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Liberty-restricting measures are basic measures in combatting any pandemic. But whose liberty should be restricted? One standard response in public health ethics is to appeal to the “least restrictive alternative” necessary to achieve a public health goal. The problem is that in practice, greater restriction of liberty can lead to greater control of the pandemic and save more lives, though with increasing burdens to others. Liberty restriction is thus a question of the distribution of benefitsbenefits benefits and burdens in a population, a question of distributive justice. In this chapter, I argue that in some pandemics, such as COVID-19, it may be a more proportionate restriction of liberty to restrict the liberty of certain groups, rather than the population as a whole. Two arguments were given in the COVID-19 pandemic for liberty restriction: (1) protection of the vulnerable; (2) protection of the health service. These These are, however, more fundamentally issues about distributive justice. I explore how several approaches to distributive justice can support the differential differential differentialdifferentialdifferential restriction of liberty. In addition, I argue that the commonly accepted justificationjustificationjustificationjustificationjustification justification justification justification for liberty restrictions (that liberty restrictions may be justifiedjustifiedjustifiedjustifiedjustified justified to prevent direct harm to others) - can be overly simplistic, as illustrated by the COVID-19 pandemic. I argue that where risk groups (such as the elderly in the COVID-19 pandemic) are more likely to utilise limited health resources, they pose an indirect threat to others during the pandemic that warrants coercion. I argue there should be a side-constraint on justice of non-maleficence.non-maleficence.non-maleficence. non-maleficence. non-maleficence. non-maleficence. This This requires that there is a limit to harm which can be imposed on individuals for others, best captured by a collective duty of easy rescue. For groups such as the young, vaccination or lockdown may not constitute an “easy rescue” of those at greatest risk. I address the issue of whether selective restriction of liberty constitutes unjust discrimination and I propose an algorithm for making decisions about selective restriction of liberty.

The COVID-19 pandemic has been a defining defining event of the 21st century. Global estimates of excess mortality indicate that it has taken fifteen fifteen million lives over 2020-21 (Knutson et al. 2022). It has closed national borders, put whole populations into quarantine and devastated economies. Almost half of workers in low or middle income countries lost a job or business due to the pandemic (Anonymous 2021). The International Monetary Fund has estimated a global loss to the world economy of US$12trillion by the end of 2021 (Bill and Melinda Gates Foundation 2020). It led to a rise in rates of extreme poverty for the first firstfirst time in 25 years, with 37 million additional people experiencing this in 2020. The pandemic toll and the cost of measures taken to combat it—both effective effectiveeffectiveeffectiveeffectiveeffective and ineffective—has ineffective—has ineffective—hasineffective—hasineffective—hasineffective—hasineffective—has ineffective—has been paid in human lives, mental and physical suffering,suffering, suffering, suffering,suffering, and economic hardship. The costs will continue to be paid by individuals and societies for decades to come. While the COVID-19 pandemic has been catastrophic, it is not unique. It is not as severe as Spanish influenza, estimated to have killed between 50-100 million people. Recent MERS and SARS epidemics were more deadly to those infected, but less contagious. Future influenza pandemics, perhaps like the hypothetical example above, undoubtedly lie ahead. We await ‘Disease X’, the World Health Organisation’s placeholder name for “a serious international epidemic … caused by a pathogen currently unknown to cause human disease.” In some ways, the COVID-19 pandemic has been a wake up-call. Children who have been home-schooled during the COVID pandemic will almost certainly face another pandemic in their lifetime – one at least as bad—and potentially much worse—than this one.

We begin by describing welfarist psychiatry before outlining the relevant challenges to improving global mental health and explaining how welfarist psychiatry meets those challenges.

There are two broad schools of ethical theory: consequentialism and non-consequentialism. According to consequentialism, the right act is that act which has the best consequences. According to non-consequentialism, the rightness of an action is not solely determined by its consequences. (Though, most versions of non-consequentialism allow some ethical relevance of consequences). The most famous version of non-consequentialism is deontology, which holds that one has an absolute duty to obey certain rules. “Never kill an innocent person” or “never lie” are examples of such rules. Christianity is one form of deontology and the Ten Commandments represent one set of rules. Medical law exists at the intersection between consequentialism and deontology. Much of medical law is consequentialist in nature. However, having evolved from a set of Christian values and principles, it retains certain deontological characteristics. In particular, it retains a commitment in many jurisdictions to the Sanctity of Life Doctrine, though this is being shed or modified as assisted dying becomes legalised. In this chapter, we will begin by defining consequentialism, and contrasting it with deontology. We will describe some examples of the influence of consequentialism over current medical law. We will close by outlining the areas where consequentialism is at odds with current medical law and how medical law should evolve according to consequentialism.