Pricing Lives in the Time of COVID-19

Auteur(s) : 
Entretien/Analyse
Date : 
27/04/2020

Numbers Count

Maybe there is no difference, ethically, between saving 10 thousand lives and saving one single life (i.e. we are morally entitled to give each person an equal chance of survival). Maybe, by saving one person, we save the world.

Maybe, from a metaphysical point of view, the value of life is infinite (i.e. it is beyond measure). Or, maybe it is just a question of principle and life has no price. Nevertheless, from a political point of view, thinking and saying that numbers do not count is simply wrong. This is particularly the case during an epidemic or pandemic, during which states are “called to account.”

Numbers are indeed part of the measure of responsibility of governments when the lives of their citizens are endangered by a terrible threat. At a time when the numbers of people infected by and dying from COVID-19 are still rising or are extremely significant, counting the dead is a political question of major importance.

But the politics of numbers is not just about counting those lives that are being lost. During a pandemic, governments have to consider another quantitative measure, that given by economic indicators. For the state, and therefore for politics, these figures are important because they are measures of the general interest. Hence, what is the economic impact of a lockdown policy? In France late March, INSEE (the national statistics agency) had assessed that a month of confinement will generate a 3% reduction of GDP; for other countries, the cost will be even higher. In fact, the economic outlook worsens every day.

Neglecting this aspect of the pandemic and avoiding the questions it raises would be an error. But let’s not get it wrong: this is not a simple economic question or a question for a penny-pinching shopkeeper. We cannot avoid this debate and we have to understand the relation between these two dimensions of the pandemic: that of lives saved or lost, on the one hand, and that of resources spent or preserved, on the other. Within the boundaries of our current knowledge of the situation, we have to make this political equation of responsibility thoroughly explicit. We have to take into account all its variables and therefore the various consequences of government decisions. Otherwise, it will not be possible to find the appropriate responses to the pandemic.

My argument is based on the premise that the state must take responsibility for the consequences of public action, and it relies on two additional observations. In the absence of both a vaccine and a treatment, failing to impose restrictions on the free movement of individuals during the pandemic will expose the population to what we know is a threat, and this decision will lead to an increase of the number of deaths—the latter being the responsibility of the state. At the same time, the state has to preserve its economic interests. Massive unemployment is the cause of further disastrous consequences and it is the responsibility of the state to avoid such chaos. Moreover, social and economic distress translates into loss of human lives. Money (be it private or public) affects people’s lives, their mental and physical health, and the social benefits they could expect in the future will be lower. Lives will be hurt or shortened if economic conditions deteriorate.

These two logics—lives and economic interests—are under tension and this tension has exacerbated. If a state is insensitive to the loss of human lives it will be accused of being cruel. If it is careless when making economic decisions, it will be accused of failing to protect the common interest. In both cases, the issue is one of finding the right balance, again, a very old tradition, as, for example, in Greek philosophy (according to Plato, the Statesman masters the art of measurement). Still, the content of this political arithmetic, based on the equivalence between two incommensurable goods—lives and material goods—remains to be clarified.

As a preamble, the “Your money or your life!” option needs to be discarded: in no way, is it a good alternative. We do not have to substract lives from amounts of money or the opposite. In such a calculation, lives would immediately translate into money and money could translate into life expectancy. Some economists consider we could attribute a monetary value to human lives as it shows in the concept the “value of statistical life.” This value is based on the average amount of money some individuals would be willing to pay to protect themselves from a risk divided by the probability given to this risk: if you agree to pay €5,000 to protect yourself from a fatal risk, the probability of which is 1/1000, then the value of statistical life is €5 million, i.e. 5000 / 1/1000. VSL is used in insurance and in public policy. Today, in the context of COVID-19, if we push this reasoning to the extreme, we could multiply the number of lives lost by this monetary value, then, we would compare this result to the financial resources used to save these lives. Eventually, we would know whether an excessive or fair cost is being paid for measures that are taken to stop the pandemic: “it is costing too much” or “it is a good deal and it is the right policy to follow.”

