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COMMENT:
A fierce debate is under way between those who believe that the current lockdowns in place across much of the world are an overreaction, and those who believe it would be barbaric to do anything other than try to avoid as many coronavirus deaths as possible.
Those in the first camp — who tend, on the whole, to lean towards the right — point out things like the fact many of those dying from the virus would have been likely to die soon anyway; that the collateral damage from the lockdowns will end up causing more harm than coronavirus itself; and that the amount of money we are effectively spending on saving each life is completely out of whack with what we would normally consider reasonable.
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Those in the second camp — who tend, conversely, to lean to the left — argue that to not do everything we can to prevent as many people as possible from dying a grisly coronavirus death would be inhumane; that we are already exposing our health workers to high viral loads of coronavirus and that if we were to allow it to spread at a faster rate, an unacceptable number of otherwise healthy workers would die; and that it doesn't actually really matter whether the lockdown is enforced or not because people wouldn't be going about their usual business anyway at this point, so the hit to business can't be avoided. (A counter to that last point, of course, is that without a scaremongering campaign from a biased "liberal" media, people might indeed be going about their business.)
Both camps make reasonable and sound arguments. And it will take a long time to be sure about who, if anyone, was right (we may never come to a consensus on this).
But there is another consideration that is largely ignored by both camps: the moral impact of the decisions being made.
How will we feel about our collective selves if we turn our backs on the people we can see dying in front of us in order to achieve some much less measurable and more uncertain future outcome? Will that guilt be more or less acute than the guilt we might feel in future when we get a better sense of the collateral damage that comes from the lockdowns?
We will try, here, to go through some of the main points of contention. But also, to consider the impact of making decisions we are morally uncomfortable with.
Those decisions, if we get them wrong, could end up having such a great impact on the fabric of our society and our sense of what it means to be civilised, that we could end up with economic damage (and by extension health and societal damage) just as significant as that caused by the lockdowns themselves.
The New York Times published a story last week under the headline "Where Have All the Heart Attacks Gone?"
The piece, written by Yale cardiologist and medicine professor Harlan Krumholz, notes that many hospitals in the US have in recent weeks become "eerily quiet", and reports a sharp decline in the number of admissions for heart attacks and strokes, both in the US and in Spain.
Krumholz suggests a couple of reasons for this. The first is that the possible triggers for heart attacks — such as "excessive eating and drinking" — have been to some extent removed, under our state of lockdown.
This seems unlikely to us. We of course are not speaking from personal experience (ahem), but we are not very convinced that excessive eating and drinking have gone away (in fact WHO is so concerned about the latter that they put out a statement this week saying access to alcohol should be restricted).
We also feel fairly confident in assuming that stress — a major contributor to heart attacks — is not particularly low during a once-in-a-century global pandemic in which millions have already lost their jobs and more than 150,000 have died so far.
The next reason Krumholz suggests seems more plausible, and more concerning: fear of being infected with coronavirus is discouraging people from going into hospital. We've seen evidence of that in the UK too.
But again, we're a bit sceptical about the idea that if you or a family member were having a heart attack or stroke, you'd be more worried about catching coronavirus than the threat of imminent death.
And even if that were the case for some people, and we're sure it is for some, we're not convinced that would account for the 40 per cent decline in heart attack procedures that the NYT reports Spain saw in the last week of March, for instance.
There's another possibility that the Krumholz doesn't mention: what if the people who would have been brought for heart attacks or strokes in the last couple of months have instead been brought in with serious cases of coronavirus? What if, in other words, coronavirus is taking the lives of people who might have died pretty soon anyway? Are we mainly just seeing mortality displacement, like we might see, for example, during a heatwave?
Sir David Spiegelhalter, former president of the Royal Statistical Society and co-chair of the Society's Covid-19 task force, has been digging into this question, and he has found that Covid risk (ie, the risk you have of dying if you contract the virus) follows a very similar pattern as general background risk (ie, the risk you would anyway have of dying in the next year). This is not the same as with many other pandemics.
This chart is from a few weeks ago but Sir David says the pattern remains intact and it illustrates the pattern very well (note this is a log scale):
Sir David explained to us (all emphasis ours):
"The pattern shows Covid deaths increase exponentially with age. Unlike, say, Spanish flu, which harmed younger people, this follows the pattern of normal risk. Whatever risks you've got, this just seems to exaggerate them — pump them up and pack a year's worth of risk into a few weeks.
