Picture this scenario: You walk nervously into the office of the oncologist to whom your primary physician has unexpectedly referred you, and as soon as you see the specialist's facial expression, you know the news is bad. You're right. "If only we'd caught this six or eight weeks earlier," the oncologist says.
This is an experience shared by thousands of Americans every year. The COVID-19 shutdown will add to their numbers. According to Anthony Fauci, the nation's most prominent immunologist, the lockdown orders, by keeping patients away from routine medical screenings, will likely result in some 10,000 excess cancer deaths over the next five years. This is a classic trade-off: allowing some people to die in order to protect others. But somehow, we never frame it that way. We deliberate poorly in times of emergency; as a result, we make bad decisions.
Let's be clear. These aren't deaths caused by the pandemic. These are deaths caused by our response to the pandemic. Even though patients in most places can now go back to the doctor, the damage has already been done. When we tell patients to skip "routine" screenings and appointments, we're sentencing thousands of people to premature and preventable deaths.
All because we failed to think things through.
Elaine Scarry of Harvard University, in her fine 2011 book "Thinking in an Emergency," reminds us of the temptation, when things go haywire, to vest government authority outside the processes of democracy. The trouble, she argues, is that in the effort to stay safe, we tend to yield "our elementary forms of political responsibility." Writes Scarry:
"The implicit claim of emergency is that all procedures and all thinking must cease because the emergency requires that 1) an action must be taken, and 2) the action must be taken relatively quickly."
At such moments, she argues, the mind goes into "exile." We essentially stop thinking.
That certainly seems to be what's happened here. Oncologists have long been sounding the alarm about the price of the shutdown. Remote medical appointments are no substitute for physical visits unless there's evidence in the blood work. Often there is. But blood chemistry can also be a trailing indicator. Clinical signs sometimes appear in the body before they are detectable in lab tests. As one oncologist of my acquaintance remarked in March, "You can't palpate lymph nodes on a video visit."
Fauci's estimate of 10,000 deaths echoed a June prediction from the National Cancer Institute July 20 article in Lancet Oncology, relying on data from the English National Health Service, concluded that lost medical visits in the United Kingdom would likely lead to enormous increases in the number of cancer deaths five years after diagnosis. Breast cancer deaths, for example, are expected to be 7.9-9.6% higher. For colorectal cancer, the predicted range is 15.3-16.6%.
Cancers will be missed early, and found too late. Here's Dr. Norman Sharpless, head of the National Cancer Institute, writing in the journal Science:
"There already has been a steep drop in cancer diagnoses in the United States since the start of the pandemic, but there is no reason to believe the actual incidence of cancer has dropped. Cancers being missed now will still come to light eventually, but at a later stage ('upstaging') and with worse prognoses."
Maybe the trade-off has been worth it; but we shouldn't make trade-offs of such weight and import without public debate.
The time to deliberate about emergencies, says Scarry, is before they occur. The problem is that we're not good at talking about emergencies that seem remote; and then, when the emergency arrives, it's too late for a conversation. At times, we try — a little more than a decade ago, a federal task force published an excellent primer on how governmental and private entities alike should prepare for a future pandemic — but few of its recommendations were ever implemented.
Scarry had in mind the poor quality of our deliberations over national security, particularly the policies governing use of nuclear weapons and the decisions about how the U.S. would defend against terror attacks after 9-11. But her reasoning applies to COVID-19 too.
When state governors and public health authorities began urging and then ordering people to stay home, they spoke only of the benefits: that by avoiding contact we'd slow the spread of the novel coronavirus. They did not add, "Sadly, several thousand people will die of cancer as a result." We were asked, in Scarry's terminology, to send our minds into exile.
Had we had debated openly and honestly the potential medical costs of the shutdown, we might well have reached the same result. We might have decided to sacrifice some lives to save many more. On the other hand, we might have chosen instead to urge more patients and doctors to continue in-person appointments, rather than closing medical offices. We'll never know, because we never had the conversation. What we do know, and must not shy from admitting, is that the policy we chose saved a lot of lives but sentenced others to death.
My mentor, the legal scholar Guido Calabresi, has argued that the best way to deal with the tragic choices we face in making policy is to talk about them honestly and openly. When we pretend there aren't any — when we talk as if the solutions we choose to one problem don't cause others — we're lying to ourselves. And the worst time to do that is when lives are at stake.
Carter is a Bloomberg Opinion columnist. He is a professor of law at Yale University and was a clerk to U.S. Supreme Court Justice Thurgood Marshall. His novels include "The Emperor of Ocean Park," and his latest nonfiction book is "Invisible: The Forgotten Story of the Black Woman Lawyer Who Took Down America's Most Powerful Mobster."
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