"There's a runaway train hurtling down the track", the old ethics dilemma goes. "The line splits in two. There are five people lying on one track and one person lying on the other. If you do nothing, five people will die. If you pull the lever, one person will die. What do you do?"
I like dilemmas like these and have my answers firmly in place. Pull the lever, of course. Maximise the number of lives saved. I pose the question to my friends because I'm interested whether their reasoning would be the same as mine. For some people, it's not as simple as all that. Technically, the runaway train is not their fault, and they reason that if they do nothing, the five deaths are not really on them, whereas if they pull the level, and assume an active role rather than a passive one, they are actively making the decision that one person should die.
There are other variations. The five people are neo-Nazis and the one person is a woman who's, like, four minorities rolled into one. Or five high school dropouts and one brain surgeon. Or maybe there's one person on each line, but one of them is a dear friend. Or maybe one's your best friend and the other one's your wife. Or your mother and your sister. Then you make value judgements based on the person's relative worth - to you, to society.
These ethics dilemmas are fun to debate until they cross over into real life. Until recently, the British healthcare system was overstretched and under-resourced, but surviving. Who could've foreseen a pandemic? Except, of course, for the Tory government, which conducted the Cygnus pandemic simulation in October 2016 and discovered that the country was woefully unprepared for the sort of the cataclysmic scenario it's facing now, yet the findings were not acted on. The Tories hedged their bets on never having to deal with a pandemic. But, to misquote one of Terry Pratchett's Discworld novels: “Scientists have calculated that the chances of something so patently [unprecedented occurring] are millions to one. But...million-to-one chances crop up nine times out of ten.”
And here we are. There's a pandemic afoot, the healthcare system has only coped thus far because millions of routine operations have been cancelled, and at a cost of many dead. Too many. Since there's likely to be surge in deaths following the bungled government advice to the public, plus the push to get people out to work without measures put in place to protect them, medical staff working for the NHS will have to make heartless choices - who lives and who dies.
Below is the rather dryly worded "Covid-19 decision support tool" that allows NHS doctors to make decisions as to whom to treat. The decisions are based purely on age, clinical frailty scale and preexisting co-morbidities. Whether or not a person is worth fighting for in ICU is decided according to a simple sum.
If you rate over 7, you don't get to go to ICU. Both my parents rate a 6 based on age and relative fitness; my father will be a 7 later on this year by virtue of turning 76. My mother might possibly be a 7 already if her deteriorating eyesight is taken into account. I rate a 4 (now that we know more about the virus, I'm basically screwed: I'm an overweight asthmatic with hypertension, and hypertension is the condition they've found most frequently among the worst-affected patients, plus the virus hits people in the lungs first). Oy vey.
It seems rather heartless and shortsighted to base a person's worth purely on age and medical statistics. What makes a person valuable? Why is youth considered more valuable than old age? Are childless people automatically less valuable to society than those with progeny? Are older parents more expendable than younger ones? How do you put a price on a life?
And this is where my favourite hypothetical dilemmas stop being straightforward. Evaluating a medical decision by its outcome and given a choice between my 72-year-old mother (of two), and a 27-year-old mother of two, no one will choose my mother in a triage situation.
To quote Prof. Kathleen Dean Moore from Oregon State University: "In triage decisions, the highest value is life; saving people is the whole purpose of medical care. Life is good. Maximize that outcome. Give the treatment to those who are most likely to live as a result, and for the longest period of time. Most often that means the youngest and healthiest patients."
If medical equipment and resources are in short supply, if my parents get sick and don't recover with minimal help, they will not survive the decision. Neither my father, whose lifelong dedication to physics has led to his being headhunted by one of Cambridge's top colleges (and has led to my family emigrating to the UK), and who, at the age of 75, still gets excited when teaching students and finding the ones that have real potential, a spark that he can nurture. My father, whose abstract ideas about the universe I can't even begin to grapple with. Nor my mother - one of the kindest, most loyal people I know, sturdy and irrepressible in spite her deteriorating eyesight, with her love of the mountains, and forests, and hiking, and digging in the garden while wearing one of my conical Vietnamese hats. Triage doesn't take into account the things that make these, and other individuals precious and irreplaceable. To those who love them, at least. Given my fatalistic streak, I realise that one of the reasons why I've always made an effort to see the people I care about, whenever I could, is because I've been stocking up on memories. Because their lives are finite, as is mine.
