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COVID-19 and the Ethics of Whom to Treat First: A Utilitarian Approach

The scarcity of resources in healthcare is always a problem. The problem is worsened by rising cases of coronavirus, mounting pressure on the available limited resources. The ethical issue emanating from this situation is the problem of whom to treat first. In the midst of scarce medical resources, who shall receive medical attention first? Between an ordinary patient and victim of coronavirus, between the critical and mild victim, and between the aged and the young, who shall be treated first? The paper adopted a utilitarian approach in solving the problem. The finding is that the number of persons to benefit from treating a particular patient, duration of treatment, age and health condition of the patient, chances of recovery, and quality of life after recovery are factors to be considered in taking the ethical decision. The work is qualitative research using library materials such as journal articles, books and unpublished materials as sources of data, while hermeneutics and philosophical analysis are applied in studying them.


INTRODUCTION
The scarcity of resources in healthcare is always a problem. The problem is worsened by rising cases of coronavirus, mounting pressure on the available limited resources. It would be proper to recall that the virus which causes the respiratory tract infection Covid-19 was detected first within the city of Wuhan, China, in November 2019. The outbreak spread with unprecedented velocity across the world within the first months of 2020 and was declared a worldwide pandemic on 11th March, 2020 by World Health Organization. A pandemic is when a communicable disease is passing so fast from person to person in many countries at same period of time. From China, many parts of Europe and North America was beaten majorly by April, 2020, but as they began to witness reduction in the outbreak, Latin America, Asia and Africa started to witness rapid case spikes. The outbreak spread to all parts of the globe in such a way that there was tumult, confusion and fear of global cleansing. Governments all over the world were forced to close their borders, limit public movements and shut down businesses and venues in order to limit the rate of the spread of the virus. Total lockdown, social distancing, shut down of social gathering, face mask order, use of sanitizer, constant washing of hands and numerous policies were enforced to checkmate the spread of the virus, but to no avail.
The statistics of the cases kept on rising daily, defying all policies and attempts to checkmate the pandemic. Though the true statistics of the cases is not easy to gather and document, due to secrecy, inadequate data collection and management, poor testing equipment and communication gaps in many nations, the Visual and Data Journalism Team of BBC news was relentless in gathering what we can lay hands on with a view of giving a cursory information on the outbreak to the populace. The data, according to them, come from various sources, including figures collated by World Health Organization, Johns Hopkins University, and European Centre for Disease Prevention and Control, UN data on populations and data from various national governments and health agencies. 1 According to BBC report, as of 21st June 2021, more than 178.4 million cases have been confirmed so far all over the world, with more than 3.8 million victims already dead as a result of the virus. 2 Cases of the disease have continued to increase in many nations, while some that witnessed apparent success in controlling the initial outbreaks are now seeing an upsurge in the spread of the infections. This development and upsurge led many countries to re-impose total lockdowns in their worst-affected parts of their nations, and renew appeals for people to wear face masks and to observe the rule of social distancing. With this upsurge, the number of patients competing to access medical facilities in these nations outweighs the available facilities. In many nations, the retired medical personnel have been recalled to join hands in handling the challenges; Governmental and Non-Government Organizations, philanthropists and religious organizations have donated medical facilities and resources, yet the problem of scarce medical facilities and personnel is not yet totally solved.
The ethical issue emanating from this situation is the problem of whom to attend first. In the midst of scarce medical resources, who shall receive medical attention first? Between an ordinary patient and victim of coronavirus, between the critical and mild victim, and between the aged and the young, who shall be treated first? Savulescu and Wilkinson asks "Who gets the ventilator in the coronavirus pandemic?" Imagine there are two patients with respiratory failure…" 3 It is undeniable fact that people should have an equal chance when there are sufficient resources. Someone should not be denied medical treatment due to his age, sex, disability, race or other factors. Such action would be partiality and unfair treatment, but not when the resources are very scarce and could not go round them. So, how can we ration the available resources when they are not adequate? Responding to these questions, this paper adopts utilitarianism as a good ethical approach. It explains the meaning of utilitarianism, and compares it with other resource allocation principles in healthcare, and highlights reasons why utilitarianism is a better option than others. It points out how utilitarianism can be applied practically in solving the problem of whom to treat first in time of pandemic. This paper concludes with certain recommendations and admonitions.

