Dear Editor,
having scanned the article by Julian S, philosopher in Oxford no less, in your journal's edition from Nov 2020 , I feel I need to comment: The mandate to prevent harm from others requires a reasonable amount of knowledge what the risk to self is. To use a narrative extract from an autoethnographic case study as example:
... what those people who experienced serious reaction to the covid vaccine are believed to have reacted to is an emulsifier called PEG -
polyethylenglycol which sounds harmless enough. I was tested for allergies comprehensively by a very thorough specialist in Ger in 1996
and that because of a series of very light reactions. I dare to assert that in the UK where I have lived for 20 years and worked in
multidisciplinary health settings, the first thing people would know about such an allergy would be if they suffered an anaphylactic shock.
Prior to that most people would only/at best have been prescribed cortisone.
I believe here enters what M. Fricker, UK philosopher in NY, calls epistemic injustice inherent in a system of health inequalities as prevalent in the UK and an approach to behaviourism in clinical practice I politely call blinkered. - So far my initial reaction to the article.
Coincidentally I then after I found the video interview where Dr Mary Ramsey for PHE declares the safety of vaccines, I felt prompted to do a little research and - surprise, surprise: The first academic paper I found, from 2016, states that allergies to PEG are likely underdiagnosed.
See: https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0172-7
Would it be fair to say that, given Dr Ramsay's position she could or even should have known of these findings? If at least one of those points is answered in the affirmative, then we have here a situation where, I am inclined to argue, an overcoming of epistemic injustice is actively prevented. Trustworthiness of a public authority rests on credibility, and that, like 'following the science' means in my understanding weighing the evidence one can reasonably have access to - not denying it.

In response to the article by Savulescu & Cameron [1] “Why lockdown of the elderly is not ageist and why levelling down equality is wrong,” we claim that the article presents an ageist approach that may be as harmful or more than the actual virus. In their work, the authors make reference to philosophical, legal, and practical aspects of locking down older adults, as they make the case for the merits of what they refer to as selective isolation. It is our position, as psychologists and gerontologists, that this approach is ageist, and is a disservice to older adults and society at large.
In the initial response to this article, O'Hanlon, O'Keeffe & O'Neill [2], have done a comprehensive job of refuting these claims based on the science that has been coming in regarding the effects of the lockdown on older adults. We wish to contribute another angle – that of the actual preferences and values of older adults themselves. No discourse about any group in society is complete without including this group. Thus, we attempt to abide by the old adage: "Nothing About Us Without Us".
In a recent qualitative study, we explored the personal experiences and preferences of older adults living in CCRCs (continuing care communities) in Israel during the height of the novel Coronavirus pandemic [3]. We were surprised to discover that CCRC residents in different locations in Israel were subjected to significant restrictions, and in many cases were not allowed to leave their personal living areas, both before and after the strict lockdown imposed on all Israeli citizens was lifted. Most CCRCs continued some form of lockdown even after Israel began reopening, a measure similar to the one Savulescu & Cameron argue for in their paper. In our in-depth interviews, residents who lived in CCRCs with such strict lockdowns, expressed anger and ongoing distress in the face of the restriction of their liberties and autonomies. Furthermore, a few of them who had personal backgrounds of earlier traumatic experiences in their lives, such as having survived the Holocaust, reported feeling that the current lockdown was reminiscent of being incarcerated and persecuted. Some went so far as to say that they were prisoners of their age, or that they felt in solitary confinement.
Lastly, many described feeling offended by the ageist and paternalistic discourse that took place at the outset of the pandemic in the Israeli media, that they felt was directed at them (statements such as: “older adults will overburden hospitals and take up precious ventilators”). Thus, the mere discussion about “selective isolation” of a segment of the population based solely on their age, is perceived by that population as offensive and disparaging. CCRC residents who felt that decisions to restrict their autonomy were made without consulting them, or that CCRC managements were not forthcoming about the decision-making process, felt even more offended and frustrated.
In this response we argue that healthcare systems may indeed be overburdened by caring for those who are most susceptible to the novel Coronavirus, yet this is attributable to the vulnerability of those very health care systems – systems that, in many developed countries have been neglected for years. Older adults should not pay the price for these underfunded, overburdened healthcare systems. Dismissing the autonomy and sovereignty of selected groups of people is wrong and may have a detrimental impact, which might even exceed the effects of the pandemic itself.

