Ethical and cost-benefit considerations

In earlier posts I laid out how inconclusive the evidence for the benefits of lockdown measures is and how varied and hard to quantify their costs are. With everything written in mind, I assume the costs of lockdown policies outweigh the benefits by large. But firstly, this is just my amateurish assumption that might be based on my preconceived notions as much as on the evidence at hand. And secondly, the question whether lockdowns, and especially stay-at-home orders, are appropriate policies is, in essence, an ethical one.

The death of the liberal society

Before getting to studies that deal with cost-benefit analyses, I want to present some more fundamental objections to stay-at-home orders. One is the notion of universal, inalienable human rights. Article 13 of the Universal Declaration of Human Rights states “Everyone has the right to freedom of movement and residence within the borders of each State.” and article 3 says “Everyone has the right to life, liberty and the security of person.”. As Julius Ruechel writes: “Liberal democracy was built around the principle that individual rights must be unconditional. In other words, they are meant to supersede the authority of government. Consequently, individual rights (such as bodily autonomy) were meant to serve as checks and balances on government power. They were meant to provide a hard limit to what our government can do to us without our individual consent.

Unlike the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights clearly defines some limitations to the freedom of movement: “The above-mentioned rights shall not be subject to any restrictions except those which are provided by law, are necessary to protect national security, public order (ordre public), public health or morals or the rights and freedoms of others, and are consistent with the other rights recognized in the present Covenant.

This is one of the legal foundations with which governments justified lockdowns, claiming they were necessary to protect public health. As laid out in the earlier posts on effectiveness of lockdowns and on their health costs, it doesn’t seem evident to me that lockdown measures, and particularly stay-at-home orders, were necessary and proportionate means to protect public health.

I lack the legal knowledge to give any deeper analysis on whether lockdowns were in accordance with human rights. I want to point to one crucial point however, that might be at the centre of this question. Article 3 of the Universal Declaration of Human Rights reads “Everyone has the right to life, liberty and the security of person”. In my understanding, this “right to life” is a protective right against being killed. It seems to be interpreted differently by some, however, who derive from this right an obligation for countries to protect their citizens from death by natural causes, such as a virus. This has been the case in Germany, for example: The constitutional court ruled that curfews were in accordance with the constitution because they meant to protect life and health, which is protected by article 2, point 2 of the German constitution which declares a “right to life and bodily integrity”. My understanding is that this right, like the respective right in the Universal Declaration of Human Rights, was first and foremost written to protect citizens from the state. The constitution was written in 1948 and 1949, shortly after the fall of the Third Reich. Note also that the first article of the German constitution isn’t the right to life, but it states that human dignity is inviolable and article 2, point 1 states that everybody has the right of personal freedom. It is not clear to me how human freedom and dignity are respected by a law that prevents people from leaving their house, based on the completely unproven assumption that this might save people’s lives. But even if it was proven in any way that stay-at-home orders and curfews save lives: In my eyes, reinterpreting a protective right against being killed by a government into an obligation for the government to protect us from forces of nature is the death of any liberal society. The German constitution was written when the country lay in ruins and there was widespread hunger. The inalienable rights it used to guarantee its citizens were not meant to apply only in good times. The right to free movement, the right to assembly, the right of education, professional freedom and other basic rights are not universal or inalienable anymore (or, in fact, they never were) but are from now on to be thought with an appendix “… as long as people are not scared enough”.

