The young and the old are by far the most harmed by COVID-19 policies, says Paul Dolan (LSE). They tend to have a stronger preference for quality over quantity of life than middle-aged people, who have been the ones making the decisions.
It is well documented that the morbidity and mortality risks of COVID-19 are trivial for younger people. Less than 1% of COVID deaths in the UK have been in people under 40. Yet every policy measure in response to the pandemic, from the closure of schools to the decimation of the night-time economy, has caused the greatest economic and social harm to younger people. We are witnessing one of the biggest redistributions of resources from those who have the worst lifetime prospects to those who have already had the best prospects in human history.
Even more disturbingly, perhaps, the policy responses are probably not even in the best interests of older people if anyone cared to ask them. Not only are older people often more strongly in favour of prioritising younger over older people in resource allocation decisions in healthcare, but they are also more willing to trade-off life expectancy for better life experiences. I have been involved in several large-scale general population studies that sought to elicit trade-offs between life expectancy and life experience in order to inform resource allocation decisions in healthcare. Our research found a pronounced U-shape in age in these trade-offs, with younger and older people having a much stronger preference for quality over quantity than those in middle age.
Young people don’t think about their mortality, but many older people have accepted the proximity of death and want to live out their remaining time as happily as possible. More than anything else, they want to spend as much time as possible with their loved ones, especially near the end of their lives. Contrast this with the restrictions imposed on those who are living in care homes, where even immediate family have been kept away. This has been nothing short of inhumane.
The explicit focus on life preservation during the pandemic has undoubtedly impeded our collective ability to come to terms with death. Terminally ill patients who know about and accept their prognosis experience less mental suffering in the time leading up to death. In contrast, higher levels of death distress (fear of death, avoidance of death or death anxiety) have been shown to be associated with a host of psychological issues, including increased susceptibility to anxiety and depression in the dying person and higher levels of burden in those caring for them.
The policy responses to the pandemic, then, have been harmful to younger and older people alike. This is interesting, because they have been enacted by those in middle age. Almost without exception, the key decision-makers and their advisors in the UK have been people in or around their 50s. This is exactly the age at which we value quantity of life most highly relative to quality of life and when we are most scared of dying. So the psychological benefits from reducing COVID risks are greatest among the middle-aged people who are most closely involved in recommending and implementing virus suppression policies.
At the same time, the costs of social distancing measures are lowest for those in or around their 50s. Many middle-aged people can work from home and avoid a miserable commute. In so doing, they are not as lonely as younger and older people, and most of them have stopped clubbing. The decisions we take as private citizens or public officials can never be completely cleansed of self-interest, and so it should concern us all that decisions that are having such a profound effect on every age group are being made by those whose demographic arguably has most to gain from suppression policies, and certainly the least to lose.
Considerable attention has rightly been devoted to the lack of diversity in decision-making and how better judgements can be made when a greater range of perspectives are accounted for. I voiced concerns in March about the narrowness of the disciplinary perspectives advising government: COVID represents as much an economic and social crisis as it does a health one, and yet health experts continue to dominate. I didn’t realise then just how potentially important it is to have a diverse age range involved in advising and deciding on policy. Any response to COVID will have more legitimacy if those most affected by it (older people) and the responses to it (younger people) are properly consulted about what they consider to be the best course of action.
So not only should the government have sought advice from social scientists as well as medical scientists, it should have engaged with experts and non-experts of all ages. Given the very different effects of COVID-19 and the policy responses by age group, I am pretty sure that a consensus would have quickly emerged to allow younger people to live as normally as possible while also doing more to protect older people. I could be wrong, but the important point is that decisions that affect people of all ages should be informed by those of all ages, and not just those in middle-age, who are currently acting in their own best interests and not properly accounting for the preferences and welfare of younger and older people alike. This is one of the many lessons that should be learned from this pandemic as we plan for future crises.
This post represents the views of the author and not those of the COVID-19 blog, nor LSE.