References

1. Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong [published online ahead of print, 2020 Jun 19]. J Med Ethics. 2020;medethics-2020-106336. doi:10.1136/medethics-2020-106336

2. O’Hanlon SA, O’Keefe ST, O’Neill D. Older people deserve better than paternalistic lockdown [published online ahead of print, 2020 Jun 19]. J Med Ethics. 2020;medethics-2020-106336.responses

3. Ayalon L, Avidor S. “We have become prisoners of our own age”: From a continuing care retirement community to a total institution in the midst of the COVID-19 outbreak. Unpublished manuscript.

On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
I shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
ARISTOTLE ON DISTRIBUTIVE JUSTICE AND WOMEN
Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, the only difference is sex. Sex cannot of itself make a difference to the capacity or performance of voting—it involves a mere chromosomal or anatomical difference. Unless one could point to an inherent property that tracked with sex that affected ability to vote, then this violates Aristotle’s principle and is unjust discrimination.’2
Distributive justice, for Aristotle seems to be about treating like people rather than like cases alike. The focus, too, is on the distribution of burdens and benefits between different people of the same category or status rather than on the just treatment of people of different categories or statuses. Chroust and Osborn say of ‘Aristotle’s Conception of Justice’:
‘Justice and Equality, which for the purpose of comparison always presupposes a duality, requires, therefore, at least four different factors: namely, two conflicting claims and two claiming persons.6 should these two persons be of unequal rank they cannot be treated alike," for the principle of Equality demands that only equals be treated equally." In this sense Equality is always proportionate equality - that is to say, it is a form of Justice which allots burdens according to the individual's ability to carry them and accords sup- port in amounts which vary with the needs of the individuals - and is called "distributive Justice." ’3
Fundamental to Aristotle’s and, I would suggest, any tenable theory of distributive justice is the notion that when x is justly given to A but not to B, A (in some sense or other) merits or deserves to receive it more than or rather than B. This merit or desert consists in the nature of and relationship between A, B and x. For instance, Aristotle would contend that scarce flutes should be given to those who can play flutes rather than to those who cannot and to the best flute players rather than to the less talented ones if there are not enough flutes to provide to provide all citizens with one.
To the best of my knowledge, he did not ever say that flutes should be given to all the members of the category or categories of citizens which had the highest proportion of good flute players. Proxies for just criteria do not seem to feature in his scheme nor do they have an obvious logical place in any tenable theory of distributive justice. For instance, it would hardly be just or fair, no matter how efficient and expedient it might be if a lecturer gave grades to the essays of students on the basis of the social categories to which they belonged on the grounds that students in particular social categories tend to get particular grades.
One might readily assume that the example that Savulescu and Cameron give of discrimination on the basis of sex is Aristotle’s own one or, at the very least, one he would obviously agree with. This is not the case.
According to Stefan Gosepath, writing in the Stanford Encyclopedia of Philosophy:
‘When two persons have equal status in at least one normatively relevant respect, they must be treated equally with regard to this respect. This is the generally accepted formal equality principle that Aristotle formulated in reference to Plato: “treat like cases as like” (Aristotle, Nicomachean Ethics, V.3. 1131a10-b15; Politics, III.9.1280 a8-15, III. 12. 1282b18-23). Of course the crucial question is which respects are normatively relevant and which are not.’4

Not all people should be treated equally, according to Aristotle, but only those of equal status. He does not seem to regard men and women to be persons of equal status. The following are among his famous quotes about women:5
Aristotle, Politics: "[T]he male, unless constituted in some respect contrary to nature, is by nature more expert at leading than the female, and the elder and complete than the younger and incomplete."
Aristotle, Politics: "[T]he relation of male to female is by nature a relation of superior to inferior and ruler to ruled."
Aristotle, Politics: "The slave is wholly lacking the deliberative element; the female has it but it lacks authority; the child has it but it is incomplete."