Lockdowns meant a radical shift in culture away from individual liberty which has long been regarded as a pillar of European societies to a sort of authoritarian totalitarianism. What is liberal about a government that can decide if and when citizens are allowed to leave their homes? Words that describe the political system in Germany, and much of Europe, in the past 2 years better are authoritarian and totalitarian. I know these are strong words that have traditionally been used for describing dictatorships rather than democracies. But depending on how you define them, they can fit a democracy, too. Cambridge Dictionary defines authoritarian as “demanding that people obey completely and refusing to allow them freedom to act as they wish” and totalitarian as “of or relating to a government that has almost complete control over the lives of its citizens and does not permit political opposition”. The last point doesn’t apply. Democratic governments have not banned political opposition and the freedom of expression has been one of the less damaged fundamental rights. However, many protests have been banned on public health grounds and everybody who speaks against Covid restrictions can report on the verbal abuse they received. Opposition has not become easier in the past two years, but it remains permitted. There is no freedom not to be offended and I am aware that in most countries that we are used to calling authoritarian and totalitarian, I would not be allowed to freely express myself like I’m doing here. Nonetheless, the government indeed assumed almost complete control over our lives. Or following the definition from Wiktionary: “Of or relating to a system of government where the people have virtually no authority and the state wields absolute control of every aspect of the country, socially, financially and politically.” This is precisely what most countries have become. The state wields absolute control of every aspect of society (including the option to “shut it down”) with the single, total goal of fighting the virus. Since March 2020, governments have been taking decisions about nearly every aspect of everyday life. When you are allowed to leave your house or your city, whom you are allowed to meet, and what you are allowed to wear have all become political decisions. The public debate focuses on details of some of these regulations but there has been hardly any debate at all whether the government should even have the power to decide on these issues. I have no better word to describe this than totalitarianism.

Furthermore, important political decisions have been delegated away from parliaments to governments who in turn often delegated them to technocrats. This wasn’t only the case in the first weeks of the pandemic. A very recent example from Germany is that the Robert-Koch-Institut (the German Center for Disease Control) had the freedom to shorten the period individuals count as recovered from Covid-19 after an infection from 6 to 3 months, by a simple update to their website. Under the current rules, such a move has far-reaching implications on the affected people’s lives: Those who lose the status as recovered (and don’t have the status “fully vaccinated” either) need to provide a negative test to be allowed to go to work or to take public transport, for instance, and they are completely banned from most of public life (e.g. restaurants). Restrictions that many would never have imagined in a “free and democratic” don’t even need to be discussed in the parliament anymore.

As someone who grew up in reunified Germany, I have taken fundamental rights such as the freedom of movement for granted. In school, we learned how such rights are the fundament of our constitution as a “free and democratic society”. When we learned about the limits of these rights, I cannot recall any examples of blanket civil rights infringements that came close to what we have been enduring for 15 months. Prison was for criminals and everyone who obliged by the law was supposed to be free. I have witnessed limitations to the right of movement, but they were always very limited in time and space. I lived in Hamburg during the G8 summit for instance. To protect the summiteers, several streets were blocked by the police for a few days. That was about the maximum of restrictions to public life Germany has known before March 2020. Stay-at-home orders have never been an accepted policy in Germany, nor in other countries that self-identified (and absurdly still do so) as free or liberal. Even when all lockdowns end one day, the feeling that the government guarantees these basic liberties will probably never return. Even though a majority doesn’t seem to be bothered too much by this loss of basic liberties, many others feel the same way. See for example this thread on the reddit community Lockdownskepticism where hundreds of users by users express similar feelings as, the user sunny-beans from the UK:

If someone told me in 2019 that Europe would become like this I’d never ever have believed. Maybe I was naive but I just didn’t think it was possible. I thought we as society had overcome this, that I had rights that would protect me from such horrible authoritarian laws. And now for the first time in my life I feel like I can never go back to that feeling of safety. Doesn’t matter what happens, the fear of losing it all will always be with me. The feeling that at any moment I could lose the right to see my family, to work, to have dreams, to have friends, to just live a normal life, will always hunt me. I just feel like I lost this huge part of myself and that from now on I will see the world in much harsher lenses.

