In the wake of the announced ending of most COVID restrictions the talk is inevitably of what the new normal will look like. Prominent in these discussions is the idea that there might be an ‘acceptable level of deaths’.
There have been substantial press analyses of this notion such as that in the Financial Times (Britain struggles to learn to live with COVID), or the piece in Nature (How many COVID deaths are acceptable in a post-pandemic world?). When asked to brief journalists about this idea their first question is almost inevitably, ‘What would be the number of acceptable deaths?’. Yet the Government will not pick a number, even if the favoured comparator is winter flu. In other words, we should be prepared to accept an annual addition of at least around 20,000 deaths from COVID. In a bad year this rises to 30,000 and even higher figures nearer 50,000 have been rumoured to be suggested. This is the new normal. And it has apparently been shaped by statistical modellers at the heart of Whitehall decision-making.
Yet we urgently need to pause and reflect on how completely unacceptable it is to start talking in these terms. For a number of reasons. First, we simply need to remind ourselves that the avoidable death of anyone is a dreadful, irreparable loss. We should never think it easy to put the deaths of human beings into a column of a statistical balance sheet.
Second, we would seem to be once again in danger of being ‘led by science’ or by that sub-set of scientists who can predict with reasonable certainty what would be the probable outcome of various possible policy options. However, as the Deputy Chief Scientific Officer Dame Angela McLean wisely said back in February we ‘need a really sensible discussion’ of what might be acceptable. ‘That’s not a scientific question,’ she added, ‘that’s a question for the whole of society.’
She is absolutely right. Acceptability is public acceptability, and we need an open, transparent, properly informed, public discussion of the issues. The public needs to know what it is being asked to accept and why. On a number of occasions, the Government has appealed to the important idea that we are all in this together. We should come out of it together and be assured after proper discussion of what needs to be done for society to recover some at least of its normal functioning.
The pandemic has been unparalleled in its catastrophic effects. No part of society has been untouched. We should now think imaginatively about the ways in which as a society we might reflect, deliberate upon, and determine next steps. We should find the means to discuss what the practical options are if we are to have the fullest possible discussion of what we as a society should do.
Third, we need to recognise that the issues at stake are not just or not even principally scientific ones, but rather fundamental moral questions concerning whether it is proper to balance a loss of live against certain predicted gains and if so, how we should do this. Ethics has been regrettably largely absent from Government policy making over the last eighteen months. It needs now to be centre stage.
Fourth, the COVID pandemic is of an entirely different order to winter flu and we are still learning about its nature, causes, and its effects. So, for instance, beyond those countable deaths due directly to COVID are the extremely serious consequences of suffering ‘long COVID’, the impact on the health services of continuing numbers of hospitalisations, and the indirect harms of living with a serious pandemic.
Fifth, and perhaps most importantly, the acceptability of deaths in this context is not and cannot be determined by a balance sheet of losses and gains that yields an optimal figure of overall casualties. There is the issue of fairness. We know from the course of this pandemic that some groups in society – such as black, Asian, and minority ethnic, and socially disadvantaged ones – have suffered disproportionately. A recent report from the Health Foundation found that ‘those younger than 65 in the poorest 10% of areas in England were almost four times more likely to die from COVID-19 than those in the wealthiest’.
In opening up society we can predict that they will continue to endure more than other groups. We know that some individuals will run greater risks than others because of their circumstances of work or their age or their existing medical conditions. Some people will have no choice of where and how they work, and thus what they thereby risk.
In short, the acceptability of who dies from COVID is not a straightforward matter of the number of deaths but rather of how these are distributed across society. Once again, it is imperative that we all acknowledge this and have the opportunity to make a collective decision informed both by what science can predict and what ethics can help us understand as morally justified.
In 1971 the then Home Secretary Reginald Maudling was widely criticised for commenting that the Government could not expect to do anything more in Northern Ireland than reduce the violence to ‘an acceptable level’. Critics were quick to point out that no violence is acceptable. The current context is very different, and the depredations of a pandemic are not the same as those of terrorism. Nevertheless, we should remember the lesson of never starting from an assumption that something awful can come in an acceptable form. Only when that assumption is exposed can ‘the whole of society ‘have ‘a really sensible discussion’ of what is acceptable.
You can listen to Dave speak about this topic on BBC Radio 4's World at one (from ~26 minutes).
Many thanks for these thoughtful comments. We should indeed be prepared to talk about the level of acceptable deaths, and I agree that too often in making policy we shy away from addressing what is fairly evidently a difficult topic. Nevertheless, my principal points were, first, that the 'we' who needs to talk about this is the public since acceptability should mean acceptance by society. No one person or group - a statistical modeller, a Government committee, a Minister, a bioethicist - should determine what counts as acceptable in the absence of public consultation and debate.
