Episode 4 - Benjamin Smart - Bioethics and Philosophy of Disease

Sahana: Hi everyone! Welcome to In Limbo Conversations. Today, we have with us Benjamin Smart from the Institute for the Future of Knowledge, University of Johannesburg. His area of research include bioethics and public policy making as well as philosophy of disease, especially causation. Today, we will be talking with him about his views on the ways in which different countries have reacted to the pandemic situation and in more detail, about the way in which the pandemic situation can be understood in philosophy of disease.

Many public policy makers and ethicists have developed frameworks (1, 2, 3) to guide decision making during the pandemic. If you were to prepare a framework, what do you think would be the broad and significant differences in those prepared for diverse socio-economically and culturally countries in Africa and America, Europe and Asia? Especially with respect to the advice given to civilians?

Smart: Broad bio-ethical frameworks such as that those cited above are applicable across multiple cultural scenarios, including Africa, America, Europe and Asia. The principles of ‘minimising harm, proportionality, solidarity, fairness, duty to provide care, reciprocity and privacy’, for example, could form the basis of any bioethical framework. The key differences lie in how, when, and where to put these principles into action.

Africa faces different challenges to Europe, so keeping to these principles requires different approaches. Covid-19 primarily affects the elderly, and since only 3% of the African population are over 65, we are seeing a much lower fatality rate in Africa than in Europe or the USA. Further, a far larger proportion of the African population are food-insecure, with South Africa recording unemployment of 29% (with some estimating that it will approach 50% thanks to lockdown). Unlike the UK and other wealthier countries, most African countries cannot afford to simply furlough the entire population on 80% salary for months on end. Lockdown in Africa means starvation, and a rise in poverty-related diseases. So, whereas a hard lockdown might be the most effective way to protect the health of the population in Europe and the USA (and keep to those bioethical principles), the same cannot be said of Africa.

Lockdown in South Africa, where I live, has been an unmitigated disaster. Predictably enough, lockdown in a country where high-population density township living is the norm, had no obvious effect on the reproduction rate of the virus. Moving from a mitigation scenario of basic social distancing, to a hard lockdown where leaving the house at all (except for groceries or medical care) was illegal, did not affect the trajectory of the curve on the log scale. Neither did the reproduction increase when lockdown restrictions were relaxed. The main effect of lockdown was the destruction of the South African economy, forcing thousands into unemployment and hunger. To add insult to injury, rampant government corruption has led to much of the aid promised by our politicians to be dispersed amongst their own friends and family.

Promoting the principles outlined above in the African context would require a strong anti-corruption policy, including at least a total ban on issuing PPE tenders to relatives of politicians. From the start, government should have focused on empowering citizens to work in an environment conducive to social distancing, ensuring a steady income for poorer families. The initial WHO advice of social distancing and handwashing did have a noticeable effect on the trajectory of the curve, and simply reinforcing the advice through advertising campaigns, and empowering citizens through free hand sanitzers/soaps, free masks, and so on, would have been far more effective and less harmful to the South African economy (and relatedly, the health of its citizens).

Covid-19 is likely to cause roughly 25,000-40,000 deaths in South Africa in 2020. To put that in context, 2018 saw roughly 63,000 South Africans die of tuberculosis. But South Africa, and many other African countries, will be suffering the consequences of the poor public health decisions and rampant corruption of 2020 for years to come.

Sahana: While reading through your book “Concepts and Causes in the Philosophy of Disease”, I remember- you had mentioned that the concept of disease which we can apply to a clinician is different from the one which we would apply for a pathologist. The clinician is more oriented towards making decisions about treatment for a specific patient while the pathologist simply has to identify the disease. In the case of the current pandemic, when we imagine the first few cases where coronavirus, as a disease, had not been identified- do you think the identification of the disease itself- the role usually allocated for the pathologist- was also put upon the doctor? Due to which the line between disease-for-clinician and disease-for-pathologist got blurred? If yes, then how do you think the case of covid-19 affects this distinction in concept of disease for clinician on one hand and pathologist on the other? Or maybe, would you see the covid-19 case as an exception rather than something that needs to trigger any critical change in the distinction itself?

Smart: The crucial difference between the clinician and the pathologist is dealing with the patient. A core aspect of the role of the clinician is to take the concerns and values of the patient seriously – not so for the pathologist. When a new disease such as Covid-19 is discovered, it is discovered in the context of a suffering patient. They are diseased in the clinical sense, since the condition is harmful to them. The pathologist then investigates samples from the patient to identify the virus. At this stage, it is irrelevant whether the patient was very sick, or entirely asymptomatic. In the case of Covid-19, most patients fall into the latter category. For the pathologist, however, even the asymptomatic patients are diseased, since there is no harm criterion in their analysis of what counts as disease.

Sahana: You pointed out some of the inadequacies of accounts of disease by Rachel Cooper and Peter Schwartz. If possible, could you please give us a brief on how their accounts would fare in explaining coronavirus as a disease? What would, if any, be the gaps in such accounts?