MATERIALS AND METHODOLOGY
Considering that this work is qualitative research in medical ethics, we sourced our data from various medical experts in the form of oral interviews and discussions on the issue. We also consulted many library materials such as journal articles, books and unpublished materials. And considering that the topic borders on ethics and value judgment, we applied philosophical skills such as hermeneutic interpretation, critical and logical reasoning (both induction and inductive reasoning), and analysis in studying the data to minimize the influences of sentimentalism and prejudice. Nevertheless, the research of this kind cannot be purely objective, but we believe its findings passed a rational acceptability test and relevance to scholars of bioethics and medical practitioners.

DISCUSSIONS Understanding the Ethical Approach: Utilitarianism
Utilitarianism is a moral philosophy of Jeremy Bentham and John Stuart Mill that emphasizes the greatest number of good to the greatest number of people. It was an influential philosophy due to its simplicity and its way of conforming to what people already believe in their time that pleasure and happiness are what people desire. From this simple fact that everybody desires pleasure and happiness, the utilitarians inferred that the whole idea of what is good can be understood in the principle of happiness, which they spoke as "the greatest good of the greatest number", and by which they meant that 'good' is achieved when the aggregate of pleasure is greater than the aggregate of pain and when an action gives happiness to the greatest number of people. 4 An action is good if it is used in achieving pleasure and reducing pain to greatest number of persons; that is, if it is useful and beneficial to the greatest number of persons.
In other words, utilitarianism is a class of normative ethical theories that encourages actions that maximize happiness and well-being for greater number of persons .5 Although there are different versions of utilitarianism with different characterizations, the basic idea that they all share is the emphasis on maximizing utility, which is often defined in terms of usefulness or greatest benefit to the greatest number or related concepts. For instance, the founder of utilitarianism, Jeremy Bentham (1780) describes utility as that quality in any object or action, whereby it tends to produce, advantage, benefits, good, pleasure or happiness...[or] to prevent the happening of evil, pain, suffering or unhappiness to the person or persons involved. 6 It would be a mistake for one to think that Bentham utilitarianism is not concerned with formulation of rules. For according to him, the business of the government or anyone that serves the public is to minimize pains to the public, while the happiness of people increases. In Chapter VII of his book, An Introduction to the Principles of Morals and Legislation, Bentham says that the ends of legislation are maximization of pleasure and minimization of pain. By pleasure, he didn't mean sexual and animalistic pleasure but the good, welfare and happiness of man. Bentham 6 insists that "The business of government is to promote the happiness of the society, by punishing and rewarding.… In proportion, as an act tends to disturb that happiness, in proportion as the tendency of it is pernicious, will be the demand it creates for punishment" (p.1). Speaking on the principle of utility, Bentham says: Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do.… By the principle of utility is meant that principle which approves or disapproves of every action whatsoever according to the tendency it appears to have to augment or diminish the happiness of the party whose interest is in question: or, what is the same thing in other words to promote or to oppose that happiness. I say of every action whatsoever, and therefore not only of every action of a private individual, but of every measure of government (p.1).
In Chapter IV, Bentham introduces a hedonic calculus, which is a method of calculating the value of pleasures and pains. According to him, the value of a pleasure or pain, can be measured according to how intense it is, its duration, certainty, propinquity, purity and the number of persons to be affected. He also introduces the concepts of evils of the first and second order. Evils of the first order has more immediate consequences but evils of the second order are those that have consequences that can affect members of the community or many people causing pain or loss or danger to many people. This of course is a greater evil. Therefore, in a situation where an action would bring pain to an individual if it is done and pain to the community if it is left undone, the action must be taken to save the greater number of people. You should not allow the whole community to perish because of an individual but can sacrifice an individual to save many.
John Stuart Mill, a disciple of Jeremy Bentham, was brought up with a view of carrying out the cause of utilitarianism. 7 His book, Utilitarianism appeared first in Fraser's Magazine as a series of three in 1861 8 and was published in 1863 as a single book. 9 Mill did not accept a quantitative measurement of utility. According to him, some kinds of pleasure are more valuable and desirable than others. In other words, quality must be considered and not only quantity as Bentham held. For Mill, the word utility means general well-being or happiness, and his view is that utility is the end of a good action. For him, utility in the context of utilitarianism refers to people performing actions for social utility. With social utility, he implies the well-being or good of many people. His explanation of the concept of utility in his book, Utilitarianism, is that people really long for happiness, and since each individual desires their individual happiness, it must follow that all of us must desire the happiness of everybody, contributing to a greater social utility. Thus, an action that has a favorable consequence to the greater number in the society is considered the best action; or as Bentham, the founder put it, the greatest happiness of the greatest number.
Mill did not only view actions as a core part of utility, but as a guide to moral human conducts. The rule is that we should only be committing actions that give pleasure to society and not selfish pleasures and satisfactions. Pleasure is therefore seen by both Bentham and Mill as the highest good in life, which is hedonism. According to them, good actions result in pleasure or happiness. There is no higher end than pleasure. Pleasure defines good character. Better put, what justifies character or action as being good or not, is based on whether it produces pleasure or happiness, the quantity and quality of pleasure, and the number of persons involved (social utility). Though, the proponents of utilitarianism differ on number of points but agree that social utility remains the best action expected from man; action that gives greatest service to the greatest number of persons. Therefore, utilitarianism is a version of consequentialism, which states that the consequence of an action is what makes it right or wrong. It is contrary to egotism and altruism as it considers collective interest in decision making, and tries to maximize the greatest possible service or social utility to the greatest number of people in society. Actions done for the interest of the community is better than the one that serves an individual selfish interest. 10

