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.