Reflecting on a year of COVID - where are we now?

It is difficult to sum up the past year in any meaningful way; difficult to muster anything more than a vague gesture of despair, an exhalation of frustration, a general anguished noise from the back of my throat. As we pass the UK’s Day of Reflection to mark the one year anniversary of the first UK lockdown, there is much reflection to be done - learning and action even more so.

Bioethics has - or perhaps more accurately, should have - played a critical role in the pandemic response since the beginning. Much though the government and policy-makers may have liked to believe that the decisions required were purely scientific and capable of neat encapsulation in slogans and mantras, the real decisions were, and continue to be, ones of trade-offs between competing interests and values.

How do we balance different interests (individual and collective; economic and social) and different risks (the risks of morbidity and mortality of COVID; the risks of poor health associated with poverty and isolation)? Whose interests (the young, the elderly, the key workers) should be given priority? On what basis and by whom are these decisions being made? These questions have come up time and time again at all stages of the pandemic: in decisions to impose lockdown and then to lift it; in decisions about how scarce resources should be allocated, whether ventilators and critical care beds or limited doses of the vaccine; and in decisions about creating a system of immunity certification and vaccine passports. These are the questions that we have been discussing, and pushing for open, transparent consideration of, since the beginning.

The beginning for us, was in many ways, before we had even heard of COVID-19. In January last year, we published our report on research in global health emergencies, the result of an in-depth two-year inquiry with an international working group. In the few-weeks window between going to print and publication, the first reports of pneumonia of an unknown cause began to emerge from Wuhan province. The Council’s report, which outlines a call for action and an ethical compass for conducting research ethically in global health emergencies, took on a startling relevance as governments the world over found themselves facing the challenge of COVID-19, and it has continued to inform a significant part of our response to the pandemic.

In February 2020, as we were confronted with images of something called “lockdown” in various cities in China, and in response to the UK government’s declaration of the spread of the novel coronavirus as a “serious and imminent threat to public health”, we published a short guide to the ethics of surveillance and quarantine. Come March, as the UK Government set out its action plan of “contain, delay, research and mitigate” and announced that all non-essential contact and travel should cease, we published our rapid briefing on ethical considerations in responding to the COVID-19 pandemic. In line with the findings from our 2007 public health report, we underlined the necessity for any public health measures to be evidence-based and proportionate, and for the aims of those measures alongside the science, values and judgements underpinning them, to be clearly communicated to the public. Two values, in particular, stand out to the 2021 reader: trustworthiness (the need for clear and trustworthy public communication on the part of governments to maintain the support of the general public, and the provision of transparent and convincing justifications for decisions taken to engender that trust) and solidarity (the just sharing of burdens: between individuals, between the state and the individual, and between countries). How far these values have been realised in the year-long lockdown is just one of the many questions to be reckoned with.

Frustrated by the Government’s repeated exhortations of “following the science” to justify policy decisions, in April we issued a statement on COVID-19 and the basics of democratic governance. “Following the science is not politically or morally neutral,” we said, “and it does not deliver policy answers - that involves values and judgements for which people are responsible and should be scrutinised, and accountable. Which values are in play and what judgements are being made? By whom? On what advice?” Although shortly after the Government pledged “maximum transparency” in decision-making and, more recently and in the context of vaccine passports, a commitment to exploring the “ethical issues”, it is a frustration that has persisted.

As the pandemic continued, and as the thoughts of many turned to a route out through testing, certification and vaccination, we published two new policy briefings on fair and equitable access to COVID-19 treatments and vaccines and antibody testing and immunity certification. The first of these highlighted the key challenges in ensuring fair and equitable access to treatments and vaccines, highlighting the particular challenges posed by commercial confidentiality laws and intellectual property rights, and emphasising the importance of solidarity and global cooperation and collaboration in bringing the pandemic to an end. One year on, and as vaccination efforts in many high-income countries continue apace but are barely off the ground elsewhere, concerns around global equity are as relevant as ever.

The second of these briefings on antibody testing and immunity certification similarly warned of the risks of inequity: that the negative effects of any system of ‘passporting’ will fall disproportionately on the disadvantaged. The briefing highlights the tension that such an approach could create between individual rights and public interests and the potential social disruption which might follow: a preference for those who can demonstrate immunity and a stigmatisation and loss of opportunity for those who cannot; the commodifying of biological markers and the creation of systems or approaches which put a premium on immunity status; and the subsequent incentive to fake, manipulate, or misreport test results. Many of these concerns have come back in a slightly different guise in the more recent discussion about vaccine passports.

By autumn, and as tier rules and will-they-won’t-they lockdowns sparked confusion, we published a short briefing which spotlighted the questions that still remained about the next phase of the pandemic response. Once again we asked for clarity on whether the government was planning to introduce immunity passports; how the UK could continue its commitment to global solidarity in the allocation and distribution of vaccines; and, crucially, of what values were guiding decision-making.

Through winter and the start of this year, our focus turned to questions of resource allocation, with regard to both NHS treatment and vaccine prioritisation. In January, as winter pressures threatened to overwhelm the NHS, we published a statement calling for authoritative and comprehensive national guidance on how decisions about the allocation of constrained resources should be made - a call which is yet to be answered in respect of future pandemic preparedness. In February, seeking clarity on the ethical values that might underpin the roll-out of the COVID vaccine, we convened a roundtable of experts to examine what the considerations should be. All those present agreed that above all, fairness should inform decisions, and that policies must take into account, and seek to reduce, existing unjust disparities between groups.

Throughout, we have endeavoured to create a space for ethical debate and reflection, both through our published briefings and through continued comment on our blog and our webinar series which brought together a range of global voices.

And what now? After a year quite unlike any other, we find ourselves turning back to other issues of pressing importance, which haven’t paused or disappeared during the pandemic. That’s not to say that our COVID-19 work is over. We are part of the UK Pandemic Ethics Accelerator, which will coordinate and mobilise ethics research excellence to inform key challenges in pandemic emergencies. We will also continue to press policy makers on the issues we have already explored - not least on equitable allocation of vaccines and COVID-19 status certification - and also to foreground the questions that need debating and to support that debate where it happens.

Crucially, our thoughts also turn to the future. COVID-19 is unlikely to leave us completely, and we must contend with the prospect of future pandemics becoming a recurring feature of modern life. The ethical questions which that brings with it will persist. There must be a space for open and informed deliberation on those questions in the public sphere and in policy-making. Without it, the lessons of the COVID-19 pandemic cannot be fully learned.