Valerie Chung
Hello everyone, and welcome to the Voices in Bioethics Podcast. I’m Valerie Chung, your host for today’s episode, and it is my great pleasure to introduce Dr. Zohar Lederman, an emergency medicine physician with a PhD in bioethics. Welcome Zohar.
Dr. Zohar Lederman
Hi.
Valerie Chung
Hi. We’re so excited to have you here. So just to get us started, would you mind taking a moment to introduce yourself and just share a little bit of your background with us?
Dr. Zohar Lederman
Yeah, sure. I’m originally Israeli, so I actually studied philosophy in Israel, and then I went to medical school in Italy, and then I did a PhD in medical ethics, in bioethics in Singapore.
Valerie Chung
Oh, wow!
Dr. Zohar Lederman
Yeah. And two years ago, I moved to Hong Kong for a postdoc right after my residency. That actually happened back in Israel. And recently, I moved to the emergency department here at HKU.
Valerie Chung
Yes, it really took you around the world. What got you initially started in bioethics?
Dr. Zohar Lederman
So I think it’s my interest and my background in philosophy, which once combined with medicine, bioethics was the natural continuation of that, although I have to say you are catching me in a bad moment when it comes to bioethics. Might be good for your listeners.
Valerie Chung
No, no, I’m sure this will be really interesting. Thank you for sharing. So today, we’re going to be talking about the bioethics of loneliness, and we’re going to be looking back at the COVID-19 pandemic a little bit, specifically. So Zohar, could you elaborate on some of the ways that loneliness can impact an individual’s health?
Dr. Zohar Lederman
Yeah, sure. So we have good evidence that has been gathering since the early 70s that social isolation and loneliness adversely affect your health. So the evidence is stronger for social isolation actually. We probably need to define what it means. So social isolation is objective aloneness, all right? So it’s the objective experience of being alone. Others can see that you are alone. You judge yourself to be alone. Being at home alone can mean, without a family, can mean being socially isolated. Being quarantined during a pandemic like COVID means being socially isolated. Being socially isolated may or may not mean being lonely, so the two are correlated, but they’re not the same. Now we know, and there’s a major report that came out in the US recently. There’s evidence connecting social isolation to ill health is very strong. And what I mean by that is we know that it shortens your life by around 26 years.
Valerie Chung
Oh, wow!
Dr. Zohar Lederman
Yeah. It increases your rates of depression, suicide, stroke, cardiovascular disease, high blood pressure, probably also reduces your immune system. We know that loneliness also had the same effect, adverse effects on your health, but the evidence for that is weaker, okay, so it’s important to be aware of that, right? So both of them are bad for your health. Both of them mean that you will die faster. You will get sicker, but social isolation is probably or what we know is that social isolation is probably stronger.
Valerie Chung
Right, right. So it’s important to make a distinction between them.
Dr. Zohar Lederman
Yeah.
Valerie Chung
Yeah. I had never read that much about loneliness in the media or even like in scientific publications, until COVID-19, which is when lockdowns and quarantines really took a heavy toll on people’s mental health, because, as you mentioned, they were isolated from others. So how has covid affected our understanding of loneliness?
Dr. Zohar Lederman
So I think public health experts and governments were aware, or and psychologists, were aware of the adverse effects of loneliness and socialization before COVID. There were a lot of studies, as I said, you know, the first article appeared in Science roughly in the early 70s about the connection between socialization and loneliness and adverse health. So we knew this for a while, and as proof of that, the UK Government, before COVID instituted ministry for loneliness, they started socialization courses. They started to really emphasize social interventions, community interventions against loneliness and social isolation. I think what COVID did was to just highlight to the rest of us, to the rest of the world, to disciplines that beforehand didn’t pay attention to it. How big of an issue this was. Basically COVID was the horn that clarified to those of us who were ignorant of the problem beforehand. How big of a problem loneliness and social isolation are.
Valerie Chung
Yeah, definitely. And I think because it highlighted to a lot of us that didn’t previously feel lonely about loneliness. But then, of course, during COVID, we were all experiencing social isolation, so maybe all of us kind of got a little taste of what that is like.
