Richard Smith: Covid-19—an oblique view on who shall live and who shall die

The day before Boris Johnson announced a lockdown (or cloistering, as I prefer to call it), I sat in a theatre in Tonbridge and watched my brother, Nicholas, playing a Nazi doctor, the director of a clinic for severely disabled children who were being systematically murdered. From the beginning of the play we know that the doctor is troubled by what he is doing, and my brother played the role convincingly.

In the second half of the play the doctor is confronted by a bishop, a character based on a real person (Clemens von Galen, the Catholic Bishop of Münster), who tells him that what he is doing is wrong. The doctor, my brother, knows that it is wrong, but he tries to defend himself. He is a man of science, a doctor, and doesn’t believe in the bishop’s “fairy stories.” Looking after these “idiots, spastics, cretins, and retards” is extremely expensive, taking resources away from the poor and from the Greater Germany. The Fuhrer has said that their lives are not worth living. It is a kindness to them and their parents to kill them. Death ends their suffering.

There are three other characters in the playAll Our Children by Stephen Unwin: a young, fanatical Nazi who has no doubt about the value of what the clinic is doing; a mother of an epileptic who in the first half comes to thank the doctor for caring for her mute, epileptic son, but in the second half comes to condemn him when she learns how her son has been murdered; and the housekeeper, a mother of three children, who represents “ordinary Germans,” who may or may not have known what was happening. The play presents the arguments of both sides, and, although we never doubt who is in the right, we are led to think about the related dilemmas of our own age and our own attitudes to things like assisted dying and the National Institute for Health and Care Excellence (NICE) putting a pound figure to human life.

At one point the doctor, my brother, talks of his 91-year-old mother who is demented and in a home. He wonders if her life is more valuable than the disabled children he is murdering. This was a chilling moment as Nicholas, Brian (my other brother), and I do have a 90-year-old mother who is demented and in a care home. I saw her the morning I saw the play. We do wonder about the value of her life, and she herself when 70 wrote a letter to The BMJ saying that she would rather be helped to die than be demented in a nursing home.

What’s more, we are in the early stages of a covid-19 pandemic that is likely to kill tens if not hundreds of thousands of people in Britain. Those over 80 have something like an 8% mortality, whereas mortality among children under 10 seems to be zero. The nation’s leaders are having to make difficult decisions about priorities. Should the priority be to minimise deaths or to preserve a functioning world for those who survive? And should the priority for intensive care be those who are most likely to benefit from the care? That is the first principle of intensive care and is being enacted much of the time—because demand almost always exceeds supply. But that means putting some lives before others, a judgement that would be unacceptable to the bishop in the play.

Even in normal times NICE puts a price on life when considering whether to approve new treatments for widespread use in the NHS. The price is £25-£30k per quality adjusted life year (QALY), and QALYs can be negative—the judgement of Hitler that some lives are not worth living. The play potentially leads you to the conclusion that that is unacceptable, no different from murdering disabled children. But if decisions of which treatments to approve or who to admit to intensive care are not made explicitly then they have to be made implicitly: the rules that govern the decisions cannot be seen and are likely to be based on power, connections, and politics and so less fair. Sharing the rules that are used to make such decisions may not guarantee fairness, but the decisions are likely to be much fairer than those made implicitly.

A combination of the condemnation of the grieving mother, the bishop’s arguments, and his own doubts meant that by the end of the play my brother, the doctor decided he could no longer go along with the murdering. The result would be that he would be sent to a concentration camp.

In the real world the bishop delivered three sermons on the murdering of the children, and his sermons were widely circulated. The instinct of Hitler was to have the bishop sent to a concentration camp, but Germany includes many Catholics: the risk of removing him was too high. Remarkably in 1941 the programme was stopped. Another example of where one person made a dramatic difference

Richard Smith was the editor of The BMJ until 2004.