When the Coronavirus appeared in the United Kingdom, the government initially adopted a relaxed response: pursuing herd immunity and ‘cocooning’ the vulnerable in their homes. The flood of cases and widely publicised fatality projections shocked the UK government into switching to a suppression strategy where people are required to stay at home.
What accounts for the initial relaxed response? As in the United States, people are reasonably concerned about the knock-on social and economic impact of a lockdown that will exacerbate the economic loss caused by the pandemic itself. Russ Roberts and Alex Tabarrok have challenged some of the more extreme versions of this argument by reminding us that, ultimately, the economy is not a thing separate from society, and that an economic system that cannot respond dynamically to the risk of excess deaths is not geared towards satisfying people’s human needs. There is still a civil libertarian element in the Conservative government that fears that extraordinary powers granted to enforce the lockdown might never be rescinded.
Nevertheless, health officials also supported the relaxed approach even when it was already known that it would likely cause tens of thousands, possibly hundreds of thousands of excess fatalities. Why? I think the origin lies in a top-down approach to health management that has a tendency to:
- Blur the key distinction between the public and private good aspects of healthcare; and
- Treat the supply of healthcare resources as fixed by external constraints and given levels of technical innovation.
This perspective is clearest in the United Kingdom where the National Health Service is the key supplier of both public and private health care goods. The NHS also has one of the lowest levels of overall healthcare spending in the developed world. But these background assumptions are present in any healthcare discourse that discounts the role of individual autonomy and community action in the co-production of health.
The top-down perspective presents public-service healthcare challenges as a series of trade-offs between more efficient and less efficient means of maximising Quality-Adjusted Life Years (QALY). A crude ‘Government House Utilitarianism’ offers ready solutions to these trade-offs that can be applied to pandemics as much as any healthcare decision. The Coronavirus mostly threatens the elderly with an already limited life expectancy and quality of life, who put pressure on health and social resources in other ways. From this utilitarian perspective, this seems to point in favor of accepting temporarily higher death rates. But this unrefined utilitarianism runs into significant problems.
First, this approach presumes that individuals are incapable themselves of making decisions to improve their health. This means that health officials spend relatively more time trying to determine optimal personal treatment plans and behavioral changes, and relatively less on where they are uniquely placed to contribute: social activity and healthcare interventions with externalities on the community. They and their resources are thereby diluted in attempts to control individual behaviour.
Second, it does not distinguish between chosen and unchosen sorts of risks. It might appear that we can effectively infer people’s preferences by observing what people are prepared to pay to avoid a marginal increased risk in mortality. But different kinds of deaths are qualitatively different, which cannot be captured in a statistical model. Moreover, individual appetite for mortality risk is unlikely to be linearly distributed. Extrapolating from private decisions to make public health is fraught with difficulties.
Finally, the Government House approach treats QALYs as fungible and distributable across persons. This ends up justifying planning for people to die in order to save resources for others. Making these sorts of trade-offs is widely recognized to be ethically treacherous in many fields of human action, but public health interventions somehow avoid appropriate scrutiny.
An illustration of where this sort of logic goes can be found in Archie Cochrane’s influential book Effectiveness and Efficiency. In a book dedicated to making the National Health Service allocate its resources efficiently according to the scientific method (as he understood it), Cochrane makes a brief foray into the public health implications of successfully extending life. He argues against encouraging people to give up smoking until the UK population has been effectively controlled by other means, including making abortion more widely available. Then he explains that is ‘obvious’ that the UK is overcrowded and there is no way that the quality of lives could be increased with more people. (pages 28-29)
We would, I think, be well advised, before encouraging everyone to give up smoking cigarettes, to control our population increase… To me it is entirely obvious that the world in general and the inhabited part of the UK in particular is already overcrowded, but I admit this is a judgement. There is no way of proving; I would, however, like to make a few points. Some day, if we continue at our present rate of increase, a majority of the population will wake up and decide the country is overpopulated and demand action. It will then, of course, be much too late. It seems not unreasonable to try out a few possibilities now such as birth control and abortion…
Overpopulation could easily be described as the country’s greatest problem… For the moment I think it would be of great assistance if ‘refusal to abort’ was registered confidentially in the same way as ‘abortion’.
In making these claims, Cochrane ignores the economic insights (discussed widely if not quite as often during his era) that larger populations offer a more advanced division of labour and that people typically contribute social resources as well as consume them. But what is more noteworthy is the premise: he believes that the needs of public health should drive population policy, rather than that the needs of the population should determine a more constrained public health policy.
The answer for some public health proponents is that there is no alternative. In some scenarios, like wars, you have to trade some lives against others (on both your own side and the enemy’s) in order to preserve the whole society. From a top-down perspective, the trade-offs that are more obvious in wartime still operate at the margin in areas like public health.
The first response to this challenge is to avoid being placed in a warlike scenario, i.e. policymakers should plan to reduce the likelihood of unexpected but ultimately inevitable shocks inducing catastrophic public emergencies. Second, in normal circumstances there are more refined ways of handling and ameliorating trade-offs. Personal choice–in discussion with clinical experts–and public choice–exercised through communal associations and democratic institutions–can give people a greater measure of autonomy. This gives decisions about how to allocate resources greater moral legitimacy. In addition, through the combined efforts of entrepreneurs in the private sector and reformists in the public sector, the trade-offs often turn out not to be as fixed and fatal as imagined. When the aim to save lives is paramount, social and technical innovations can emerge remarkably rapidly. A regime that gives up on lives past a certain age has also given up on pushing the frontiers of prosperity, happiness and humanity.
Defaulting towards trading lives against other lives betrays a zero-sum mentality. The mentality goes against our knowledge of the power of spontaneous cooperation and the morals underpinnings of a free society.
Nick Cowen is a Lecturer in the School of Social and Political Sciences at the University of Lincoln.