On a steamy Saturday in August, Toronto’s Eaton Centre is bustling. Unmasked shoppers stream through the mall. Diners sit elbow-to-elbow in the food court. Outside, Yonge-Dundas Square is alive with music and festival tents, and passengers spill out of streetcars and from the subway station to join the crowds.
Two and a half years ago, most people out here on this summer afternoon, like others across the country, were confined at home. Back then, each day brought grim new reports of more residents dying alone in long-term care facilities. Overwhelmed health care workers described patients gasping for their final breaths. And confronted with a deadly new virus, Canadians dutifully complied with public health orders to leave home only for essentials, wash and sanitize their hands frequently, and stay two metres apart.
Now, even though epidemiologists and infectious disease experts warn the pandemic is certainly not over, it increasingly feels as though it is.
Carrying on as though everything is back to normal comes as a trade-off, however. In most situations, masks, proof of vaccination and, in some jurisdictions, self-isolation after a positive test are no longer mandatory, now that vaccines have blunted the public’s risk of death and severe illness. But COVID-19 is still a killer – albeit predominately of older adults, those with underlying health conditions, and the unvaccinated – and its long-term effects in the form of long-COVID and lasting health complications remain unknown. Without further efforts to reduce the spread of the virus, Canadians and policy-makers have tacitly accepted that these deaths, along with the amount of illness and social disruption COVID-19 still causes, are simply a part of life now.
But are we making the right calculation about how much loss we’re willing to live with? The answer is far from clear-cut. Rather than responding only once we’ve blundered past our breaking point and it’s too late for prevention, some bioethicists say we need to carefully weigh the costs.
Giving in to pandemic fatigue is not consequence-free, said Maxwell Smith, a bioethicist at Western University.
“We shouldn’t consider solely whether people are ‘tired of masks’ and other public-health measures – everyone’s tired of them,” he said.
Instead, we should also consider whether we are willing to tolerate the consequences of dropping them, including the potential for increased burdens on the health system, interruptions to school, staffing shortages, and illness amongst the most vulnerable, Dr. Smith said. “That’s a much different question and one we haven’t adequately confronted.”
So far this summer, hospital admissions, deaths and reported cases have been far lower than earlier Omicron waves this winter and spring, but nationally, they are still comparable to numbers recorded last fall. COVID-19 deaths in the last week are roughly three times higher than they were at the same time last summer. The number of people infected is likely far more than official case counts, since testing policies changed in various parts of the country starting in December. And none of this data adequately captures the magnitude of suffering involved, nor the fact each number represents someone’s child, parent, spouse or friend.
Historically, society has considered the level of illness and death from a disease to be acceptable when those illnesses and deaths primarily affect the least advantaged, Dr. Smith said. When a disease is suppressed to a point where average members of the public no longer feel their lives are endangered, they tend to stop caring about it, even if it still threatens those who are vulnerable, he said.
Even though that’s how people have dealt with pandemics and epidemics in the past, Dr. Smith said, we should question whether it is, in fact, the course we should take now with COVID-19.
“That’s a really crucial ethical consideration,” he said. “We need to be asking, ‘Well, do we still have responsibilities to those who aren’t so lucky?’ ” That includes older adults and those whose medical situations, socioeconomic circumstances and occupations put them at greater risk, he said.
In determining how much loss is acceptable, however, there are many other factors to consider, said Anita Ho, a clinical associate professor at the Centre for Applied Ethics at the University of British Columbia. One can’t look only at potential deaths from COVID-19, but must consider other potential deaths when more public-health measures are in place, she said.
For example, Dr. Ho said, distancing rules mean clinics may accommodate fewer patients, and people may delay seeking necessary medical care or avoid hospitals out of fear of infection. In Hong Kong, suicide rates rose during periods of highly restrictive public-health measures, she said.
To maintain the public’s trust, authorities must ensure public-health measures are necessary, proportionate to the urgency and severity of the situation, and the least restrictive possible, Dr. Ho said. She added protecting the public doesn’t always have to be about imposing restrictions, but includes education and encouragement.
People may be more inclined to voluntarily take precautions, such as wearing masks, when they trust the government is not overreaching and paternalistic, she said.
“At some point, we also have to trust the people,” Dr. Ho said. If they’re given adequate tools and support, she said, “we can empower them and trust them to also do the right thing.”
For the most part, provinces and territories are letting people decide for themselves whether to take precautions against infection.
In Quebec, Robert Maranda, a spokesman for the Ministry of Health and Social Services, said in an e-mail there is no determined threshold for an acceptable mortality rate. Other provinces did not directly answer what they deemed acceptable, but offered explanations for staying the course for the time being, including the fact they have high vaccination rates and strong public support for lifting restrictions. Most said they were balancing the risks of COVID-19 with the burdens of public-health measures.
Anna Miller, senior communications adviser for Ontario’s Ministry of Health, said Ontario has fared better than many jurisdictions during the pandemic.
“The province has cautiously lifted restrictions, and the economy is recovering,” she said in an e-mail.
Ironically, however, eliminating mask mandates and vaccine requirements, which was meant to improve the economy, may actually be prolonging some of the economic costs of the pandemic, according to CIBC Capital Markets economists Avery Shenfeld and Andrew Grantham.
