An ethic for the epidemic

Common sense is perfectly familiar with tragic moral dilemmas, where no way out is simply good, and the only morally justified option is to grasp the nettle of the lesser evil. Patrick O’Brian gave us a swashbuckling example in his 18^thcentury tale of the Royal Navy, Master and Commander. Somewhere in the wastes of the South Atlantic, HMS Sophie is engulfed in a violent storm. Suddenly, her main mast snaps and crashes into the sea, sails, rigging, and all. Through the howling wind the midshipman screams to the captain that, unless they cut the wreckage loose, the ship will be unbalanced and sink. But there’s a problem; for, clinging to the wrecked mast is a sailor who was blown over with it. If the ship is cut free, he will drift off into the watery vastness and drown. The captain decides. He calls for axes and orders another sailor nearby to help him cut the ropes binding the ship to the fallen wreckage. This sailor happens to be the best friend of the poor wretch floating on the broken mast; and as he lifts his axe and brings it down on the ropes, tears stream down his cheeks. The choice was a terrible, tragic one. But it was right. If we really must choose between saving a ship’s company or a single sailor, we ought to prefer the greater number. And in doing so, we need bear the doomed sailor no ill will and show his life no disrespect.

Faced with the Covid-19 epidemic, none of the responses open to the Government is simply good. All of them would damage things we value. Each one would cause evil. Presumably, then, the Prime Minister and his colleagues should take the option that causes least evil — as Toby Young has argued in a controversial article (The Critic, 31 March). Adjusting Dr Neil Ferguson’s figures (“Report 9: Impact of non-pharmaceutical interventions to reduce Covid-19 mortality and healthcare demand”, 16 March), Young estimated that Government’s original strategy of mitigation would have resulted in 370,000 deaths, whereas its present strategy of suppression would result in only 20,000. Reckoning the economic cost of lockdown at £185bn, he inferred a price of £500,000 for each life saved. He then applied to this the criterion used by the National Institute for Clinical Excellence (NICE) to decide which new drugs and medical procedures to fund — those that would achieve a year of worthwhile health for one person for under £30,000 — and concluded that, to be justified, public expenditure of £500,000 would have to add over sixteen-and-a-half years of life to each person saved. However, according to the social scientist Noah Carl, the average number of life years likely to be added is only 11 (“How Many Life-Years Could Be Lost to Coronavirus Disease in the UK?”, Medium, 28 March). Since, according to NICE, this would warrant an expenditure of only £330,000, the Government’s policy of lockdown is overvaluing the lives saved by a third.

What is more, that very policy is causing severe economic contraction, which, some argue, generally causes a decline in life-expectancy. Thus, Philip Thomas, Professor of Risk Management at the University of Bristol, has calculated that, if the lockdown causes the UK’s GDP to fall by more than 6.4 per cent “for a significant length of time”, more years of life would be lost than if the Government did nothing (“Recession could kill more than coronavirus”, IAI News, 7 April 2020). In fact, many economists are predicting an economic impact far greater than that. It follows that the Government’s present cure is worse than the disease: it has chosen the greater evil. Instead, it should choose the lesser one by reverting to its original strategy of letting the epidemic run its course, so that the population achieves herd immunity.

If only it were that straightforward. A calculation is only as accurate as the figures fed into it, and Toby Young’s figures, though well informed, are still only guesstimates. Dr Ferguson’s estimate of the number of deaths under lockdown has already been exceeded: whereas he predicted 20,000, official sources recorded 25,097 at the end of April, which may be only half-way through a period of more-or-less severe lockdown. If the prediction of deaths resulting from a policy of suppression is an underestimate, then so might be the prediction of deaths from a policy of mitigation. It could well be the case that a policy of herd-immunity would leave in its trail many more than 370,000 fatalities. The Harvard epidemiologist, Professor William Hanage, reckons at least 600,000 (“No matter how you crunch the numbers, this pandemic is only getting started”, Guardian, 16 April).

The truth is that we have no certain knowledge of the number of deaths that the policy options would deliver. In Radical Uncertainty: Decision-making for an unknowable future (2020) John Kay and Mervyn King are generally sceptical about government’s “obsession with cost-benefit analysis”, and in a recent article they argue that the effect of the Covid-19 pandemic on the economy “will not necessarily be clear even after the outbreak is long over… We will never really know either the infection rate or the mortality rate from coronavirus because many people will catch the disease but never be tested, and very many of those who die will be people with underlying health issues (which may or may not have killed them anyway) who then test positive for the virus in the course of treatment” (“Into the Unknown”, Prospect, May 2020).

Moreover, the claim that a prolonged lockdown would, through economic distress, consume more human life than the alternative does not go unchallenged. David Stuckler’s study of the impact of economic crises on public health points in the opposite direction, indicating that, while economic downturns are correlated with a rise in suicides, homicides, and deaths from alcohol abuse, they are also correlated with a decline in traffic deaths, cardiovascular deaths, and deaths from drug abuse. He finds “no consistent evidence that rates of mortality from all causes increased when unemployment rose” (“The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis”, Lancet, 25 July 2009).

The upshot of all this that the Government does not know which option will result in fewer deaths over the long-term. It cannot choose the lesser evil, because it cannot find it.

However, if it does not know where the lesser evil lies, it does know other things. It knows that the demand for life-saving healthcare has risen dramatically and might rise further. It knows that, were that demand to overwhelm the healthcare services, many would die otherwise preventable deaths (from all causes), and many more would be inflicted with otherwise preventable suffering. It also knows that a collapsed healthcare system, during a lethal epidemic, would strike at the heart of public confidence and foster social unrest, culminating in radical political disorder.

