The second objection to selective lockdown is around the ‘we are all in it together’ narrative, and raises concerns around discrimination and unequal treatment of different population groups. We offered reasons against these objections. Some of us have argued that the temporary unequal treatment is not a form of ageism against the elderly because age correlates with an ethically relevant criterion, namely risk posed by COVID-19. Actually, it could be argued that lockdown is ageist against the young.
The fact that, as mentioned above, we are three weeks ahead of the modelled predictions in terms of reduction of daily deaths suggests that the impact of vaccines might actually have been underestimated. As we saw above, we got to less than 200 deaths per day on 25 February instead of mid-March (as predicted by the model), and we had less than 150 deaths per day on 2 March instead of 21 March.
Thus, if lockdown is to be justified, the Government needs to address these two questions:
The first objection to selective shielding is about feasibility. Some people think that it would be impractical – even more impractical than locking down an entire population – to selectively shield certain people. For example, one might say these people would still be exposed to primary carers or perhaps to some family members. We should not forget the nature of lockdown as an exceptional public health measure. That it is exceptional implies that as soon as there is an alternative that is less burdensome and less restrictive of individual freedoms to keep the virus at a manageable level, we should adopt that alternative. It also means that lockdown cannot be a preventative or a default measure to control the pandemic, and that we need to be prepared to accept some level of risk or else freedom is meaningless.
We do not want to claim here that lockdown is not justified. But we do claim that in light of these data, the Government needs to update its justification and answer additional questions. More specifically, the Government 1) needs to be open on whether the modelling it has used has underestimated the positive impact of vaccines in reducing hospitalizations and deaths and 2) has the burden of proof of providing the justification for continuing with its very cautious roadmap, which basically entails another month and a half of lockdown and 2 and a half months of very tight restrictions.
Whatever the justification for keeping lockdown in place, the Government has an obligation to explicitly address at least these two questions.
The ‘roadmap’ designed by the UK Government to ease restrictions is cautious, with non-essential businesses and hospitality sector in outdoor areas allowed to reopen on the 12th of April at the earliest, and the full service of restaurants and pubs in indoor spaces from the 17th of May at the earliest (still with some restrictions). This means another month and a half of lockdown and almost 3 months of very tight restrictions, which will further exacerbate the devastating impact of pandemic restrictions so far, especially for young people.
While the drop in hospitalizations over the past months has been attributed to lockdown by mainstream media, it is plausible to assume, in light of the data above, that a major role has been played by vaccines, rather than by lockdown alone.
Given the success of the vaccine roll out in the UK and the higher than expected drop in COVID-19 deaths, it is legitimate to ask whether lockdown should continue to be the key strategy to contain the pandemic or whether the ‘roadmap’ announced by the UK Government should be adjusted. Because lockdown is a very exceptional measure, the burden of proof is on the Government to provide answers as to why the easing of lockdown is proceeding at the current pace and not faster. The impact of lockdown is devastating for the economy, mental health, and employment rates and the cost and benefits are in many cases very unevenly distributed. For instance, the young are at highest risk of redundancy, but benefit less from lockdown because COVID-19 pose a very low risk on them. 1 in 4 children and teenager self-harmed over the last year, further exacerbating a pre-existing trend. If the lockdown is justified at this stage, the Government has the burden of proof of providing a strong justification for this.
Such justification might need to be updated with respect to the one offered when the roadmap was announced on 22 February. That justification was centred on the target of “keeping infections rates under control” as determined by 4 tests: successful vaccine deployment program; vaccines being successful at reducing hospitalizations and deaths in the vaccinated; infection rates not putting unsustainable pressure on the NHS; and the risk assessment not being significantly altered by new variants.
Again, even accepting for the sake of argument that this is a valid point, it does not apply to vaccination, since vaccination is an easy and practical procedure.
- Has the modelling used by the Government been too pessimistic? Has it underestimated the impact of vaccines and/or overestimated the impact of lockdown?
Two main objections have been raised against the proposal of having selective lockdown or shielding of the most vulnerable.
Moreover, according to a recent report by Public Health England about the Pfizer vaccine, even “those over 80 who develop COVID-19 infection after vaccination are around 40% less likely to be hospitalised than someone with infection who has not been vaccinated”.
Even assuming those criteria are fair, the justification now needs to take into account the “very very impressive” and “spectacular” results of vaccine rollout, to quote a lead researcher from Public Health Scotland. As we shall see below, there are reasons to think that the vaccines are producing better results than those expected by the Government and assumed by the modelling used to inform the roadmap. Plausibly also because of the vaccine roll out, the drop in COVID-19 deaths in the UK is now three weeks ahead of the estimates of the modelling that the Government has used to design its roadmap: while the modelling estimated that COVID-19 deaths would fall below 200 a day after mid-March, we reached that point on 25 February. The model suggested we would have as few as 150 deaths per day by 21 March, but we are at that point now.
