Living and dying with covid: Not all deaths are equal
Dr Sarah Chan, University of Edinburgh.
- The covid-19 pandemic has been tracked largely in terms of numbers of deaths, but death is not the only harm we should take into account: other negative consequences such as non-covid health impacts and social costs need to be considered.
- We also need to explore the ethical values that underlie judgments about these harms, both of different sorts of deaths, and of the other consequences of the pandemic.
- Effective pandemic policy-making requires us to understand the values of diverse publics that influence how people judge and respond to risks.
Death, it is generally thought, is a bad thing. In particular, untimely or unexpected deaths are considered undesirable: a harm, something to be avoided – but at what cost? Which deaths – what sorts of deaths, and whose – should we be most concerned about, and what are the values that underpin such judgments?
The course of the covid-19 pandemic has been tracked, to a large extent, by numbers: harms accounted for in terms of numbers of covid-19 deaths; risks of harm, whether of covid death, ‘long covid’ or simply catching the disease, measured in percentages and epidemiological statistics. Yet this focus on quantifying the direct health-related impacts of the disease has drawn our attention away from both the wider effects of the pandemic, and from scrutinising the moral values by which the harms, not only of death but of other consequences, are characterised. In other words, if the consequences of a specific course of action must be evaluated ‘all things considered’, what, in our quest to avoid covid-19 deaths, have we neglected to consider?
In the first place, when weighing up the consequences of pandemic policy decisions, other harms and costs must be accounted for. The most commonly cited of these are the economic impacts of the pandemic and of public health measures such as lockdowns taken in response. The wider picture, however, must include other considerations such as non-covid health harms – for example, missed cancer screening; postponed surgeries; poor mental health – and social costs, such as missed education, or (even harder to measure) loss of social cohesion, or political disenfranchisement. While these have begun to enter into the discussion, there has been little serious attempt to measure and weigh such consequences against the stark numbers of covid-19 death tolls; nor do we currently have a framework within which to make such comparisons.
Beyond this, what has also been somewhat lacking is an articulation and examination of the moral foundations of pandemic policy. In our enthusiasm for measuring numerical values, we have paid less attention to the ethical values that underpin our judgments about the nature and seriousness of harms – including, but not limited to, death. Moreover, there has been little attempt systematically to explore the values that diverse publics may hold in relation to both deaths and other consequences of the pandemic.
In the first place, consider that not all deaths are equally bad, and not all risks, whether of death or other harms, are created equal. Even leaving aside the unpalatable question of whether it is better or worse that certain people die than others, certain sorts of deaths might be thought more or less undesirable than others. For example, is it worse to die from covid-19 in a hospital corridor because no beds are available, than to die from covid-19 despite having received the best possible care? Is it worse to die from covid-19 or from a delayed cancer diagnosis? People may have views and preferences on these questions, and we cannot say they are wrong or irrational to do so.
Death is a harm, first and foremost, to the person who dies and those they leave behind. Therefore the harm of a given death must be judged in relation to how bad it is perceived to be by those who suffer it. In other words, most if not all deaths are objectively bad, but different sorts of death can be subjectively harmful to different extents: the value (or rather disvalue) attached to death and to other harms is often conditioned by context, something for which mere numbers cannot adequately account. Public policy requires a way to characterise and incorporate these more nuanced approaches to harm.
Such contextual factors will likely also shape individual judgments about risk. Consider vaccination decisions, for example: even though the risks of dying from an adverse reaction to a covid-19 vaccine are much smaller, percentage-wise, than the risks of catching and dying from covid-19, people may feel differently about incurring the former by taking action to be vaccinated, than about being exposed to the latter through omitting to receive a vaccine. At a population level, if ‘herd immunity’ requires at least 60% of people to have effective immunity though vaccination, this goal could be reached either by 90% of the population receiving a vaccine that is 70% effective, or by 70% receiving a 90% effective vaccine – and yet, individual people may have views about which vaccine they would prefer. Again, to be effective, public health policies will need to take into account the different views and values that inform such decisions.
Much of the focus, when it comes to public understandings of risk in the covid-19 pandemic, has been on communicating information about risk in a meaningful and realistic way. To be sure, how risks are conveyed and interpreted is important: take for example the heavy reliance on epidemiological data as policy justification from the start of the pandemic, and more recently, the regulatory responses to emerging risks of vaccine adverse events. To be meaningful and effective as a justification for policy and an incentive to change behaviours, information about risks requires explanations beyond the numbers, of what these risks actually mean to people. But while the “public understanding of risk” in this sense remains a significant consideration, understanding how publics judge and respond to risks, and the diverse values that influence such judgments, is equally crucial in shaping effective and ethical pandemic policy. Adequately addressing the challenges of the ongoing covid-19 pandemic, as well as our ethical preparedness for future pandemic emergencies, demands that we develop the tools to do so.
This work is part of the Foresight workstream of the UK Pandemic Ethics Accelerator.
Dr Sarah Chan, Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG.
The UK Pandemic Ethics Accelerator is a new initiative that brings UK ethics research expertise to bear on the multiple, ongoing ethical challenges arising during pandemics. We provide rapid evidence, guidance and critical analysis to decision-makers across science, medicine, government and public health. We also support public debate on key ethical challenges.
The UK Pandemic Ethics Accelerator receives core funding from the Arts and Humanities Research Council as part of UKRI’s covid-19 funding. Grant number AH/V013947/1.