'Not all deaths are equal': Ethicists debate 'acceptable' level of COVID fatalities

·6-min read
Closeup portrait of a young African American woman with face mask on the studio against white background.
More than 127,000 people have died with the coronavirus in the UK alone. As society continues to open up, ethicists have debated what level of deaths is 'acceptable'. (Posed by a model, Getty Images)

Britons have lived with coronavirus restrictions for more than a year, with many enduring severe ill-health and the loss of loved ones, all during an economic downturn.

The vaccination programme's unprecedented rollout means the worst is hopefully over, with just five new registered deaths within 28 days of a positive test on 23 May – down 99.6% from the peak of 1,325 on 8 January.

Ethical questions about measures to prevent the virus's spread will remain, however, particularly as new infectious outbreaks inevitably emerge.

When it comes to the coronavirus specifically, early research suggests the infection is mild in four out of five cases, but can trigger a disease called COVID-19. 

Scientists from the UK Pandemic Ethics Accelerator collaborative have questioned whether some deaths are acceptable, with preventative lockdowns not necessarily being justified.

In the paper Living And Dying With COVID: Not All deaths Are Equal, Dr Sarah Chan – from the University of Edinburgh – argues patient fatalities are "not the only harm" brought about by the pandemic, with officials also having to take "non-COVID health impacts and social costs" into account.

The UK is aiming to suppress the coronavirus to "acceptable levels", rather than eliminating the infection entirely. 

Read more: Coronavirus death risk triples among patients battling another airway infection

A team from the University of Oxford has therefore argued "we must make a societal decision about the harms we are and are not willing to accept to suppress the virus". A trade-off must occur between deaths, "liberty" and "equality" – a "trilemma".

This comes after experts warned a "cancer crisis" is "replacing the COVID crisis" in England, with more than 300,000 people having missed urgent checks since the start of the pandemic.

Unable to marshal the right cells and molecules to fight off the invader, the bodies of the infected instead launch an entire arsenal of weapons — a misguided barrage that can wreak havoc on healthy tissues, experts said. (Getty Images)
The coronavirus is thought to be mild in four out of five cases, but can cause a disease called COVID-19. (Stock, Getty Images)

The UK Pandemic Ethics Accelerator collaborative – which has received £1.4m ($1.9m) funding from the Arts and Humanities Research Council – is addressing key moral questions as part of UK Research and Innovation's rapid response to COVID.

Since the coronavirus emerged, a country's success has largely been measured on its case numbers and deaths. According to Dr Chan, this does not go far enough. 

"The wider picture must include other considerations such as non-COVID health harms, for example missed cancer screening, postponed surgeries [and] poor mental health," she wrote.

Throughout the pandemic, officials have stressed the NHS is open for business. Nevertheless, cardiologists from one Scottish hospital reported the number of patients presenting to their clinic fell 53% during the first lockdown.

People may have avoided going to hospital over fears they would catch the coronavirus or put medics under additional pressure.

When it comes to mental health, more than half a million Britons took an online suicide prevention course during the first lockdown.

Read more: GP says it is 'nothing short of a miracle' that she survived COVID

Dr Chan is also concerned about "social costs, such as missed education or (even harder to measure) loss of social cohesion, or political disenfranchisement". 

"Beyond this, what has also been somewhat lacking is an articulation and examination of the moral foundations of pandemic policy," she wrote.

"In the first place, consider not all deaths are equally bad and not all risks, whether of death or other harms, are created equal."

Professor John Coggon, from the University of Bristol, referenced Lord Jonathan Sumption's "proactive argument that we should assign different values to different lives, by reference to the likely healthy years a person has to look forward to, to establish what (if any) coronavirus restrictions might be justified".

In the 1990s, lawyer economist Cass Sunstain flagged how "the diminution of one health risk simultaneously increases another health risk".

Speaking of this issue, Dr Chan said: "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."

While the coronavirus vaccination programme has been deemed a huge success, it is "unlikely to be enough to eliminate the virus", wrote the Oxford team.

New Zealand introduced an elimination strategy, with the country now considered to be in a "post-elimination stage".

If implemented in the UK, "severe restrictions on international travel" would be required, which "the government has been reluctant to endorse given the importance of international trade to the economy".

Read more: Physical inactivity doubles coronavirus death risk

Treating the coronavirus as "endemic" – an infection that commonly occurs in a particular area – "will require us to make a societal decision about the harms we are and are not willing to accept".

Humans have long lived with seasonal flu, which has caused fewer than two deaths per 100,000 people every year in Europe for the past two decades.

Tuberculosis was behind around 100 deaths per 100,000 people a year in England and Wales at the beginning of the 1900s.

"Such comparisons are illuminating, because they provide a baseline for the number of deaths from an infectious disease we have historically been happy to live with," wrote the Oxford team. 

"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."

Watch: Do coronavirus vaccines affect fertility?

When it comes to coronavirus restrictions, Prof Coggon worries some have been more affected than others, like women or people of a non-white ethnicity.

"Even for an individual person, health is a complex value: something that is good for your physical health may harm your mental health," he wrote.

"Looking then across communities and across time, account must be given to who enjoys health benefits, when and at what costs – including costs to others.

"From education and employment to trade and travel – ethical questions about protecting health and harming health should be at the heart of government decision-making."

Read more: Sunshine linked to lower coronavirus deaths

Some people have suggested society should be opened and just the most vulnerable restricted in order to protect their health, like the elderly or those with underlying medical conditions.

"These targeted strategies involve forms of unequal treatment and possible discrimination," wrote the Oxford team.

On the other hand, Jamie Webb from the University of Edinburgh and Hugh Whittall from the Nuffield Council on Bioethics have argued: "Young people have made great sacrifices in terms of freedom, income and employment, often with the explicit goal of protecting older generations. 

"They now face a post-pandemic economy where already entrenched inequities have been exacerbated by the virus."

Watch: What is long COVID?

While coronavirus deaths may be a blunt measurement, a team from University College London (UCL) has stressed these numbers will "continue to influence government responses for some time to come", but should be "ethically fit for purpose".

In August 2020, a review of the death-counting procedure reduced the UK's fatality toll by more than 5,000.

"The revised rules insisted that to count, deaths must have occurred within 28 days of a positive test," wrote the UCL team.

"The reason? A drive to standardise counting procedures across all four UK nations for clearer comparison, and concern the overall mortality burden due to COVID-19 was going over-reported.

"Now as death rates fall and COVID-19 recedes in importance as a cause of death, it is time to take stock."