31 Jul 2020
Late last year, pre-COVID, the UK Government appointed a Moral and Ethical Advisory Group whose role is to advise on moral, ethical and faith considerations in health and social care related issues including, but not limited to, flu pandemics.
The group adopted the ethical framework for the response to pandemic influenza (previously agreed across Government) and so one would expect it to be using this to assist in the formation of the Government response to the COVID-19 pandemic. However, the terms of reference suggest that the Group advises only in respect of “questions and issues put to it”. The extent to which issues are being put to it is not known.
Debate about how to exit from lockdown is increasing. What evidence is there that the ethical dimension of that process has been considered? So far there is little or no such evidence.
The ethical framework is designed to be used in a structured way by people who may not have formal training in ethics, to ensure that key ethical issues are identified. How this could work can be illustrated by a brief example – the question of whether people over 70 should be advised to remain in lockdown at home for more than a year. The example isn’t a comprehensive account of the issue but aims to illustrate the approach. Whether the framework is being used in this way is not known.
The framework’s overarching principle is of equal concern and respect, which is then separated out into eight principles. These are not ranked in order of importance – they all matter. The first principle is respect. Relevant issues here concern keeping people informed, enabling them to express views on matters that affect them and (subject to other principles) respecting people’s choices about their care. People over 70, including the former Home Secretary Lord Blunkett, have expressed concerns about the potential impact of a prolonged lockdown on their personal, professional and family lives. There would need to be strong countervailing arguments against allowing people, properly informed about the risks, to make choices about how to live their lives.
The second principle is minimising harm. The framework is clear that this covers physical, psychological, social and economic harm. Treating people with respect means that evidence of the harms that may be prevented by locking down all over 70s, or those with certain underlying health conditions only, needs to be examined, as does the question of whether the harms are so significant that they outweigh any informed choice a person might wish to make (keeping things in proportion, principle 6). The harms that seem to being prioritised are the person’s physical health interests, including preserving life; as well as contributing to reducing harms for others by decreasing burden on the health service. There is limited evidence of the Government considering possible harm to the person’s mental health, and the impact on the other members of the person’s family in the context of lockdown.
If older people wish to make an informed choice to leave their homes and undertake certain social activities, it is necessary to ask whether it is fair (the third principle) to ask them not to do so in order to benefit everyone else by reducing burden on the health service. Are there other ways that the burden on the health service can be reduced that share the burdens more fairly? Any means of reducing burden on the health service is likely to involve harms to someone or some sector of society (such as pubs, for example), as reducing transmission of infection will be necessary; but in the same way that creative means have been found to keep supermarkets open with socially distanced queues and restricted numbers in the shop, consideration of such measures in other sectors of society as we emerge from full lockdown warrants consideration rather than expecting older people to make greater sacrifices.
During a pandemic, all of us have a responsibility to work together (principle 4). In the context of this example, this might mean an older person taking responsibility by avoiding situations that are particularly high risk (because of crowding) as well, of course, of self-isolating if symptomatic. The person may be able to demonstrate flexibility (principle 7) in adapting their behaviour to different situations as well as any new understanding about Covid-19 and its management, rather than being subject to an inflexible requirement to remain at home.
Reciprocity (principle 5) means that those who are asked to take on increased burdens during the pandemic should be supported in doing so. This is particularly important in terms of supporting members of health and social care services, but in the example of the older person it is also necessary to ask how they would be supported in taking on the burden of prolonged home isolation.
The final principle, of good decision-making, comprises a number of elements. Firstly, openness and transparency so that the basis on which decisions are made, including any ethical assessment, is clear. Those concerned by a decision should be consulted as much as possible in the time available (has there been any consultation with representatives of older people, for example?).
The ethical framework is not a calculator: judgments are still needed about the weight to give to different principles in specific situations, and this means that those making an ethical assessment need to have access to appropriate evidence (for example, scientific and clinical evidence) in order to inform the necessary balancing exercise between principles.
Secondly, decisions should be reasonable in that they are rational and evidence-based; and inclusive, in that they take into account any disproportionate impact of a decision on particular groups of people. Any route out of lockdown should comply with these decision-making requirements, and be demonstrably consistent with the Government’s own ethical framework as a whole.
Thank you Elaine for a thought=provoking blog about ethics and this current pandemic. My questions are the same as Hilary. Why are experts not using these frameworks in decision-making with colleagues? This also applies to Health Impact Assessment in planning. What can we do to overcome these barriers?
Thanks Mary. In terms of changing the situation, I think it is important to look at the culture of an organisation as a whole and not just at the behaviour of experts. Hilary highlights the importance of leadership from the top, and that has implications for management development programmes. In a wider sense, it is important that addressing the ethical dimension is an integral part of professional training and development in order to encourage people to take personal responsibility for identifying and addressing such issues (with specialist assistance if necessary) from the start of their career.
Excellent blog. These are similar to our trust drivers and one of the things we are looking at in our Trust in Governance report is that all these frameworks are developed and rarely are they used and listened to - why is that. Would love to know your views on this. We are looking at things like the mindset of people - their own assumptions and biases, ordinary institutional things, like no time, and communications issues - they might have done this but who would know.
Thanks Hilary. I agree there are probably a range of reasons why such frameworks are not used as much as they could be, but lack of awareness of them, lack of confidence in using them, and a tendency to think “dealing with ethics is someone else’s job” may be important. Having someone in an organisation who can champion the importance of looking at ethical issues is really helpful.
Thanks Elaine, yes, probably the very ordinary human reasons! 'someone else's job' is a key part for us too. When things go wrong in em tech the reasons are usually about values and ethics and taking seriously the opinions of people who's opinion you don't value - these 'are not the job of governance' time and again!
But I did CSR for 20 years and this idea of 'having someone who can champion' is also problematic, because then it is their job, they are the 'someone else' which means, phew, you don't have to do it! The main effective driver was the CEO who championed it, lived it themselves and didn't let up on the detail of implementation. Haha in this current context of Covid and the UK government!
Keep up the good work, look forward to more blogs from Council members they are all interesting.