A shared humanity: COVID capitalism and the future of the health care ethics

Introduction

“Medicine is a moral community,” Edmund Pellegrino and David Thomasma write, “because it is at heart a moral enterprise and its members are bound together by a common moral purpose.” ¹ The moral community that comprises medicine includes doctors and nurses who professionally administer treatments and curing remedies. As such, these individuals must align the ends of medicine with those of the common good. This community identified by Pellegrino and Thomasma must extend, however, beyond merely those who professionally consider matters of health. The moral community must also include the everyday citizens who participate in their neighbor’s health. Health care workers’ ability to align their actions with the ends of medicine (e.g., healing, caring, curing) is dependent to some extent upon the support of the community outside medical facilities to maintain such bonds of care.

The global pandemic of COVID-19 illustrated and continues to illustrate the fragility of community support for health care. Take, for example, the proponents who argued for the morally appropriate risk to the elderly to stimulate the economy. Chief among the proponents of this position was Texas Lt. Governor Dan Patrick, who famously proposed that the elderly should willingly sacrifice their lives to resume economic stimulation for their children and grandchildren. At the time of Patrick’s statements, medical professionals warned the elderly against exposure until a vaccine emerged. In this instance, however, the crisis created by economic concerns overrode the competing and more pressing goods in the medical sphere to protect the vulnerable from infection. Furthermore, supporters of Patrick’s position believed the various economic problems necessitated such a sacrifice and outweighed the good provided by the very lives of the elderly. This risk exposes the communal perception that health is subordinate to the economy. While the economic problems created by the shelter-in-place order represent important elements to consider, a dichotomy between physical and economic health presents a false choice to citizens. This false choice arises from the larger practical reason that funds what I term “COVID capitalism,” a form of capitalism that willingly sacrifices lives to deadly infection for economic profit. If the community works against the goods of health by exclusively privileging economic concerns, then the community’s health will necessarily suffer. Health cannot be an individual concern, as COVID capitalism would encourage, because health is a social concern.

This vicious economic formation should concern the Christian community. Though a large portion of US Christians evacuated their moral responsibility to care for their neighbors by refusing to wear masks and refusing to get vaccinated due to “religious convictions,” Christians must recognize their commitment to health care as an expression of neighbor love. The fact that many Christians choose to evacuate these concerns illustrates that COVID capitalism is but an expression of a larger economic formation that malforms communities away from the common good. Nevertheless, the subordination of health care to economic stimulation challenges health care ethics. A solitary gift of the pandemic was the clarity with which captivity to economic reason and practices came into view. As such, an opportunity to present virtues that clearly resist the moral formation of economic reason emerges. If COVID capitalism formed communities away from the virtues, practices, and postures necessary to promote health, new practices must emerge to resist it.

To this end, I argue that a virtue ethics approach to health care corrects the greater malformation of the economic reason that prohibits it. Furthermore, virtue ethics privileges the vulnerable as an essential task of health care ethics, which is not merely the responsibility of nurses and doctors but the entire Christian community. The virtues cultivate the postures of dependency and vulnerability in an age of COVID capitalism that only cherishes autonomy and competition. Dependency and vulnerability are key components of a shared vision of humanity, however, that provides an account of the good and goods necessary to sustain a virtuous community. In this time of crisis, an economic system can use the disorientation of a global pandemic to exploit the sick and place economic values above shared humanity. When shaped by COVID capitalism, competition and autonomy prevent the embodiment of communal virtues that prove important for the defeat of COVID-19. Only in this environment can a new way of thinking about humans outside the logic of economic reason alone become possible. In short, dependence and vulnerability cast a vision for common humanity in which individuals are not isolated in economic enclaves but rather are held deeply inside their shared humanity. A shared humanity enables a practical reason that can balance economic goods and health care not in competition but as a part of the singular vision of the good life.

COVID capitalism: Neoliberalism in the present crisis

COVID capitalism, as a discourse, is an isolated occurrence within the COVID-19 pandemic but emerges in the context of a larger form of economic reasoning already operative in the present age, namely neoliberalism. Scholars struggle to define neoliberalism, but for the sake of this work, I cite Wendy Brown, who defines neoliberalism as “a peculiar form of reason that configures all aspects of existence in economic terms.” ² Patrick’s call for the nation’s elderly to sacrifice their wellbeing for the economy arises out of this economic thinking that encompasses and surpasses moral thinking, which only secondarily considers the health of the elderly alongside the economy. In short, human dignity becomes a secondary virtue when the good becomes synonymous with the economically advantageous. Though, as I argue, this posture already existed below the surface, it was fully exposed during COVID-19.