“Flights are cancelled when crew members call in sick, hospitals cut back services because staff members are ill, and live entertainment shows are postponed for the same reason,” they wrote in an Aug. 8 Economic Insights report.
They noted the number of working hours lost to employee illness is considerably higher than expected, based on pre-pandemic trends. And while only a small number of Canadian workers with long-COVID have been forced to entirely step away from the labour market so far, Britain offers a cautionary tale of what could happen if the pandemic stretches on and Canada fails to control future waves, they said. They pointed to a study that showed 0.6 per cent of the population in Britain is now “severely affected” by long-COVID.
When it comes to employee illness, there’s no single right answer to how much lost productivity is acceptable, Dr. Shenfeld explained in an e-mail. Rather, it’s just one more area where Canadians are faced with a trade-off. For instance, judging by their behaviour when there are no mandates, Canadians prefer to not wear masks, he said, and installing better ventilation equipment is an expense that would take money away from other uses.
Reducing disruptions from COVID-19 is not all about government-imposed requirements if Canadians won’t support them, Dr. Shenfeld said, echoing other experts who emphasize that mitigating the social, economic and health damage from COVID-19 does not necessitate a return to stay-at-home orders and school and business closings.
Dr. Shenfeld suggested an aggressive campaign for booster shots could reduce severe cases and contain the hours lost because of illness.
Additionally, businesses could choose to require or even simply recommend wearing masks indoors for employees if they experience excessive losses in hours worked because of COVID-19, he said.
Though ideally everyone would take precautions, such as wearing masks, to increase protection for those around them, Heidi Janz, an associate adjunct professor at University of Alberta who specializes in disability ethics, said she doesn’t expect to see governments reintroducing mandates unless a situation arose where large numbers of healthy, able-bodied people were to get sick.
Dr. Janz, who has cerebral palsy, said the deaths of older people and disabled people have largely been met with a collective shrug. Society’s general attitude, she said, has been that “they’re more susceptible to the virus, so if more of them happen to die, it’s unfortunate, but kind of whatever.”
As everyone manages their own risks, it’s important that individuals be offered options that allow them to do so, Dr. Janz said. For example, options to attend work or school remotely should be guaranteed for people with disabilities or underlying health conditions, even when they aren’t available more broadly, she said.
“We need to move forward, clearly,” she said, “but there are ways of doing so ethically.”
Preventing further social inequity may mean tapping into Canadians’ sense of patriotism, Dr. Smith, the bioethicist from Western University, said: “Let’s make sure that we do the best we can for all Canadians, not just those who are privileged enough to not face a significant threat from this virus any longer.”
Even though it may be unrealistic to prevent every death, hospital admission, or outbreak, people can still take reasonable steps that would prevent many of them, without causing much hardship, such as improving indoor air ventilation and filtration, wearing masks and getting vaccinated and boosted, said Dr. Smith, who has a PhD in public health. In fact, these measures would lead to fewer economic and social disruptions, allowing people greater freedom to do whatever they wish, he said.
Dr. Smith noted influenza is often held up as an example of an illness, for which an estimated 3,500 deaths per year are considered acceptable, requiring no need for people to change their routines. But rather than use the toll of influenza as an indicator for what Canadians can bear, he said, perhaps people ought to ask whether they’re willing to live with that level of mortality in the first place.
“We might want to change the paradigm here and say: maybe moving forward, we could do more to prevent those kinds of illnesses.”
Bhutan chose ‘lives over livelihoods’ in COVID-19 approach
The small Himalayan country of Bhutan has been an outlier in this pandemic, adopting a principle of “lives over livelihoods” that has led to an exceptionally low number of COVID-19 deaths, in spite of its bare-bones health care system.
Madeline Drexler, a journalist and a visiting scientist at the Harvard T.H. Chan School of Public Health, has written a book on how Bhutan navigated the pandemic, to be published by the World Health Organization in September. She explained the country’s strategy:
How much COVID-19 death and illness was Bhutan willing to accept at the start of the pandemic?
King Jigme Khesar Namgyel Wangchuck set out a remarkable set of precepts. Among these: Strive to prevent any deaths from COVID-19. Prioritize lives over livelihoods. Overprepare, don’t underprepare. Don’t worry about the costs. These instructions would inform every subsequent policy discussion and decision.
How has that changed?
In early 2022, Bhutan’s terms of engagement with the coronavirus quietly shifted. Partly that was because Bhutan had shielded its people from the worst of the pandemic. By early March, only seven individuals had died from COVID-19. Equally impressive, Bhutan boasted one of the highest vaccination rates in the world.
Its prime minister announced once children ages 5 to 11 were fully vaccinated, life would return to near normal, although mask-wearing, hand hygiene, and other precautions would stay in place.
Why was there such low tolerance for deaths?
Zero mortality springs directly from Buddhism, Bhutan’s official religion. In the minds of Bhutanese, every human life is considered precious. The King’s “lives over livelihoods” edict also derives in part from the country’s guiding Gross National Happiness policy, which prioritizes well-being and happiness over conventional socioeconomic indicators of progress.
What have been the costs?
Bhutan’s stringent pandemic policies exacted a steep price. Sealing the country’s borders in March, 2020, devastated the tourism industry, leaving tens of thousands out of work. Gender-based violence rose. Depression, anxiety and substance use increased. On the positive side, Bhutan did not see an increase in non-COVID deaths.
This interview has been condensed and edited.
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