How much quality of life and life-expectancy should we be expected to sacrifice to flatten the curve? The answer is not “infinity.”
(The following piece was originally published on Medium on March 24, 2020.)
The past few days at work have been surreal. In preparation for an expected influx of COVID-19 patients, and to preserve our dwindling supply of personal protective equipment (PPE), all elective surgeries at my hospital have been canceled. This leaves me, a standard surgical floor nurse, without the majority of my usual patient population. In the calm before the storm, it strikes me as strange that the rest of the world isn’t functioning. I casually chat with a co-worker who tells me that her small business is now underwater. Everyone I speak with knows someone who is now suddenly out of work.
And in some sense, this is necessary. I learned early in college nursing classes about the importance of social distancing and public quarantine interventions when addressing a pandemic. During the Spanish Flu, cities that implemented interventions early saw relatively few casualties, and those that did nothing were immediately overwhelmed. Businesses and individuals can stand to pause for a while for the sake of their fellow citizens — lives are on the line, after all.
But the preceding moral proclamation, righteous as it feels, leaves one serious element unspecified: Time. How long exactly can our country remain at a standstill? Waiting even six months seems likely to fundamentally disfigure the society we’re trying to preserve. I’m not saying I know exactly how much economic growth is proper to sacrifice to save a life, but it isn’t unlimited. In a capitalist society, gainful employment is health and well-being. The consequences of sky-high unemployment will manifest in population health statistics years down the line.
The issue here is … well, death. Won’t people die if we lift restrictions too early? First, remember that people will die no matter what; it’s how many that matters. Second: We have no reliable data on which to base our decisions. We’re instituting widespread quarantine based on nothing because the consequences of betting wrong at this stage of the game are near limitless. However, the appropriate length of societal shutdown expands or contracts based on answers to the following questions:
- What percentage of overall cases require hospitalization?
- What percentage of hospitalized patients younger than 65 require ICU care?
- How many intubated patients above age 75 survive?
- What percentage of intubated patients suffer lifelong morbidity related to chronic lung injuries?
- How much extra capacity has our health care system added to prepare for a surge in critical patients?
- How much damage has our economy sustained so far, and when will the damage begin to cause fundamental and irreversible insults to mobility and quality of life?
Right now, we don’t have good answers to any of these questions. Pundits who speak or write as if we do are speculating at best. However, in a few weeks, we may finally have some decent answers (in the form of slightly tighter ranges of outcomes) to these questions. Each possible scenario will result in a certain amount of lives lost to COVID-19, and our leaders will have to pick the range of outcomes they deem most bearable. The wider the range, the less clear the decision. I am not a public health expert, but I worry that the majority of these scenarios will involve a choice between continued economic shutdown for six months or more and an epidemic curve that outstrips hospital capacity.
I’m not excited about the idea of outstripping hospital capacity. This will put me — and more so the physicians I work with daily — in horrible ethical positions of deciding who lives and dies. The trauma and stress will be overwhelming. The lives lost will be real — they will not have been expendable. They will include people like my aunt and uncle from Enumclaw, WA. Mobile and vivacious in their 70s, their “retirement” consists of full-time volunteering with senior services like meals-on-wheels, as well as full-time caregiving for my wife’s WWII veteran grandfather. Words cannot describe the level of grief and despair my family would endure with their loss to this terrible disease. This is personal.
Equally traumatizing will be the depression and despair of millions left unemployed, hopeless, and poverty-stricken. Not to mention the early deaths and chronic diseases associated with impoverished health behaviors. No one gets out of this alive and intact. Make no mistake: Six months of an economic shutdown will cause a depression that makes 2008 look like the roaring twenties. The American experiment may well cease to exist, at least as we currently understand it.
I’m not saying I know how to strike the proper balance. However, as we approach this conundrum, consider this: Everyone understands that there is a difference between death resulting from negligence and death resulting from tragedy. If a nursing home resident gets COVID-19 because an employee didn’t wash their hands, this is negligence. A human caused the infection through willful blindness, and this rightly triggers a sense of moral outrage at such injustice. However, notwithstanding regulatory negligence on the part of the Chinese government, no human “caused” this virus. At least as it regards our current predicament in the United States, there is no one to blame for this tragedy. Our cries of outrage and grief go up against the fabric of existence itself; even against God if we haven’t quite killed him yet. And now, we’re faced with a horrible truth: Endless preservation of life will become destructive to its ends. Though politicians and pundits obfuscate and pretend that this amounts to ageist genocide, it is at this vital moment that these honest conversations must take place.
Now, no matter how carefully I edit and revise this post, some people will find a way to accuse me of “hating old people” or something similarly slanderous and absurd. That is fine. I have worked in nursing homes and hospitals with this 65+ population for my entire nursing career. I am happy to let their consistent words of thanks for my compassionate and high-quality care to do the talking for me. Still, I will remind readers of what I’m NOT saying:
- We should lift restrictions right now (we shouldn’t).
- The economy is more important than the lives of the old and/or senile (it isn’t).
- We should not make substantial economic sacrifices to save hundreds of thousands of lives (we should).
Rather, I’m simply stating what we already know, but are too afraid to say clearly: The level of our sacrifice should be substantial, but not unlimited. There is a limit, and it can only be defined if we’re both courageous and humble enough to admit its existence.