In The Internet Encyclopedia of Philosophy, Wayne P. Pomerleau writes

‘Given natural human inequality, it is allegedly inappropriate that all should rule or share in ruling. Aristotle holds that some are marked as superior and fit to rule from birth, while others are inferior and marked from birth to be ruled by others. This supposedly applies not only to ethnic groups, but also to the genders, and he unequivocally asserts that males are “naturally superior” and females “naturally inferior,” the former being fit to rule and the latter to be ruled. The claim is that it is naturally better for women themselves that they be ruled by men, as it is better for “natural slaves” that they should be ruled by those who are “naturally free.” 6

BREAST SCREENING FOR CANCER AND UNJUST DISCRIMINATION

Savulescu and Cameron write:
‘Discrimination is not always unjust. If there is a morally relevant difference, it may be acceptable. The government invests millions in screening women for breast cancer, but not men, even though breast cancer does occur in men. The reason for this is that breast cancer is much more likely in women. So, you will save more lives with the limited resource the government has available for prevention and treatment of breast cancer if you (justly) discriminate between men and women in this way.
This is not sexist because there is a morally relevant difference sufficient to justify different treatment: the probability of developing breast cancer. However, if there were a better, more accurate proxy for breast cancer risk besides sex, say some genetic mutation, then to continue to discriminate on the basis of sex would be unjust, all else being equal.’7
It is certainly true that discrimination is not always unjust. However, it is not true that all discrimination that can be morally justified is not unjust. Discrimination requires not merely a moral justification but a moral justification of a particular sort in order to render discrimination just.
Justice pertains to the treatment of people rather than cases. For instance, to use an example of my own choosing, lecturers who are acting in their capacity as private citizens, are not morally obliged to treat other private citizens impartially when, say, they are inviting guests to a dinner party. They might, without acting unjustly, discriminate between them on the basis of their personal preferences and prejudices. However, when they are acting qua lecturers and, for instance, marking the essays of their students, they are morally obliged to do so impartially and to give the same marks to essays that are equally good and proportionately more or less marks to those that are proportionately better or worse.

Acting justly does not merely mean treating their students the same unless there is a moral justification for treating them differently. It means treating them differently only when the difference in treatment is morally justified by a corresponding and proportionate difference pertaining to the merits of the essays that are submitted by them. In other words, the allocation of different treatment, of, say, benefits and burdens, is just or unjust regardless of the consequences of that particular allocation. The virtue of distributive justice does not lie in the consequences of any particular distribution of burdens and benefits but in its appropriateness.

