Listen: The Ethical Calculus of Reopening

A medical ethicist weighs the options.

Coronavirus cases are on the rise in many states. A vaccine is, for now, a distant dream. How do we negotiate the ethical trade-offs of the deaths to come in the meantime? Lydia Dugdale, a medical ethicist and the author of The Lost Art of Dying, joins to discuss.

Listen to the episode here:

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What follows is an edited and condensed transcript of their conversation.

Katherine Wells: I don’t know how to comprehend the scale of death that we’re seeing right now. Do you feel like you have a better handle on it, or has this been sort of overwhelming for you, too?

Lydia Dugdale: I think among doctors there’s probably a wide range of how people are processing this, and I can’t claim to speak on behalf of every single physician. But we see death all the time. And especially in my role taking care of adult patients, they’re thinking about aging and their mortality and getting the proverbial house in order. This is what I’ve been writing about for the last decade or so; I’m kind of thinking about death all the time.

Wells: One of the things I’ve been thinking a lot about is what kind of death is … I don’t know if the word is acceptable or just something that we have become accustomed to? And what kind of death is novel? And this is such a novel form of death.

Dugdale: That’s right. It’s a shock. It came upon us very quickly, and sort of unlike the flu, which drags out over months, it just slammed us. I think the degree to which it was absolutely preventable is a matter of debate, honestly. Because you can’t lock down everyone forever, right? Even for me, working as a doctor during this time—there’s thousands and thousands of people related to health care that are being exposed and have to be exposed for the sake of caring for their patients. There’s no absolute lockdown possible.

Wells: So the idea that no one would ever be exposed is impossible, but we can make choices about how many people are exposed and how necessary those exposures are, right?

Dugdale: That’s right. We can. So we’ve all seen the curve, right? And we’ve all been told, Flatten the curve. The curve is really the number of cases over time and that area under the curve is the number of people who either get sick or die, depending on which curve you’re looking at. The question then is, if we flatten the curve—which I really believe we did in New York—does the actual area under the curve, meaning the number of people who die, does that change? Or does it just get stretched out? And that’s what we don’t know.

Wells: Meaning, is the absolute number of deaths the same no matter how fast or slow it goes?

Dugdale: There was a lot of hope initially that while we flatten the curve, we’d come up with a vaccine, or a treatment, and then we’re out of the woods. But so far that hasn’t played out.

Wells: Jim, we’ve been talking about this. It doesn’t seem like a vaccine is going to come within any reasonable period of time, right?

James Hamblin: No, not in the near future. It’s not going to come in one pill or one magical practice that suddenly makes this a totally survivable condition. But doctors are at least getting better at identifying crashes and managing people to some degree, right?

Dugdale: We’ve definitely made advances, for sure. But there’s still so much we don’t understand about this virus. There’s no magic bullet. I think in American medicine, Jim, as you know, people are really looking for that magic bullet. What pill I can take so that I can get up and walk and go home.

Wells: I’m just going to ask you this really directly because it hasn’t been as clear to me as I would like it to be. You both think that we are at a point where a vaccine is not going to come in time to make a meaningful difference in the number of deaths we have, at least in the United States?

Dugdale: That’s right. Yeah, not in the next year, probably.

Wells: And so the important question to be asking is how do we get through the reality that the pandemic is just going to tear through our country? How do we get through that in the most ethical and least horrific way possible? Is that right?

Dugdale: I think so, yeah, that is right.

Wells: I guess I’m trying to figure out: What are the ethical trade-offs that are being made here? To me, it just seems like any death is bad.

Dugdale: Any death is bad, but there are also deaths from the economic shutdown. So there is one way that people have framed this as deaths of old people and racial minorities juxtaposed to the economy. I don’t like that language at all. I don’t want people to die, but at the same time I am also seeing substantial suffering, which leads to deaths, because of the economic downturn.

I’m in New York City. I know that there’s been an uptick in intimate-partner violence. There’s been an uptick in child abuse. There’s the problem of a lack of education for at least six months. We already know that kids who do no summer work fall behind by about a half a year. Now you have kids missing several months of school and no summer work—they’re probably going to fall behind by a year. Then there’s a lack of access to food: Many kids in New York City get their meals through the school system.

Then there’s all of this data that we have on the correlation between socioeconomic status and health. A job loss, losing health insurance, correlates with worse health outcomes. Then there’s the questions of suicide, alcohol, drug overdose. There have already been predictions in the medical literature that we should expect to see a spike in all of those. You take all of this and you say there are real health outcomes that are bad from this lockdown.

Wells: Right. It’s not just some sort of abstraction; it’s that we are balancing multiple kinds of harms.

Dugdale: That’s exactly right. We’re always making trade-offs.

Hamblin: The question that I have: Isn’t there a third way? There’s this sort of pull between do we go back to the way we used to do things? Or do we stay in a shutdown mode? I worry sometimes people see that as a false dichotomy instead of thinking: Can’t we open the streets and make parks bigger? Can’t we make more places for people to do the things they love in new and different ways? Instead of sheltering in place and waiting until we can go back to the system just as it was—there’s a lot of economic benefit to be had just by thinking of new ways to give people the lives that they want.

Dugdale: I think you’re right. There will be some novelty that comes out of this that’s really good. A lot more people will be working from home more, fewer people will be on the roads, there may be less pollution. We’re not going to go back to life as we knew it in January. That’s just not gonna happen.

Wells: What is like the highest projection [of deaths] that you’ve seen? We’re now at 120,000 deaths.

Dugdale: The number out of the U.K. was 2.2 million for the U.S.

Wells: We’ve probably avoided reaching 2.2 million, but let’s say it’s somewhere between 200,000, which is a given at this point, and 2.2 million, which was the highest prediction we’ve seen. For the purposes of this discussion, say the number ends up being in the middle of that, and it ends being 1 million in the U.S. over the next two years. How do we do that in the most ethical way possible?

Dugdale: So to talk about ethical death, I guess the preface should be that mortality is 100 percent, right? Death is always a tragedy. It rips holes in communities. It’s something that we grieve about, and rightly so. At the same time, is all death preventable? No. Will all people die? Absolutely. And so my own work then has been starting from a posture of saying, I’m finite. And because I have a finite existence, I need to anticipate my death and prepare for it.

More than a decade ago, I stumbled across this body of literature from the late Middle Ages called the Ars Moriendi, which is Latin for “the art of dying.” These were handbooks that developed in the aftermath of the mid-14th-century outbreak of bubonic plague, which devastated Western Europe. Some historians think that maybe up to one-third of Europeans died. So people who survived went to the leading social authority at the time, which happened to be the Church, and said, You need to help us prepare for death, because this plague could come back or there could be war or there could be famine, but we could face massive loss of life again and we need to be prepared.

Hamblin: We’ve talked about kind of having the conversation with family and having an advance directive and making your wishes known, but apart from that, how does one prepare for death?

Dugdale: So it’s getting at questions such as, What gives my life meaning? And then along with that, it’s these bigger existential questions. Why am I here? What is this for? What does life mean? What does it mean to be human? There are the advanced directives, but I really think, as a primary-care doctor, that these conversations, they’re not just one-offs. You don’t just sign the document. I talk about it each year with my patients.