I'm unlikely to survive a triage decision. Neither would the husband of a friend of mine, who is in his 50s and disabled, and has a young child. My friend told me: "My kid cried himself to sleep this week worrying that he won’t “get to live a long life with dad because of the virus”. His words, not mine." The same boy told his mother: "I’m not scared of ANYTHING!...except...you and dad dying...and my heart being broken." Ben is seven.
I don't have children. By choice. I've never been broody, never really felt the need to pass on my genes. I have never been enamoured with babies. I've been known to go gooey over cats and have had to train myself to coo over friends' babies in a similar fashion, because that's expected, particularly of women. To comment on their tiny extremities (As opposed to what, abnormally large fingers and toes?). To say that they are beautiful even if they look red and wrinkly, which is how babies generally look when born. But I've very much enjoyed the company of my friends' children, once they were old enough to communicate with properly. I don't talk down to them, call them "sweetie" or pinch their cheeks. I treat them like miniature adults and they seem to respond to that. I'm not convinced that they see me quite as an adult, since I'm not that much taller than them and don't act like their parents. I like their energy and their curiosity. They ask interesting questions and say some very insightful things. The son of one of my closest friends has a thing about using precise language to describe different situations, and questions his mother when she says one thing when meaning something else. I'm completely with him on that. Expressing oneself imprecisely leads to confusion and chaos and for as long as I can remember, I've fretted about explaining myself clearly for fear of being misunderstood.
Many years ago, when I was a care worker, I became friends with a terminally ill client, with whom I used to have long conversations about life, and he tried to persuade me not to rule out having a family. "It's a crime for intelligent people not to reproduce", he'd joke, explaining to me that having children was the best thing he'd ever done, and that one of the most rewarding things in his life was watching his sons grow, and sometimes getting an illuminating glimpse of the men they'd eventually become. Even so, my solitary lifestyle and my transient profession doesn't lend itself well to child-rearing. Also, I'm too aware of how easy it is to be a bad parent, and I fear that I'd fall short of being the good parent I'd want to be. If you're going to be a parent, you have to put another living being's needs first, every single time. You have to be sure you can do it, and really want it, and I'm not convinced that I want it enough. And maybe I'd pass on my genetic curses and end up with some vertically-challenged control freaks with Asperger's, and anxiety levels through the roof. Or maybe I'd be really overprotective, coddle them and stunt their chances of growing into independent human beings who are not afraid of the world.
When I was a kid in the Soviet Union, we were expected to be independent from a young age. I went to the bakery for my mother from the age of five, could use matches safely, without burning the house down, at the age of six, and was left by myself in the flat on a number of occasions, because Soviet parents often had no outside support to lean on. I really didn't like being left alone, though my abandonment-related anxieties may well be hard-wired from birth rather than tied to specific events. Some kids are just naturally anxious; one of the brightest little girls I know, whose attentive mother dotes on her, gets separation anxiety when her mother steps into the other room. But anyway, given the choice between an overprotective parent who never let me out of her sight, or a mother who trusted me to be independent, I'd definitely choose the latter, because I have no fear of travelling the world alone, and generally like my own company. I worry that I wouldn't be able to give my own children the sort of upbringing that my loving mother has given me.
I've wandered off at a tangent again. Apologies. Bottom line is, I don't have kids, and society in general seems to value people with functioning reproductive organs more than it values non-parents. Because the whole point of life is to perpetuate more life, right? (Unless the parents in question are stereotypical council house dwellers on the dole, or else single mothers, in which case they are 'leaching off society's goodwill'). And if you don't produce offspring, then you're seen as deficient, strange, incomplete, a genetic dead end.