COVID-19 is a once-in-a-lifetime global crisis. Certainly, other crises defined generations prior to COVID-19, but this present crisis changed life in a way not witnessed for a century. Furthermore, such a global crisis exposed economic rationality at the heart of everything done in the West, especially in the United States. Therefore, the response to COVID-19 occurred through the ideas available for economic reasoning. The infamous economist Milton Friedman writes, “Only a crisis—actual or perceived—produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around.” ³ Friedman’s point is that humanity can only respond to a crisis based on the ideas “lying around” before it, even if those ideas were ill-equipped for the task. For example, the United States, one of the wealthiest nations in human history, relied heavily on the ideas central to free market capitalism as the means to respond to COVID-19.

However, free market capitalism is not a monolithic economic system; it has many iterations and expressions. Therefore, one must focus on the mode of free-market capitalism in its neoliberal form. This form of capitalism, which turns all thinking into economic thinking, contains a specific practical rationality inherent in its deployment. Neoliberalism, Adam Kotsko writes, “maintains the conditions necessary for vigorous market competition, trusting in the price mechanism to deliver more efficient outcomes than direct state planning ever could.” ⁴ Neoliberalism then relies on the individual freedom of consumers and producers to operate independently of direct state interference to set the terms of the rules of the economy as a means to govern a peaceful order.

Kotsko recognizes that neoliberalism presents a compelling account of freedom that swallows other competing goods. The neoliberal account of freedom so vigorously defended by many relies on two elements: autonomy and competition. Autonomy arises as a virtue in direct relation to society’s preference against external coercion or intervention. This virtue arises, at least in part, from the Enlightenment doctrine of heteronomy, which affirms the will’s ability to choose independent of external coercion. ⁵ Autonomous freedom from coercion also includes, however, one important feature when extended into the economic sphere: freedom from dependence. For example, one needs to look no further than the shape friendship takes in such neoliberal communities. In neoliberalism, friendship cannot constrain one’s moral life; rather, friends must serve as a utility to profit. ⁶ In such friendship, central moral practices, such as accountability cannot exist because they cannot limit or infringe on autonomy. The prize of autonomy can find no use for others except they serve the interests of the autonomous self.

In addition to autonomy, neoliberalism does not allow friends in the full sense because one must compete. Theologian Kevin Hargaden writes, “We embrace the logic of competition because it promises us we can be winners.” ⁷ Winning allows the individual to be recognized over and against their neighbor and prevents the type of care essential for true friendship. Skidelsky and Skidelsky write that competition becomes a “zero-sum game, because everyone, by definition, cannot have high status. As I spend more . . . I gain status but cause others to lose it. As they spend more to regain status they reduce my own.” ⁸ Such a cycle never ends; more status equates to more success and less status less success. The goal of success creates greater freedoms and privileges. In short, it brings greater freedom. Under neoliberalism, one must make it to the top alone because, at least economically, one cannot share success. Competition encourages autonomy, and autonomy energizes competition. At their base, consumers do not want to depend on their neighbors for the items they desire. They simply want to own. Any place for the community would require a lack of autonomy. Therefore, consumers compete to win these items over their neighbors, so they do not need to be dependent upon them.

One must understand Patrick’s comments within this central emphasis on competition and autonomy. For better or worse, the economy secures one’s status and freedom. Theologian Philip Goodchild goes as far as to observe that in modernity, the economy replaces God as the objective guarantor of value. ⁹ Therefore, Patrick’s comments present the internal logic of neoliberalism. Patrick continues,

No one reached out to me and said, as a senior citizen, are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren . . . And if that’s the exchange, I’m all in. ¹⁰

Patrick’s “America” is the neoliberal American economy because he wishes to preserve its central practices by his death. Patrick’s potential choice is not what stands out most, but rather why the choice seems necessary. Patrick continues, “And that doesn’t make me noble or brave or anything like that . . . I just think there are lots of grandparents out there in this country like me . . . that what we care about and what we love more than anything are those children.” ¹¹ The sentimental posture of this quote masks that the assumed prize of these grandchildren will be the economy. In other words, the flourishing of the nation’s grandchildren is less contingent on the presence and wellbeing of their grandparents and more dependent on their unhindered access and assimilation into the full potential of the economy.

Communities of health: The elderly and health care workers in COVID capitalism

Health is a community concern, and one cannot be healthy alone. Ideally, health should be a shared good toward which all strive. Even before the COVID-19 crisis, health care workers experienced long hours, heavy patient loads, and a lack of workers. ¹² COVID-19 increased these hardships on health care workers and even led to many early retirements in the field. Many nurses, for example, experienced high amounts of patient death during their long shifts. The impact of the loss of life under medical care that extended over many months of the pandemic left a psychological toll on nurses, leading to greater burnout and fewer health care workers. The relative instability of the health care system, thus, could not focus on general community health but only on disease prevention.