There is a difference between morally justifying an action or policy and morally justifying it as a just one. Justice is not the only moral virtue. For instance, taxation is necessary to finance the operations of the state. If, somehow, it is not possible to formulate and implement a just and fair system of taxation, it might be morally justifiable to collect the necessary taxes unjustly and unfairly. Similarly, in the dire extreme emergencies that wars and, possibly, pandemics, can create, unjust and unfair actions and policies might, arguably, be morally justifiable.
There is, of course, a difference between successful and unsuccessful attempted justifications. To offer a moral justification for an action or policy is not the same as actually morally justifying it.
Just as lecturers in their role as lecturers have a moral duty to treat their students as students impartially, and their students have a corresponding moral right to receive such impartial treatment, the state, its agencies and agents have a similar moral duty to treat all citizens impartially and they each have a moral right to receive such impartial treatment and equal due consideration. What such impartiality consists of is often debatable and typically non determinate. In many cases, for instance, with regard to general policy decisions such as whether and where to build particular roads and bridges or, say, whether or not to adopt particular foreign policies, it appears to have little if any practical political relevance. However, where the distribution of benefits and burdens which are individually consumed or borne is concerned, the significance of the matter and its practical relevance grow hugely.
As a matter of justice, in the distribution of burdens and benefits that are enjoyed or borne by individual citizens, the state, its agencies and agents have a moral duty to treat individual citizens impartially. The citizens individually have a moral right to receive such impartial treatment. This means treating them the same unless the differences in treatment between particular individual citizens is purposefully and consciously related to morally relevant and proportionate differences between them. It means too, I suggest, giving explicit and implicit request to receive such benefits and to be spared such burdens equal and appropriate consideration.
If some particular people are, say, known to have cancer of a particular sort, they have a need for treatment for it which other people are not known to have. They could reasonably be said to, in some sense, deserve to receive scarce appropriate treatment rather than those who are not known to have such a need. It would be plausible to say that it would be just to discriminate in their favour in the allocation of NHS health treatment that was appropriate to their needs.
However, it would not be just to allocate such treatment only to those people in some arbitrarily demarcated category – the ‘elderly’, for instance – which had the highest proportion of sufferers from cancer. To give such treatment to all members of such a category would be not be just. Proxy justice is not justice any more than fools’ gold is gold.
Screening for cancer in general or cancers in particular is not a need in the same sense that treatment for them is. Some people might have a psychological need of such screening but there is no obvious reason for restricting the allocation of the procedure solely to them. The real or supposed benefits of screening for breast cancer could be enjoyed by any and all citizens. People who are women, people who are men, people who are both and people who are neither might all get and can all suffer from the fear that they will get breast cancer. Each and all of them can have a legitimate interest in having and knowing the results of such a scan. In the planning of their own lives and with regard to the thoughts and feeling with those with whom they interact, this information can be, or seem to them to be, important. That a person belongs to a category that has few or, even, hardly any members who will get breast cancer need not make the results of a screen test for breast cancer of any less significance to that person.8,9
To restrict free NHS breast screening for cancer to women is unjust discrimination.10 The likelihood of saving more lives by devoting a particular amount of resources to the screening solely of women rather than, indiscriminately, to those who want to receive it might (or might not) be a moral justification of the discrimination but that would not automatically make it just. The differences in treatment are not justified as deserved differences. Similarly, to give higher marks to the essays of male or female students might, in some circumstances, have a morally desirable outcome. That might (or might not) morally justify the discrimination but it would not thereby render it just.
Suppose that it were discovered that the incomes of the fathers of students was a reliable proxy for the allocation of the likely worth of their essays. It would be very wrong to allocate marks to essays on such a basis rather than reading them no matter how accurate and cost-effective such a procedure turned out to be. We could not say that it was slightly just or as just as we could manage. Proxies might be useful with regard to expedience, but they have no proper role in the exercise of justice.
Similarly, too, the difference in treatment of elderly people by the state that is implied by the proposed selective lockdown policy of Savulescu and Cameron is unjust. The difference in treatment is not a deserved difference even if it were to be successfully morally justified on grounds other than justice.
We can typically choose to waive our moral rights to benefits that we are offered. Thus, for instance, women are not compelled to have free screening for breast cancer on the NHS. Burdens, penalties and punishments rather than benefits are compulsory and they are more usually more difficult to justify than the allocation of benefits. In this regard, a coercive selective lockdown of the elderly is fundamentally different from and even more morally abhorrent than a selective, sexually discriminatory distribution of NHS. Elderly people do not in any sense deserve such treatment any more than other people do no matter how beneficial Savulescu and Cameron suggest that it might be for the NHS or society in general.
If there is a second wave of COVID-19, infection, not all elderly people will catch it and not all of those who do will require intensive, scarce and expensive hospital treatment whether or not there is a lockdown of any sort. Similarly, not all of those who catch it and require intensive, scarce and expensive hospital treatment will be elderly. If all citizens should be treated the same unless they are more likely to require intensive, scarce and expensive hospital treatment if the catch Covid-19, it follows that, as a matter of justice, those who are likely to require such treatment should be treated differently. Not all who are elderly should be treated the same and not all who are non-elderly should be treated the same. Those who are elderly but would not require intensive, scarce and expensive hospital treatment should be treated differently from those who are elderly and would do so. The same can be said for those who are non-elderly.
However, it would be, in my view, unjust to lockdown those who would require intensive, scarce and expensive hospital treatment. They do not deserve to be treated thus differently to obviate their need for such treatment. If we want to deviate from the principle of the allocation of NHS treatment on the basis of medical need, we should do so without selectively prohibiting potentially needy people from coming and going from their homes as they please.
The argument of Savulescu and Cameron which I have considered is unconvincing. It is based on an under-developed, underspecified and implausible account of distributive justice.

