How Many Deaths Can We Live With?

In late March Texas Lt. Governor Dan Patrick was criticized for saying that as a 70-year-old man at high risk for complications from Covid-19, he'd be willing to risk his own death in exchange for reopening the economy. He claims many other senior citizens think the same way. The criticism was severe and not just ideological, though conservatives have seized on his remarks as part of their inspiration for a more accelerated reopening.

What Dan Patrick said was disturbing, especially since he spoke those words a month ago, when any reopening would have led to way more deaths than there has been. But his idea is not new. "Make room for others, as others have made room for you," Montaigne wrote half a millennium ago, a line echoed in 1994 by the late surgeon and bioethicist of "How We Die," Sherwin Nuland: "We die so that the world may continue to live."

Not voluntarily, you say? Not true. We hardly think twice about sending young people who've not yet reached the prime of their lives to die at war, always under the banner that they're dying to protect their country, whether they really are or not (and in most wars, they're not: it's sheer waste.) Dan Patrick was not saying anything too different. He was flipping the tables, with older people taking on the mission, with ends at least more noble or defined than the death of an 18 year old in places as ghostly as the purpose. He sees the economic collapse as an existential threat to the United States no different than a major war. Looking at the unemployment numbers, at the cratering in the price for oil, at the elimination of entire segments of the economy, he's not wrong. The novel coronavirus is damaging the economy more than any conflict in the past century and at this rate may exceed the damage of the Great Depression.

The coronavirus is not going away, and its deadliness is no longer in dispute and nowhere near comparable to such things as the seasonal flu, as even President Trump acknowledged soberly on Monday. "More than 2 million" Americans would have died had there not been a shut-down, he said. And "we're still going to lose between 50 and 60" thousand, "with our guard up." Trump's own words. Conversely, the Institute for Health Metrics and Evaluations, whose models have been used across the country to measure Covid-19's peak impact on hospitals, estimates that deaths would have been kept to 6,000 by August, instead of the 67,000 currently projected, had stay-at-home measures been imposed in the United States just two weeks earlier than they were.

Immense economic hardship causes suicide, domestic violence, untreated health crises like heart attacks and strokes that have nothing to do with Covid-19.

So shelter-in-place rules work. And with the coronavirus untamed, any reopening means an increase in the number of people who will die. There's no way around it. But there's no way around the other reality, either. Close to 30 million Americans are now out of work. Immense economic hardship causes suicide, domestic violence, untreated health crises like heart attacks and strokes that have nothing to do with Covid-19. A prolonged economic crisis on the scale of a great depression will tally up its own body count, and may damage the country's fabric in ways we cannot imagine.

Dangling out of its historical or ethical context Dan Patrick's idea is shocking. But the question it raises is the heart of the matter: it's not whether we are willing to accept a certain amount of deaths as the country is reopened, it's how many deaths are we prepared to accept. The question may seem taken from a Shirley Jackson story. But that calculus is applied in society all the time: we would not have 38,000 deaths on our roads every year if we banned driving, but no one would accept a ban on driving. Same thing with the 36,000 annual gun deaths, which would be eliminated without guns anywhere, or, for that matter, the 80,000 deaths from diabetes or 140,000 lung cancer deaths, which could be significantly reduced with a ban on sugar and tobacco. No one would accept a ban on either.

The comparison to a communicable disease is not exact. The risk of unknowingly catching a deadly virus is far higher in an uncontrolled environment than risk of death from behavior or illnesses that in part result from personal choice, though fatality's luck of the draw is not minor in those. (The four deaths on State Road 100 last weekend were caused by a driver crossing the center line. His three victims had no chance.) But you get the point. No one would accept 2 million dead from the virus, but we did accept roughly 34,000 deaths from the seasonal flu in 2018-19, even though that comparison is flawed, too: no social distancing has ever been considered necessary for the seasonal flu. Clearly, there's a balance, a fatality rate we may not say is acceptable, but a fatality rate we accommodate in many ways, because we recognize that as Gov. Gretchen Whitmer of Michigan put it, "there's no such thing as zero risk in the world in which we're living." The ethical challenge is in finding that balance.

Radical calls for continued lock-downs or immediate reopenings aren't helping. Framing the debate in ideological terms would be worse: we'd have two camps fighting each other instead of maintaining a unified front against an opportunistic virus. The months and possibly years ahead call for plans to live with the virus while accepting a measure of risk, as in any war. But they also call for minimizing risk to the extent possible, especially when the risk is disproportionately borne by the elderly and the sick. We're learning enough by now to know that once that's put in place, the realistic, acceptable risk may end up being far lower than feared. Ingenuity does not depend on a vaccine.

That means re-imagined accommodations at work, at school and in public places, including mandatory masks in certain areas, normalizing working away from the office (as long as the work gets done, geography is irrelevant), a more hybrid approach to education, where it doesn't have to be all virtual or all in person. It means an unprecedented investment in public health, starting with massive testing for the virus and its antibodies and a far more elaborate contact-tracing system tied to phone apps and real-time, public dashboards. It means easily identifying those who have recovered and developed immunity, and who could be working in high-risk jobs. It means a long sabbatical for normalcy.

All of us of any age volunteering for that sort of sacrifice, rather than sacrificing elderly lives-or any lives-will get us much closer to that common goal of not just flattened but conquered curves. With those assurances, the din of extremism just may have a little less appeal, living life again a little more so, and trading any life so the rest of us may live would be relegated to the unacceptable.