disaster
imaginary that shapes our moral sensibilities. We need not just new tools, but
new stories. In the remainder of the paper, we suggest a disaster imaginary
that makes sense of our status as vectors and an accompanying ethical framework
for response that centers on the multidimensional experience and elaboration of
vulnerability.
4. We Are The Essential Resources: A New Disaster
Imaginary
In
the pandemic, our status as vectors of infection has made us aware of—and wary
of—our interconnectedness in new ways. This awareness, we argue, calls for a
new disaster imaginary to orient our moral awareness, including our formulation
of ethical dilemmas, the premises and priorities that we bring to our normative
reasoning, and our motivations for action.
Even
as pandemic public discourse has focused on the scarcity of resources, calls to
solidarity have been everywhere, as we have been called to social distance as
“an act of love” (Zahniser and Smith 2020) and, amidst assurances that most of
us would experience relatively mild symptoms, we shuttered schools and
businesses in solidarity with those whose immune systems would not withstand
the virus. Angus Dawson and Bruce Jennings argue that solidarity should be
understood as a “shaping sensibility” for ethics, an orientation that makes
ethical decision making possible (Jennings and Dawson 2015a, 32). But
solidarity has largely been absent from pandemic preparedness and disaster
ethics. Dawson and Jennings recount how, as the North Carolina Public Health
Task Force formulated their pandemic plan, they rejected solidarity as “not
important” to Americans, who were understood as primarily focused on their
“individual lives” (Dawson and Jennings 2012, 71). When calls to solidarity do
arise, they are sometimes dismissed as the solidarity of mutual survival or
self-interest (Dawson and Jennings 2012, 74) which are often short-lived in a
disaster (Jennings and Arras 2008, 12).
We
argue that calls to solidarity are harbingers of an alternative, emergent
disaster imaginary that harnesses our uneasy awareness of our
interconnectedness as vulnerable vectors of contagion. Solidarity, for example,
helps us to make sense of why pandemics are a particularly morally damaging
kind of disaster. COVID-19 exploits our interconnectedness, spreading most
quickly where community ties are the tightest, often through communal practices
of mourning and celebration. In Albany, Georgia, a funeral became a “super
spreader” event, giving this small city one of the highest rates of confirmed coronavirus
in the country (Barry 2020); New Orleans’s Mardi Gras festival may have
contributed to the high number of cases in the city (Faussett and Kravitz
2020). To slow the spread of the virus, we are called to close down local
spaces for connection and suspend the institutions through which we rely on one
another; the subsequent economic fallout is not the result of scarcity, but of
our interconnectedness.
These
obligations to social distance do not reflect a social contract (Kessler 2020),
in which we are equal, rights-bearing agents, but a recognition that we are
members of and vectors in a community as interconnected and vulnerable as a
single organism. This conception of solidarity draws on the ethics of uBuntu,
which coalesced in apartheid South Africa to shape a revolutionary solidarity
from a context of brutal rupture. uBuntu’s central principle that “a person is
a person through other persons,” conceives of us as embedded, embodied beings,
interdependent on one another for our very identities and life projects—and, in
a pandemic, for survival (Sambala, Cooper, and Manderson 2020; Berghs 2017;
Shutte 2009, 93–94; Thomas 2008).
uBuntu
transforms our disaster imaginary by treating us as one another’s most
essential resources. In doing so, it allows us to see the mundane challenges of
the pandemic as moral hardships and dilemmas. Social distancing reveals how
deeply we are ourselves through and with each other; many of us are profoundly
lonely. Others, meanwhile, are cloistered at home with our children of varying
ages, standing up ad hoc homeschools, structuring hours and days and
weeks without the everyday partnerships we rely on—without teachers, friends,
grandparents, babysitters, coaches, counselors, and pastors. It is deeply
strange, unnatural, and morally damaging not to share one’s children, not to
share in the project of helping them grow. The burden is nearly impossible for
one person or one set of parents to share. We are discovering how parenting is
sustainable only because of one another, how our own moral projects depend upon
communal and institutional arrangements that allow our children—and ourselves—to
grow together.
This
perspective helps to make clear how much a disaster imaginary grounded in the
state of nature fixes our moral attention on scarcity and the allocation of
resources. uBuntu helps us see that this is not the only moral priority.
