How is the medical profession to cope with the appalling moral dilemmas it now faces?

The idea of anyone deciding which of their fellow human beings will live or die is a viscerally repugnant one. Who wants a society in which “bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care”? The person who said this added “Such a system is downright evil.”

But wait. These words come from a tweet by the Tea Party conservative Sarah Palin, former governor of Alaska. She used them in the context of opposition to the Affordable Care Act, popularly known as Obamacare. In the same tweet she coined the phrase “death panels” to describe committees that made life and death decisions. Republicans successfully associated these with European-style health care.

In a sense, Palin was right. Any government that provides healthcare has to make decisions of who to prioritise and this will make a difference to who lives and dies. But the alternative is to leave it to insurers to decide who among the assured is covered and to let those who can’t afford insurance to proceed unimpeded to their graves.

There can be no avoiding cost-benefit analysis in healthcare, which means there is no avoiding the horrible tasks of selecting who lives, directly or indirectly. With the Covid-19 epidemic heading towards its peak, it’s essential that we get clear about the ethics of how we do this in extreme circumstances.

In general, cost-benefit analysis works very well when the costs and benefits being compared are of the same kind and are clearly measurable. If there is a choice between two equally safe and effective drugs and one is twice the price of the other, of course you choose the cheapest.

Matters soon complicate, however, when you compare different types of costs and benefits, especially when there is no clear metric. Should the government spend £1.6bn on culture (which is the budget of the Department for Digital, Culture, Media and Sport) or on hospitals? The question asks us to compare apples and pears. The benefits of the arts are not (mostly) concerned with health and they can only be measured by pseudo-scientific metrics devised to please bean counters.

These differences are stark and clear. But even within healthcare, the problems of imprecise measurement and impossible predictions involving different variables is common. Should you extend life at lower quality or allow a person to die sooner in better health? Is it better to spend money that enables the lame to walk or the deaf to hear? Is there more benefit in saving the life of a sprightly octogenarian with perhaps 20 years left in them or a ten-year old with an underlying life-threatening condition? We cannot possibly answer these questions definitively.

One tool which attempts to resolve such issues is the quality-adjusted life year, or QALY. If you measure the value of medical treatments by how many years they are likely to add to a person’s life, matters are fairly simple, despite the inherent uncertainties. But most of us are concerned with quality as well as quantity of life. My mother, for example, refused chemotherapy because she’d rather have died sooner than endured treatment.

Adding the quality dimension, however, introduces problems of measurability. Take the case of Havi Carel, a philosopher who was diagnosed with a rare life-threatening lung disease, lymphangioleiomyomatosis. It limits what she can do and requires her to carry oxygen at all times. Does this mean her quality of life is less than that of someone free from a major condition? Almost certainly not. Indeed, she is the kind of person who has used adversity as a spur. She is now widely respected by her peers and healthcare professionals for her work on the phenomenology of health. She has as rich a life as any other philosopher, perhaps richer than many.

In extreme cases, the quality of life issue becomes a legitimate reason for prioritising funding. If a ventilator is needed for someone with Covid-19-induced pneumonia, it would be wrong to keep it attached to someone in an irreversible coma. But most of the time, any supposedly objective medical indicators of quality of life will ignore what matters most to how people deal with chronic illness or disability: their attitudes, how much support they receive from friends and family and so on.

These cannot be easily measured and it would be foolish—even repugnant—to try. If someone is prone to depression, that is no reason to put them behind a cheery optimist in the queue. Medical professionals can judge how much life an intervention is likely to add but all the time a person is conscious and able to express their views, no one should make a life or death judgment about how much that life is worth living.

That does not mean there are no life or death decisions to be made at all. At the policy level, it is right that the government ensures medical resources are used efficiently and it has to take into account the relative efficacy of different interventions. However, this is very different from making clinical decisions about which individuals should live or die. Here the main criterion has to be a medical judgment about who is most likely to survive. Age will be a factor here, but only because that does affect your odds, not because doctors are saying older lives are worth less.

Whatever we think the right criteria might be, it is naive to leap from the instinctive repulsion we feel at the idea of deciding who lives to condemnation of the need to do so in hospitals. Such decisions are being made already and if Covid-19 progresses as expected, many more will follow. We should respect and support those charged with making them rather than being ready to pounce when we think they got it wrong.