"Covid deaths are a fixed proportion of the people dying . . . although that's probably not true of people who are likely to be exposed to very high doses, such as healthcare workers."
Although it has not yet been established that a higher viral load can lead to more severe coronavirus, the evidence points towards that being the case, so the part about health workers is important, particularly in the context of the "but they would have died anyway" argument made by the lockdown critics.
So how many people dying from Covid-19 would have died this year anyway? That's a trickier question.
Imperial's Professor Neil Ferguson told us a couple of weeks ago that "from our crude analysis, it's plausible that of the order of two-thirds of the people that have died so far might have died in this year anyhow". Sir David reckons that might be a little high, but says it would be "a reasonable proportion".
Sir David also points out, however, that we are likely to have excess deaths because of people not getting access to medical treatment.
And that is already coming through in the data: the latest numbers from the Office for National Statistics showed 6,000 excess deaths in the week ending April 3. Almost 3,500 of those mentioned coronavirus on the death certificate, leaving around 2,500 that didn't.
It is of course not possible to come to any hard conclusions about what caused these deaths, and indeed it is very likely that many of them — perhaps even most — were the result of undiagnosed coronavirus cases.
UCL clinical epidemiology professor Harry Hemingway and his team recently put out a study (soon to be published in peer-reviewed form in The Lancet) that estimated the number of excess deaths the UK would see over the next year, and put that number at between 35,000 and 70,000.
Hemingway told us it was likely that most of these excess deaths would be the result of less non-emergency care (so not so much treatment for heart attacks or strokes, as the NYT piece suggests):
"There are a bunch of policies that are having material changes on the way care — elective, non-emergency care primarily — is given. It's a reasonable question to ask: is the way things are being organised appropriate? There will be a range of answers to that. It is likely that there are unintended healthcare consequences of these delivered actions."
It is of course impossible to know for certain how many people will die from Covid-19.
The one thing one can pretty much guarantee is that forecasts will be wrong. (Indeed Imperial's prediction that the UK could limit coronavirus deaths to 20,000 under the current "suppression" strategy already looks too low.)
But even if we did know how many people will die, is this really about the numbers?
The government has made it clear from the start that its strategy is geared towards not keeping the number of deaths as close to zero as possible, but rather not overwhelming the NHS.
So we're not just, as the lockdown sceptics often argue, sacrificing our future prosperity for the sake of savings a few hundred thousand old people. It's about making sure our health system is functional (although the sceptics could argue back that other vital systems could become dysfunctional).
What would it feel like to be living in a country in which we knew that if we were in grave danger, there would be no safety net to rescue us?
As Sir David said to us:
"In a bad flu year we have 25,000 excess deaths from flu - that's happened a couple of times over the past five years and it didn't make any news at all. Hugely it's actually about the mode of dying. These can be awful deaths, awful. And also it's the speed at which they're happening and the threat of an overwhelmed health service. If the health service is overwhelmed, to society that's just completely unacceptable."
Conservative commentator Toby Young — who very much sits on the "lockdown sceptic" side of the debate and who has even created a website to share such scepticism — wrote an interesting piece in The Cut recently that argued that "spending £350 billion ($726.5b) to prolong the lives of a few hundred thousand mostly elderly people is an irresponsible use of taxpayers' money".
Young estimates that, via its bailout programme, the government is spending about £500,000 for each life "saved". He compares this with the £30,000 maximum that the National Institute for Clinical Excellence (NICE) reckons it's worth spending on each quality-adjusted life year (Qaly), and says:
"How many Qalys will the Government be adding to those people whose lives would otherwise be lost to coronavirus if the lockdown hadn't been imposed? For it to be worth spending £500,000 per life, using NICE's evaluation criterion, the answer would have to be about 16-and-a-half.
"And that seems optimistic, given that the average age of those who've died from the virus in the UK to date is 79.5 and average UK life expectancy is just short of 81. This suggests the lockdown is extending the lives of 370,000 people by an average of less than one-and-a-half years."
Several things are wrong with this.
For a start, each year that you manage to stay alive, your overall life expectancy increases.
