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Memento Mori

You are going to die, and so is everyone you love. Unless you are part of the extraordinarily lucky generation whose lives overlap with the time when cellular immortality is finally invented, “the price of life is death”. That does not mean that life is meaningless or short; when Beetham said those words he was mourning the loss of Mallory and Irvine on Everest. His subsequent conclusion that “so long as the payment is made promptly, it matters little to the individual when the payment is made” is by no means one that you must accept; a long and happy life lacking the peaks of a short and thrilling one may still be just as fulfilling, if not more so.

At the same time, almost everything worthwhile in life carries some risk with it. Love carries the possibility of rejection, sports of injury, eating of choking, travel of crashing. It is possible to go too far in seeking to avoid danger; as Jonathan Waterman puts it, “no journalist wrote about the banality of city life or how easy it is to become yet another automaton paying bills and working nine to five” so that “when death finally approaches in some antiseptic white room, just as you have been waiting for it, you sense that you have already been dead for years”. A life without any risk would consist of sitting in a carefully padded room, waiting for the last sands to run out of the hourglass.

This opening is not an attempt to grab the reader by the collar and force them to stare into the empty eye sockets of the reaper, but to draw attention to the point so clearly expressed by Aristotle; virtuous courage is somewhere between feelings of fear and confidence. We should not be heedless of cost, but equally we should not let the fear of those costs govern our lives entirely.

Mortality is frightening. It is particularly so in a culture that has relegated death to the status of something that happens to other people in carefully sterilised rooms, rather than something that walks with us. A virus that sweeps through a country killing tens of thousands is a potent and disquieting memento mori; each newspaper headline becomes a reminder that you came from dust and will return to dust in time.

Wanting to avoid this fate is entirely natural. Choosing to fight the disease is healthy. Entering lockdown to halt its controlled spread was a noble sacrifice; what it emphatically was not was a job done and the end of the matter. A national quarantine is a sensible step when you don’t have a plan; it lowers the number of cases and gives you time and space to increase the capacity of your health system to handle cases. It is not something that can last for a year or more, nor something that should.

We will need more courage now as we start to find the way out, because any feasible path will mean facing up to two harsh truths alongside our own mortality. The first is that anything short of total lockdown will result in ‘avoidable’ deaths. The second is that the cost of maintaining lockdown to avoid them would not be worth it.

Neither of these views are popular. Expressing them will not win you friends. But at the same time they underlie decisions that we make continually in everyday life. When the NHS decides which medicines and treatments to fund, it is making decisions about the value of life. When we decide to get into a car or a plane, to go climbing or swimming, we take on an increment of risk. The pandemic makes an additional demand of us; when we decide how much risk to bear, we must take into account the fact that we are also, to a degree, deciding for those around us. The presence of these external costs means that there is a role for common rules and policies to find an acceptable minimum risk of transmission; it does not mean that remaining locked in our homes until the uncertain advent of a vaccine is the answer.

Defining an exit strategy is about finding the degree of risk we’re willing to tolerate, and accepting that there are valid trade-offs to consider. Immunity passports will see some locked away longer than others, and could see younger people deliberately catching the disease in order to resume some semblance of normality. Testing, tracing, and quarantining would significantly reduce the caseload, but would present higher risks than a policy of locking everyone away until a vaccine is found. Staying in lockdown would tank the economy, rob the young of time, and leave us with uncertainty about when (if ever) any vaccine would be ready.

Dialogue around these trade-offs often focuses on money and deaths, partly because these are easy to measure when other costs are hidden. But lost hours and days being hard to measure does not mean they are without meaning; the psychological toll can be heavy, the strain on relationships severe, and the opportunity to be young does not, generally, come around twice. If we want to put these costs on an even footing with those more easily measured, it may be easier to think of each option as a series of transfers.

What incidence in the rate of depression are we willing to see in the young and healthy in order to reduce the risk to the vulnerable by 1%? What about to reduce it by 10%? How much should the middle-aged pay in lost earnings to avoid one infection in the healthy population? How much to avoid one hundred? How much time are we willing to take from the young to tack on to the lives of the elderly? Because that is, in one sense, what we are doing here. How many days in the prime of their lives locked inside their flats and bedrooms is worth another day of living to someone in their 90s? Is the ratio 1:1, 1:2, 1:10? How much economic harm are we willing to inflict on the working population? If this sounds callous, remember that we already make this calculation when we fund the NHS; in this case, the treatment and cost is simply that of locking the young away.

When the NHS makes these decisions it weighs them by quality-adjusted life years; the number of years in perfect health gained by funding a course of treatment. Implicitly, this suggests that not all deaths are equal. If a man of 91 passes when he might have seen 92, that is sad. If a mother of two dies in her thirties, that is tragic. We are all heading to the same place, but we have different distances left to travel. A policy which takes too much from those at the start of their journey to give to those almost at the end of theirs is morally flawed.

Image courtesy of Arallyn!, used under a Creative Commons licence