The shift away from individual liberties has changed the definition of “public” goods, too. Were the streets and parks of our cities once seen as goods that stand to every individual’s disposal, they are now effectively goods under government control. “Public space” used to be a second home for me. Public space was a promise to the landless to have their individual freedom to use the land around them. Now, public space has revealed itself as less of an individual claim but rather a space that underlies the full control of the public through executive power. A place that you may be granted access to at most times, but sometimes they can take it from you indefinitely or you have to prove to have “a reasonable excuse” for using public space. As a side note, hardly anyone who used the slogan “reclaim the streets” in better times actually did so when the streets were literally taken from them.

Governments now define singlehandedly what is essential, too. Millions of people whose work certainly felt essential to themselves were told that it is not essential to the society. If I feel that I need to see a friend to talk to, it does not matter as soon as society, through its institutions, decides that it is generally not essential to see friends. Individual risk assessment was replaced by a government-enforced social distancing regime. Even in a pandemic, maybe especially in a pandemic, there would be a strong ethical cause for allowing individuals at risk to decide how they want to deal with this risk. Elderly people who prefer to maximise their life expectancy could be given individual assistance (e.g. by delivering groceries to them) while others who want to spend the rest of their earthly days playing with their grandchildren should equally be allowed to do so. But in many cases, even the last wishes of dying people had to stand behind the the rules of authoritarian micromanagement.

An area of life that has been labbeled “inessential” almost entirely is culture. Intangible cultural heritages have been damaged and no one can put the costs in numbers. Culture always changes, but I was used to society valuing cultural heritage so I think the destructive impact of lockdown policies on parts of our culture should be taken into account. These costs are mostly not caused by stay-at-home measures though but are due to “milder” policy interventions such as bans on gatherings and venue closures. We became used to seeing football matches without cheering fans. Carnival was cancelled entirely. Night clubs had been closed for nearly 1.5 years and when they reopened, they weren’t the same. Instead of being a refuge to immerse into the music and forget about the problems of daily life, they have become places of medical segregation where the “unvaccinated” are refused entry. In most countries, masks continue to serve as a reminder of lockdown culture no matter where we go. Large concerts have not taken place and in some countries, there is no perspective of mass events being ever allowed again to the same extent as before 2020 and without masks, vaccination passports or other Covid restrictions. In most European countries, restrictions remained in the summers of 2020 and 2021 despite extremely low caseloads. They remained throughout 2021 (with a few exceptions like the UK, Denmark, and Sweden) even after everyone had been offered vaccination. It’s almost 2 years since “2 weeks to flatten the curve” to prevent overflowing hospitals during the first outbreak in an immunologically naive population (disregarding cross immunity). But in most European countries, restrictions remain in place, because the culture changed. For many people, safety from pathogens has become a main priority in life. Enjoying music with strangers is not valued much by the median voter anymore. Life expectancy is at an all-time high in human history, yet prolonging the life of older people has been given priority over maintaining the life quality of all. I am certain that the perspective of the stranger as a threat to our health instead of someone who increases our pleasure in enjoying something has tremendous consequences for social cohesion. I first wrote the last sentence in the summer of 2021, but half a year later, I should add that the notion of the “unvaccinated” stranger as a threat to our health doesn’t improve social cohesion either.

Cost-benefit analyses

Note that all the following applies for any “lockdown” non-pharmaceutical interventions and are not limited to restrictions on movement. Even under the premises that individual rights have to stand behind in a pandemic, it still seems a reasonable requirement for policies that they do more good than harm. Yet governments did not perform a comprehensive cost-benefit analysis before announcing lockdowns (see e.g. Allen 2021). Any sober estimation of undesired effects were sidelined over the fear of collapsing hospitals.

How could such a cost-benefit analysis have looked like? Which currency can we measure costs and benefits in? Economists’ favourite GDP would not be the best choice: The vast majority of people who died from Covid-19 in richer countries are retired, so if we limit our cost-benefit analysis to economic effects, we would see elderly people as net receivers rather than contributors and their death might increase GDP per capita. But luckily, most people don’t value human lives only for their contribution to the economy. Most people agree that it is morally imperative to save a human life.

