The reality, though, is brutal. To decide what is considered “value for money,” the institute uses formulas that measure the length and quality of life added by a medical intervention—“quality adjusted life years,” or QALYs. Each QALY is equal to one year of life in perfect health. Generally, the institute considers medical interventions costing £20,000 to £30,000, or about $25,000 to $38,000, per QALY gained to be cost-effective. Interventions costing more than that might not be sanctioned. In effect, then, the government has already placed a cost on life.
The problem, as Wood explains, is that resources are finite and burdened by competing demands. In dealing with COVID-19, the government can’t simply stop addressing everything else, like cancer, flooding, crime, or, of course, Brexit. And while debates that weigh economic considerations against people’s health are uncomfortable, all governments rely on economic growth to fund public spending. In other words, decisions about how to contend with the coronavirus must weigh the wider economic impact, because in the end, the economy will affect the government’s ability to keep people alive.
Over the next few months, the challenge for Johnson—and every other leader of a democratic country—is to convince the public that he is making reasonable, fair, and equitable decisions in the short term and striking the right balance among the country’s social, medical, and economic interests in the long term. The challenge is leadership.
Henry Kissinger once said that the difficulty of leadership is that, by design, all the easy decisions have already been made before they can reach the prime minister’s or president’s desk. The tough calls are all that’s left. “Real dilemmas are difficulties of the soul, provoking agonies,” he wrote. Many decisions faced by leaders are between two sets of evils; the skill is to pick the lesser.
The dilemma for Johnson is simple: How much time, money, and social upheaval should be spent saving lives from COVID-19? He will have to make this decision in the dark, weighing reasonable expectations of what will happen if he does or does not act in certain ways. He will be presented with scenarios that consider crime rates, drops in consumer spending, job cuts, tax losses, and strains on a health system dealing with other illnesses—as well as deaths from COVID-19.
Kissinger explained the dilemma of leadership: “The most difficult issues are those whose necessity you cannot prove when the decisions are made. You act on the basis of an assessment that in the nature of things is a guess, so that public opinion knows, usually, only when it is too late to act, when some catastrophe has become overwhelming.”
Johnson, then—and U.S. President Donald Trump and French President Emmanuel Macron and German Chancellor Angela Merkel—will be judged in hindsight for decisions taken without that privilege. Did he overreact or underreact? the public will ask. Did he calm a volatile situation or induce panic? Did he show leadership or reveal a lack of it? Is he up to the job? Faced with trying to ensure public confidence in his leadership, Johnson’s first reaction was to turn to experts. Those experts immediately threw the ball back to him.