ne of the most philosophically interesting questions is how to determine a person’s “cause of death”, and one of the most philosophically interesting documents is the death certificate. You may not be surprised to learn that the first such certificate emerged in London during outbreaks of the plague in the 16th century. It had the portentous name of “bill of mortality” and was used to record how many people had died in a given area, thus alerting healthy people of the places to avoid.
The taxonomy was crude, as documented by Kathryn Schulz of The New Yorker. By the 17th century in England you could die “of Bleach and of Blasted, of Cramp and of Itch” and of the “Rising of the Lights”. As our A doctor writing out a certificate has to determine which of this capacious list should be included in the section on cause of death. Line A asks for the “Disease or condition directly leading to death”. Line B asks for “Other disease or condition, if any, leading to A”. Line C asks for “Other disease or condition, if any, leading to B”. In other words, the causal chain leading from life to death is afforded a maximum of three links (with an additional line on “contributing” conditions). An example might be: death caused by pneumonia, in turn caused by cancer.
Yet despite the extensive list of causes, here is a word you will never find on a death certificate: “recession”. This despite the fact that recessions cause mortality and suffering on a large scale, through multiple channels, such as chronic disease, mental illness and constraints on healthy choices because of poverty, as the economist James Banks has detailed. In other words, economic factors can, and do, operate as earlier links in the causal chain of mortality — links that do not, and cannot, figure on death certificates.
I mention this because we are told that government decisions are based on “science”. This makes it sound as if science is a unitary discipline that uses data to provide objective answers.
In truth, science is multifaceted, made up of different paradigms, data sets, heuristics, theories and models. Medics look at mortality in a particular way, economists in another, evolutionary biologists in yet another. Each of these perspectives can be useful, depending on the question being asked. And each can be defective if used in isolation, or beyond the scope of its empirical orbit.
This brings me to Covid-19, perhaps the most complex political problem of modern times. It is wrong to call it a health problem, an economic problem or even an epidemiological problem. The way we deal with this will need to draw upon knowledge in all those domains, and more. A medic will inevitably use the lens of disease to think through an appropriate response, an important part of any discussion. But such a perspective will neglect other issues of significance. For instance: when an economy shrinks, innovation declines, leading to deaths that might have been avoided through advances in scientific knowledge. Medics are unlikely to have the training to reason through the dimensions of this counterfactual. An economist is better placed.
This suggests that the deepest question facing the government is not determining what scientists think, for they think different things. The question is how to draw upon the arsenal of scientific knowledge that impinges on this multidimensional problem, and then to triangulate this knowledge to chart the wisest course. The phrase “our decisions are guided by the science” therefore raises a very deep question indeed. Basing decisions on a narrow branch of science — or, say, a single epidemiological model, not yet peer reviewed, from Imperial College — is not scientific.
The leak of the membership of the government’s scientific advisory group for emergencies (Sage) caused some turbulence, not least because of the news that Dominic Cummings has attended some of the meetings. One question will be whether the prime minister’s chief adviser listened and observed, or participated and steered. Another will be whether the principal members of the group are sufficiently broad in outlook to consider the full health and behavioural implications of such a complex crisis. There are a lot of mathematicians and modellers.
Either way, the advice of Sage can represent, at most, one input into the broader judgment facing the government. It is how these considerations interact with those of the Treasury that will drive the most consequential set of decisions of a prime minister in recent times. The balance between lives and livelihoods, between the demands of a functioning economy and those of public health, is now pressing upon ministers. Ultimately, however, it is only Boris Johnson who can decide — and without the twenty-twenty precision of hindsight available to his critics in the years to come.
What is abundantly clear is that the political risks are by no means symmetrical. An easing of social restrictions will lead to short-term fatalities that might otherwise have been avoided. The causal chain from the political decision, to the contracting of Covid-19, and to death (for those susceptible) is short and direct. It doesn’t take a leap of imagination to see a future inquiry drawing this connection and ministers being demonised for their actions. If a vaccine is found quicker than expected, say within six months, these excess deaths will have particular emotional resonance.
Sustaining the lockdown, on the other hand, will lead to hardship and death through a longer and more convoluted causal chain. In 10 years’ time, in 20, those passing away will not have “lockdown” written on their death certificate but a gamut of mediating pathologies, their lives blighted, economically and psychologically, by the attrition of this artificially induced economic coma. Counterfactuals about the fuller lives that might have been lived, the innovations that might have been sparked and the deaths that might have been avoided, will not enter future medical analysis, perhaps not even the history books.
My sense is that the British public recognises the terrible bind confronting Johnson as he convalesces from an illness that almost ended his life. We would be wise to remember that when a scientist offers an opinion, they always speak from a position of partial knowledge while often, if unconsciously, smuggling in assumptions and value judgments. This is why a decision based on “science” is not necessarily scientific or, indeed, wise.
Sunday, 26 April 2020
Matthew Syed on C19 from The Sunday Times