But at what cost? And what makes life valuable? Would it be justified to spend the rest of our days in isolation if it just saves one life? Even if we agree that saving human lives is virtuous, it would be impractical to equate life with the attempt to postpone death for as long as possible. And even if we interpret life as the sheer avoidance of death, the reality of a pandemic, or more fundamentally, of a society, constantly requires valuing lives against each other. Confront people with a trolley problem like this: A trolley is bound to roll down a track to which a toddler is tied. If you pull a lever, the trolley is redirected to another track to which two elderly persons are tied. In this scenario, many people would be willing to sacrifice two elderly people for one baby. The largest experiment made in this regard was the Moral Machine Experiment conducted with half a million volunteers from all over the world. Confronted with a situation where an automated car had to decide between killing different people, respondents showed a strong preference for saving children over saving the elderly. So, to leave the metaphor, I am not alone with my opinion that public health policies should not have the only aim to minimise the absolute number of deaths at all costs. We should rather take into account the number of life years that are saved which implicitly means that children are given greater weight than old people. For an early application of the trolley problem framing to Covid-19 containment policies, I recommend Paul Frijters’ blog article from March 2020.

When evaluating public health policies, the WHO has used the measures of “Years of potential life lost” and disability-adjusted life years (DALYs) that weighs years lived with a disability less. The idea is that if people are given the hypothetical choice to live x years with a disability and y years without, for people to be indifferent, x is usually considerably larger than y, i.e. people would accept to die earlier but in a good overall health condition. A related concept is quality-adjusted life years (QALYs) that weighs years lived by the overall health in which someone spent them. A year in perfect health equals 1 QALY and death equals 0. All these calculations may seem cruel to people unfamiliar with public health. They are in fact commonly used nevertheless. The WHO calculates with DALYs, and QALYs are used in cost-utility analyses of public health interventions in the United Kingdom. Another very similar measure to QALYs are WELLBYs, “well-being years”

The Dutch Ministry of Economic Affairs carried out a cost-benefit analysis using QALYs in the spring of 2020. The analysis was not published at the time, but it was brought to light over a year later thanks to a freedom of information request by a Dutch lockdown skeptic (see this article in the Daily Skeptic). The Dutch assumed that one year of lockdown would save 100,000 QALYs. With a value of 80,000 Euro attached to each QALY, the expected benefits of lockdown would equate 8 billion Euro. The costs were estimated to be 70 billion however. Therefore the authors concluded that “a one sided focus on mortality should be avoided” and the “health of the elderly should not be given an indisputable priority”.

Fan et al. (2021) estimated the global number of DALYs due to Covid-19 until 30 April 2021 to 32 million. Meanwhile the Covid-19 Mental Disorder Collaborators (2021) estimate that the pandemic has caused 10.7 million additional DALYs for major depressive disorder and 9.05 million for anxiety disorder. It’s clear that these can only be rough estimations.

As a side note, and at the risk of being called heartless, I do not think that it is fair to assume that dying from Covid is always worse than not dying from Covid. Even though most of us do not like to think about it: We are all going to die and postponing this inevitability for as long as possible is not always in the best interest of the respective person. There are millions of ailing old people suffering from chronic pain or fighting a hopeless battle against cancer. There are millions of old people suffering from severe dementia who cannot take any conscious responsibility for their life (or death) anymore but whose younger self had felt nothing but agony if they knew how they would live their last years. Most of us know people whose death was nothing but a relief for themselves and their loved ones. Modern medicine can keep people alive for a long time but in some cases, it is a life deprived of dignity. Given that nearly all people who died from Covid-19 were old or sick, it is fair to assume that for many, Covid-19 meant a relatively quick death that prevented them from years of suffering. Of course that does not hold for all and maybe not even for most Covid deaths but given that the median of Covid-19-related deaths is above 80 in Germany, it is likely that a significant share of them was suffering or was about to suffer from conditions that can make death look more like a promise than a threat.