That means that while 81 is the average UK life expectancy at birth; by the time an average person has reached the venerable age of 79.5, they can expect to live for another nine or ten years, depending on their gender. (You can find a calculator here that illustrates this nicely and that should give you a good sense of your own point in your journey toward death, should you wish to know.)
So the 16-and-a-half years Young estimates that the average person would have to carry on living to make the government's expenditure economically worthwhile, according to NICE's criteria, doesn't look quite so unrealistically optimistic.
But Young also misses a more important point: people are far more willing to pay for a cure than they are for prevention. Standard cost-effectiveness considerations of how much it is worth spending to extend lives is thus put aside when there is immediate risk of death in front of us, at which point people tend to feel a duty to act to save those lives.
This is the so-called "rule of rescue". The paradigmatic example used in explaining this moral imperative is that of a little girl who is stuck down a well.
At this point society, even though it might not have bothered to put in place measures that would prevent little girls from falling down wells, or that would rescue them once they had fallen in, would deem it grotesque for someone to carry out a cost-effectiveness analysis of how much it was worth spending to save the girl's life. (This kind of moral impulse is also evident in the more than £11.5 million that has been spent trying to find Madeline McCann, and in the money spent in 2018 in saving the boys stuck in a cave in Thailand.)
Jonathan Wolff, who is the Alfred Landecker Professor at Oxford university's Blavatnik School of Government, has written about the tension between the rule of rescue and cost-effectiveness analysis and argues that normally society tends to hedge its bets, doing a little bit of a prevention and a little bit of curing. He told us:
"We're much more willing to pay for cure than we are for prevention. The way this comes up in thinking about health systems is that we are prepared to pay much more for hospitals than public health even though we get much more benefit out of public health than we do out of hospitals. This is just a highly concentrated example of the prevention-cure bias."
But although one can clearly see the irrationality of such a cognitive bias, there is also the possibility that turning one's back on such a moral imperative could have bad consequences for our sense of collective duty, nationhood, and even of civilisation itself. Wolff continued:
"If we can't actually care for the people dying in front of us, there's a sense in which the value of human life, or human relations, is ignored and trampled upon. If you can't care for the people in front of you, you wonder what the meaning of any of this is."
Wolff suggests that as well as the epidemiological and economic modelling being done for policymakers, there is a another kind needed:
"We need a third kind of model - a type of moral model, looking at how would we regard ourselves and our own behaviour and character if we did different things. If we were very callous now and very calculating would we feel cheapened or would we feel brave? Is it cowardly to treat people in front of you rather than taking steps to make sure other people don't die? These are interesting questions about moral character and they're so hard to predict."
Boris Johnson, before becoming ill with the virus himself, declared himself the head of a "wartime government". We might also consider the way in which our moral perspective on the current crisis varies and contrasts with the way in which we might think about the sacrifice of young lives in a military context.
The current dilemma reminds Alphaville of a parable that is sometimes used in therapy.
The parable (of which there are several versions online) tells the story of a village on a river, whose inhabitants start seeing young children coming down the river, drowning. Most of the villagers jump in to save the children but there are too many to save them all. One man walks away, and the others are aghast. "How could you walk away and not save these children?" they ask. The man tells them he is going to find the point at which the children are falling into the river so that he can stop them.
The reason this is used in a therapy context is to illustrate the idea that it is sometimes more efficient to tackle the source of a problem rather than the plethora of ways that issue is manifesting itself in our lives. In effect, one has to go backwards to deal with it.
In the case of coronavirus, it's the opposite way round: one has to go forwards to try to foresee the problems that will arise from the kind of economic devastation brought about by lockdowns, as well as the health consequences of so many resources being directed towards tackling the virus.
One also, though, has to try to think about the societal problems that could arise from turning our back on the moral impulse to save people who are dying in front of us, no matter how rational one might think that is.
How many of us would find it too grotesque to ignore the children dying in the river even if we reckoned we were going to save more lives by stopping them in the first place? Is the man who walks off to find the point where the babies are falling into the river ultimately going to save more lives? Is he therefore the greater hero or does our humanity demand that the most important lives to save are the ones right in front on us?
We have some uncomfortable and hugely difficult questions to answer in the current crisis. But if we are to try to limit, as much as we can, the many ways in which this virus is likely to damage our global society, it's important that we have a hard think about some answers.
Written by: Jemima Kelly
© Financial Times
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