Don’t count on it

Jonathan Aldred explains how there is more to equations than numbers when it comes to Covid policy.

According to Boris Johnson’s former chief adviser, Dominic Cummings, when the pandemic hit Britain in March 2020, Johnson was deeply hostile to lockdowns because the “economic damage is more damaging than the loss of life” and because Covid was “only killing 80-year-olds.” Whether or not Johnson actually said these things, could his comments form part of a legitimate argument against lockdown?

Questions about Covid policy last year might seem irrelevant to our future. But the essential question Johnson faced then remains the same today: how to balance Covid mortality and morbidity risks against the social, health and economic costs of measures to reduce those risks? Of course, the unexpected, extraordinary efficacy of vaccines and the speedy rollout of jabs means that we no longer face the tragic choices between ghastly alternatives that we did last year. As economists put it, the terms of the trade-off are vastly improved today. But the trade-off is still there.

Talk of trade-offs, and Johnson’s alleged comparison of economic damage against loss of life, seems to point us firmly in the direction of cost-benefit analysis (CBA). The great strength of CBAis that it insists we look at all the impacts of lockdown, not just the direct and immediate impacts on Covid. However, it goes badly astray by trying to put a money value on every impact, ranging from Covid morbidity to the benefits of schools being open.

This process of monetisation does not allow us to sidestep the difficult ethical judgements involved in comparing such radically different things. It is the problem of comparing apples and oranges. Instead, monetisation just obscures the ethical judgements as they become hidden in the details of the analysis, implicit in countless technical assumptions, which vary according to the preferences of the analyst.

It is not surprising, then, that many commentators and policymakers have concluded that CBA is inappropriate for Covid policy making. Tim Besley and Nick Stern at the LSE appear to favour cost-effectiveness analysis (CEA) instead: “Framing policy as seeking the least costly way of keeping the infection rates and reproduction number, R0, below acceptable thresholds … is a powerful way of thinking in relation to this pandemic.”

Monetisation just obscures the ethical judgements.

But there is an obvious problem: focusing on this narrow, Covid-specific goal ignores the serious non-Covid harms that may be the side effects of such a focus. Put another way, just because we reject traditional CBA for Covid policy guidance, must we fall back on CEA, and abandon all hope of a rational, holistic comparison of all the pros and cons of different policies?

The stakes remain high. Many prominent scientists argue that until spring 2022, perhaps longer, Covid risks will remain too great to permit a return to the old normal. We may have to wear masks and practice social distancing in some contexts, and some high-risk indoor activities, ranging from clubbing to singing in church, may be banned or heavily restricted. All these decisions are ethical and political, not scientific.

Scientists cannot tell us, for example, how to balance the benefits from allowing the full resumption of all pre-pandemic social activities (music, sport, religion, theatre, etc.) against the risk of increased Covid transmission. Science cannot make these decisions for us because they involve comparisons between fundamentally different kinds of good and bad – Covid mortality and morbidity versus a complex mix of economic, wellbeing and mental-health benefits.

The first step, then, in developing a framework for thinking through future Covid policy, is to acknowledge that these policy choices are mostly about ethics, not economics or science. These are our choices to make, collectively as citizens. In the national conversation we urgently need here, a diversity of voices is essential. The scientific experts on whom the government has relied are almost all white, middle-class professionals, working mostly from home, aged 35-65. We must hear more from working class and BAME communities as well as the young and the old.

Second, any sensible framework for government policymaking must be based around a comprehensive list of all the good and bad consequences (pros and cons) of different policies. The best-known example of this consequentialist approach is utilitarianism, which has been heavily criticised as a code of personal morality by moral philosophers. Utilitarianism recommends that you carefully, relentlessly, calculate all the pros and cons of your options, paying no attention to history, loyalties, or personal commitments. The critics are right: utilitarianism is a grotesque guide to private life.

We don’t want policymakers to be guided by personal loyalties or commitments. As far as possible, we want them to be neutral, impersonal and objective.

But its defects become virtues when used to guide government policy. We don’t want policymakers to be guided by personal loyalties or commitments. As far as possible, we want them to be neutral, impersonal and objective. We want policymakers to consider carefully all pros and cons – in essence, we want their heads to rule their hearts, not the other way round. As private individuals, some people may follow absolute moral principles – Ten Commandments style – regardless of the consequences. But it would be deeply irresponsible for policymakers to act “regardless of the consequences”.

For a Covid example, crude, rights-based ethical theories involve moral absolutes; people talk about their right to “personal safety” and worry that Covid makes some environments “unsafe”. This way of thinking is useless for policymakers. We cannot make any environment entirely Covid-safe, any more than we can make any road entirely safe for drivers or pedestrians. We must ask, how safe is safe enough? And we can only answer by balancing pros and cons as well as risks and benefits. In sum, for policymaking, there is no defensible alternative to balancing all the pros and cons. There is nothing to stop us considering an ethically much richer range of policy impacts than utilitarianism, including impacts affecting needs, rights, and histories.

Third, while it is often inappropriate to measure the pros and cons in monetary terms, we should still quantify them in their own units – at least if we have enough reliable information to do so. And we must take special care not to ignore impacts which cannot be quantified. As Einstein reputedly said, “Not everything that can be counted counts and not everything that counts can be counted.”

Not everything that can be counted counts and not everything that counts can be counted.

If we take our ignorance and uncertainty seriously, there will be much that we cannot quantify. But this is not as disastrous as economists often assume. Much of the progress towards making Covid policy is not due to quantification, but to the ethical work elsewhere in the analysis. For example, deciding which impacts are, ethically-speaking, relatively trivial and can be safely ignored. In Europe and the US, compulsory mask-wearing has been heavily influenced by the belief that the drawbacks of mask wearing in many public spaces are mostly ethically trivial compared to the benefits. Of course this belief might be mistaken in some environments (such as schools) but the point is that the policy decision here did not rely on the quantification of impacts.

Judgements about fairness can also make a big difference to policy, regardless of whether impacts can be quantified precisely. For many years, survey and interview research has consistently shown that the public favours the NHS prioritising the young for treatment, all other things being equal. For example, we might prioritise a treatment giving two extra years of life for a 20-year old over three added years for someone who is 80.

The underlying idea of fairness here is the “good innings” where the previously healthy octogenarian has had their time, their share of good life. In sharp contrast, people regard dying at 20 as deeply unfair, so we should do everything possible to postpone it. And two years of extra life is more valuable when it is 10% of your life.

Supporters of inter-generational fairness also point out that a narrow focus on Covid deaths sits uneasily with the health inequalities arising from the extreme economic inequalities of modern Britain. If you are young , say 18-20, and poor in Britain today, you are unlikely to reach the average age of those who’ve died from Covid. Statistically, you are more likely to die sooner. If there is a consensus around the idea of a good innings, it could have a big impact on Covid policies, given that Covid mortality and morbidity is highly skewed by age.

There is no deep schism between young and old here. Many elderly people support the good innings principle, and indeed extend it beyond the NHS to suggest that the young, who have perhaps been hit hardest by lockdown, should now be our priority, given that vaccines have reduced Covid risks to low levels.

For a final example of the power of deciding our ethical priorities, regardless of any quantification, many of us know of an elderly person whose greatest fear during the pandemic has not been death, but being isolated and unable to see their family because of restrictions. Once you are old enough to be forced to confront your own mortality, you understand keenly that there is more to life than avoiding death.

Jonathan Aldred

Jonathan Aldred is a Fellow and Director of Studies at Emmanuel College, Cambridge.

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