Dr. Zohar Lederman
Yeah, absolutely. And further that, what we know, there is good evidence now I think to show this, and particularly in Australia, there’s good study that shows this. So, right? So during COVID, more and more people experience social isolation and loneliness. It became really stuck. What’s interesting is that loneliness rates have increased, or seem to have increased after COVID compared to pre-COVID period. So not all studies, and the study in Taiwan that doesn’t show this, but most studies, I would say, show that loneliness has increased after COVID compared to pre-COVID, even without the social isolation and quarantine.
Valerie Chung
I see. Do you know the reason for that?
Dr. Zohar Lederman
We don’t know. We don’t know. One of the theories that people became much more and, I mean, we see that in young kids, right? People became much more socially anxious, right now, people fail to be you know, social skills are like a muscle. You need to exercise, them if you don’t exercise them, you know, kids who didn’t go to school for three years, didn’t get to exercise them, they feel social social anxiety, and they would prefer staying at home rather than going outside and play.
Valerie Chung
Yeah. So in many of the articles that I read during the pandemic, loneliness was very often described as an issue faced more by elderly people, most likely because they were living alone, or maybe they experienced the death of more of their friends or people around them. So, as you said, kids nowadays as well. But are there other populations that are also more vulnerable to loneliness than others?
Dr. Zohar Lederman
Yeah, so interesting. So it’s probably a myth, or a partial myth, that the elderly suffer from loneliness more than other populations. I think there is good evidence to suggest that actually the elderly may suffer or may be less vulnerable to loneliness for two reasons. One is the expectations are lower. So what is loneliness? So we talked about social isolation. What is loneliness? Loneliness is a distressful mismatch between the social relations you expect to have and the social relations or connections you perceive to have. So that means expectations. The elderly usually have low expectations of social relations, right? So as a teenager, you expect to be social 20 hours of the day, whereas as an elderly, they are fine being social for two hours of the day. So that’s one. Second the elderly, there is some proof to suggest that the elderly can cope better with loneliness and social isolation, right? So they initiate more activities. They are happy with staying at home and reading books. They are happy with volunteering in different activities. They are happy going to a museum, just like that in their neighborhood or in the city. The young folks tend to do that less. Now, even before COVID, the largest study that existed before COVID, the BBC survey, actually showed that the population most at risk is younger around the world, not only in the UK, is young adults, 18 to 24, right? So they had 40% loneliness rates. All right, that’s a huge number. Whereas the elderly 65 or above had 24%. It’s a really big difference. So probably, and this is somewhat controversial still, because you have conflicted evidence, but probably the population that is most at risk is this 18 to 24. Now, having said that other groups that we know are at risk but are smaller in general, in absolute terms, are immigrants. So immigrants, asylum seekers, all those who transfer to other countries, they suffer from it, from loneliness and social isolation. People who are disabled, people who are sick, right so they can ambulate less. They are more dependent on others. People with mental disorders. So people with depression, for instance, can find it harder to socialize. And I had another and obviously LGBTQ population also, it tends to be, and there’s having a study in Hong Kong, tends to be more lonely than other populations.
Valerie Chung
Yeah, so it obviously seems that there’s a very real justice issue here, specifically what you said about the immigrants and the asylum seekers, because there’s a feeling of being isolated from their home where they can’t go back, and that sort of makes them want to be at home even more, right? So in your research, I’ve read that you argued loneliness is a negative social determinant of health, and individuals have a right not to be lonely. So that’s kind of also linking to the bioethical principle of autonomy, right? So how do you think the other bioethical principles can also be applied here.
Dr. Zohar Lederman
Can I? Can I return the question to you, how do you? How does that relate to autonomy?
Valerie Chung
I would see that as kind of you say individuals have a right not to be lonely, and I see autonomy as a right that individuals have, or what individuals should have to make their own decisions.
