I'm not an epidemiologist, a virologist, a public health expert, or even someone whose practice has been substantially affected by COVID-19 -- other than being unable to treat the patients I would otherwise treat -- so when it comes to the pandemic, I don't claim any particular expertise. But ever since March, I have felt a nagging feeling that to find the answers on how to deal with it, we are looking in the wrong place.
Two important publications offer very different visions of the way government and society should respond to the challenges of COVID-19.
Dr. Chris Hammond.The Great Barrington Declaration emphasizes the harms associated with lockdown -- for physical and mental health, for jobs, and for the economy. It argues for an opening up of society to allow people at low risk of harm to live normally while shielding the vulnerable. The declaration has attracted vehement criticism not only for its "libertarian agenda" but also for its unreferenced assertions and (the critics say) lack of scientific validity. Is it possible to shield the vulnerable? Is herd immunity feasible?
The John Snow Memorandum presents a more conventional and mainstream view. It summarizes (and references) what we can be sure about. It argues against allowing an uncontrolled outbreak in those at low risk, emphasizing the challenges of shielding (sometimes large) vulnerable groups and the likely human cost in lives lost to COVID-19. But critically, it too makes unreferenced assertions about, in particular, the socioeconomic effects of an uncontrolled outbreak.
How do we reconcile the differing visions offered in these two statements?
The evidence about COVID-19's biology only seems to get us so far. We know how it's spread, we know it is highly transmissible, we know it is an order of magnitude more lethal than the flu for some identifiable groups, and we know some of the mitigations we need to put in place to reduce its transmission -- and therefore the number of lives (or years of life) lost. We count in minute detail the infections, admissions, and deaths attributable to the virus and we can see the effect of some lockdown policies on these numbers.
But there is much we don't know, especially about the effects of our response. What is the effect of lockdown on the health, wellbeing, education, and socioeconomic status of the population of people who, critically, would otherwise be unaffected by the virus and who therefore only experience the harms of the remedy? These effects are more difficult to measure and are therefore relatively invisible. They may arise distant from current events and be subject to many confounders, though some assessments of health-economic impact of both COVID-19 and lockdown have been attempted.
Critics of lockdown suggest that its cost is orders of magnitude more than current "willingness to pay" thresholds and that it is therefore not justifiable on this basis. Others argue that more effective lockdowns mitigate the economic effects of the virus and (in effect) that things could be much worse. A meaningful reckoning is impossible in the short term and both sides of the argument are complicit in extrapolating beyond the evidence in suggesting the balances of benefits and harms of differing strategies favor one argument or another.
Moral values
Perhaps an examination of our values can help. Maybe our attitudes to the huge changes in society imposed by governments worldwide can be better explained by what we consider important, rather than by the imperfect and incomplete biological and economic science we have on COVID-19. Here are a few questions:
- Do we have a moral obligation to protect the vulnerable?
- If we do, is this absolute, or are there circumstances where this might be negotiable? How long does this obligation last? Are there sacrifices that we are willing to make in the short term that become unbearable longer term?
- Even if it were possible, would an accurate accounting of the benefits and harms of lockdown policies be sufficient for definitively choosing a (least-worst) policy? Or are there reasons to override such an analysis?
- Should individual liberty and autonomy be subordinated to an externally identified collective good?
- Should we allow story and narrative to play a role in determining policy?
- Is it reasonable to ask frontline staff to implement -- at scale -- generic policy when faced with decisions about individual people? Who is responsible for the individual and personal moral hazard associated with a policy decision being implemented in practice?
These are not new questions. The broad concepts of utilitarianism, libertarianism, and egalitarianism have been argued over for centuries by moral philosophers.
There will never be a right answer, and the availability of vaccines also promises to add a new dimension, but these questions will need exploring anew in the context of COVID-19, especially in the worst-case scenario of short-lasting immunity and the virus becoming endemic. Can we stay locked down forever, unable to socialize, meet friends, work, or travel? Such a prospect seems intolerable in the long term, but this position reflects my personal values, rather than dispassionate scientific analysis.
Ultimately, it is our value judgments about these moral questions, as much as the science, that should determine our response. We should discuss these issues alongside the emerging scientific evidence, but this discourse seems surprisingly absent.
This is not an argument for procrastination to allow a few more centuries of academic moral philosophical debate about the choices on offer. Decisions need to be made now by us, or rather by our leaders. But if we understand the values on which they base their decisions, we will find it easier to comply.
Dr. Chris Hammond is a consultant vascular radiologist and clinical lead for interventional radiology at Leeds Teaching Hospitals NHS Trust, Leeds, U.K.
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