To this end, many governmental figures proposed a shelter-in-place order to alleviate the pandemic’s pressure on health care workers and decrease the spread of COVID-19. Almost from the beginning of the various lockdowns, however, opponents such as Patrick decried the infringement on autonomy and the loss of market competition. Workers’ and the general public’s shared moral commitment to health were not maintained. The libertarian desire to choose for oneself, however, is never solitary. As Patrick sees things, choice must come at the expense of the elderly and others who are uniquely vulnerable to the virus. Furthermore, individual choice further strains the medical community that cares for the patients impacted by this “autonomous” choice.

To honor the autonomous choice of some, others must die, as Patrick readily admits. The disposable nature of the elderly in the wake of COVID capitalism materially emerges through the various health problems they encountered during the pandemic. To be clear, not all health issues encountered by the elderly were solely related to contracting COVID-19. Other health concerns also increased in adults from 50 to 80 in the United States due to a reticence to seek medical care out of fear of exposure. ¹³ Many adults already avoided care for chronic illness, but this fear increased among the elderly, who made up 80% of the mortality rate of the initial wave in 2020. The ableist and ageist mind-set at the heart of COVID capitalism can only envision the market’s needs and not the needs of a complex health system. In such a COVID capitalist frame, the market creates a social contract wherein the health of the elderly does not compare to the market’s needs. Thus, Patrick speaks logically within this frame when he insists that the elderly must pay the price for autonomy and competition.

The desire for autonomy and competition free from the restrictions imposed by shelter-in-place orders and the impact on the elderly further strained health care workers to exercise unethical oversight of patients. One cannot blame health care workers alone for this, but the high patient loads already encouraged in health care communities pushed hospitals to this limit. A classic tenet of health care ethics is the recognition of the patient as a person. During the exacerbated height of the COVID-19 pandemic, nurses were assigned higher patient loads due to a lack of health care workers and increased mortality rates. ¹⁴ The health care workers serving their patients could not provide the intimate and necessary care to the patients created by increased exposure. Though the increased workload and shift obligations were an emerging issue prior to COVID-19, the pandemic again further exposed the weakness in the health care system to care for patients.

To be clear, the critique of COVID capitalism and its more sinister logic does not negate the serious economic concerns posed by the pandemic or the various other concerns, such as mental health or domestic abuse, often outside the scope of defense of the shelter-in-place. These concerns are also important. The purpose of this critique, however, is merely to highlight that a concern for the economy need not exclude public health, and choosing one over the other is a false choice. Ethicist Cathleen Kaveny argues that the challenge must envision the economy as a place where individuals can flourish rather than a “demigod we sacrifice human beings to.” ¹⁵ The debate, then, is never the choice of one good over the other but the ability to weigh various goods. This exercise requires the development of practical reason, the ability to weigh, as Kyle Lambelet argues, “the goods or principles at play in a concrete situation . . . and to judge how they ought to act in such a situation to preserve those goods,” and make the most prudential choice that honors the myriad of goods at work in any situation. ¹⁶ Thus, the ethics that must emerge in response to COVID capitalism must reclaim a thorough account of the practical reason necessary to weigh these goods in question.

Virtue ethics: The medical community

Within a COVID capitalism lens, humanity is supremely implicated in destructive systems that lack the ability to maintain health. To be able to weigh competing goods prudentially, the ethical framework must shift. Largely, goodness in COVID capitalism consists of the freedom to be free from external coercion to compete for a scarcity of resources. Practical reason in COVID capitalism thus weighs actions based on their relative profitability through maximizing autonomy and competition. A theological perspective, however, can and must challenge such forms of practical reason, namely that one must measure all activity to a solely economic calculus. In such a harsh calculus, measuring people’s lives exists merely in their usefulness or ability to generate profit, leaving some as expendable. Such economic reasoning supports health only insofar as it participates in profit-making, and health care only exists as a means for the economic good rather than as a good itself to be weighed alongside economic flourishing. Kaveny observes that the assumption that the economy must take a “planned moment of rest” during the pandemic seems ludicrous to many. ¹⁷ Thus, health in general and the health of the elderly in particular can only play an instrumental purpose in society.

