Everything is unfair
Ethical concerns are an important factor in policymaking, and fairness often figures prominently in this respect. But are we really using it in the way we do?
In last week’s post, I referred to the challenges in setting policies for vaccinating people against COVID-19. If the aim is to protect the people who are the most at risk of the disease, then it makes sense to give priority to the elderly and those with underlying conditions, and to work your way down from there to the young and healthy, the people who are unlikely to develop serious symptoms, let alone require hospital admission.
There are clear instrumental motives for such an approach: the risk is not just to the individuals, but also to society as a whole. People who are seriously ill with COVID-19 use up scarce healthcare resources, which are then unavailable to others who might also need them for unrelated reasons. Vaccinating those at risk first takes the pressure of the health system, and is therefore an intervention that serves everyone.
Nevertheless, there is also an element of fairness entwined in the strategy of distributing scarce resources (the vaccine) first to those whose need is the greatest. But how far should we go to enforce such fairness?
On 29 December 2020, Dr. Hasan Gokal, an emergency physician in Texas, was in charge of an early vaccination event in Texas, mostly for emergency workers. As the event drew to a close, a vial remained with ten of the eleven Moderna vaccine doses it held still available. They had to be used within six hours, or they would go to waste. Dr. Gokal asked the staff manning the event, but either they had already had a jab, or they declined the offer. He called a colleague whose parents and in-laws he knew were eligible for the vaccine, but they were not available. Meanwhile the clock was ticking. So he called the people in his phone contact list to ask them if they had older relatives or neighbours who needed to be inoculated.
When he got home, two elderly women with underlying health conditions were waiting for him, and he gave them a shot of the vaccine. He then drove to a nearby house where he knew four people of between nearly 70 and over 90 years old lived, all with health issues. They got a jab, and so did a housebound woman in her late 70s. By now, three doses remained, and three people had agreed to meet the doctor at his home. Two were waiting as he got back from his vaccination tour — a woman in her 50s working as a receptionist in a health centre whom he knew vaguely, and a woman of around 40 he did not know at all, with a child that relies on a ventilator. As time ran out, the last person called to say he would not be coming. So with minutes to go before the vaccine would go to waste, Dr. Gokal turned to his wife who, as she suffered from a chronic lung condition, was also eligible, and gave her the last dose of the vaccine.
The next morning, he completed the paperwork relating to the ten vaccinations he had carried out. A few days later, he was called to his boss and the HR director, and as he confirmed he had administered the 10 doses as described, he was fired. The reason: he abused his position to place his friends and family in line in front of people who had gone through the lawful process to be there. He had acted unfairly.
Immunization will, we all hope, lead us out of the interminable lockdowns and allow us to return to the economic and social activity that has been so profoundly impaired for nearly a year. If the people who are inoculated were given a vaccination certificate, activities ranging from visiting relatives in care homes to international travel for business or leisure, could restart gently and ramp up as more and more people get a vaccine. Such a document is not new: it is already required for conditions like yellow fever to enter countries like Australia, China and Mexico. But this is on a different scale, and there are naturally concerns about fraud and counterfeit.
However, a widely raised objection is that it would be unfair. A Wired article invites us to “[i]magine being locked indoors while your immune neighbours galavant (sic) around the park”. It cites Robert West, a health psychologist at University College London, who warns for a loss of social cohesion as a result of sharpened ingroup/outgroup tribalism, and Adam Oliver, a behavioural economist at the London School of Economics, who fears it might undermine the message that “we are all in this together”. In a comment in the journal Nature, Natalie Kofler, a molecular biologist at Yale University and Françoise Baylis, a bioethicist at Dalhousie University in Halifax, Canada, also argue such documents will lead to social stratification between “immunoprivileged and immunodeprived” people. Forbes quotes the CEO of the World Travel and Tourism Council, Gloria Guevara: “we should not discriminate against those who wish to travel but have not been vaccinated”. Let’s not take the faster route back to normality, because that would be unfair.
How fair is fair?
Fairness appears as a criterion in decision making and in policy setting, because it is an important element in how we experience and judge our (and others’) treatment in society. It is an instinct that develops at young age in humans, one we even share with other primates, Maria Konnikova writes in the New Yorker. We don’t like being disadvantaged (or even being advantaged) compared to others, and we don’t like it if others are being disadvantaged (or advantaged).
The Ultimatum Game, a classic, popular instrument in experimental economics, shows we are even willing to make material sacrifices to prevent perceived unfairness. It involves two players: a proposer, who is given a sum of money, and a receiver, with whom the proposer can share the money. The proportion offered to the receiver is entirely at the discretion of the proposer — they can keep all the money, give it all away, or share anything in between. The receiver can decide to accept, or to decline the offer. In the latter case, neither player gets anything. A meta-analysis by Jean-Christian Tisserand, an economist at the Dijon-Bourgogne Business School, of 42 research papers that used in total 97 instances of the game, found that receivers often decline offers of 20% or less of the total sum, and frequently refuse offers between 20 and 40%. This means that receivers literally forego an amount of up to 40% of the money, just to stop the proposer from getting an unfair amount.
Avoiding unfairness in decisions or policy making is a deontological choice: it is deferring to an ethical rule, rather than to reasoned consideration of costs and benefits. For ethical rules that are broadly objective and clearly defined, this may be a sensible approach inviting little or no challenge. Few people will question the judgement of, say, a dairy in which health and safety practices ensuring neither staff nor customers are poisoned are adopted for ethical reasons, without a thorough cost-benefit analysis.
But outside the formal simplicity of experimental games, fairness is neither an objective concept, nor clearly defined. It is very much in the eye of the beholder, closely linked with (perceived) entitlement, group affiliation and ideology. Its Wikipedia disambiguation page, even when you ignore the more frivolous possibilities, refers to a range of (mutually incompatible) perspectives on justice, to absence of bias and more.
It is therefore all too easy to invoke fairness in a self-serving manner: if we don’t like something, we can find a way in which it violates some fairness principle. A moment’s reflection will confirm that most non-trivial decisions are disadvantageous to someone, whether it concerns a rise in Value Added Tax, the fact that supermarkets can sell clothes during lockdown while clothes shops cannot, or whatever. The same is true for leaving things as they are. For almost any ‘something’, both doing it, and not doing it, someone can claim that it is unfair to somebody. Everything is unfair.
This makes fairness practically a useless criterion to guide decision-making. The absurdity of firing a doctor who ensured precious vaccine did not go to waste for violating a fairness rule, and of holding back a return to economic and social normality because a key device to allow that to happen would be unfair are stark illustrations.
If the best argument we can make for or against a decision is that it is unfair, we don’t have an argument.
Originally published at http://koenfucius.wordpress.com on February 19, 2021.
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