Not only does this approach clash with our psychological or moral intuitions, but it also undermines values such as dignity and lacks robustness in logical terms because it evades the issue of political responsibility. Increasing national wealth is not the primary objective of a state; ensuring the security of its population is. In the logic of political responsibility, life must be prioritised over money. Yet, and even if these two goods (life on the one hand and money on the other) are not comparable, this does not mean that there is no link whatsoever between them and that we are entitled to neglect material concerns in political decisions where lives are at stake. “Numbers count,” as they are constitutive elements of a political art of measurement, the terms of which need to be made explicit.

 

Paying For Lives, Paying With Lives

It is all the more important to find a measured response to emergency situations when decisions to impose a lockdown are a priori very costly. A sense of measure is equally necessary, if not more so, when considering questions of whether to shorten quarantine periods or to put an end to them in order for economic activity to resume.

I have summed up in a basic table some of the major steps of the different decisions that have been made and applied since the beginning of the crisis.

The confinement and its costs

Politics of confinement

Evolution of the virus

Economic costs

T0: Start of the epidemic in China—November 2019.

Patient zero in Wuhan—17 November 2019.

The Chinese government attempts to silence whistleblowers and sanctions them, notably Dr Li Wenliang — December 2019.

266 cases are declared—end of December.

 

First case declared outside of China, in Thailand—13 January 2020.

Stock indices are at their highest (the value of Dow Jones has tripled since 2008).

 

News about the epidemic has little or no effect on the economy or finance.

T1: Start of the confinement in China—end of January 2020.

4,000 cases declared in China at the beginning of the lockdown.

 

Start of the epidemic in Europe.

 

Number of deaths worldwide by 31 January: 213.

The Shanghai Stock Exchange falls 10% after the announcement of the lockdown.

T2: Start of confinements in European countries—February 2020.

 

United Kingdom recommends aiming to build herd immunity.

 

Confinement decree in Italy—end of February.

The epidemic spreads in Lombardy (Italy).

 

First cases in France.

 

Number of deaths worldwide by 28 February: 2,857.

Start of a stock market crash in Europe, Asia, and the United States when Europe announces lockdown measures.

T3: End of confinement in China—March 2020.

 

 

United Kingdom progressively imposes social distancing measures.

According to Chinese sources, no new cases in China.

COVID-19 declared a pandemic by WHO—12 March.

 

The progression of the pandemic slows down in Italy, close to a peak.

 

Exponential rise of the spread of the virus in the United States in March.

 

Number of deaths in the world by 31 March: 37,271.

 

As some models had predicted in March, the number of deaths increased significantly during the first two weeks of April in the United States.

Stock exchanges over the globe have lost more than 30% of their value.

 

United States announces a $2 trillion plan for the economy.

 

Forecasted costs of confinements are released.

 

Foreign direct investments have gone down 40%.

 

Major recession predicted in the United States.

 

In the United States, Australia and Germany, China is blamed for having caused the pandemic. Several class action lawsuits are filed in the U.S. Plaintiffs are asking for trillions of dollars.

T4: Potential progressive end of lockdown in Europe and the United States.

The European and United States governments consider the progression of the pandemic is slowed enough to authorise a progressive restart of social and economic activities in their respective countries.

The European and United States governments consider that the economic costs of strict social distancing rules are too high given the number of lives that might be saved by maintaining these rules.

T5: Eradication of the virus.

What is the demographic and health assessment?

What is the economic assessment?

How and why have such decisions been made and what do they tell us about political responsibility in the face of this crisis? Since the early stages of the crisis, epidemiologists have been working on several models to confront the dangers of COVID-19 and have elaborated different scenarios. Two of these models stand out while the tensions arising from equating human lives and material and collective interests are exacerbated. We find two opposing logics, each of which obviously has variants. The first, driven by principles of humanity, is that of the preservation of human lives which requires, in the short term, economic sacrifices and the decision to confine the population. Its principle is “paying for lives.” The second is based on a pragmatic and materialistic approach as it justifies the lifting of confinement measures or the refusal to impose social distancing rules. Unless the pandemic has completely disappeared, this type of decision involves a great amount of risk as we gamble with human lives. It therefore implies a principle of “paying with lives,” as the resumption of economic activities is deemed important enough to make this choice. “Paying for lives” and “paying with lives” are two essential elements that help us to understand what the price of human life is from a political point of view.