The moral formation of COVID capitalism only impedes the ends of medicine, namely caring, healing, and curing. The virtues necessary to engage in medicine must align and coordinate with these ends. Competition and autonomy cannot care for the needs of every neighbor; thus, certain individuals must face a greater risk for infection, greater isolation, or other health factors due to isolation. As such, this situation places greater pressure on health care workers to practice medicine in a way that troubles the worker’s ability to develop virtues that align with the ends of medicine. Higher patient loads and longer shifts, for example, lead to more mistakes and burnout, increasing patient loads and shifts for the remaining workers. ¹⁸ The cycle created by COVID-19 and the acceleration of cases due to the opening economy expedited a significant exodus from health care. ¹⁹ Therefore, one must recognize that the good of health and the good of the economy conflict with one another and thus require prudence, exercised not only by medical practitioners but also by the community as well, to support health care workers and community health itself. The intimate connection between the moral choices in the community and the medical field is ever present in COVID capitalism. The general health of a community depends largely on the desires and actions of the community. When discussing the medical community, therefore, one must not only think of doctors and nurses. The community at large, albeit differently, must also commit to the virtues that lead to the end of the practice of medicine.

Before considering the virtues necessary for the proper ends of medicine, one must consider the moral formation cultivated by virtues. Virtue in the ancient tradition was an attempt to find eudaimonia. The standard English translation of the word (“happiness”) tragically does not convey the original intention of the phrase. Ancient philosophers recognized eudaimonia not as a call to a general state of mind or pleasure, but rather as a shared understanding of a life well lived. Undoubtedly, eudaimonia is satisfaction, but satisfaction in perpetuating certain habits and acquiring desired virtues. To them, the moral life was an end, not a means to posture or to gain power. Seeking the latter ran counter to eudaimonia’s aim. The virtue ethics tradition broadly recognizes four cardinal virtues: prudence, fortitude, temperance, and justice. Pursuing practices and habits to be shaped into these virtues enables one to live well. Like an athlete perpetually training in the fundamentals of their sport to play the game well, these virtues help humans live their lives well. To be clear, living well is not necessarily a life of financial success but rather a life of flourishing, which should include health.

The cardinal virtues are essential to develop the practical reason necessary to hold in tension the health of the community and the economy. These cardinal virtues revolve around a gravitational matrix at the center of which exists the well-formed agent. In short, virtues travel in packs. For example, a good roommate, friend, or spouse all possess similar virtues. This assumes, then, that the people one desires to have in their community possess similar formations. The virtues that make up communities of character either directly or indirectly appeal to the cardinal virtues because they represent the good life worthy of emulation. Therefore, the virtues share a singular vision of the good life, for “life” defined appropriately.

Temperance forms the agent into desiring actions that do not lead to the performer’s destruction. It means avoiding that which might bring harm or shame and doing that which brings life. It encourages the practice of complementary virtues, such as humility, gentleness, and sobriety. Like temperance, prudence also affirms a kind of moderation.

The prudent person must weigh the competing goods in any given situation to make the most morally appropriate choice. In this way, prudence is the mother of all virtues, which aligns with the true practical reason that allows humans to develop the skills necessary to evaluate and perform the good simultaneously. The prudent person does not merely repeat a universal moral code abstract of context but can truly discern what is just and upright in any given situation and often seeks the wise counsel of others. The vices the prudent person resists are impulsivity, inconstancy, and negligence.

Justice is perhaps the most familiar virtue of all and involves recognizing and delivering what is due to another. The one who practices justice not only refrains from evil acts against one’s neighbor but also acts in such a way to affirm another’s dignity. Though justice has many subtle elements, justice concerns one’s ability to think communally. The community of justice acts in the interest of the common good.

Finally, fortitude is the resolution in the face of difficulty. One can recall Paul’s admonition to the Thessalonians as a call to fortitude, “hold fast to what is good” (1 Thess 5:21, NRSV). Fortitude, therefore, is the ability to do good in the face of uncertainty, even if a single individual is the only one doing it. A virtue closely related to fortitude is magnanimity, which encourages one to rejoice in the practice of virtue even if others do not laud one. Fortitude is a kind of resilience that finds joy in doing good only for the sake of doing good.

How do the virtues lead to eudaimonia? The answer lies in flourishing. In COVID capitalism, flourishing is primarily expressed as individual economic prosperity. Virtuous flourishing, however, is not a call to accumulate wealth but to grow content with oneself, one’s community, and the world. Flourishing, in the virtuous sense, is a communal concept even when expressed by an individual agent. As one can see from the cardinal virtues, virtue ethics encourages internal and external discernment. Temperance is a kind of self-care wherein one commits to loving oneself and neighbors as people worthy of love and affection. Justice is the recognition of that same love and respect due to another. In other words, virtue leads to a shared recognition of our own and one another’s dignity to shape our actions in such a way as to honor that dignity. As such, virtue must be not only a concern of the medical community but also the public at large.

