Living and dying with covid: The tough choices ahead

Living and dying with covid: The tough choices ahead

Dr Jonathan Pugh, Professor Dominic Wilkinson and Professor Julian Savulescu, University of Oxford


  • The UK is currently aiming to suppress the virus to acceptable levels, rather than to eliminate it completely.
  • The suppression strategy means that we must make a societal decision about the harms we are and are not willing to accept to suppress the virus.
  • This decision means that we will have to make trade-offs between three key values: reducing covid mortality, liberty, and equality. This is a trilemma.
  • To make a decision about what is acceptable in suppressing the virus, we cannot simply appeal to comparisons between covid-19 and harms caused by other infectious diseases – we have to confront the fundamental conflict between values in the covid trilemma.

This piece has been published in The Conversation.

As mass vaccination continues to be rolled out, the UK is beginning to see encouraging signs that the number of covid-19 deaths is reducing, and that the vaccines may be reducing the transmission of the coronavirus.

While this is very welcome news, a mass vaccination programme is unlikely to be enough to eliminate the virus, so we need to turn our thoughts towards the ethics of the long-term management of covid-19.

One strategy would be to aim for the elimination of the virus within the UK. New Zealand successfully implemented an elimination strategy earlier in the pandemic and is now in a post-elimination stage.

An elimination strategy in the UK would require combining the mass vaccination programme with severe restrictions on international travel to stop new cases and variants of the virus being imported. However, the government has been reluctant to endorse an elimination strategy, given the importance of international trade to the UK economy.

One of the main alternatives to the elimination strategy is to treat the coronavirus as endemic to the UK and to aim for long-term suppression of the virus to acceptable levels. However, adopting the suppression strategy for the long term will require us to make a societal decision about the harms we are and are not willing to accept to suppress the virus.

The liberty, equality and mortality trilemma

The first year of the pandemic has taught us that without suppressive measures, covid-19 will lead to significant death and harm, including long covid. However, evidence suggests that mitigation measures, such as lockdowns and effective test, trace and isolate systems, may be effective in reducing transmission of the virus.

Yet these measures have their own costs. For instance, lockdowns significantly restrict civil liberties, and they also cause a wide range of other harms, including significant non-covid mortality and morbidity. Recent estimates suggest that UK lockdowns could lead to 100,000 non-covid deaths and deaths from the virus itself may account for only about 54% of the overall death toll of the outbreak in the UK.

The extent of some of the costs of mitigation measures could be lessened by targeting these interventions more specifically at certain groups, such as those who have not been vaccinated, or those who have a particularly high risk of death from covid-19 (such as those over the age of 65). However, these targeted strategies involve forms of unequal treatment and possible discrimination.

This is the fundamental trilemma of the long-term suppression strategy. The societal decision we make about the acceptable level of viral suppression involves a choice about which of three competing values we should prioritise and which we must compromise.

We can maximise one or two of these values, but we can’t have all three. Since there is likely to reasonable disagreement on this question, and since we are not currently in an emergency stage of the pandemic, there are strong reasons to take the time to ensure a fair process of democratic deliberation about how this choice is made.

We might be able to reduce covid-19 deaths while safeguarding equality, but only if we are willing to accept the potential need for prolonged lockdowns, severe travel restrictions and the cost to freedom and general health that entails. We might be able to reduce covid-19 deaths while protecting the freedom of those who do not pose a transmission risk by implementing covid-certification schemes, but only if we are willing to accept the inequality that such schemes involve.

Finally, we can give everyone in society as much freedom as possible, but only if we are willing to accept the increased covid-19 mortality and morbidity it will likely involve if the virus has not yet been sufficiently suppressed in other ways.

The moral question about the suppression strategy has been framed as one concerning how many covid-19 deaths we should be willing to accept each year, inviting comparisons between covid-19 and annual deaths from other infectious diseases in recent years (such as influenza – which has caused fewer than two deaths per 100,000 people per year in European countries since the beginning of the millennium), and those that we have lived with in the past (such as tuberculosis – which caused around 100 deaths per 100,000 people per year in England and Wales at the beginning of the 20th Century).

Such comparisons are illuminating, because they provide a baseline for the number of deaths from an infectious disease that we have historically been happy to live with. If we accept a bad flu year with over 22,000 deaths in England without imposing significant societal restrictions, then perhaps we will come to accept the same number of deaths with covid-19.

But these comparisons are relevant to only one of the key ethical values. In the context of covid-19, we might have to risk a higher number of deaths in the absence of significant societal restrictions or inequality.

To make a decision about what is acceptable, we have to confront the fundamental conflict between values in the covid trilemma.

This work is part of the Prioritisation workstream of the UK Pandemic Ethics Accelerator.

Contact details:

Dr Jonathan Pugh, Professor Dominic Wilkinson and Professor Julian Savulescu, The Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House , St. Ebbe’s Street, Oxford, OX1 1PT.

About the Accelerator

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.