Pricing lives appeared as a question at the start of the crisis, even before the pandemic was officially acknowledged as such. We do not have enough reliable information concerning China, but everything leads us to think that it took for the Chinese regime a certain amount of time to acknowledge the existence and the spread of the virus. Patient zero was detected in mid-November (Time 0). At first, China refused to halt the spread of the emerging epidemic by blocking the economy of the city of Wuhan. Chinese authorities did not want to send a negative signal to the world because it would have hurt its interests. The Chinese government even sanctioned Dr. Li Wenliang and other whistleblowers who spoke out about the dangers of the epidemic.

For two months, China paid for the preservation of its interests with human lives. It is only when the official number of deaths was revealed, and when it became obvious that the rates of the infection increased exponentially, that China imposed confinement measures. Given the authoritarian nature of the regime, the measures taken were sudden and drastic (T1). The calculation according to which it was deemed better to stop the economy suddenly and for a short period prevailed over the idea of gradual confinement that would have been less costly in the short term but also less effective health-wise. Moreover, the effects of confinement measures on the propagation of a pandemic are, historically, relatively well known. A study of the spread of the Spanish flu in 1918 shows that cities that adopted strict confinement measures had a far lower mortality rate. The later confinement measures are applied, and the less strict they are, the more it is difficult to control the spread of the virus.

Even though the existence of the virus was well-known, European states and the United States neither interrupted economic relations with China nor implemented preventative healthcare policies within their borders. Here too, the aim was to not disrupt economic life or interfere with the logic of material interests. For the states that made this choice, the number of lives at risk was not considered to be significant enough to go against their national and material interests.

In response to the epidemic, the evidence of which had become obvious, China imposed very strict measures at the regional level at T1. This was the first step toward a change of balance: it was no longer possible to pay for the pursuit of economic interests with human lives, and was therefore necessary to accept to pay for lives. During this lime (from T1 to T2), European countries and the United States temporised. At T2, progressively and generally less abruptly than China, first Italy (end of February), and then later Spain, France, the United Kingdom, and eventually the United States (end of March), imposed confinement (or social distancing) measures. They decided to pay for lives, because the loss of present lives and especially the anticipated future casualties were deemed too significant.

Whereas, as a policy, paying with lives is difficult to justify and to assume publicly, paying for lives is considered to be a much more legitimate position. It is highly publicised and usually generates a strong consensus in the public space. We need to pay to save lives, “the state will pay,” declared President Macron on 16 March. And indeed, it is for the state a matter of responsibility. The state is responsible for the security of its citizens and must protect them from life-threatening dangers. The state’s resources are used to protect the health of the population, prevent ailments, heal the sick. Measures that cost huge amounts of money, in particular quarantine, are put in place. The country’s loss of income becomes the price to pay and, in the end, confinement has a huge material cost. Ultimately, when it saves lives, this political decision is the reflection of a clear preference for current lives rather than future lives (even if the economic costs of those measures will hurt the lives of numerous people in the future).

Despite this resolve to control the pandemic and to bear some of its costs, at the beginning of the crisis that was spreading in Europe, an alternative to confinement was proposed: herd immunity. This was the United Kingdom’s first choice. It is best to accept a certain number of deaths caused by the spread of the virus that circulates rather freely among the population. Then, once a peak has been reached—rather rapidly it is assumed—infected people as a group will protect the others through their immunisation. This solution has a major advantage as opposed to confinement policies: it is much less disruptive for the economy. This gamble is essentially a utilitarian calculation, and in the early stages of the crisis, the words of UK Prime Minister Boris Johnson left no doubt about his choices: “Many more families will lose loved ones,” i.e. that’s the price to pay. Since then, the UK reoriented its policy, and in a quirk of fate, Boris Johnson was contaminated by the virus a few weeks later but, as he declared, was saved from certain death.