There are profound ethical reasonings for the value of a human life to be infinite or immeasurable, but this line of thinking makes it difficult to perform any cost-benefit analyses and is therefore not too common among economists. As Douglas Ward Allen (2021) writes:

In economics, the concept of “value” is based on the idea of maximum sacrifice.  How much one is willing to sacrifice, at most, for something determines that individual’s economic value of the thing.  Thus, when it comes to the value of an individual’s life, this value is determined by the actual individual.  In practice, what is measured is how much individuals are willing to sacrifice to extend their life a little bit by reducing some type of harm (called a ‘marginal’ value), and then use this to determine a total value of life. Every day people make decisions that directly and indirectly are based on their marginal value of life.  The decisions to eat poor foods, smoke, accept dangerous employment, cross a street, drive a car, exercise, or engage with others all entail risks to life and therefore imply a value of life.

Allen performed a cost-benefit analysis for lockdown policies in Canada. His calculations are based on the following thought experiment: Suppose you could live one year under lockdown vs. X months under pre-lockdown normal conditions: How big is X, i.e. how many months would you be willing to give up? Allen calculates that if X was 10, i.e. the average Canadian would prefer to die two months earlier for passing on a year of lockdown, the costs of lockdowns in years of lost (valued) lives exceed the benefits by the factor 3.6 even when using the initial Imperial College model from March 2020 that grossly overstated the number of lives lost in the absence of lockdown and which never became reality anywhere in the world. Using a more realistic model with updated assumptions Allen calculates the costs of lockdown to outweigh the benefits by the factor 282 for Canada. In a similar approach, Frijters estimates the global costs of all Covid-19 containment policies (not stay-at-home orders alone) to outweigh the benefits in healthy lives lived or happy lives lived by the factor 50.

Joffe and Redman (2021) review 11 cost-benefit studies on lockdown measures that all came to the conclusion that lockdowns were highly inefficient policies. The smallest ratio of costs to benefits was 2.5 and the largest 26. As the authors note “these cost-benefit analyses have made assumptions in favor of lockdowns (i.e., marked reductions in COVID-19 fatalities), and very conservative against lockdowns (e.g., not including the predictable effects of loneliness and unemployment on lifespan and chronic disease, of societal disruption on world food insecurity and poverty rates, of interrupted health care on conditions other than COVID-19; and using the highest estimates of the value of QALY or WELLBY)”.

A good read on the costs and benefits of “lockdown” policies is Joffe (2021). Ari Joffe puts some numbers in context, e.g. regarding different causes of death. He calculates that on 4 September 2020, 3,500 people had died following a SARS-CoV-2 infection per day. By 30 June 2021, an updated figure is 6,800 deaths per day: 3.95 million Covid-19-related deaths due to Our World in Data divided by 577 days since 1 December 2019. 3,500 or 6,800 deaths per day are certainly huge numbers without context. Joffe (2021) provides context by pointing to some other common causes of death: 1,100 persons die of Malaria each day which predominantly affects children and thus likely causes more years of life lost than Covid-19. Even Measles with 384 daily fatalities might be comparable to Covid-19 in years of life lost. Influenza causes more than 1,000 deaths a day and HIV nearly 2,000. Motor vehicle collisions claim the life of 3,700 people a day which implies more years of life lost than by Covid-19 given that most people who die in car crashes are not over 70 years old. All these figures are dwarfed by the estimated 22,000 people daily who die prematurely due to tobacco use and the 30,000 who die prematurely due to dietary risk factors.

If we want to minimise the years of life lost which I deem ethically superior over minimising the absolute number of deaths in a given period no matter the age of the deceased, we should focus more on providing bed nets and Malaria treatment, improving road safety, raising awareness about the negative impact of smoking and on promoting healthy food. The first two issues mainly affect poorer countries while the latter two are global phenomenona. I am not convinced of the authoritarian, coercive type of policies that became fashionable lately, but even softer “nudging” interventions such as a tax on sugar, bans on tobacco ads or cooking classes in secondary school could save more QALYs or DALYs than any lockdown measures.