REFERENCES
1 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.

2 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
3 Anton-Hermann Chroust & David L. Osborn, Aristotle's Conception of Justice, 17 Notre Dame L. Rev. 129 (1942). https://scholarship.law.nd.edu/cgi/viewcontent.cgi?article=3967&context=...
4 https://plato.stanford.edu/entries/equality/

5 https://orb.binghamton.edu/cgi/viewcontent.cgi?article=1106&context=sagp

6 https://iep.utm.edu/justwest/#SH1b

7 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
8 McLachlan HV. A proposed non-consequentialist policy for the ethical distribution of scarce vaccination in the face of an influenza pandemic. J Med Ethics May 2012, 38 (5) 317-318.
9 McLachlan HV. On the random distribution of scarce doses of vaccine in response to the threat of an influenza pandemic: a response to Wardrope. J Med Ethics Feb 2015, 41 (2) 191-194.
10 As my wife, Sheila, has pointed out to me, the allocation of breast screening in the UK is also unjustly ageist.

Interpreting and translation are unregulated activities in most countries, yet interpreters and translators perform challenging work in sensitive domains, such as medicine. Interpreters and translators rarely have access to ethical infrastructure and the function and ethical boundaries of ‘interpreting practice’ are not widely known .

Translators or interpreters do not cease being human beings with human rights, when they enter their profession. All human beings, including interpreters, possess human rights and human freedoms. Conscientious objection is a right derived from the human right to freedom of conscience. Human beings (interpreters) are not machines; machines, when maintained, are on the whole very predictable and reliable. Interpreters like other human beings can be creative, self-aware, imaginative and flexible in their thinking.

Limitations exist in workplaces that cannot allow for a variety of opinions, thoughts, beliefs and conscientious positions.

Moral distress is a wide spread problem for health care providers in a range of acute and community health care settings. The understanding of moral distress may differ depending on the extent to which the problem is located in individual and/or systemic /structural factors. Healthcare staff members (as human beings) react in various ways when ethically/morally challenged: they may withdraw from ethically challenging situations; change their position; and/or continue to raise objections and voice concerns about situations.

Moral courage should be a highly esteemed trait displayed by individuals, who, despite adversity and personal risk, decide to act upon their ethical values during difficult ethical dilemmas. The challenge in today’s constantly changing healthcare and political environments is to be certain that professionals understand what ‘moral courage’ is, why it is important for all settings in which they practice, teach, research, and/or lead, and how moral courage can be demonstrated when ethical challenges face any interpreter or other healthcare staff member. Outcomes of moral distress, such as decisions to leave the role of interpreter (or other roles) will cause concern among health care leaders and society.

Systemic changes are needed as part of a response to apparently rising levels of moral distress in health care. It is important that all healthcare professionals, political leaders and management , value and support their peers who have the courage to stand up and speak out even when others are silent or differ in opinion.

Background:
Joanna Drugan (2017) Ethics and social responsibility in practice: interpreters and translators engaging with and beyond the professions, The Translator, 23:2, 126-142, DOI: 10.1080/13556509.2017.1281204

Dragoje, V., and D. Ellam. 2004. “Shared Perceptions of Ethics and Interpreting in Health Care.” Paper presented at the Critical Link 4 conference, Stockholm, Accessed 19 October 2015 http://www.criticallink.org/cli-5/.

Purtilo, R.B. (2000). Moral courage in times of change: Visions for the future. Journal of Physical Therapy Education, 14(3), 4 – 6.

Pauly, B.M., Varcoe, C. & Storch, J. HEC Forum (2012) 24: 1. https://doi.org/10.1007/s10730-012-9176-y

Murray, J.S., (Sept 30, 2010) "Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Manuscript 2.DOI: 10.3912/OJIN.Vol15No03Man02