The idea of herd immunity has not convinced governments, apart from some countries such as Sweden and the Netherlands. However, reluctance to impose lockdown has not disappeared, in particular when social distancing measures are expected to last for a few months or more. Another country that expressed strong reluctance is the United States. The effects of the pandemic were downplayed and likened to a common flu (i.e., we refuse to pay that much for so few lives saved). After having acknowledged the seriousness of the situation and imposed social distancing measures, three weeks later, President Trump declared that the economy needed to be reopened by Easter and that churches needed to be full again—a nice illustration of Max Weber’s theses on the development of capitalism. Recently, Donald Trump changed his position again: the forecasts of the price to be paid with human lives appeared too high. Until mid-April, the president of the United States was still torn between conflicting injunctions.

Believing that the positions of Johnson and Trump are merely the reflection of these two leaders’ populism, their personalities, and, ultimately, their lack of discernment is wrong. The thesis of herd immunity had been approved by much less capricious rulers, in particular among French political figures. In addition, the idea of “reasonable deconfinement” has progressed elsewhere. In Italy, assuming that a great many citizens will have become immune, former prime minister Matteo Renzi called for a progressive resumption of work in May. At the time of his declaration (March 2020), his country was in the world the country with the greatest number of deaths caused by the pandemic.

 

Proportionality, Predictions, and Kairos

In order to protect the population against a major health risk, a state can decide to shut down its economy because it is responsible for the security of its citizens. However, there is no law to dictate the conduct that should be adopted when the health protection measures that save individuals also have severe effects on the economy. The problem is all the more difficult to solve considering that economic losses affect human lives. Given its power, a state has to assess the measure most suitable for the given situation. Finding this right balance is the true art of politics.

This requirement for finding the right measure is not unique to the field of health. In environmental matters, if priority is given to human lives, should the value of future lives not be considered in relation to the necessary (and costly) economic reforms to be implemented? This is a matter of proportionality. The question of proportionality is also central in the field of warfare where it stands as one of the essential legal standards of the laws of war. According to this rule, in order for the use of force to be authorised, the number of civilian casualties that are likely to result from an attack must not be excessive as compared to the value of the military advantage that is being pursued. In this case as well, human lives are put in balance with material interests.

Proportionality is a future-oriented assessment and rule that rely on predictive claims. In the context of the pandemic, two goods—lives to be saved and costs to be borne—are placed in the political balance. Numbers count and, empirically, two types of knowledge both using data and statistics are at the heart of the politics of pricing lives. Both epidemiologists and economists are involved, and both take a predictive approach. Epidemiologists and economists seek to establish the progress of the disease by means of curves and statistics, country by country and city by city. They try to identify the inflection points of the curves (of the number of deaths or new infections), pointing at the moment when growth stops being exponential and from when no new cases are detected. Economists analyse the macroeconomic effects of different policies, in particular by comparing containment measures (a priori more costly) with those relying on the development of herd immunity. Today, epidemiologists and economists are very much in demand and future studies specialists also offer their skills whether they base their models on collective intelligence or super forecasting.

It is very much a challenge to set what is the opportune moment, the kairos, when a policy needs to be inflected, such as the move out of confinement or the need for more or less strict social distancing measures. It is the very essence of the politics of pricing lives and therefore of the ‘political’ to search for this right balance. Although predictions are merely ‘indications about the future’, it is indispensable to cross-check epidemiological predictions with economic and financial forecasts and compare different hypothetical situations, i.e. scenarios (maintaining confinement on the one hand, possibly relaxing confinement measures on the other).