Utilitarianism and other Resource Allocation Approaches in Healthcare Delivery
One popular approach to the issue of whom to treat first in many hospitals at sundry is egalitarianism: the principle of "first come, first served". Egalitarianism argues equal treatment for equal need [11][12] and that no factor should be used to discriminate against any person from receiving medical treatment. 3 Therefore anyone that comes first should be treated first. Imagine there are ten patients, the one that came first was an old man of 85 years suffering from covid-19, and may likely be on ventilator for weeks and is likely to die due to his old age and other related health challenges, and there is another patient who can make use of the ventilator for just 24hours and is likely to survive because he is stronger: Who among them shall be treated first? If health workers insist on allowing the old man who came first to access the available ventilator for weeks, it may result in deaths of other patients. And there is a great possibility that the old man would not survive after using the ventilator. Is this not a bad decision? The man is not saved and others too lost. The man, even if he is saved, is likely to die soon due to his age and other health challenges. More so, saving the life of such an old man who has little or nothing to contribute in life at the expense of the lives of other able men seems very absurd.
Another principle is the severity of the patient. Critical patients are given immediate attention to save them. This is why hospitals do have emergency units. The Emergency Department is a very vital aspect in the healthcare community. The emergency room is used for the purpose of giving urgent attention to patients in critical condition. 13 Many at times, patients arrive to the emergency room through ambulance, ranging from accident victims to unexpected injuries and sudden critical illness. 14 Considering the severity of emergency patients in giving them attention first is very ethical and reasonable, but this cannot serve as a general approach to the case of whom to treat first, because there may be possibility that all the patients are critical and the medical resources scarce. On the other hand, there may be a situation where none is critical. More so, there may be a situation where there is a coronavirus patient and an ordinary critical patient in the emergency room. In this situation, who should be attended first? In other words, severity is not a general criteria or principle that applies in all circumstances but in exceptional and emergency cases only.
Obviously, many medical practitioners consider the socioeconomic status of patients. Social status plays a great role in people's influences and regard, but is not an ethical ground on the issue of whom to treat first, as it amounts to discrimination. Similarly, other factors such as possibility of survival, quality of life after survival, duration of treatment and host of others are very relevant but must be considered in line with the principle of utilitarianism. 15 Utilitarianism as we have seen considers the number of persons to benefit from treating a particular patient first. It therefore considers the interests of many other than individualism; it is community oriented, and that is why we consider it a best approach to the issue of whom to treat first in the time of pandemic. Pandemic threatens the world with global cleansing, and utilitarianism being a principle that considers the salvation of others in treatment of an individual is therefore recommended.