Virtue ethics for medical workers is an instructive place to begin for thinking of an alternative to COVID capitalism. For the most part, medical ethics relies on a principle-duty approach, wherein workers are expected to apply certain principles to specific patients. Medical professionals know how to treat and ethically rely on principles to implement treatment. Yet, through the relationships forged in medical care, doctor and patient exist in a caring bond with one another. Being bound to the patient in care requires more than only the knowledge of treatment and the duty to administer it. Rather, there is a bond of trust and cooperation to promote the health and wellbeing of the patient toward their own physical flourishing. As such, recent medical ethics attempts to turn from a principled account of medical ethics to a virtue-centric approach to express this relationship better. This shift provides a promising way to engage in COVID capitalism.

To be clear, virtues rely on principles to some degree. Principles, such as those in the Hippocratic oath, form certain goods that the doctor or medical care worker must orient. The medical worker does not merely apply principles abstractly, however, but recognizes, as Pelligrino and Thomasma argue, that the principle is not simply “a duty in the Kantian sense, but [is] part of her character . . . and identity.” ²⁰ A virtue-centered ethics of medicine weighs principles, facts, and patient contexts to perform the actions necessary for an ethical account of medicine. Prudence, justice, fortitude, and temperance all appear in this lens. One must recognize the needs of the patient (justice), resolve to commit to a course of treatment even when difficult (fortitude), know the right amount of treatment needed (temperance), and weigh treatments alongside other principles, facts, and contexts in certain situations (prudence). The ends of health care shape characters, and the cardinal virtues provide the means to apply those ends in varying contexts.

The patient also plays a role in this context. In this analysis, the patient and doctor enter a unique relationship that binds them at the site of health. Each works to clarify, represent, and find the facts, principles, and contexts of the situation in need of health care to achieve “the good for the patient.” ²¹ The quality of care given to the patient through this relationship “rests in the ordering of principles and concrete lived realities at the moment” of medical treatment. ²²

The unique role of virtue ethics for health care workers is an instructive point of departure from the practices of COVID capitalism and neoliberalism, namely autonomy and competition. First, the “caring bond” between patient and health care worker destabilizes the myth of autonomy. The patient requires the expertise and training of the doctor or health care worker, but the doctor also requires patient input to secure facts and contexts necessary for determining appropriate medical treatments. In short, no pure autonomy exists, only relative autonomy in a mutually cooperative relationship of medical practice. Furthermore, medicine’s unique role illustrates that its purpose must exist outside the logic of competition. Pelligrino and Thomasma argue that one should distinguish medicine from the practice of business in which “by contrast the competitor’s vulnerability is something to be exploited”; rather, medicine must treat and care for the vulnerabilities of others. ²³

Dependency and vulnerability: Virtue ethics and the general public against COVID capitalism

A virtue ethics approach to medical care enables a new moral vision for doctors and medical care workers. The roles inhabited by the characters of doctors are distinct, however, from the general public. The two groups’ virtues are connected but distinct. The virtue ethics approach charted for medical ethics must include a place for the public so the character formation essential for virtuous medicine may proceed unhindered. Medical care workers already possess practices and principles inherent in their profession. The general public, too, must rely on principles and practices that enable virtues for prudential weighing of communal health. These practices and principles must directly resist the formative power of autonomy and competition. I contend that two such practices, dependence and vulnerability, shift citizens away from autonomy and competition while concurrently opening them to realizing the possibility of health as a communal concern and care for the elderly specifically. These practices cultivate the virtues necessary for a community to weigh economic goods and health care.

Carol Gilligan illustrates the shift to dependence necessary for overcoming competition and autonomy. She says she has always “sought to represent the voices of contemporary American girls and women as they talked about moral conflict and choice, and to amplify and validate these voices by associating them with the voices in western literature.” ²⁴ Through focusing on women’s voices, Gilligan offers a tangential account of moral discernment free from many of the pitfalls of Western philosophy and neoliberalism.

Gilligan’s shift occurs within her proposed reframing of the moral question. Traditionally, moral discernment occurs through presenting an agent with a moral problem and asking, “How would you resolve it?” ²⁵ This method, Gilligan argues, arises in Piaget’s analysis of a child’s development. In the Western tradition, especially post-Enlightenment, moral development “consists of a system of rules.” ²⁶ Through learning how to deploy rules, a child can learn how to respect the rules. However, Gilligan proposes a new means of judging one’s moral sensibilities. She writes, “I did not begin by posing a moral problem and asking, ‘How would you resolve it?’ Rather, I asked people how they would define what a moral problem is.” ²⁷ Through experience and decisions made in the individual’s life, Gilligan finds a different account of the moral life than a system of rules.