During the major episodes of the last century—SARS, H3N2 flu in 1968, H2N2 flu in 1958, and the Spanish flu in 1918—epidemics have resulted in a “V” type economic curve: the economy plunges after an epidemic then rebounds as strongly and suddenly as it dropped. There are multiple factors to such a scenario: the choice of when to interrupt confinement is one of them. Going out of lockdown too early could have disastrous health and economic effects. The “V” curve would then transform into a “U” curve (the fall of the economy triggers a shorter or longer recession before rising again) or, worse, an “L” curve (the economic downturn triggers a lasting recession). In the case of a premature end of lockdown, we could also imagine a “W” curve showing that after a short economic revival, the economy would drop again because of a new rise in the number of people infected and number of deaths. Given this, it seems better to end confinement too late than too early. Better to pay for lives (the cost of a long-lasting lockdown) than to pay with lives (a lockdown that would not eliminate some hotbeds of contagion from where the virus may spread again). But coming out of confinement too late is also dangerous economically and socially.

For several reasons, the decision to come out of confinement is a more difficult decision to make than the decision to start it. Indeed, the accumulation of the number of deaths creates an emotional shock and gives a clear signal, much clearer than the—progressive—slowing down of the number of deaths in a context where the chances of resumption of the pandemic remain high. In addition, starting and ending lockdown does not entail the same type of responsibility. In the first case, inaction would make the government indirectly responsible for the suffering of the population. In the second case, the government’s action makes it directly responsible for the rise or fall in the number of deaths as well as for the state of the economy. In terms of responsibility, the difference between action and inaction is a well-known phenomenon both in psychology and philosophy (in terms of principles, killing is worse than letting die, yet the two have the same result). Therefore, and in a context of high uncertainty, the government is under higher pressure when it has to decide to come out of confinement than when it decides to impose that restrictive rule on the population.

When deciding to end the lockdown, the state is faced with a major dilemma. While the number of deaths is high, leaders have to take into account the expectations of the population in a particularly stressful situation. But given the economic constraints and the social effects of a long confinement (individuals’ loss of confidence in their projects, family violence, social anomy), it will not be possible to maintain confinement long enough for the virus to entirely disappear, given that according to some forecasts it could last a year or more. It is therefore necessary to come up with solutions of partial deconfinement, probably leaving room for back-and-forth movements that will not be abrupt, or at least let’s hope for that. After having decided some shops can open, it would be difficult and costly to close them again. France entered confinement progressively and will come out of confinement even more slowly. On 13 April, President Macron announced the postponement of the lifting of social distancing measures. Confinement was extended and restrictions will be lifted step by step. The return to a “normal” life that would include all the activities we knew before will take a long time.

The state has to identify that moment when paying for lives will be more difficult to bear than paying with lives and act accordingly. When making these hard choices, it has to take into account all available information and knowledge as well as listen to the population, who could and should express its preferences. Does a majority of the population prefer to be protected by strict measures (corresponding to the maximum health precaution) or does it prefer more flexible measures (corresponding to a partial confinement that exposes the population to greater risks)? National parliaments and civil societies have a role to play to relay the population’s expectations in terms of security and risk. Indeed, hearing the preferences and the demands of the people is a requirement for any responsible political leader. Are we so eager to be protected that we make prolonged concessions in material terms (the recession is affecting people’s lives) and in terms of rights (social distancing affects our right to freedom of movement)? Alternatively, are we ready to accept some degree of risk (by going to restaurants, taking the train, working, we accept the possibility of being infected with the virus but we also do so when other viruses less dangerous than COVID-19 circulate) in order to support economic activity and enjoy full freedom and autonomy? By way of comparison, in the case of terrorism, when the tension between freedom and security is prevailing, those who are being suspected of terrorist activities are the most affected by rules that restrict their liberty and rights; in the case of pandemics, everyone is subjected to heavy restraints on his or her liberty.

I have argued that, in the conditions set above, pricing lives occupies a pivotal in the definition of state responsibility. The state has to seize the tipping point when the burden of a long confinement outweighs the reasonable risk of seeing the virus continue to spread by infecting fewer and fewer people. The responsibility of the state also constitutes an act of trust in its citizens because it will have to transfer part of its responsibility to each person: coercive measures should make way for common sense and for everyone’s sense of correct balance.

Illustration: Frontispiece by Abraham Bosse of De Corpore Politico (1652) by Thomas Hobbes.

Ariel Colonomos will soon publish Un prix à la vie - Le défi politique de la juste mesure with Presses Universitaires de France.