The tragedy of our dangerously overwhelmed health care system is not only
that there are not enough ventilators to go around. It is also that people must
suffer alone, must die alone, must give birth alone; it is that our system is
so broken that even a basic right to human company must be surrendered
(Goldstein and Weiser 2020). Many of us fear not just getting sick, not just
dying, but dying alone. Many who are grieving are grieving because they
could not be present for a person essential to them, for birth or for death or
for suffering. We are grieving not just the inevitable moral failures that will
come from lack of resources, but from the lack of humanness, of being human
with and through one another. These, too, are moral failures.
uBuntu’s
moral imaginary is relational and emergent in ways that reshape the moral
priorities of response. It values a multidimensional appreciation of
“otherness,” an awareness of how individuals shape their communities even as
their communities shape them (Berghs 2017; Eze 2008). This sharpens our
awareness of how our interconnectedness is organized through existing and
emergent inequalities, as when already vulnerable “essential workers” and their
families are required to disproportionately shoulder the risk of contagion, and
sheltering in place is itself a mark of privilege. But uBuntu’s
multidimensional conception of solidarity is also a shared commitment to the
future, a process through which we are continuously becoming ourselves through
one another even in conditions of rupture (Eze 2008). Unlike the state of
nature imaginary, it does not conceive of disaster as a suspension of our
normal priorities; its goal is not a “return” to our “normal” commitments. It
understands us to be transformed by disaster. Nor is it consequentialist in the
utilitarian sense, focused on measuring efficacy through concrete outcomes.
Rather, it is futurist, orienting us towards the new world shaped by both the
disaster and the response itself (Van Binsbergen 2001). In this sense, it is
particularly well-suited to the extended nature of pandemics as our perceptions
of ourselves, our communities, and our moral horizons are permanently
reoriented.
The
problems we encounter in disasters, and the responses we build, are transformed
when our collective energy and imagination is oriented through the
understanding that, as vulnerable vectors, we are “persons through other
persons.” The history and sociology of disasters show that this inclination to
solidarity is present in survivors already (Solnit 2010; Drabek 2016; Quarantelli
1999); reframing our story of disaster to unleash the powers of this perception
would both alter the problems we see in disasters and increase our power to aid
them. In the next section, we show how the perceptual shift that uBuntu’s
disaster imaginary grounds is a multidimensional approach to supporting the
networks that care for the vulnerable.
5.
Vulnerable Vectors and the Labor of
Care: Pandemic Care Ethics
In New York City, as COVID-19 cases surged and the city felt like a place under siege, traffic replaced by endless ambulance sirens, the federal government deployed the USNS Comfort to the city. The hospital ship docked in New York Harbor to celebrations, a symbol of rescue, staffed by navy medical personnel immediately greeted as heroes. But in fact, the ship treated only 182 patients over a three week period when the number of COVID-19 cases in New York City was well over two thousand a day (Fuentes 2020; NYC Health 2020); it was the existing, over-crowded hospitals that absorbed the surge, not the ship that had become a symbol of the impotence of a militarized, “heroic” response. The USNS Comfort sat on the edge of Manhattan, a visceral reminder that response is most effective when it fully empowers local responders.
In
this section, we turn from our shared disaster imaginary to the ethics of
response. We know that local responders are interconnected, each a vulnerable
vector embedded in a set of caregiving relationships. To succeed, a pandemic
response should somehow surge and support these existing care networks,
including both responders and their dependent relationships. In making this
move, we draw on the ethics of care, theorized originally by feminists seeking
to transform our moral intuitions by insisting that what characterizes humanity
is that all of us are vulnerable, and, at some point or another, dependent on
one another for survival and flourishing (Engster 2005, 59; Kittay 2001). We
argue that care ethics’ epistemic orientation towards the needs, capabilities,
and preferences of the vulnerable should shape the institutional patterns and
priorities of response (Engster 2005, 54–55) orienting a responsive state that
surges existing and emergent response networks that care for the vulnerable
(Fineman 2008). The shifts in perspective harnessed by uBuntu’s disaster
imaginary of emergent solidarity enrich this multidimensional account of care,
expanding our perception of the moral dilemmas of the pandemic and orienting
our awareness to the ongoing transformation of our relationships and
networks.
Care
begins with attentiveness to vulnerability, arguing that the universality of
vulnerability produces a universal duty to care (Engster 2005). We discharge
this duty through existing networks, relationships, and institutional
arrangements, as well as by developing emergent strategies for extending those
structures in emergencies both mundane and catastrophic. Emergency Management
doctrine aligns with this, advocating that all emergencies are fundamentally
local (FEMA 2017). We know from the sociology of disasters that neighborhood
assets, like regular community members and clinics or hospitals, are much more
likely to provide care than any mythical response entities or Navy ships. But
care ethics complicates the distinction between “responders” and “victims,”
instantiating the value of “whole community” response by recognizing survivors
as participants in networks of care: much of the labor of disaster response,
from search and rescue to the identification and protection of the vulnerable,
is done by survivors themselves, through existing community ties and
organizations (Drabek 2016). Understanding the labor of response as a
collective project requires us to rethink the story of moral heroism in
disasters, challenging savior narratives and reminding us that communities in
rupture tend to save themselves.
