Health has become the political issue of the day. We have to ration health care and it has to be seen to be rationed fairly…. Doctors will ration health care if they have to. But the situation that led to the under capacity- shortage of staff, equipment, beds, plant and then morale, needs an independent enquiry. It is our short term horizons, and first past the post electoral system that stinks… and ensures that the under capacity will continue after the crisis is over.
The Times’ Daniel Finkelstein opines 17th March 2020: Doctors need help deciding who lives and dies – Parliament must take the lead in weighing up the economic and medical trade-offs that will be required in this crisis
In the summer of 1944 a new and terrible weapon was unleashed on Britain. The first V1 bombs began to land shortly after D-Day. The Germans had developed a way of killing that didn’t require a pilot and could destroy the centre of London and cripple its government.
Only it didn’t. The bombs landed, and kept landing, primarily to the southeast of the capital. Thousands did die and many buildings were destroyed, but the consensus of historians is that if the centre had been hit many more would have died and much more would have been destroyed.
And this judgment is important, because the diversion of the bombs to the south was a deliberate act. Winston Churchill sanctioned a programme, using double agents, that deceived the Nazis about where their bombs were landing and made them carry on missing the administrative centre of London.
Was this “playing God”, as one cabinet minister argued at the time? Was this sacrificing the less powerful so that the seat of government could escape? Or was it a difficult but acceptable choice in the circumstances?
The moral dilemma that faced Churchill is one that we grapple with all the time, as we make decisions on rail safety, to give one example. If you stop all the trains you can ensure 100 per cent safety on the railways, but people may travel by road and that can be more dangerous. Yet most of the time we don’t discuss the trade-offs we make. It’s too uncomfortable.
The present crisis means this silence is unsustainable. The government, scientists, economists and health workers are all facing agonisingly hard decisions, and they shouldn’t make them by themselves. Apart from anything else it isn’t fair on them.
In his splendid short book Would You Kill the Fat Man? the philosophy writer David Edmonds recognises in Churchill’s dilemma an example of what is known as the trolley problem. Over time this thought experiment has become fearsomely complicated. But at its core is something simple.
A tram (or as Americans call it, trolley car) is heading for a group of five people tied to the tracks and will kill them. You have the chance to divert the trolley by pulling a switch, but if you do it will go down a spur and kill one person. What should you do?
But here is another version. It isn’t a spur, it’s a loop. If the trolley was left unimpeded after you switched the signal, it would eventually loop around and kill the five people after all. It only doesn’t do that because it is stopped by the body of the one person. In the spur version you would be delighted if the one person leapt up and escaped. No one would die. In the loop version you need the one person to die because their body will stop the trolley. Should you pull the switch?
Or yet another version. A trolley car is hurtling towards five people who are tied to the track. You are standing on a bridge above it all. There is a fat man next to you and you realise that his bulk is just large enough that he will stop the train if you push him off. He will die but five will be saved. Should you kill the fat man?
Spur seems pretty straightforward, at least at first. You can save a net four lives. Pull the lever! But loop and especially fat man are much harder. They save the same number of people but they involve intent to kill, and the more intent they involve the more our intuition rebels against it.
There was something of this in the debate over the weekend about herd immunity. Part of the debate was about how many lives could be saved by immediate action. But part was about intention. It may be (and this depends on vaccines and other medication) that in the end we have to rely on herd immunity to bring an end to this crisis. But it is one thing arguing that herd immunity might happen in the end, and quite another arguing that herd immunity, which can only happen as a result of many people dying, should be an intentional aim.
I said that the spur option seemed straightforward but even with this there are complications. It’s all easy when the six different people tied to the track are anonymous and undifferentiated strangers. But what if the one is a child, and the five are old? Or the five are very sick and the one is full of vigour? Or the one is your relative and the others are people you don’t know?
Gordon Brown, when he was prime minister, once had a trolley-type question put to him after a speech on globalisation. If there were a tsunami and he was on the beach and could warn only one British person or five Nigerians, what would he do? Rather cleverly he instantly replied, while acknowledging his responsibility as British PM, that modern communications would allow him to warn both and he then spoke about the need for early warning systems.
He was quite right, of course. The first response must be to try to save as many lives as possible and to reduce the dilemmas. But it’s obvious it won’t dissolve the problems entirely. Hospital staff are going to have to choose between patients — young and old, sick and less sick, acute and less acute. They are already doing it, actually, as they put off operations to keep intensive care beds free.
Parliament and government need a proper debate and must provide guidance, and if necessary law, to assist medical staff in this unenviable task. If, for instance, young are to be preferred to old we had better discuss that preference in all its complexity.
But it isn’t only medical staff who face a dilemma. Our entire strategy involves a trade-off. We are choosing to suppress the disease in a way that will do great harm to the economy. And that seems the right choice, to me at least. But we should recognise, at least, the cost. There will be a cost to pay in terms of human life in an economy that, however much is done to pump it up, will be smaller than it once was — not just in less life quality, but in the amount of lives.
If we are poorer, we will have less that we can spend on healthcare and on fighting disease and people will die. I would like to see the government modelling on this, too, as we consider when and if to take breaks from suppression over the coming year.
And not only modelling on the impact now. The economic impact will be felt for years to come. It’s another spur complication. If one person would be saved but five people yet unborn might die young, would you pull the lever?