Dr. Zohar Lederman
Yeah. Okay, so the way I perceive autonomy, and you know, they may have taught you differently. The way I perceive autonomy is of two kinds. I distinguish between moral autonomy and personal autonomy. Moral autonomy is what we refer to when we talk about the full principle, and you know, the rights of patients in medical care, so they have a right to refuse treatment, for instance, etc, etc. I think what you’re referring to, what I understand, is personal autonomy, and this is the right of people to pursue their life goals, to be free of undue pressure from the governments or from coercion by others. They should be free to do what they like, as long as there’s no significant risk to harm others or to harm the social ethos, etc, etc. So in that case, yeah, absolutely. So, one population I didn’t mention is, like you said, is those who are least well off, those who are of low socio-economic strata. In that case, absolutely. So, people who have less, who can buy less, who have less power in society. What we found is or not, what we researchers found this entire literature on Social Determinants of Health is that, or at least one explanation, is that social determinants of health affect your health and affect your well-being by reducing your personal autonomy. It all boils down to personal autonomy. And obviously this is one explanation, all right. So basically what it means is, once you have a social determinant of health against you, really they are all negative if you think about it, you compare yourself to your peers, and you see you are less well off. You have less than them. You are less worthy than them. Then you, it reduces your autonomy. It reduces your ability to be all you can be right, to live a fulfilling, prosperous life. All right, my argument is that, and again, based on the empirical evidence, people who are lonely, or at least in some instances, when they compare themselves to their peer, their loneliness, their social isolation, causes them to feel less worthy compared to their peers, inferior compared to their peers, right? It makes them lose okay. This is one mechanism by which loneliness can affect your ill health, can affect your health adversely, is by reducing your personal autonomy. The literature on social determinants of health, particularly Sir Marmot, who is a famous figure here, will tell you that reducing your personal autonomy causes ill health and premature mortality, and basically, this is the mechanism by which social determinants of health affect your health.
Valerie Chung
Yeah, wow. And I think that also links back to what you were stating previously about the difference between the expectation of how much people should be socializing versus the reality of how much people are socializing, and that kind of like feeling of being less worthy. So I also wrote a recent piece on this topic that you wrote about how loneliness is essentially the lack of solidarity, right? So even though they’re very closely related, there should be a clear distinction made between them. And some people believe that loneliness is typically used as a more negative term, but solidarity can sometimes be viewed as positive. Sometimes people like being alone. They like having their alone time. And you’ve argued that ethical loneliness exists. So what exactly is this and how can we make loneliness more ethical?
Dr. Zohar Lederman
Alright, so there’s a lot to unpack there. First of all, maybe you should stop reading my article.
Valerie Chung
They’re very interesting.
Dr. Zohar Lederman
Read more interesting stuff. So a few things, there is social isolation, there is loneliness, and there is solitude, and solitude is the more positive experience of being alone, right? So you can imagine a philosopher or poet walking alone in the desert, developing themselves, etc. Or a monk living somewhere in the
Valerie Chung
In the mountains.
Dr. Zohar Lederman
The mountains, and praying and being close to God.
Valerie Chung
Yeah.
Dr. Zohar Lederman
Or to the essence of the universe. So you have those three things that encompass or that can describe the experience of aloneness, of being alone. All right, now the article that you mentioned, Oh, yeah. Let me first talk about ethical loneliness. Ethical loneliness is one particular account of existential loneliness, or phenomenological loneliness, put forward by a philosopher in the US who noticed that survivors of great injustices, such as Holocaust survivors, when they came and gave witness report about their experiences, were not heard well, all right? So basically, the investigator of the interviewers heard what they wanted to hear, rather than what these people actually said or wanted to communicate, right? So she looked at the literature and the report, and just saw that, you know, Holocaust survivors complain that the researchers, the people who came to ask me questions, they asked me the questions, but they didn’t listen. So what I said didn’t have any meaning to them. And she came up with this idea of ethical loneliness, which is very different, first of all, from other accounts of loneliness that are out there. So the traditional understanding of loneliness that I mentioned. And for her, is this experience of a very specific experience of first having suffered an injustice, like the Holocaust, like other instances. So I wrote about it in the context of Palestinians in Gaza, particularly healthcare workers, healthcare worker who died, who was killed by Israeli forces. So that’s the experience of suffering, going through an injustice. And then when you come to report on it, to bear witness to it, you are not able to right? So it’s a kind of epistemic injustice. This is that’s the term we often use in philosophy, epistemic injustice. Your voice is not being heard and is not being heard well, all right? So you are devoid of contributing to the pool of knowledge of humanity, basically. So you really, what it means in a deep level, is that you are devoid of your right or your ability to be part of humanity. That’s what makes it so perfect. All right? I kind of was inspired by that, and after reading several accounts of loneliness by immigrants, asylum seekers, I came up with this idea of loneliness as lack of solidarity. And you know, it may be the concept itself may be accurate in capturing the experiences or may not, but it’s a tentative attempt to try to capture the experiences of asylum seekers and immigrants, etc, etc. What does that mean? So solidarity in bioethics has very specific meanings. One meaning is that you have solidarity with someone if you identify with them in some meaning, meaningful aspect, and you are willing to carry a burden to a system because of that identification. Okay, very specific notion of solidarity. There are others, but this is the main one. It seemed to me, after reading a bunch of accounts of immigrants, that when they describe loneliness, when they complain about the loneliness, the loneliness they that they feel, is not the kind of loneliness that we refer to as a traditional account of loneliness. In summary, we said before about, you know, they’re being distressed about this mismatch between the expected and perceived social relations. No, sometimes they come with their families. Think about the asylum seekers in Hong Kong.