Joffe estimates that lockdowns costed a minimum of 5 times more WELLBY under very unrealistic assumptions. For example, Joffe assumed that lockdowns would eradicate the virus and prevent any infections which is clearly not a realistic assumption. Changing the assumptions to presumably more realistic ones renders a cost-benefit ratio of 50 to 87. Also, “importantly, this cost does not include the collateral damage discussed above (from disrupted healthcare services, disrupted education, famine, social unrest, violence, and suicide) nor the major effect of loneliness and unemployment on lifespan and disease”.

Miles et al. (2020) calculate the costs and benefits of lockdown in the United Kingdom in terms of QALYs. They calculate the cost-benefit balance for under different assumptions regarding the lives saved by lockdown and the economic costs of lockdown. Their analysis does not include any adverse effects of lockdowns on physical and mental health or any other costs except GDP lost. Even under the most unrealistic assumptions of 440,000 lives (not QALYs) saved through lockdowns and an immediate economic recovery, the costs of lockdowns exceeded the benefits by 125 billion Pound. Miles et al. calculated with a value of 30,000 Pound per QALY which is “the figure used in evidence-based resource decisions within the UK health system. (…) In using this yardstick, we are treating decisions on how to
face COVID-19 in the same way as decisions in the UK are made about resources to apply to the treatment of cancer, heart disease, dementia and diabetes
“. Miles et al. acknowledge that in the United States, a QALY is valued around three times more but equally point out that the benefits would still not outweigh the costs.

These cost-benefit analyses make estimates for the entire population. It is noteworthy that even if cumulated costs exceed benefits by far, some groups benefit from lockdowns. As policy making is always an act of balancing opposing interests, its outcome can only be understood if taking into consideration who are the groups which benefit and who are the groups which lose out from an intervention. Regarding any SARS-CoV-2 containment measures, those who benefit (if the measures were effective, which they mostly are not) are those aged 60 and above who account for the vast majority of Covid-19-related hospital admissions and deaths. For coercive measures such as stay-at-home orders, those benefitting are actually only a subgroup of the elderly, namely those who value their safety from the disease more than their freedom to enjoy their last years of life according to their own will. On the other hand, even younger people who are extremely anxious about infections subjectively benefit from containment measures. People who prefer authoritarian policies and like to impose their will on others clearly benefit more than those who value individual freedom. For strict lockdowns with stay-at-home orders, poorer people with little space, parents, children, and young adults are among the groups most negatively affected. People with a lot of space, private gardens, and the possibility to work from home are among those for whom their personal cost-benefit analysis could rationally be in favour of stay-at-home orders measures.

I am not aware of any cost-benefit analysis that comes to the conclusion that lockdowns have been beneficial for society as a whole (please write me if you know of one and I will include it). The common belief that they were and are beneficial is mostly grounded on a blinkered view on suppressing the virus with optimistic assumptions concerning their effectiveness, and neglecting any negative effects. This is particularly odd when you compare it to the approval process for vaccines and the public discussion about their safety. In early 2022, raising questions about vaccine safety has been stigmatized by large parts of the public. Much of the media doesn’t allow for publishing any other opinion than that everyone should get vaccinated. But in early 2021, German media was still full of discussions on whether it was safe to get a shot of the Astra Zeneca vaccine after some 5 in one million developed blood clots. People worried about this side effect even though the vaccine had been approved in large clinical studies. These studies were somewhat rushed and I can understand people’s worries that too many corners might have been cut in the approval process. But side effects of non-pharmaceutical “lockdown” policies are far more common while there has been no scientifically sound admission process at all. If lockdowns were a vaccine, they would certainly be rejected. Clinical studies for any policy intervention might be too much to ask for, but to prevent policy makers to rush policies that do more harm than good, it might be necessary to put a heavier burden of justification on them. The idea of universal human rights that I portrayed further above could perhaps be an effective checks to keep policy makers from causing mayhem.