An acceptable level of deaths?

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).