Studying primarily young pregnant women considering an abortion, Gilligan found that these individuals did not first approach a system through a system of rules, but rather, these women made their decisions through their understanding of “responsibility.” ²⁸ This moral emphasis shifts the entire narrative of moral decision-making. The group’s moral quandary, namely abortion, did not match the system of rules approach sustained by the wider public. This recognition is significant in Gilligan’s approach because it offers a new way to think of moral discernment. She writes,

The full view of choice, of the relationship between other and self, was fundamentally different. Choice, rather than being seen as an isolated moment, was a moment in an ongoing narrative of events, which in the abortion decision were specifically the events of the relationship. ²⁹

The events leading to the pregnancy, the events during the pregnancy, and the possible future events if the birth would or would not occur are all considered in the choice. Therefore, the decisions were made in the context of the relationship between the community and the agent rather than through rules. “There was,” Gilligan continues, “no way to separate self and other into a distinct opposition.” ³⁰ Any rules or norms are negotiated, not in isolation from one’s support community, but only within them.

Gilligan’s different voice in moral discernment stands in direct opposition to the moral thinking embedded within COVID capitalism. As previously stated, COVID capitalism relies heavily on autonomy. In that logic, relying on others is morally distasteful; indeed, lasting friendships hinder the ability to choose. Instead, one must possess economic mobility and detachment as two means to express autonomy. The resources one accumulates are for the express purpose of self-sufficiency, and individuals compete to become the most autonomous beings. Therefore, the rules of neoliberalism are a system that must be applied, even in a pandemic, to make moral decisions.

Against autonomy, Gilligan’s method of moral discernment uncovers another virtue: dependence. Gilligan recognizes that this term carries significant baggage in our culture because autonomy is regarded as the highest virtue and dependence is viewed as the greatest weakness. ³¹ Yet, when Gilligan asked a different group of young women the meaning of dependence, they revealed an alternative account. She observes,

The girls conveyed the assumption that dependence is positive, that the human condition is a condition of dependence, and that people need to rely on one another for understanding, comfort, and support . . . Dependence, rather, was created by choices to be there for others, to take care of them, to listen, to try to understand, and to help. ³²

Dependence, in the eyes of these young women, expresses a relationship of care. Furthermore, dependence is not the malformed “passivity” of humankind’s natural capacities in favor of overreliance on others. ³³ Rather, it means to these women that “someone would be there when you need them.” ³⁴ Therefore, dependence is an “active” choice that sustains relationships of moral community and care. ³⁵

Gilligan’s account of dependence provides an appropriate alternative to COVID capitalism because it leads to human flourishing during a pandemic. Evaluating Gilligan’s shift to dependence suggests that the good inherent in COVID capitalism is profoundly flawed and limited. Only through reliance on others does care emerge as a possibility. This move to dependence will necessarily lead to the formation of a practical reason that can be correctly discerned in a world of differing goods. When dependence becomes a central practice, ethics shifts from rules to responsibility. In a moral community, as the one in which the general public is bound in medicine, one must ask for whom we are responsible. To depend on others is not a moral weakness, but a recognition of the ones with whom we share the responsibility of care. Specifically, elderly persons serve as a reminder that the young once needed the care of the elderly. “Honor your father and mother, so that your days may be long in the land that the Lord your God is giving you” (Exod 20:12, NRSV). In this passage, God commands the Hebrew people to recognize their own needs as children for their parents, as well as their need as adults to treat their aging parents well. The mutuality in the command entails responsibility for the old to the young and the young to the old. With the recognition that humans flourish through mutual dependence, medicine emerges as a distinct possibility.

In addition to dependence, a shared vulnerability must also emerge as a distinct practice, contrary to autonomy and competition. In Alasdair MacIntyre’s work, one finds an account of virtue that undergirds all ethics. ³⁶ Still, MacIntyre recognizes that any virtue ethics that does not consider those impacted by “bodily illness and injury, inadequate nutrition, mental defect and disturbance, and human aggression and neglect” is inadequate for the task of moral reflection. ³⁷ Much like Gilligan, MacIntyre strays from traditional narratives of autonomy and competition toward dependence-based ethics. And, in addition to dependence, MacIntyre places equal weight on vulnerability. Practical reasoners are vulnerable at one stage or another and thus are dependent upon others. In our vulnerability, due to sickness or other deficiencies in our ability, we desire, as Gilligan already expressed, to know someone will be present.