Second, acceptability is not a simple matter of a trade-off between otherwise avoidable deaths and something valuable thereby gained. We need to know what is being balanced against the deaths. And, most importantly, we need to acknowledge that in the case of COVID deaths have been inequitably distributed across society. The pandemic has been unfair in its effects. We need to ensure that the recovery at least is fair.
It is of course a global pandemic and we too often forget that there are good moral and prudential reasons for our society to help ensure that the world as a whole recovers from it. It would not be acceptable for some countries to suffer many more deaths than they should because they are short of vaccines or medical care that others could easily supply.
I agree we cannot ignore global perspectives in a world where interconnectedness and the potential spread of variants that escape vaccines or are resistant to therapies are all to real, and when problems are compounded by social and economic inequality.
With regard to acceptability of death in U.K. setting, we might wish to make some comparison with seasonal influenza, where the annual death toll is estimated at 10-20,000 and where vaccines have around 40% efficacy with around 70% uptake in the over 65’s. We appear to find these deaths acceptable. So should this be a yardstick for Covid deaths.?
With regard to the quality/ quantity/ cost arguments, I agree they need evaluation. However whilst I can see that some older people would be prepared to act altruistically (as they see it) with respect to treatment and their position in the vaccine queue others do not hold that view. We venture into rather troubled waters if we mandate altruism in society’s older and frailer members, as indeed seemed to be the expectation in the early phase of the pandemic when the guidance on triage on frailty scores was rapidly challenged and withdrawn.
Living with Covid won’t be easy so we have difficult conversations-rather than diktat- and now seems an appropriate time
I agree that Ethics needs to be more involved in both the recovery from the Pandemic and in the approach to further waves and the emergence of new variants that may be more transmissible or breach the protection afforded by immunisation.
Much of the ethical debate has centred on the initial response to this and previous pandemics rather than how we should behave in emerging from it. As Dave has pointed out Covid has features that were not predicted and could not be extrapolated from previous outbreaks.
Moreover the ethical principles developed to deal with previous possible pandemics and reapplied to this one have not necessarily been adhered too or applied in the transparent and proportionate way that may have been envisaged. For example it is unclear as to how fairly the overarching principle of equal concern snd respect has been applied. With emergence from restrictions and competing personal and public responsibilities the principle of solidarity may well be eroded. What constitutes a proportionate response is not clear.
With regard to deaths, we need to consider what deaths are avoidable or preventable or what constitute excess deaths and what means are necessary to alleviate or moderate them as part of the debate on what might be acceptable.
Much emphasis has been placed on the role of vaccination to provide immunity for both the vulnerable and the wider community. But as matters stand the under 18s, whether vulnerable or not, will not be vaccinated despite the fact that they form around 20% of the total population. Although less likely to die than the elderly the potential impact of long Covid cannot be ignored, but needs to be balanced against the wider social and educational detriments of lockdown. and wider global imperatives to protect the vulnerable.
The need for a wider nuanced debate seems stronger than ever, if informed choices are to be made by those charged to do so for the public good.
Thanks for this helpful comment.
While I agree with Dave's argument that the notion of acceptability needs to be considered in a more nuanced fashion, I am a little disappointed by the failure of UK bioethicists to engage with the sort of issues raised by Daniel Callahan and others in the US about what it is appropriate to invest in maximizing survival regardless of cost or quality of life. Too many people are going unchallenged in their apparent claims that nobody must ever die of Covid for the pandemic to be considered to be over or that biosecurity measures should continue indefinitely because of their impact on deaths from other respiratory viruses. There are some fundamental bioethical issues about the expectations of care homes, which are clearly in the business of slow end of life care - compared with hospices where death is more imminent. We need to discuss these institutions within the same framework of what it is compassionate to do for a frail person with severe cognitive impairments.
Well done, Dave, an excellent and much needed piece. Delighted that the Council is in such good hands.... I thoroughly enjoyed my time on it.
An additional important point is that this is a global pandemic - what happens in the UK impacts other countries, whether that is in the form of exporting vaccines, or exporting new variants of concern.
That said, it actually seems to be to be entirely reasonable to talk about 'an acceptable level of deaths', because we are always making trade-offs between length and quality of life.
Some level deaths has to be acceptable, because none of us appear to be willing to entirely sacrifice quality of life for length of life. We do not spend all our spare time and money supporting medical research into those things that are most likely to kill us (in the UK, mostly diseases of ageing).