In the COVID-19 pandemic, support for first responders has too often taken the form of empty celebrations of heroism: We do not have masks for you doctors, but we will clap for you, is the unfortunate refrain. In a utilitarian framing of disaster response, heroes are those who take on the impossible task of determining which sacrifices are “acceptable”: which patient gets a ventilator, who makes it out of a flooded hospital. We are comforted by this familiar action-hero vision of heroism, even as it assures us that these sacrifices are acceptable in impossible circumstances. And the narrative of heroism also insists on the autonomy of the hero, thus absolving us of collective responsibility for the structural failures that produced circumstances requiring heroism. The “essential workers” we celebrate as heroes are often underpaid line staff doing difficult or mundane work without benefits or employment protections. Yes, these staff may be personally exceptionally brave and self-sacrificing, but proclaiming them “heroic” is theater. It imagines them as autonomous agents discharging a supererogatory duty, and thus it obscures the patterns of vulnerability and dependency that leave them little choice but to expose themselves to mortal danger (Jennings and Arras 2008, 117–120).
But
care is rarely supererogatory; it is mundane by definition (Engster 2005).
Grounded in the moral realities of mothering, care ethics orients our moral
admiration away from discrete and awe-inspiring acts of heroism and towards the
repetitive labor of reproducing ourselves and one another even in times of
crisis. Responders and essential workers, in this framework, are best
understood not as heroes but as caregivers—still entitled to admiration but
reliant on something much more crucial: sustainable support. As New York’s
existing hospitals surged to treat mountains of cases, doctors, nurses, EMTs,
janitorial and other hospital staff were infected in alarmingly high numbers,
and the state ran out of personal protective equipment (PPE) in the first weeks
of response (Manjoo 2020). But PPE, although critical, is not the whole story.
Since caregivers are vulnerable to contagion, they become vectors in their
families and communities. Surging caregiving requires the state to provide,
innovate, and invent resources to support this expanding chain of vulnerability
to keep the chain of caregivers intact.
A
response oriented through a multidimensional account of care must concern
itself both with surging networks of care and with the sustainability of that
surge. Care itself is a vector of vulnerability, what Martha Fineman calls a
“derivative dependency,” arising as those providing care need additional
resources and support in order to continue effectively supporting others
(Fineman 2004, 57–58). Supporting health care workers means attending to new
dimensions of vulnerability as other family members take on primary childcare
duties, as health care workers deemed high risk are kicked out of apartment
buildings or as new workers step in to take over when frontline responders
become ill; it means tracking and redeeming the economic and mental health
costs borne by civilians who form the front line of pandemic response.
Against
the consequentialist moral calculus of utilitarianism, always focused on the
linear phases of disaster—impact, response, recovery—care harnesses uBuntu’s
understanding of emergencies as unfolding in time, through repetitive labor as
one vulnerability begets another. This is critical in a pandemic, in which the
timeline of response is indeterminate; caring networks can be effective over
time only when they support caregivers, rather than reproducing greater
vulnerability.
In
the CDC’s ethical guidelines for a pandemic, little attention was paid to the
distribution and elaboration of vulnerability within existing, essential
networks of care (Kinlaw and Levine 2007; Jennings and Arras 2008, 115). While
the protocols enacted to “flatten the curve” are best understood as a
collective act of care that treat all of us as responders complicit in
containing contagion, these policies have strained every system of caregiving
in our society to its breaking point, from our state governments to our largest
hospitals, from nursing homes to families. Nuclear and intergenerational
families, with their embedded patterns of gendered labor, have been expected to
absorb these shocks. Parents and other caregivers found themselves in the
impossible position of juggling suddenly full-time care labor with full time
work responsibilities or the stresses and uncertainties of unemployment.
The
distribution of this strain has not been even; just as women shoulder the bulk
of care labor in “normal” times, it is women whose caretaking labor has been
strained to the breaking point in COVID-19. As women face increased duties of
care within the home that will reduce working hours, they accounted for more
than half of the jobs lost in April 2020, with unemployment rates for women of
color creeping over 20% (Gupta 2020). Even among highly educated women, the
strain will transform career and earning trajectories, as academic journals
report an unprecedented drop in journal submissions by women and in some cases
an increase in submissions by men (Fazackerley 2020; Kitchener 2020).
