WASHINGTON — With all 50 states now reopened to varying degrees, state and local officials are wrestling with how fast to reopen the rest of the economy as the number of COVID-19-linked deaths continues to climb nationally and the number of unemployed Americans soars past 38 million.
Death counts, hospitalization rates and other health metrics have largely guided the decisions Gov. Andrew M. Cuomo and tristate region governors have taken so far to reopen, but with unemployment rates reaching record highs and small businesses at the brink of bankruptcy, ethicists contend policymakers are faced with grim ethical considerations — save lives or save livelihoods?
Without a readily available vaccine and amid concerns from some epidemiologists that a second wave of COVID-19 infections could hit in the fall, public officials have been forced to reckon with “the calculus of how much economic opening leads to how many deaths?” said Dr. Jacob M. Appel, director of ethics education in psychiatry at New York’s Icahn School of Medicine at Mount Sinai.
“Where do we draw that line? What’s the tipping point?” Appel said. “The idea that we should save every life is implausible. The idea that we should open the economy if it's going to cost 5 million lives is also implausible. There's some midpoint.”
President Donald Trump, who has ramped up calls for a full-fledged reopening of the economy, also has said “one life is too many” when asked how many deaths are acceptable in calculating the risks of reopening.
Cuomo has said the “cost of a human life is priceless” and that there should be no trade-offs between public health and the economy.
But Appel said those political pronouncements may offer comforting sound bites, but they ignore scientific models that show reopening will invariably lead to more people dying from the virus.
“As a matter of philosophy that's lovely, but as a matter of public policy that simply doesn't reflect our policy outside of the pandemic,” Appel said, referring to the political statements. “If our goal were really to save all lives at all expense we would require everyone to have a flu shot. But we don't do that, because we make some trade-offs between people's freedom and the health care of others …
"If we were really interested in saving lives, we would spend a vast sum of money on both preventive health care and research, maybe 30% or 40% of the U.S. [Gross Domestic Product.] We would have very, very few consumer goods and much less economic freedom. We don't make that trade-off. So in normal times, the idea that we always try to save lives even if it reduces the quality of life simply isn't true. The question is in the context of pandemics, how do you view that underlying calculus when the stakes are much higher?”
Dr. Mildred Solomon, president of The Hastings Center, a nonpartisan bioethics think tank based upstate, said that while the debate to reopen has been framed as a trade-off between saving lives or saving jobs, political leaders should “stop thinking” it has to be one or the other. "You can have both your life and your livelihood and, in fact, you have to focus on both because if we lose our livelihoods, we will lose our lives as well.”
“We humans like to think in either or, black and white,” Soloman said. “We say, 'we think that we have to trade off between economic well being and health,' when in fact they are very intertwined … the goal should be to solve a problem that takes into account all the different things we have to consider and recognizes interrelationships between economic and health well being.”
Some of the country's leading economists, who have served in both Republican and Democratic presidential administrations, have likewise argued in a letter to Trump that "saving lives and saving the economy are not in conflict right now."
"Our paramount concern at this moment should be to slow the spread of this virus and equip our health care system to effectively respond," wrote members of the Economic Strategy Group, an offshoot of the Aspen Institute, a nonprofit think tank. “We will hasten the return to robust economic activity by taking steps to stem the spread of the virus and save lives."
Trump, in calling for governors to further ease their social distancing restrictions, has argued that tens of millions of workers will remain unemployed if states stick to a phased reopening strategy that was advocated by his own administration.
“I think that a lot of these states … the ones that are, sort of, sticking to a certain, very rigid pattern, I think they’re going to stop,” Trump told reporters on Thursday. “I don’t think the people are going to stand for it. This is a country that’s meant to be open, not closed.”
Trump's press to reopen comes as protests have cropped up throughout the country from people arguing that stay-at-home orders have been too restrictive. Often the protests have been led by the president's supporters calling for lawmakers to roll back social distancing rules.
Trump has acknowledged there are likely dire consequences to reopening, telling ABC News recently “it’s possible there will be some” deaths associated with a rollback of the federal social distancing guidelines. But he has repeatedly argued that keeping businesses shuttered or functioning at a limited capacity is not only taking an economic toll but impacting the mental health of Americans.
“Will some people be affected? Yes.” Trump told ABC News anchor David Muir on May 5 when asked about reopening. “Will some people be affected badly? Yes. But we have to get our country open and we have to get it open soon.”
Trump’s push to reopen comes as the number of confirmed COVID-19 cases has soared past 1.5 million and more than 92,000 people in the U.S. have died from the virus — a number that’s expected to climb to 143,000 by August, according to projections by the University of Washington Institute for Health Metrics and Evaluation. The institute initially projected half that amount in March, but revised its figures amid a loosening of social distancing guidelines across the country.
The institute’s forecast, which is among those used by the White House Coronavirus Task Force, projects that by August 32,132 New Yorkers will have died from the virus.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has repeatedly laid out the difficult choices facing government officials as they weigh their reopening strategies.
“It’s the balance of something that’s a very difficult choice, like how many deaths and how much suffering are you willing to accept to get back to what you want to be, some form of normality, sooner rather than later,” Fauci told CNN in an interview earlier this month.
Health and Human Services Secretary Alex Azar, in an interview with CBS’s “Face the Nation,” said that while the ongoing debate over the pace of reopening “gets set up as a health versus economy kind of conflict … it’s actually health versus health.”
“We see reduction in cardiac procedures, cancer screenings, pediatric vaccinations,” Azar said, noting the temporary halt on some elective medical procedures at hospitals. “There is … a very real health consequence to these shutdowns that must be balanced against as we try to reopen this economy and move forward.”
Cuomo has argued that the debate over when and how to reopen should not be framed as a binary choice that pits the health of New Yorkers against their economic well-being.
"To me, I say the cost of a human life is priceless, period," Cuomo said a May 5 briefing. "Our reopening plan doesn’t have a trade-off. Our reopening plan says you monitor the data, you monitor the transmission rate, you monitor the hospitalization rate, you monitor the death rate. If it goes up, you have a circuit breaker: You stop. You close the valve on reopening.”
Long Island’s county executives echo Cuomo’s stance, arguing that a ramp-up of testing and contact tracing will allow officials to focus on containing specific hot spots instead of requiring across-the-region closures.
Nassau County Executive Laura Curran said “it’s not one or the other … we can find the balance” between working with local businesses to reopen while ramping up testing and tracing of COVID-19 cases.
Suffolk County Executive Steve Bellone said “there haven't been any decisions in this that are just purely black and white,” but with the number of cases across the region steadily dropping the “main focus right now is reopening the economy safely.”