It is interesting to suggest that the sociodemographic composition and homogeneity of a group of leaders (and the academic homogeneity of their advisors, all three as proxies for their attitudes regarding death in this case) conditions their ability and willingness to design policies that have similar cost/benefit ratios for both ingroups and outgroups (i.e. those with diverging attitudes concerning mortality). This is a very important issue in representational regimes and I believe there is an urgent need for greater diversity, especially in the UK.
I was reminded of an article in the Economist contrasting levels of “mortality salience” across the globe (https://www.economist.com/international/2020/10/10/covid-19-is-helping-wealthy-countries-talk-about-death). In the UK, at the start of the outbreak, there was stupefaction at Johnson’s statement that families would “lose loved ones”. How would a British politician fare if they were to suggest quality of life over quantity? Essentially, how deep is the U-shaped curve in attitudes towards death across the British life course? Would people in the UK, however academically and sociodemographically diverse, really reach a consensus that does not attempt to elongate/protect life?
Also, one of the biggest concerns has been stress on public health services, i.e. overwhelming increases in aggregate demand on the NHS. I presume it must be difficult to stratify public health policies against a contagious virus despite households being less “multigenerational” than they were several decades ago. Would people be willing to forego their right to treatment in order to enjoy a few more “quality” days of life?
The costs/benefits of covid-mitigation policies have not been the same across social groups. Those in occupations in which “remote working” is impossible have been disproportionately affected. Children, teenagers and young adults have also missed out on educational and socialising opportunities. However, I think this means that these groups require extra support, not that the core strategy of preserving life (i.e. “quantity”) should be completely overhauled. Finally, I don’t think that the middle-aged probably enjoy social isolation any more than other age groups.
Thank you very much for this article ! It’s been months that I’ve been waiting for such analysis to get published.
It is an interesting observation that it’s middle-aged people who’ve been making the decisions which mostly affect older (in immediate health terms) and younger (in socio-economic terms). But the flaws in the type of ‘focused protection’ scheme Dolan suggests have been pointed out many, many times: it’s simply impossible to allow younger people to live and catch Covid freely while keeping older (and not old, but nevertheless vulnerable people) safe from it. Our society is mixed. Young people are carers and hospital staff and shop-workers. And older people, no matter their historical privileges as a group, would simply not comply with being cut-off ‘for their own protection’.
The reality of what is suggested here is a world in which NHS professionals are instructed to turn individuals struggling to breathe away at the doors to die at home so that young people can keep pubbing and clubbing. Presumably between breaths these dying people would agree, as the doctors carefully explained to them, that it’s great the student unions are open, while the bereaved families could console themselves with the knowledge that everyone had a banging night at Fabric.
My point here is what people without acute disease say about acute disease should be treated with an extremely high degree of scepticism. As someone who has experience much acute disease, I see the naive dismissal of disease in everyone who is fortunate enough not to have experienced it. I think of it as “health privilege”. It’s a mix of “it won’t happen to me” and “everything will be fine in the end”. I’m sure Paul Dolan will know what those biases are called.
On the other side of the same coin, people who have experienced Covid-19 often strongly exhort others to take it more seriously. As the lived experience of Covid is apparently transformative of attitudes, it would be instructive to ask people who have had Covid whether they believe restrictions should have been looser, or stricter, although the sample would unfortunately be heavily biased by excluding ~70,000 people who we might expect would favour the latter.