Application of Utilitarianism
It is an undeniable fact that people should have equal access when there are sufficient medical resources. As noted before, no one should be denied medical treatment that is available on ground of his sex, age, race, disability or any other factor. Such discrimination is unfair and immoral.
But when the resources are scarce and could not go round, certain factors must be taken into account in deciding who would be given priority. Imagine there are many coronavirus patients in a hospital. The first patient is an 85 years old COVID-19 infected man, with severe dementia, who has been staying invalid in a nursing home. The second person is also a critical coronavirus patient, a young man of 40, with four kids and wife depending on him for survival. There are also other young and prospective patients with diverse serious cases waiting in the queue. The hospital has only one ventilator. The old man, the young man of 40 and a great number of the patients need the ventilator too. Who among these should be treated first when the resources are scarce? If the doctor insists on treating the old man first, who is likely to be on ventilator for a longer period of time due to his age, with little chances of survival, and minimal years to be enjoyed when cured, the young man of 40 as well as great number of persons on the queue may die.
Moreover, the old man is already invalid, and his death, though may be painful to his people but would not make them to be liabilities to society. In fact, his death would be a blessing to them in disguise as they are relieved of the burden of taking care of him. His survival is of little or no benefit to the society at large. On the other hand, the death of the young man is a colossal loss to his wife, four children, dependent relatives, community and larger society, both emotionally, socially and economically. The young still has quality life to live, much impact to make and his usage of the ventilator may not be long, giving chance to others to use and be saved. By implication, the young man should be given priority over the old man.

RESULTS
Utilitarianism, therefore, holds that resources should be utilized to save the greatest number. According to utilitarianism, medical officers should take actions which bring about the most good. They must take decisions that would enable them save many lives with limited resources than to waste them on a single or few patients. 5 It is better to lose one and save many than to save one and lose many. In order to achieve this, they need to take the following factors into consideration: 1. Number: One obvious factor to be considered in application of this principle is number. This is the stand of Bentham when he talks about quantity. According to utilitarianism, facilities should be used to bring about the greatest good for the greatest number. If you can save ten people, or one, you ought to save the ten. You also have to consider the number of persons to be happy if a particular patient is cured and the number to suffer as a result of his death. 2. Duration of Treatment: To save the greatest number of people, duration of treatment must be considered. Between a person who is likely to stay longer on a ventilator and one who is likely to stay for a shorter period, who should be treated first? Treating a person that is likely to stay longer on a ventilator would increase the number of deaths. 3. Age and Health Condition: Similar to duration of treatment is age and health condition of a patient. Aged coronavirus patients and those with other health challenges stay longer in ventilators, consume more medical resources and hardly survive the attack of the virus. In Italy, age and health condition are so much considered. A document from Northern Italy states: "The criteria for access to intensive therapy in cases of emergency must include age of less than 80 or a score on the Charlson comorbidity Index [which indicates how many other medical conditions the patient has] of less than five" (see Savulescu and Wilkinson 2020) 3 . So if one is more than 80 years or has other medical challenges more than five, he would not be treated. This is because "What might be a relatively short treatment course in healthier people could be a longer and more resource consuming in the case of older or more fragile patients". 15 In Niguarda, doc-tors decline life-prolonging treatment to patients over the age of 60. Are we to blame them for taking such a cruel decision? We mustn't not because the resources are insufficient. The number of patients outweighs the available resources. Therefore, they must decide whom to be saved first with the scarce resources and whom to be neglected or allowed to die, if God wills. 4. Certainty/Chances of Recovery: Bentham also emphasizes on certainty, probability of recovery. A doctor should not waste the limited resources on a patient who is likely to die, while others that are likely to survive are allowed to die. Such action is wicked and unethical. A wise doctor should consider treating the younger persons and others whose cases give assurance of recovery. Old people and those with complicated health challenges hardly survive the attack of coronavirus, and that is why in many countries, they are left untreated. 5. Quality of Life after Recovery: Mill 9 in his book, Utilitarianism highlights the importance of quality of life in utilitarian decisions. According to him, some kinds of pleasure are more valuable and desirable than others. In other words, quality must be considered. We must consider the state of life after recovery, its usefulness, and expected life span. Between a coronavirus victim who is more than 80 and has been invalid on bed as a result of a stroke and a young man of 40, who is to be cured? The young man still has many years to live if God wills; he is still active, useful and has more visions to fulfill. Such a case needs less argument. He deserves attention first.
How can we apply utilitarianism in cases between ordinary patients and COVID-19 patients? Who is to be treated first?
The same factors apply. We have to consider how urgent the patient needs the medical facilities, the number of facilities to be consumed, chances of survival, age and health condition, quality of life after recovery etc. A question may be raised on the issue of quality of life after treatment. How about a young man who is a criminal and has been terrorizing the community? Should we treat him before an old man, who though is very old but has better character than the young man? This is not an easy question to answer. But we have to reason: How many people would die if we embark on treating the old man? You don't just consider quality of life alone but the totality of the factors. Truly, utilitarianism cannot easily solve all the issues and challenges behooving medical practitioners in times of pandemic but is indeed a veritable guide in managing the insufficient resources in face of an outlandish number of patients.