Valerie Chung
Yeah.
Dr. Zohar Lederman
Right. They come with their families, with their partners, with the kids. They don’t have that kind of loneliness. They may have left their friends in their home countries, but still, I mean they come with the families. They develop new friendships here. Rather, the kind of loneliness that they develop is the loneliness that one feels when one is abandoned by the world, by humanity. So when you feel that no one can identify with you in some meaningful way, and when you feel that people or the world or humanity are not there to assist you, then you feel that kind of loneliness. And I think right now, what we are seeing in Gaza is specifically, it’s very, very relevant to this. Right now, Palestinians are being destroyed. The Palestinian culture is being destroyed in Gaza. And it seemed, I mean, right now, there are some positive changes, but for a long time, they felt abandoned by the world. And then you can think about them as being loneliness. They’re being lonely because of lack of solidarity.
Valerie Chung
Yeah, absolutely. And what you said about Gaza, of course, is very relevant right now. So it’s obviously not just a public health issue. It’s, it’s what, much more than that. It’s philosophical. It’s, it relates to everything that has to do with someone’s injustices and just how someone is treated or perceived within the world. So given its kind of very interdisciplinary nature, how would you say bioethicists can become more involved?
Dr. Zohar Lederman
That’s a very good question. So first of all, I totally agree. So part of my research is indeed pushing this idea, arguing this for this idea that loneliness is much more about the health impacts.
Valerie Chung
Yeah.
Dr. Zohar Lederman
Loneliness has to do with, with the essence of what we are, the essence of being humans, of the essence of humanity, right? It really affects us in a deep way, beyond our health. Now, bioethicists have mainly neglected the issue of loneliness. I’m not sure why. There are a few writings here and there, but nothing really serious. I think it’s changing slowly, and that’s a good thing, but usually what I say is, and I recently just wrote about it, but don’t read it. I think bioethicists can do several things. One is, well, first of all, to make an argument, to make a link between loneliness and what governments and other individuals owe to those who are lonely. Okay, so first of all, focus on this public health aspects. What does that mean? It means that you need to figure out what loneliness is, how to measure it. You need to from a philosophical, ethical perspective, you need to make an argument that human beings have a right, or are entitled, to not feel lonely, and then you have to figure out, okay, what do we need to do about it? Okay, what do governments and individuals, given a human right against loneliness, and given what we know about the health impact of loneliness, what do we do about it, all right? From, you know, potentially, from a justice perspective, as what do we owe others? But this gets complicated. Why? Because, as I said, there are different kinds of loneliness, as expressed by the embodied experience of other people, right? In the literature, in narratives, and we cannot dismiss those. So a full account of loneliness and a full public health or community or social justice approach to loneliness will account, or will try to account for all those kinds of loneliness. So that means we first, we need to understand the problem, and philosophers, bioethicists, first need to understand or elaborate or think about or capture the different kinds of loneliness, and realize that different individuals may suffer from different kinds of loneliness at the same time. It can be loneliness as lack of solidarity, ethical loneliness, political loneliness and the traditional kind of loneliness, right? So you can move on your own to a new country and be alone because you don’t have a partner, but also because you feel abandoned by humanity.
Valerie Chung
Right.
Dr. Zohar Lederman
Once we have that, then we can seriously think about the obligations we have towards those people, and once the conversation becomes normative, then obviously that’s the business of ethicists and bioethicists. So first it’s articulating the problem, understanding the problem, and then figuring out exactly what we owe to the lonely people.
