As mass vaccination continues to be rolled out, the UK is beginning to see encouraging signs that the number of COVID deaths is reducing, and that the vaccines may be reducing the transmission of coronavirus.
While this is very welcome news, a mass vaccination programme is unlikely to be enough to eliminate the virus, so we need to turn our thoughts towards the ethics of the long-term management of COVID-19.
One strategy would be to aim for the elimination of the virus within the UK. New Zealand successfully implemented an elimination strategy earlier in the pandemic and is now in a post-elimination stage.
An elimination strategy in the UK would require combining the mass vaccination programme with severe restrictions on international travel to stop new cases and variants of the virus being imported. However, the government has been reluctant to endorse an elimination strategy, given the importance of international trade to the UK economy.
One of the main alternatives to the elimination strategy is to treat coronavirus as endemic to the UK and to aim for long-term suppression of the virus to acceptable levels. But adopting a suppression strategy for the long term will require us to make a societal decision about the harms we are and are not willing to accept.
The liberty, equality and mortality trilemma
The first year of the pandemic has taught us that, without suppression measures, coronavirus will lead to significant death and harm, including long COVID. But evidence suggests that mitigation measures, such as lockdowns and effective test, trace and isolate systems, may be effective in reducing transmission of the virus.
These measures have their own costs. Lockdowns significantly restrict civil liberties and cause a wide range of other harms, including significant non-COVID mortality and morbidity. Recent models suggest that in the long term, the mitigation of the pandemic could lead to 100,000 non-COVID deaths. On the figures from this model, deaths from the virus itself may come to only account for about 54% of the overall death toll of the outbreak in the UK.
The extent of some of the costs of mitigation measures could be lessened by targeting these interventions at certain groups, such as those who have not been vaccinated, or those who have a particularly high risk of death from COVID, such as those over the age of 65. However, these targeted strategies involve forms of unequal treatment and possible discrimination.
This is the fundamental trilemma of the long-term suppression strategy. The societal decision we make about the acceptable level of viral suppression involves a choice about which of three competing values we should prioritise and which we must compromise. We can maximise one or two of these values, but we can’t have all three.
We might be able to reduce COVID deaths while safeguarding equality, but only if we are willing to accept the potential need for future lockdowns, severe travel restrictions, and the costs to freedom and general health that entails. We might be able to reduce COVID deaths while protecting the freedom of those who do not pose a transmission risk by introducing COVID certificates or passports, but only if we are willing to accept the inequality that such schemes involve.
Finally, we can give everyone in society as much freedom as possible, but only if we are willing to accept the increased COVID deaths it will probably involve if the virus has not yet been sufficiently suppressed in other ways.
The moral question about the suppression strategy has been framed as one concerning how many COVID deaths we should be willing to accept each year. This invites comparisons between COVID and annual deaths from other infectious diseases, such as influenza, which has caused fewer than two deaths per 100,000 people per year in European countries since 2000, and those that we have lived with in the past, such as tuberculosis, which caused around 100 deaths per 100,000 people per year in England and Wales at the beginning of the 20th century.
These comparisons are illuminating because they provide a baseline for the number of deaths from an infectious disease that we have historically found acceptable to live with. 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.
But these comparisons are relevant to only one of the key ethical values. In the context of COVID, we might have to risk a higher number of COVID deaths in the absence of significant societal restrictions or inequality.
To decide what is acceptable on the suppression strategy, we have to confront the fundamental conflict between values in the COVID trilemma.
Jonathan Pugh works for The University of Oxford. This work was supported by the UKRI/ AHRC funded UK Ethics Accelerator project, grant number AH/V013947/1.’ The UK Ethics Accelerator project can be found at https://ukpandemicethics.org/
Dominic Wilkinson receives funding from the Wellcome Trust and the the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation rapid response to Covid-19 (AH/V013947/1).
Julian Savulescu receives funding from the Uehiro Foundation on Ethics and Education, NHMRC, Wellcome Trust, Australian Research Council, UK Research and Innovation (Arts and Humanities Research Council) as part of the Ethics Accelerator Award AH/V013947/1, WHO. He is a Partner Investigator on an Australian Research Council Linkage award (LP190100841, Oct 2020-2023) which involves industry partnership from Illumina. He does not personally receive any funds from Illumina.