National Post (National Edition)
In a pandemic, the philosophy of death is suddenly top of mind
IN A PANDEMIC, THE PHILOSOPHY OF DEATH IS SUDDENLY TOP OF MIND
Death is an awkward subject at the best of times, let alone when a pandemic reminds everyone it is their common destiny.
The moral questions about what the risk of death compels the living to do about it are not exactly new. They are as old as philosophy and religion. But they do feel unfamiliar as they rise with such urgency as a matter of public policy.
A letter was shared widely last week from a Michigan hospital, for example, outlining its triage criteria for intensive care, making clear that other conditions such as cancer, heart disease or trauma could make a patient “not eligible” for intensive care or mechanical ventilation.
“Patients who have the best chance of getting better are our first priority,” read the public letter from Henry Ford Health System.
Soon after, the Toronto Star reported details of a similar triage protocol for Ontario, a last-resort system with several escalating levels, in which patients could be disqualified from ICU based on their likelihood of dying anyway, either of COVID-19 or other illnesses.
The philosophy of saving the most lives possible in swamped hospital emergency rooms is suddenly a matter of universal concern and confusion. If hospitals are overrun, will they operate on a first-come first-served basis, offering each patient a medical fight to the bitter end? Or will doctors face more panicked and utilitarian considerations about who is most likely to benefit from their intervention, as they did in Italy, where a coldly neutral age cutoff for life support was put in place, based partly on battlefield strategies from military experience.
Canadians are bracing for that sort of scenario, even as they desperately try to avoid it. After watching the foreign death toll of COVID-19 rise with increasing concern but not terror, Canadians are now seeing their fellow citizens dying in large numbers, and are learning their names.
Those names are slowly being overshadowed by the numbers, however, as the tally of deaths rises in lockstep with the infection rate. Canada has just entered triple digits. America hit quadruple digits last week, and by this week was closing in fast on 4,000.
All this has the effect of revealing societal attitudes toward death and the risk of it, and in some cases changing them.
Two leading academic bioethicists consulted by the National Post, for example, offered vastly different views about the risk of death in pandemic medicine as it applies to emergency physicians facing another day in an overrun hospital.
Reports have described doctors in New York hastily writing their wills, mindful that in other countries medical staff have been overrepresented in the death counts. Dr. Frank Gabrin, 60, who worked at East Orange General Hospital in New Jersey, this week became America’s first emergency physician to die of COVID-19.
Udo Schuklenk of Queen’s
University said doctors are under no moral obligation to continue serving in a hospital system so underfunded and ill-equipped that doing so puts their lives at risk. Eike-Henner Kluge of the University of Victoria said they are obliged, in a country where health care is a monopoly for the sake of society, because serving in an emergency “is where you pay the price for joining the medical profession.”
More common is the worry about whether people who are already ill or weakened can survive a case of COVID-19, and how much hospitals will be able to do to help them.
It demands an unfamiliar way of thinking, of discriminating among patients by how much life they have left to live, and how good it will be.
There is even a simple mathematical calculation that quantifies the burden of disease, known as “quality adjusted life years,” in which you multiply each year of life by its quality, to help decide whether a possible intervention is worth the risk. When you start using the concept to triage people in the ICU, however, as if some people have more of a life to save than others, a darkness seems to fall over this system of economic risk analysis.
“The darkness is not caused by the system,” Schuklenk said. Quality adjusted life years is simply a neutral measure of a disease’s burden and the potential effect of medicine. The darkness is caused by the wider situation, he said, by the contagion and the inadequacy of the response.
Schuklenk said he is skeptical that all Canadian hospitals have implemented clinical protocols for when their capacity is exceeded, to spell these policies out for patients and their families, as the Michigan one did. He pointed to one British Columbia example of a hospital network that has promoted a utilitarian framework that clearly explains triage based on objective, evidence-based criteria. But he noted that a neutral measure “goes psychologically against what doctors do,” which is to save the life in front of them, and not to write intensive-care admissions policy in a panic.
As the Michigan letter showed, it can also cause public distress, and the hospital quickly issued a statement that it hopes to never have to use this “worst case scenario” policy. The Ontario document is similarly described as a last resort.
It may yet be needed. Canada had 105 deaths as of Thursday. In the United States, the death total nearly quadrupled in the past week and by Thursday was 3,846. New research forecasted 80,000 people may die of COVID-19 by the end of July, even assuming strict and widespread adherence to social distancing and other precautions. The estimates ranged as high as twice that, according to Christopher J.L. Murray, a pioneer in measuring the burden of disease and the director of the Institute for Health Metrics and Evaluation at the University of Washington.
U.S. President Donald Trump this week presented the familiar graph that compares the virus spread with and without precautions. His administration’s goal, he said, is to achieve the flattened curve in which between 100,000 and 240,000 Americans are expected to die of COVID-19, as compared to the steeper curve of taking no precautions — resulting in more than a million projected deaths.
That marked a major shift in his attitude toward death.
“The whole concept of death is terrible,” Trump said last week, when he was still adamantly maintaining that America’s COVID-19 death rate is less than one per cent.
It had the sense of an arbitrary number chosen because it sounds small, but is actually not. For example, the Murray paper notes the disease is projected to infect between 25 and 70 per cent of the American population. If you lowball that, and say perhaps a third of Americans get it, and one in a hundred of them die, you are talking about a million people.
Trump gave a hint of the upper limit of this reasoning, saying: “There’s a tremendous difference between something under one per cent, and four or five or even three per cent. So that’s something that we’re learning now.”
It was a revealing vision of capitalist values in a president who had then chosen Christianity’s holiest day as a target date to reopen the American economy, predicting it will be “beautiful.”
Trump has now walked that back, and warned of hard times and many deaths to come, but not before the notion of human death in service of the economy caught on among his loyalists. This was reflected in the statement of Dan Patrick, the lieutenant-governor of Texas, who said old people like him are willing to risk their own lives by lifting precautions to protect the economy for their grandchildren, almost to sacrifice themselves for the nation’s prosperity.
All else aside, this is at least a new way for Boomers to think about death.
Since then, the cold logic of whataboutism has run rampant, with the argument that COVID-19 precautions are overkill because there are already other diseases that kill similar numbers of people. When Trump lawyer and former New York mayor Rudy Giuliani tweeted that 7,500 people die every day in America, as a point of “perspective,” New York Times reporter Maggie Haberman pointed out that no one made that point on 9/11.
The way we think about dying is changing before our eyes, not just because of the pandemic. It is only in the 21st century that more people globally started dying of non-communicable diseases than infectious ones.
Philosophically, we struggle to keep up. Evolutionary geneticists sometimes talk about the three eras of death, which has always been the main factor in human natural selection, but comes in different styles.
For most of evolutionary time, death came through disaster, like getting eaten by a wild animal or killed by a rival. With civilization came disease, shared through society. Only recently, thanks to medicine, have we tended to die of decay, and it has become the cultural archetype.
Pandemic takes us back, in a sense, to the unfamiliar age of disease.