This desire to know the presence of another illustrates the importance of vulnerability as it leads to dependence. Even though a communities’ most basic moral impulses lie in desire satisfaction, MacIntyre acknowledges that desire satisfaction is merely egocentric. ³⁸ This impulse easily maps over the competition/autonomy of COVID capitalism. The charitable actions of the economy’s so-called “winners” can be read as benevolent, but only insofar as they already possess these goods. The COVID capitalist society prefers the benevolent winner over goods held in common. MacIntyre writes that the division

between self-interested market behavior . . . and altruistic, benevolent behavior on the other, obscures from view just those types of activity in which the goods to be achieved are neither mine-rather-than-others’ nor others’-rather-than-mine, but instead are goods that can only be mine insofar as they are also those of others, that are genuinely common goods, as the goods of networks of giving and receiving. ³⁹

Under the twofold emphases on competition and autonomy, the recognition of shared networks cannot be honored.

COVID capitalism might argue that shared goods are a fiction and that any goods available in the market are finite; thus, one must compete for them against one’s neighbors to obtain them, including in medicine, where the weak, the elderly, and vulnerable must be sacrificed so competition can continue. MacIntyre challenges such a view by placing shared recognition of vulnerability at the center of communal life. MacIntyre counters that “the basic political question is what resources each individual and group needs.” ⁴⁰ The question is, then, not which groups are worthy of salvation through the market, but how the market obscures vulnerability and our need for one another. The problem emerges when communal relationships exist in conflict with one another rather than participating in a shared vulnerability. ⁴¹

Competition allows, to some extent, recognition of a shared vulnerability but ultimately requires that one exploit it. On the one hand, is the vulnerability associated with the economy and, on the other hand, the elderly. The COVID capitalism of the present pandemic pits these two groups against each other, adjudicating which group must be saved according to their productivity. ⁴² For MacIntyre, this moral discernment is counterfeit because it fails to encourage the virtues of “giving and receiving” necessary for the awareness of the “common goods and common needs.” ⁴³ Vulnerability encourages these virtues instead through a shared recognition of our common needs and goods. MacIntyre writes, “Those who are [not yet old must] recognize in the old what they are moving towards becoming.” ⁴⁴ In the case of COVID capitalism, one must adjudicate between age groups based on which group can be eliminated and still maintain productivity. In vulnerability, there are shared needs, but these needs are not barriers to shared goods. In short, vulnerability prioritizes care for each other over any economic calculus. Without the virtues essential to giving and receiving, this “awareness [of shared vulnerability] cannot be achieved.” ⁴⁵

Vulnerability thus leads to an account of the good and of the goods preferable to COVID capitalism. It is not preferable because it enables a better way to decide who lives and dies, but because it rejects the false dichotomy altogether. In COVID capitalism, one cannot save those most susceptible to COVID-19 and the economy, and this either-or strategy does not exist in MacIntyre’s account of giving and receiving. To flourish despite COVID capitalism, one needs both MacIntyre’s vulnerability and Gilligan’s dependence. MacIntyre maintains that “we would need . . . to be able to receive from others what we need them to give to us and to give to others what we need to receive from them.” ⁴⁶ We recognize our vulnerability, namely our need and our dependence on others to fulfill that need, as they depend upon us to provide for them.

Dependence and vulnerability orient listeners rightly to the comments made by Lt. Governor Patrick. Regarding his first position, Patrick states, “There are more important things than living. And that’s saving this country for my children and my grandchildren . . . we’ve got to take some risks and get back in the game and get this country back up and running.” ⁴⁷ In this, he recognizes his shared vulnerability and that he does not want to die, but this recognition is not his error. Patrick’s error is the assumption that his children and grandchildren benefit more from economic advantage than from the presence of their father and grandfather. Of course, they too are vulnerable, but, Gilligan argues, he helps them negotiate their moral development. MacIntyre stipulates that the elderly cannot be neglected due to their lack of productivity, but instead that they offer wisdom extending beyond their economic utility. The value Patrick brings his children and grandchildren cannot be quantified. Furthermore, their lives cannot be quantified in relation to him. He proves this in his willingness to die for them. They both share their need for one another and, thus, are vulnerable. In turn, they depend on one another to fulfill their shared needs. This shift serves not only a need for presence but of moral discernment, as well as the virtues of giving and receiving that are capable of orienting the economy to society’s shared goods rather than goods to the economy. Only through a new moral formation can the weeds of economic reason be uprooted and a new way of relating begin to take root. Furthermore, only through this recognition can actions, such as a lockdown, emerge to make medicine a moral possibility.

