How do we decide who will live and who will die in this global pandemic?

Three years ago, I did a blog posting which posed an ethical dilemma.

There is a runaway trolley barreling down the railway tracks. Ahead, on the tracks, there are five people tied up and unable to move. The trolley is headed straight for them. You are standing some distance off in the train yard, next to a lever. If you pull this lever, the trolley will switch to a different set of tracks. However, you notice that there is one person on the side track. You have two options:

Do nothing, and the trolley kills the five people on the main track.
Pull the lever, diverting the trolley onto the side track where it will kill one person. What would you do? Which is the most ethical choice?

I don’t want to overdo the analogy, but there is a real sense in which governments around the world are facing a similar dilemma in relation to the coronavirus crisis. For the sake of simplification, let’s assume that the objective of public policy is to minimise the number of lives lost and that somehow we forget about all the other social, economic and environmental issues. As with the thought experiment that I quoted, there are no options in which nobody dies. The issue is how many, who and how.

If governments do nothing and just let the virus rip – the equivalent to letting the trolley run its course – we know that there will be deaths and we can quantify those deaths fairly accurately. We can collate the number of deaths in hospitals within days of them occurring and we can collect the number of deaths in care homes and the community within weeks. And we know, more or less in real time, not just how many are dying but who they are.

Now suppose the government actively introduces lockdown measures – the equivalent to pulling the lever and diverting the trolly – we know that fewer will die of the actual virus – that is, on our hypothetical railway system – but if this action requires closure of the economy – in our model the closure of the railway system – we can only guess at the additional deaths and the causes and identity of the people dying and that information will only become available months or even years in the future.

This is where we are now. We do not know how many of those dying from Covid-19 would have died anyway in the next few months or years and we want to maximise longevity and not simply balance the number of deaths in the long run. We do not know how many extra deaths will occur as a result of ill people not going to doctors or hospital plus loss of life caused by unemployment, poverty, suicide and abuse.

It will be many deaths – maybe more than Covid-19 deaths – but those will not occur now and they will not be broadcast by the media each day, so they will be much less visible to the public but just as tragic for the individuals concerned and for their families and friends.

I don’t know the answer to this dilemma. I just know that we have to balance the knowledge of very visible virus deaths now against the assumption of less visible non-virus deaths now and in the coming months and years. Striking the ‘right’ balance – a decision that will change over time – is a tough call and we should be as transparent as possible about how these complicated decisions are made.


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