I think your argument, Ally, might be a bit overly emotional. Lockdowns themselves cost lives in many ways, from police brutality involved in enforcement, as well as disproportionate punishments which dog the lives of previously law abiding people, to depression and associated suicides, and to the shortening of life expectancy caused by unemployment and economic damage… not to mention children and students condemned to worse quality of living for ever more due to the harm lockdowns did to their education, harm that can never be undone. Society can do a lot if it puts its collective mind towards things, and this means we have mroe than enough capabilities to help those elderly who wish to to shield while the invulnerable build herd immunity. With the spending already wasted on track-and-trace alone we could have given >£60K worth of support to each and every vulnerable person, in terms of the resources to do it focused protection can always be afforded because it will be less costly and less damaging than lockdowns. We must not assume that, however much some may want them, harder restrictions actually help stop covid, places like Peru (worlds hardest and lonegst lockdown) and Belgium (a long and strict lockdown but not top of the charts for it) have had more deaths per million to covid than places like Sweden, Belarus, Tanzania and the american Dakota states, none of those places locked down at all. Wanting harder restrictions may give kneejerk satisfaction, but the stats suggest that severity of restrictions doesn’t do anything to reduce the harms covid causes [ https://www.frontiersin.org/articles/10.3389/fpubh.2020.604339/full ]. Above all we must remember that lockdowns have been costing more life years than covid ever plausibly could, that subset of casualties of lockdown, those from increased suicides alone, are getting pretty close in life-year counts to the life-years practically lost to covid, and the harms of lockdown will spiral on long after the disease is eradicated by a mixture of natural infection induced herd immunity, and also vaccine induced herd immunity.
And older people, no matter their historical privileges as a group, would simply not comply with being cut-off ‘for their own protection’.
They can be free to make their own choices. Personally, if I were forced (at the point of a gun) to self isolate I wouldn’t mind if the youth went clubbing or not.
Once the NHS has been “saved” it comes down to a question of liberty. Do you want to be free or not?
Er, show me the evidence that restrictions have helped? Virus gonna virus. Offer support to vulnerable groups and crack on – like we did every previous flu before Government started experimenting with communist policies.
But your lockdowns didn’t save anyone did they? And now we all have to suffer the consequences.
‘it would be instructive to ask people who have had Covid whether they believe restrictions should have been looser, or stricter, although the sample would unfortunately be heavily biased by excluding ~70,000 people who we might expect would favour the latter.’ Since fully a quarter of those who died with Covid mentioned on their death certificates were suffering from dementia, I think not. They could have expressed no cogent opinion; and their relatives might well have felt that their death was a blessed release.
I could not disagree more with a previous commentator who suggests that those without experience of acute disease dismiss it. On the contrary: I suspect that the middle aged fear of death and disease (which I agree is significantly influencing policy makers) and the refusal to accept mortality, probably stem from the fact that most middle aged people have not yet experienced severe illness, disease and pain. We fear it, because we see it on the horizon: but it is an as yet unexplored country, and one we (foolishly) hope to avoid ever visiting.
I am middle aged, and I have suffered from a life threatening acute disease with prolonged “side effects” which continued even after the threat to my life was removed (and which to some degree will be lifelong – lack of balance, poor motor control). I know I am immensely lucky to be here. Death came calling for me and went away with a flea in his ear. The experience – of being strapped down to a bed in an ICU, catheterized, on three different intravenous drips, in terrible pain and frightened – before the merciful curtain of coma descended – has taught me to respect the reality of illness. I know now that pain and illness and death lurk in the world outside and in our own bodies. They are inevitable. We cannot avoid the unexplored country. We are all heading towards it. And we – the middle aged – need to come to terms with this. A life spent scuttling away from risk, spent denying death, is not a life well lived.
And less conceptually and personally – yes, I can’t really see how anyone could possibly deny that age diversity is desirable in decision makers. And currently appallingly lacking. No serious attempts (if any at all) have been made to consult young people and the elderly about what they would prefer. Why not? Partly out laziness and disorganisation, and partly because the results of that consultation would, very clearly, clash with the views of those in power over us – the prosperous middle aged.
Thank you so much for writing this article! The question of whether older people actually want harsh COVID restrictions is something that I have been wondering throughout the pandemic, and yet one that I have almost never seen discussed – I have seen one or two brief references in newspapers saying that older people, according to polls, were less supportive of lockdown than the young, but no in-depth discussion of this question. Finally, 9 months after the first lockdown was announced, somebody bothers to answer this question in depth!