Studies of recent epidemics, like Zika and Ebola, show that while income levels
generally dropped immediately following the outbreak, men’s earnings eventually
recovered, while women’s did not (Lewis 2020). In the current pandemic, as
childcare providers are amongst the hardest hit, women may find it difficult
work in an already strained economy (Kennedy and Mayshak 2020). And even as
women face disproportionate hardships in the social and economic fallout from
pandemic response, they also make up the bulk of essential laborers providing
the caregiving of response (Robertson and Gebeloff 2020). Often caregivers
themselves, responders and essential workers faced untenable obligations
exacerbated by a persistent overlooking of the multidimensional nature of
caregiving networks.
Just
as vulnerability is unevenly distributed, the labor of care is unequally
shared, and those who take on the bulk of caregiving labor become additionally
vulnerable. We misunderstand the nature of the disaster when we focus on moral
dilemmas and heroic choices, rather than attuning ourselves to the matrix of
ripple effects that produce a strikingly raced and gendered pattern of pandemic
labor. A care ethics response framework calls us to expand our conception of
disaster response by rethinking our “normal” moral priorities and practices, by
prioritizing attentiveness to vulnerability and developing responsive
structures that both surge caregiving and build collective responsibility for
the resilience of caregivers. In this way, it offers us a concrete moral
structure for enacting commitments to solidarity through sustainably extending
existing networks of care.
6. Surging and Sustaining Solidarity
In
New York City as March faded, COVID-19 cases spiked. At Elmhurst Hospital, in
Queens, patients jammed hallways as the neighborhood death toll mounted.
Ventilator allocation was at the forefront of many minds (Mcvane 2020; Correal,
Jacobs, and Jones 2020). Ethical guidelines for allocating scarce medical resources
in New York State organized around the modified utilitarian “save the most
lives” approach, giving preference to health care and other essential workers,
to the young over the old, to the healthy over the unhealthy (Wikler 2020; New
York State 2015). Terrible decisions would have to be made.
Just
like Lombardy, acceptable sacrifice was the utilitarian narrative these doctors
had accepted to prevent chaos. Just like Johannesburg, the impact and response
were racialized, with many more people of color dying based on underlying
structures of racial injustice. Just like Memorial in New Orleans, staff
accepted this descent into chaos and isolation as a natural part of the
disaster. They believed it had to be that way.
But
within twenty minutes of Elmhurst lay more than 3,000 empty hospital beds. Not
reported in the news, perhaps, but there. Ready. Under the pressure of the
pandemic, New York City, like Lombardy, had created a network of care designed
to responsively share resources, the staff at Elmhurst were able to redefine
their trolley problem. They recognized that their localized vulnerability was
embedded in an interconnected network that surged to support them, and those
patients were transferred instead of unfairly triaged (Dwyer 2020).
As
this perceptual shift at Elmhurst shows, once we understand ourselves as
interconnected, we can collectively construct a disaster imaginary of
solidarity. In this way, pandemics can be ethically innovative disasters. Their
cruelty is in their exponential spread as they exploit our interconnectedness,
infecting a network node by node. But in doing so, they make our
interconnectedness, our relationships as vulnerable vectors, visible. We can
use this new awareness to surge response by supporting those providing care. In
COVID-19, we see uBuntu’s awareness of our interconnectedness, of the ways that
the community makes possible the individual, and vice versa. In networks
springing up to feed and transport frontline workers, to babysit their kids, we
see care ethics’ attunement to the ways that surging caregiving through
existing networks produces new vulnerabilities, requiring emergent strategies
of care. The extended and uncertain nature of the pandemic requires us to learn
to sustainably surge these networks of care (Tolentino 2020).
But
our interconnectedness as vulnerable vectors is not simply the result of the
infectious nature of the virus. Our analysis of the derivative nature of
dependency in care networks suggests that we are always vectors of
vulnerability in crisis. In closing, we point to the ways that other disasters,
too, are characterized by the strains on multidimensional networks of care, as
emergent dependencies exacerbate existing inequalities and beget new dimensions
of vulnerability. Our framework understands disasters as producing networks of
interlinked people who need care and are giving it; the ethics we propose will
help to surge and sustain that entire network, not force us to break it apart
and choose between the pieces.
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