In addition to the counter formation enabled by the practices of dependence and vulnerability for a fuller appreciation of health care and the elderly, these practices also allow for a deeper appreciation of an economic flourishing not tied to COVID capitalism. These practices cultivate the flourishing envisioned by the cardinal virtues as eudaimonia rather than as individual wealth. These practices present one’s neighbors not as barriers to true flourishing, as do competition and autonomy, but rather as essential to it. The virtues are communal in that one’s ability to exercise them requires the presence of others as the promise and fulfillment of the moral life. Flourishing, in the virtuous sense, requires this communal perception and shared human dignity. The ends of a well-formed agent, therefore, include the flourishing of others.

In COVID capitalism, however, the ends of the neighbor must be sacrificed so the individual can cultivate their autonomy and compete. The inability of the neighbor, through exposure, to compete is a weakness to be exploited. Thus, when the agent finds their ends exclusively in the logic of the market, exorbitant pressure weighs on the health care community.

So, in contrast, envisioned through virtue ethics and eudaimonia, the neighbor’s weaknesses must not be exploited. Rather, the needs and vulnerability of the neighbor reflect back on the individual’s needs and vulnerability. As in the doctor-patient relationship, a relationship of care emerges as a more pressing need than competition. A person’s flourishing diminishes in the face of one’s neighbor’s suffering rather than in one’s own ability to consume and produce. Thus, those with means will, in times of economic scarcity, surrender their material means to care for those who are sick and dying, because a crisis is a time to exercise justice, prudence, fortitude, and temperance. The ability of the virtuous to locate economics as a relative and not absolute good only comes from knowing their flourishing vis-à-vis another’s flourishing. The greater risk for the virtuous is not a lack of economic success but rather a lack of character in the face of crisis. One would hope that these values might be the resources available in times of disease rather than the acute formations of neoliberalism.

Conclusion

During the rise of COVID-19 cases in the United States, a young social worker in the Veteran Affairs Hospital in the Midwest maintained the cases of veterans nearing the end of their lives. ⁴⁸ One such elderly veteran was within a few days of death and wished to communicate with his wife, who was also confined to a nursing home since she was advanced in years and could not visit without fear of contracting the disease herself. The man was blind and hard of hearing and thus could not talk to her over the phone or easily write her letters. Therefore, this young social worker, compelled by a sense of eudaimonia derived from the cardinal virtues, offered to communicate on the veteran’s behalf with his wife and communicate her responses back to him. In the final days, the social worker communicated messages of love, gratitude for a lifetime of memories, and fidelity to the very end. In these deeply personal messages, one glimpses the humanity possible in a community of virtue, one not to be found in COVID capitalism. Not only are the elderly veteran and the wife dependent upon and vulnerable to the social worker for messages from their beloved one, but the social worker depends on the couple to illustrate and embody the virtue of fidelity. They share needs and remain dependent on one another to fulfill them. The couple and the social worker share something inexplicably sacred and, dare I say, good. This sacred value is not supported and guaranteed by the economy, solely because the sacred character of this deeply human experience cannot be bought. Rather, it can only be shared as the love between them. The social worker does not treat the elderly couple through utility but as sacred persons of shared vulnerability and dependence. The proper use of medicine thrives in the context of such care because this care does not merely treat symptoms of the disease but the whole complex, fragile person and their flourishing.

The lesson learned in this story is that virtues are necessary for dependence and vulnerability. The act of kindness embodied by the social worker illustrates her recognition of her vulnerability in this space and their dependency on her. The couple’s commitment to love shows their need to be vulnerable to and dependent on the social worker. Mutual dependence and vulnerability by both parties accommodate a shared humanity. Humans are not price-points on a spreadsheet but are deeply fragile fellow creatures held in God’s love and care. Unlike neoliberal rationality, the goal of medicine is not autonomy governed by competition. Rather, it requires the opposite. Society must envision vulnerability and dependence as character traits that define people’s actions in this crisis. MacIntyre writes:

To identify an occurrence as an action is in the paradigmatic instances to identify it under a type of description that enables us to see it as flowing intelligibly from a human agent’s intentions, motives, passions, and purposes. It is, therefore, to understand an action as something for which someone is accountable, about which it is always appropriate to ask the agent for an intelligible account. ⁴⁹

Generations after the current one will look back to this time and ask for an account of society’s actions. One may hope that vulnerability and dependence will hold the key to such an account. Gilligan’s insight teaches that humans negotiate moral decisions in relationship to others. For better or worse, they will look to us for help. We are their tradition, and we are their ancestors. Like the social worker, these actions might be “unhistoric,” but I hope that people will contribute to the growing good of shared humanity for the world and that one day society might not be so ill as most individuals live these hidden lives.