The vaccination program in the UK is revealing extremely effective. Two studies carried out by Public Health England and Public Health Scotland found that the Pfizer and AstraZeneca vaccines have reduced hospitalizations by 81% only in the over 80s, but considering younger age groups, the study from Public Health Scotland shows that “by the fourth week after receiving the initial dose, the Pfizer and Oxford-AstraZeneca vaccines were shown to reduce the risk of hospitalisation from Covid-19 in up to 85 per cent and 94 per cent, respectively”. This is higher than the assumption made by the model that the Government has used as a basis for its ‘roadmap’, whose most optimistic prediction was a reduction of severe cases of 80% for the Oxford/AstraZeneca vaccine and 86% for the Pfizer vaccine after 1 dose. In the Government’s statement announcing the new roadmap, the assumption was that the Pfizer vaccine would reduce hospitalizations and deaths by 75%.
However, even assuming for the sake of argument that the objections based on inequality and discrimination are warranted, they do not constitute objections to opening up society once the shielding of the vulnerable is provided by vaccines. The vulnerable would be free to have a normal life in the same way as younger people would, assuming the vulnerable accept the vaccine..
- What is the justification for keeping lockdown in place instead of less restrictive measures for all, or instead of lockdown for a smaller portion of the vulnerable population?
Moreover, let us assume that the modelling that informed the Government’s roadmap was correct and there has been no underestimate of the impact of vaccines. Even in this case, the vaccine will still offer a very significant layer of protection to the vulnerable. Thus, even if we think it’s premature to lift the lockdown for everyone, the vaccine roll out might allow easing the lockdown for younger, non-vulnerable people, while the lockdown is kept in place selectively for the vulnerable who have received the vaccine.
Vaccination, as is being rolled out in the UK (that is, largely through an age-based prioritization strategy) should be seen as a form of selective shielding which preserves the large benefits of the “old-fashioned” selective shielding, introduces additional benefits, and is immune from the standard objections to old-fashioned selective shielding.
It might be that the last of the four tests – the risk posed by a possible new variant – provides sufficient justification for keeping lockdown. But if so, the Governemnt would need to be explicit about this and would need to explain how the same risk of new variants, which will likely be always present, will be dealt with in the future. At which point, if any, will we consider the risk posed by new variants acceptable?
In light of these data, the Government would need to justify using indiscriminate lockdowns to achieve something – protection of the vulnerable and the NHS – which data suggest is now achievable without overburdening the whole society (as lockdown is doing) and possibly even without burdening those who need protection the most (as selective shielding would do). Vaccines are offering a level of protection to the vulnerable (roughly 80-90% drops in hospitalizations and deaths) that, if it was achieved through measures like selective shielding, would plausibly justify considering selective shielding successful. But vaccines do this without the downsides of indiscriminate lockdown or of selective lockdown.
So what is the reason for keeping lockdown in place for everyone?
The standard objections to selective shielding of the vulnerable – that is unfair/discriminatory and that is not feasible – no longer apply when the shielding is provided by vaccines rather than by selective isolation measures. And at least the objection that selective shielding would be unfeasible or ineffective does not apply when it is supported by the current age-based vaccination strategy: the data strongly suggest combination of vaccination and shielding offers a sufficient level of protection to the vulnerable to lift lockdown for the remainder of the population.
And again, even if we assume that the model informing the Government’s ‘roadmap’ is correct and that the best protection to the vulnerable is offered by a combination of shielding and vaccination, we should ask if the inequality at stake is more unfair than the current indiscriminate lockdown. The devastating impact of lockdown on young generation is starting to emerge – the most recent example, among the many we could give, is the study about 1 in 4 teenagers having engaged in acts of self-harm over the past year. Given the very minimal risk posed by COVID-19 on young generations (the risk of death from COVID-19 is less than 0.1% in the under 40s), it is a real question whether younger generations have been treated unfairly and are victims of a kind of reverse ageism. One reasons commonly offered for keeping also the young people in lockdown is that they also benefit from it, because of the risk of long-covid. However, the risk of long-covid has the same age-based pattern as the risk of death: it is way higher in the elderly and in those with certain pre-existing medical condition. Given the smaller risk, it is at least questionable that long-covid makes lockdown in the best interest of young people. In any case, if long covid is the reason or part of the reason why lockdown is kept in place also for the young, the Government would need to be explicit about this, so that we have the information necessary to ethically evaluate such risk assessment.
An alternative to lockdown had already been proposed by some of us before vaccines were available. We proposed a form of selective lockdown, or shielding of the vulnerable, whereby only those at high risk of COVID-19 complications are either requested or incentivised to self-isolate. The others would be allowed to go on with their normal lives, thus minimizing some of the devastating impact of lockdown. Modelling by Ragonnet et al suggests that this strategy could allow to achieve herd immunity with a much lower level of mortality. Oxford Uehiro Centre for Practical Ethics, University of Oxford The benefit it preserves is protection from COVID-19 for the elderly. The additional benefit is that such shielding is provided without the liberty restrictions and mental health costs that selective lockdown might entail.