The idea of triage has led me to contemplate my own worth to humanity. I'm a travel writer with considerable breadth of travel experience. I am capable of writing and communicating ideas. I can advise you how best to get around Siberia, organise a trip into the heart of Papua New Guinea, or tell you where to find the best coffee in Vilnius. I can tell you stories of adventure with the rainmaker from the Trobriand Islands, or what it's like to fly over the Maasai-Mara at dawn in a hot air balloon, or dive for rock lobster off Chile's Robinson Crusoe Island, or trek to Colombia's Lost City, or cross the Beagle Channel in a storm in a motorised dinghy, or visit the eerie ship graveyard near Nukus, Uzbekistan, where the Aral Sea will never return. Drop me anywhere on earth, and I'll land on my feet.
When I was younger and more idealistic, I believed that I was doing a public service by encouraging people to travel, interact with other cultures, and broaden their minds. Because if you're well-travelled, and you see more similarities than differences between yourself and the people of far-off lands, surely that encourages great unity among humanity, more empathy towards human suffering. Surely I was making a direct contribution to peace on earth. I still believe that there's great value to travel, but not the peace on earth bit, plus there are the environmental repercussions to consider. I've been privileged to see more of our world than most people get to see in their lifetimes, and I love the fact that perpetual travel has led me to constantly absorb new knowledge, whether it's about the strict rules that govern the lives of Aboriginal Australians, or techniques used to produce Mexico's most exquisite ceramics. Surely this knowledge and experience that I've accumulated is valuable in the abstract, or if passed on to others, even if I don't have progeny.
Surely there are other values beyond youth, and health and parenthood? How about furthering the knowledge of our world for its own sake, or meticulous record-keeping of what has already come to pass, or creative ways of recording what it means to be human, or endless empathy towards those who aren't kin? Without all of those, humanity loses its experience, its grace. Everything has to be learned anew. I think about some of the people whose presence in my life has significantly enriched it, who don't have children, and yet who are invaluable to humanity, at least in my (admittedly biased) eyes. They include some of my oldest friends - an award-winning performance poet who mentors inner-city kids; a historian producing original research on the Japanese space program; a no-nonsense, immensely practical woman who can knock out a would-be mugger with a single punch, and produce some of the most elaborate, delicate cakes you'll ever eat. And my former educators: my former maths teacher and head of year, who'd spread her wings over the stroppiest, neediest teenagers, and always found time to listen to their problems; and my former history teacher - a fount of historical knowledge who believes that the Holocaust was a human tragedy, rather than a Jewish one, and who arranged school trips abroad when I was a teen, believing that it's good for children to be exposed to things that they might otherwise never get to see. I still have the little flag with the Star of David that I found on the snow at Treblinka during our trip to Poland.
Maybe it shouldn't be about just saving the lives of those with the most years left to live, or those fruitful of loin. Though I admit that I'm just trying to find reasons to spare the people that I personally care about (and my own life), if it came to that, and trying to find ways around the heartless triage rules.
But maybe there's another way of looking at it. There's a larger point to be made: deciding who should live or die under the present system is a false dichotomy. Maybe we should strive towards a well-provisioned healthcare system that's not beset by years of government cuts and plagued by shortage of staff. One that doesn't require its doctors and nurses to make these terrible choices.
I'd like to finish with a quote from the same professor of philosophy that I'd quoted earlier. She hits the nail on the head, and though her quote relates to the US healthcare system and government, the same can certainly be applied to the NHS and the current British government:
"No matter how fair or careful a triage decision is, it is still tragic. Something irreplaceable is always lost—a life, of course, but wisdom and laughter and love. The critical question, then, isn’t so much whether the triage committees are making moral or immoral decisions. The moral duty comes before that, and it falls on every one of us, to resolve never to sicken someone else by careless risks, swaggering self-interest, misguided priorities, or arrogantly incompetent leadership. We are smart enough, and good enough, to design an economy and a health-care system in which no one needs to decide who dies."