Valerie Chung
Yeah, and that all sounds incredible, but I can think of so many challenges that might arise, like, given that there’s so many different types of loneliness, it could be very hard to measure, especially because everyone’s experience of it is different, and so qualitatively, it could be very hard for the government to measure that in order to implement different policies or community based initiatives that help people.
Dr. Zohar Lederman
Absolutely, I think that’s my one of the main challenges. You know, if, if loneliness is a subjective experience, so what? So what? Now, we owe everybody resources for them not to be lonely. In some cases, when someone is lonely, they really need to just struggle harder to find things to do. In some cases. In most cases, it’s probably, not, probably individuals need help. They cannot cope with their loneliness by themselves. Are we going to have a clear-cut solution or a clear-cut threshold to define which is which and what cases of loneliness, you know, in which cases of loneliness we should intervene, and which we shouldn’t? I don’t think that would be possible. And right now, our measures of loneliness are not appropriate. If we are serious about the different kinds of loneliness, right now, we don’t know how to measure them at all, so we don’t even know the extent of the problem. So how do we solve it if we don’t know the extent of the problem.
Valerie Chung
Exactly. And I mean, apart from the measuring, if they then are able to do that, the government, it’s so many tiers, right? So in the community, you can have support groups for immigrants, for example, but then also politically, you would essentially be having to change the perception of governments or officials of these immigrants or asylum seekers. So that’s also very difficult, and it’s definitely going to take time.
Dr. Zohar Lederman
That’s why we need students to take
Valerie Chung
We need bioethicists to
Dr. Zohar Lederman
We need students of bioethics to take on this huge project. I do think it’s worthwhile, because first, it’s a fascinating philosophical problem, and also, I think loneliness is a serious issue, and it’s really a pandemic worldwide, and we should really be more serious about it in bioethics and beyond.
Valerie Chung
Definitely. So just to wrap up and going back to COVID-19, from where we started, it obviously taught us many, many lessons regarding public health issues and public health ethics, right? So what do you think is the biggest takeaway that we can have in terms of loneliness or the pandemic? And in a future pandemic, what can we as bioethicists then do to prevent loneliness to the extent that we saw during COVID and after, as you mentioned.
Dr. Zohar Lederman
In general, without any regard to loneliness right now, I think the most significant lesson that COVID taught us is that public health is worth nothing if there’s no trust, among individuals and between individuals and governments and scientists and healthcare professionals. Without trust, no matter how good your vaccines are, your quarantine measures are, your isolation measures are, nothing would work. So you know, this is a truism in public health, the best way to mitigate the next pandemic is to prevent the loss of trust, of public trust that became so clear during COVID. So that’s in general. In the case of loneliness, absolutely. So we know there’s another pandemic coming, and we need to prepare much better for the next time we have to engage in social isolation and quarantine and lockdowns. So that means, practically speaking, we need to include loneliness mitigation measures in pandemic preparedness plans, for instance, right? So every country is supposed to have a plan to take out from the draw and implement during an outbreak, infectious disease outbreak. Most countries didn’t do that during COVID. So, they should, and most of these plans don’t have any articles relating to loneliness and social isolation and probably mental health, so we should include that into these programs. And in general, for the future, I think bioethicists and all stakeholders should be much more cognizant of this potential adverse effects of measures against an outbreak, right? Social isolation, loneliness, and we should engage much more seriously in preventing and addressing them during pandemics. And it does have to be complicated, right? So one of the things that I, with colleagues, argued is that even during a pandemic, even during an infectious disease outbreak, we ought to be and even in light of the risk to public health, we ought to allow family members to visit their loved ones in the hospital, in a COVID world. Even though it poses risk to public health, we need to reduce that risk as much as possible, while allowing family members to be present and to accompany their loved ones, whether they get better or not, because one of the greatest injustices that happened during COVID is that people went to hospitals and died on their own, or they died a lonely death, surrounded, at best, in the best case scenario, by people who they don’t know, wearing, you know, white coats or protective measures and without their loved ones.
Valerie Chung
Yeah, that’s really interesting. So dying alone, as well, is something that governments could implement policies to ensure that doesn’t happen to people, for sure. So Zohar, I’m so glad that you were able to take the time to be here today and have this discussion with us. Thank you so much.
Dr. Zohar Lederman
Thank you.
Valerie Chung
And once again, I’m Valerie Chung, and this has been the Voices in Bioethics podcast with Dr. Zohar Lederman.