Smart: Rachel Cooper states (crudely) that a patient is diseased if and only if they have a condition that is (i) harmful in the eyes of the patient’s society, (ii) unlucky to get, (iii) potentially medically treatable. Symptomatic cases of Covid-19 certainly satisfy these criteria. Symptomatic Covid-19 can causes serious respiratory problems (and even death), to catch it requires a certain amount of bad luck, and there are already plenty of medical treatments (ranging from paracetamol for fever to intubation). It’s less clear whether the asymptomatic cases of Covid-19 would count as disease under Cooper’s definition, since arguably the ‘harm’ condition isn’t satisfied. However, one might argue that an asymptomatic patient suffers various other forms of harm (e.g. forced to self-isolate).

Peter Schwartz’s account of disease is a development of Christopher Boorse’s biostatistical theory. Schwartz argues that a patient is diseased if a physiological subsystem (in the case of Covid-19, the lungs are most affected) is (i) performing subnormally relative to the patient’s reference class; that is, performing poorly relative to other people of a similar age and of the same sex, and (ii) that this subnormal function has negative consequences. Clearly in the case of symptomatic Covid-19, the patient’s lungs can be very badly affected, and this would certainly count as disease. I do not believe, however, that asymptomatic cases would count as disease under Schwartz’s account, since the patient’s lungs function at a perfectly normal degree of efficiency.

Sahana: On a related note, how would you analyse covid-19, from your original account of disease as ‘harmful function’? What would constitute, in this case, the functional states which harm a specific patient?

Smart: According to my position, which is a development of Jerome Wakefield’s 1992 account, a patient is diseased if at least one of her physiological subsystems (organ, tissue, cell) is performing the function for which it was selected (via evolution/natural selection) at a harm-causing degree of efficiency. Covid-19 has multiple symptoms that fall into this category, including high temperature, loss of sense of smell, and the more deadly symptoms of respiratory difficulties. Any patient that suffers from these symptoms would count as diseased under my account. I would argue that asymptomatic cases count as cases of disease for the pathologist, but probably not for the clinician. Arguably those who get Covid-19 but remain asymptomatic are better off (due to resultant immunity) than those who are yet to contract the virus.

Sahana: In a counterfactual account of causation for diseases, we usually attempt to come up with counterfactual claims to figure out causes of illnesses or death like: “If x had not occurred, y would not have occurred”. Could you give us, say, two examples of counterfactual causal claims we could apply in case of covid 19, given the currently available empirical evidence?


  • If humans had not mistreated animals in ‘wet markets’, then nobody would have died of Covid-19.

  • If people had not gathered in large groups (protests, beach-goers etc) then fewer people would have died of Covid-19.

Sahana: We see in the news- over the months, that- there are symptomatic and asymptomatic infections of covid-19, which is related to so many factors about age, status of immune system, the comorbidities; how would you describe this in dispositionalist terms? Would we say that a patient a is disposed to react in such-and-such way to the virus? How do we ensure that all the other factors are correctly represented in such causal accounts of diseases as dispositions?

Smart: Absolutely. Different patients are disposed to react to pathogens in different ways. The effect a pathogen such as a virus has depends every bit as much on the dispositions of the patient as it does on the dispositions of the virus itself. In dispositionalist terms, the symptoms a patient experiences are the mutual manifestation of multiple disposition partners: the properties of the virus, and those of the patient. One can never be sure exactly how a particular patient will react, but knowing the patient’s comorbidities is fundamentally important to understanding and predicting her disease course. We know that the dispositions of Covid-19 are such that patients with diabetes are more likely to require hospitalisation than those without comorbidities. To truly understand the virus is to understand how it is disposed to affect patients with a diverse range of properties.

This must translate to public health policy, and in many cases it just hasn’t. Again, we know that younger populations are not as disposed to get severe symptoms, and yet African governments with very young populations persisted with economy-crushing lockdown policies.

Sahana: In the end, I wanted to ask a bit about regularity account of causation.

Do you think that covid-19 could be seen as a strong case for or against regularity account of causation? In the sense that, we have evidence that fever and cough are definitely two symptoms of the disease but also that there are a range of other symptoms, and then, also- the particular factors about the person’s lifestyle and specific health status- we have even come to a place where there are reports that perhaps, this is not just a respiratory but a multisystem disease- basically, there are constantly changing positions and evolving reports- it is not possible to draw any necessary connections- moreover, we cannot even draw regular connections. In such a situation, what do you think about someone who supports a regularity account of causation about the disease?

Smart: If we’re thinking about the metaphysics of fundamental properties, I don’t see disease as providing any evidence in favour (or against) a dispositional view. Biological organisms are extremely complex, each one being entirely unique. So when a person comes into contact with a virus, it is always a single-case uniformity. It is very useful to think in terms of dispositions, however. Conceptualizing disease interactions/disease courses in this way has practical advantages for medicine. But at a fundamental level, causation could still be entirely deterministic, and there could be nothing more to causation than Humean regularities. As I say, though, thinking about causation in Humean terms in medicine is unhelpful. From an epistemic and practical perspective, it makes more sense to talk about dispositions.

Sahana: That's an interesting way to look at it.

Our readers can check the description below to know more about Smart's research. Thank you Benjamin for joining me today!

Read more about Benjamin Smart's research at: https://www.uj.ac.za/contact/Pages/Dr-Ben-Smart.aspx.

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