Pandemic Ethics: Extreme Altruism in a Pandemic

Written by Julian Savulescu and Dominic Wilkinson

Cross-posted with the Journal of Medical Ethics blog

Altruism is one person sacrificing or risking his or her own interests for another’s interests. Humans, like other animals, have a tendency towards altruism. This is usually directed to members of their own group. An example is donating a kidney to a family member. This is quite risky – it involves immediate risk of death from anaesthesia or post-operative complications, and long term risk of kidney failure.

But sometimes people are altruistic towards strangers.

Altruism often involves fairly small personal sacrifices. (For example, most people donate to charity, but in countries like the UK, it is typically only a tiny proportion of their income) Where someone can cause great benefit to another person at little or no personal cost, there is an ethical obligation for them to do so. This is the Duty of Easy Rescue. A whole movement has arisen called Effective Altruism which aims to ensure that altruistic acts do as much good as possible.

Altruism can also be extreme. Some people give up their entire livelihood to work overseas for aid agencies or charities. During a pandemic, health workers may take on significant personal risk to provide front-line medical care. In times of war, people may choose to literally give their life for others of their nation.

We can define extreme altruism as an act taken for the benefit of another that involves making large life-altering or life-threatening sacrifices or personal risks.

Society’s approach to extreme altruism is inconsistent. At times of obvious societal need, it encourages it (for example, clapping on the doorstep for ‘key workers’ is in order to offer our appreciation for their altruistic assumption of great risk) or even requires it by conscription of military personnel. At times of perceived lesser need, it is discouraged or even banned. For example, in normal times people are only allowed to take part in research, even if they do so with full knowledge and for no payment, if the risk of the research is minimal, and not if the risks are similar to everyday life. In some jurisdictions, altruistic kidney donations to strangers are banned.

It is not clear why extreme altruism should be limited to national emergency. If someone is competent, knows all the relevant facts, and is thinking clearly and choosing autonomously, they should be able to sacrifice their interests or even life for others. If someone is permitted to participate in highly risky personal activities for purely personal benefit (e.g. climbing Mount Everest, base jumping, or boxing) they ought to be permitted to at least take equivalent risks for the benefit of someone else (e.g. participating in research). Just as a rational, clear thinking person who is competent should be able to sacrifice their own life through suicide for any reason, they should be able to do this for the benefit of others.

We have argued at various points for extreme altruism in medicine. In one sense, there is a constant national emergency: we are all aging and slowly dying. There is a war against aging and death: we are fighting it with medicine. And people should be able sacrifice their interests or lives in this war. 

Extreme altruism extended to COVID-19

Even if this metaphor is slightly hyperbolic, there does appear at present to be a war against COVID-19 and a pandemic emergency. Most governments and citizens perceive this to be a crisis and whole states and economies have shut down. We argue that extreme altruism should be allowed in the current pandemic and give examples based on previous work and one novel proposal: the very elderly or infirm, such as nursing home residents, volunteering for risky challenge studies.

1. Risky trials in COVID patients with severe illness

One of us has previously argued that dying patients should be able to engage in risky trials or use untested medications with significant risks if they are dying, for example in motor neuron disease. This principle is the basis of a subsequent “right to try” legislation in the US and which failed to pass in the UK.

We can extend this to COVID-19. People should be able to consent to take part in trials, or even compassionate use, of risky interventions on COVID-19 provided these generate usable knowledge of benefit to others.

This is not a purely altruistic case, as patients severely affected by COVID-19 stand to benefit and may have little to lose  in trialling possible treatments. It may be in their interests, even though there is also risk involved.

In reality, many of the most severely affected will have diminished consciousness and be incompetent, and therefore unable to ethically consent to such a trial. Therefore, competent people now, or in the early phase of their illness when they retain competence, should be able to make advance directives for extreme altruism. This might take the form of consenting now to trials of dangerous drugs. They could also consent in advance to other interventional studies of significant risk, if they would imminently die.

2. Voluntary research euthanasia – COVID-19 patients for whom the disease will be fatal

When a patient will certainly die, they should be able to consent while competent to experimentation being performed on them for others, even if the experimentation may itself likely or possibly end their life sooner.

For example, if someone with respiratory failure from COVID-19 is not recovering and will be extubated and die, lung biopsies could be taken for the sake of better understanding the disease. If the patient understands and consent to this, it may be ethical to undertake these studies, even if it would not benefit the patient and may even hasten their death.

3. Organ donation euthanasia

Two of us coined the term organ donation euthanasia whereby a person who will die can die from having their organs extracted so that the organs can save more lives, rather than waiting until they are brain dead.

Similarly, a person could consent in advance to donation of their organs if it were decided that they would have medical treatment withdrawn on usual grounds, and they would certainly die of respiratory failure over a period of hours or days. Organ donation euthanasia could possibly apply to some cases of COVID-19 where life prolonging medical treatment is either withdrawn or withheld. In those jurisdictions where euthanasia is legal (Netherlands, Belgium, etc), euthanasia could occur by surgical removal of vital organs under deep anaesthesia. Obviously, this would be limited by concern about transmission of COVID-19 to the organ recipients. It might therefore be restricted to patients who were initially positive, but subsequent swabs have become negative. It may also be restricted to organs unaffected by the virus (for example, if it were clear that livers were unaffected by coronavirus, it might be possible to donate livers).

4. Military research service

It is notable that vaccine trials in China will be conducted in a military installation. One of us has suggested previously that soldiers could trade active service in areas of armed conflict for participation in risky research, such as challenge studies.

Early or risky vaccine trials of a COVID-19 vaccine could be conducted on soldiers in exchange for avoiding active service, which involves risk of death.

5. Nursing home volunteers for risky research

It could be objected that in all these cases, the altruism is minimal or absent. In cases 1 and 4, it may be in the participants’ overall interests. And in cases 2 and 3, there is no harm or real risk involved. However, we choose to call these examples of Extreme Altruism because all these practices involve what would ordinarily been seen extreme risks or sacrifices.

Here is an example of Extreme Altruism that might involve significant sacrifice of interests. Some residents in nursing homes and care facilities are competent. Some of these may choose to take on significant risks in the war on COVID-19. For example, some people have elected to complete “Save Other Souls” advance directives. They choose to forego treatment (like a ventilator) so that someone else may be able to access that treatment.

They could also be allowed to consent, with full disclosure of risks and no pressure, to take part in risky research which would accelerate the discovery of vaccines or treatments, such as:

• Risky challenge studies involving COVID-19
• Early phase trials of vaccines or treatments.

Challenge studies would require movement to a secure research facility. Currently challenge studies of coronavirus infect patients with mild strains of coronavirus (non-COVID-19), but they only recruit healthy volunteers.

Some bioethicists have argued that challenge studies using the SARS-COV2 virus (which causes COVID-19) would be ethical – but again, only in healthy young adults.

But why couldn’t an older patient elect to take on the risk of a challenge trial?

Their motives might be purely altruistic – they want to do something to help others in this purported dire emergency. Or they might be partly self-interested. They might believe they will contract the virus and want early access to vaccine or treatment. Or they may be fatalistic or wish to die, or at any rate not care if they die sooner rather than later.

One reason not to enrol ‘higher risk’ patients, like those in a nursing home, is that they might require intensive and invasive medical treatment if they end up becoming seriously unwell. However, that wouldn’t apply if the patients had previously (and separately) completed a living will indicating that they would not wish for invasive medical treatments in the event of becoming seriously unwell.

Perhaps many nursing and care home residents wouldn’t want to take part in risky research. But they ought to be given the opportunity, if they are competent.