Of course, the fact that so few have bothered to ask about the preferences of the old is in and of itself revealing – the attitude of many seems to be that they are obsessed with protecting the old but have no interest in what the old actually want, which may reveal a potentially quite paternalistic and disrespectful attitude towards the old. Shamefully, I have seen some younger people boasting about effectively locking up their elderly relatives and harassing them for trying to go out – behaviour that would have been seen as abusive up until this year.
Thank you for writing an interesting and informative article discussing an important but almost entirely ignored question.
Obviously, another interesting implication of your analysis is that people do not necessarily support or question COVID restrictions solely due to self-interest – the old, who are benefiting the most health-wise, apparently also question the restrictions more than at least some groups who benefit less(i.e. the middle-aged). One’s philosophy on life in general is extremely important in this regard.
I think it was Ian Fleming who wrote or said “I’m not wasting my days saving my days.” Or words to that effect. I’m 54 and agree with the article.
Paul I couldn’t agree more. In Scotland we are living in a public health police state where precautionary restrictions are taking priority over every other aspect of life . In addition to the demographic situation of the policy makers, we should also be aware that the SAGE committee draws on a very narrow funnel of expertise. As indeed does the Scottish and Welsh Governments .. Epidemiology, Virology and Respiratory disease is a massive and complex knowledge domain. Unfortunately the ‘thought leaders” often have no credible qualification beyond a narrow public health training or in an entirely unrelated area of science. Many seem either statistically bereft and lacking in rigour or able to model the last error but unable to see any bigger confounding picture . Labour market economists don’t normally pronounce on industrial economics and vice versa. But economics is quite a unified cannon of expertise. It would be fine if this produced diversity of thought but it doesn’t. The main public proponents of lockdown vary from geophysicists to behavioural sociologists. That coupled with generalist advisors who tend to gravitate towards those they consider to be world leading authorities and who are more interested in aligning to government policy than challenging the prevailing thought patterns. This creates a vicious circle of groupthink and illogical decision making based often on nothing other than expediency. So keep schools and supermarkets to manage risk but close health clubs and hospitality. Stop people travelling internally but pay no heed to the millions of international flight arrivals.
As others have commented it is heartening to read someone questioning the rationale of lockdown. One point which stands out for me is the observation that we have a poor relationship to and with death. Further our societies obsession with the preservation of life at all costs. A good read for anyone with these obsessions is The Lazarus Strategy- How to age well and wisely by Dr. Norman Lazarus.
My aged mother would happily trade a few months or even years of her life to spend more time enjoying what she has left.
Having myself been a widower and nursed a spouse through a painful disease over several years and ultimately death I am acutely aware that our most precious and equally distributed resource ( at least on a daily basis) is time. It strikes me as a massive error of judgement to expect time to be willingly sacrificed in order to extend life (assuming the data correct on the percentage of those dying from Covid with a preexisting morbidity and average age) for a small number of people.
Watching a loved one die is the worst thing I have had to do. To all intents and purposes I lost my wife or at least the woman I fell in love with about one year into here treatment, that she fought so hard for three more years was truly extraordinary, but it was also deeply painful for us both. She had only tiny moments of time free of pain and with some sort of happiness during those three years. It was only right at the end that she experienced a moment of extraordinary peace and I have to say on reflection happiness as she said her final words to me. Tears are in my eyes as I write, I will always be grateful to her and for her. I miss her to this day despite having recently married.
I know also one other thing she would say if she were here, “you have to take the risk of living”, and so we must.
I am not for one moment suggesting we ignore the virus and its awful consequences merely that we should exercise care, distancing and consideration for others, but locking us up will when history is written be proven to be one of the most catastrophic acts inflicted on our society.
Sadly there are those whose behaviour is nothing short of selfish and perhaps we are all paying a price to contain that selfishness. Time will tell.
Regarding the main thrust of this article which focuses on the fact that middle-aged are making these decisions, I would point out that these same people are those who are invariably on the highest incomes, with the pensions to match, and as such have the least to be concerned regarding the long-term damage their lockdown policies are liable to cause.