RECOMMENDATIONS
Life is very important and should be preserved at all costs. As we said in the beginning, selecting those to be treated and allowing others to die is very unfair, but not when the resources are insufficient to go round. When the resources are limited and the number of patients competing to access the resources is greater than the available resources, medical officers should consider certain individuals first before others, using utilitarian principles, which advocates greater happiness to the greatest number of persons. Utilitarianism gives us a better guide on how to make acceptable choices in such a situation to minimize the effect of limited resources. It shows us how the limited resources can be maximized to the benefits of many. This is the best approach to handle the issue of limited resources in time of pandemic. But if the resources are sufficient and all things good and fine, ceteris paribus, there is no need to evoke such an approach. In order to avoid such ugly situation, we recommend the following: 1. Government, Non-Governmental Organizations and philanthropists should join hands in providing the requisite health facilities in time of pandemic. Pandemic is very challenging as the number of patients often increases more than the available resources. All hands must be on deck to tackle this problem, otherwise, health officers would be forced to make decisions on who to live and who to die. 2. Private hospitals should be called upon to assist. Many countries' policy of restricting private hospitals from management of pandemics like coronavirus is very unhealthy. If they feel that they are not trained to handle such issues, why not give them ad-hoc training to ease government hospitals? 3. Retired health workers needs to be recalled to assist in such a period. Some countries did so during this era of coronavirus while some insist on using few health workers in active service. Peculiar problem needs peculiar attention and less protocol. 4. Public Enlightenment. The public needs to be enlightened on how to minimize the chances of getting the infection. This can be done through mass and social media. 5. The necessary policies such as social distancing, use of sanitizer, frequent washing of hands with runny water, restriction of movement and social gathering need to be enforced. People are too stubborn and at times need to be forced to follow these rules and save their lives and the lives of many. 6. Families with aged people and persons with health challenges should take serious precautions to protect them from getting the virus as their chances of survival are very minimal. 7. Palliative should be given to citizens to ease their suffering and create a conducive atmosphere necessary for these rules to be obeyed. The reason why lockdown did not work out in many countries was hunger.
People are hungry and must go out to earn a living. 16 Its consequence is the daily increase of new cases.
8. Era of pandemic is not an opportunity to make money. Many politicians pay lip service to the problem of coronavirus. The funds earmarked for procurement of medical facilities and tackling the problem were embezzled in many nations. This is a bad omen.

CONCLUSION
In conclusion, egalitarianism and other approaches to the case of whom to treat first may be good but not in an era of COVID-19 pandemic when the available medical resources are insufficient compared to the number of patients. Since the situation already on ground in many nations is beyond human control, we have to adopt utilitarianism as an alternative ethical approach to limit the effect of the virus and save many lives. Utilitarianism as we have seen is a kind of consequentialism that is against egotism as it seeks the interest of the greatest number of people in society. We know that the interest of society is better than that of an individual. Though application of the utilitarian approach is not so easy, but having highlighted some factors which health practitioners should put in consideration, we hope that the challenge is half-solved.

ACKNOWLEDGMENT
Mrs Nkiruka Uzoagu, who proofread this work and helped to enhance the grammar.

Conflict of Interest: None
Originality: This work has is original research. It has not been be submitted simultaneously or published elsewhere.
Approval on involvement of Animal: No animal is involved, and therefore not applicable.
Approval on involvement of Human Being: No human being was mentioned in this work, and therefore not applicable.