Knowing these things, it makes sense for the Government to aim at equipping the NHS to cope with the increased demand, by moderating the spread of the virus. That, of course, is the purpose of the present lockdown. But the lockdown, as we know, cannot be maintained forever. It, too, causes damage: failed business, unemployment, mental illness, domestic violence, suicide, and — in extremis — social unrest and political disorder. And in the long-term it would be counter-productive, since in shrinking the economy, it reduces tax-revenue and thereby depletes public funding available for healthcare. Hence, the present search for ways of relaxing the lockdown without having the virus let rip. But that raises further ethical issues.

Judging by the English record to date, about ninety per cent of those dying from Covid-19 are over the age of 60. (And since official figures have only recently begun to include deaths in care-homes, the actual percentage is likely to be well north of ninety.) Therefore, if the demand on healthcare services is to be kept under control, it would make sense to concentrate on moderating the spread of the epidemic among the elderly. This indicates a need to keep that group of citizens more locked down than others.

Understandably, not everyone is happy with this. No less than Lord (David) Blunkett, Home Secretary from 2001-4, has protested against the “gross inequality” of discriminating against older people in requiring them to remain under lockdown, while others are permitted to emerge from it: “if someone suggested that your ethnicity would determine whether you were going to be allowed to return to some sort of normality, the world would implode. Discrimination against older people because ‘they’re old’ is equally totally unacceptable” (“To incarcerate people solely on age grounds is an outrage”, Daily Telegraph, 28 April).

Because of the negative connotations that now adhere to the word, perhaps we need to remind ourselves that there’s nothing wrong with discrimination as such. We discriminate all the time, and often quite rightly. We do not treat children as we do adults, nor convicted prisoners as we do innocent citizens. Indeed, in those cases, it would be unjust if we failed to discriminate. So the question to be put to Government policy is not whether it is discriminatory, but whether it is unjustly so. It would be unjust, if it treated older people differently for no sufficiently good reason. In this case, there is certainly a good reason: the public need to prevent the healthcare services from being overwhelmed; the fact that the infected group most likely to require intensive hospital care are citizens aged over sixty; and the further fact that enabling the healthcare services to cope with demand is in the interests of older citizens, too.

This is a good reason, but it might not be a sufficient one, since, arguably, the restriction is disproportionate or, to use the legal term, “overbroad”: it confines more people than is necessary to achieve its aim. In other words, it is not discriminate enough. That is because 95 per cent of those over-sixties who have died from the virus already had an underlying health condition (“Coronavirus: 95 per cent of victims in England hospitals had underlying health conditions”, Sky News, 28 April). What that implies is that a restriction aiming to moderate demand on healthcare services could afford to be more sharply targeted at those elderly already suffering from serious ill health. Only if such precise targeting were not practicable — in terms of individual self-discipline or public enforcement — would a more indiscriminate lockdown of the elderly be morally justifiable.

Another response to the prospect of elderly people suffering prolonged lockdown has come from Lord Hope of Craighead, a former justice of the UK’s Supreme Court. Writing in the Times, he urged the striking of “a balance” between the public interest and the right to respect for a family life (letter, 21 April). Such an appeal to a right tends to imply that what it protects is clearly defined, and that it can therefore equip the individual with a robust shield against whatever public interest is bearing down on him. But that is not so in this case. Rights assume normal social circumstances, and in a national emergency — such as war in 1939-45 — it is not uncommon for rights to be suspended altogether or severely qualified, albeit under certain conditions and for limited periods. The Covid-19 epidemic has created a national emergency, and whether the right to respect for a family life should continue to permit grandparents to see their children and grandchildren face-to-face, given the risks to public safety, is exactly the question that needs to be answered. Answering it will involve consideration of a variety of factors, none of them rights: the good of family relationships, the public interests in containing the epidemic and letting the economy revive, and the duties that those interests generate.

If the freedom to resume normal relations entailed risks to their own health only, the elderly could, and should, be left to decide for themselves. However, since the vast majority of those dying from Covid-19 are aged over 60, that freedom also entails risks to the capacity of the NHS and so to the lives of others. Therefore, the government has a duty to decide how much freedom it is socially safe to grant the elderly, and what restrictions they have a duty to suffer.

Once lockdown is relaxed, virus-related deaths will increase. As and when the NHS seems able to cope, the right of elderly people to risk seeing their loved ones face-to-face should expand.

None of this is to deny the severity of the burden of lockdown on older people, who are often more isolated than others. Writing as a seventy-two-year-old, David Blunkett put it well: “In every sphere of our lives, both with our physical and mental health, it is clear that social interaction, positive activity, and keeping our brains alive, keeps us alive. Take that away and you will have a devastating impact on a growing ageing population” (Daily Telegraph, 28 April).

This damaging impact, this evil, is not what we want or intend. What we intend is to sustain the healthcare services throughout the epidemic. But, tragically, it seems that we cannot do that without also causing the unwanted side-effect of the prolonged confinement of older people. If, however, we are sincere in not wanting that side-effect, we will do everything in our power to mitigate it. So, while sufficiently good reasons may justify a policy of unequal treatment, and while that treatment violates no right, the Government — and, under its coordination, civil social bodies such as churches and charities — still have a duty to show due care for the elderly, by striving to minimise the unavoidable, necessary evil we require them to suffer for the public good.