Ethical considerations in responding to the COVID-19 pandemic
This rapid policy briefing outlines ethical principles that must be considered when developing public health measures in response to the COVID-19 pandemic.
Ethical considerations for states
Proportionality, effectiveness, and necessity of interventions
Many public health interventions, including some of those being considered or already implemented as part of the Government’s coronavirus action plan, involve intrusion by the state in the private interests of individuals, either in order to protect the interests of others, or for the wider public good. Such trade-offs between competing interests raise difficult ethical questions. Interventions that interfere with personal liberties need to be carefully and transparently justified, both by reference to the good which they aim to achieve (including clarity as to the precise nature of the Government’s health goals), and by reference to the evidence supporting their likely effectiveness.
The trade-offs involved in introducing many public health measures become particularly challenging when the intrusion into personal liberties has significant social, economic, and health effects on individuals (as in the significant lost income that may result from self-isolation) – and/or where the benefit of these interventions may at times be for others, rather than those experiencing these negative effects. As a general principle, when seeking to attain appropriate public health goals, the state should minimise as far as possible the degree of intrusion or coercion in people’s private lives and choices.
Any intervention should be proportionate to the effect that it is intended to achieve. Robust evidence that the intervention will be effective in achieving the desired aim is important in demonstrating that the intervention represents a proportionate response to the particular health threat. In the absence of such evidence, interventions held to be necessary should be accompanied by an evidence-gathering programme. The more intrusive the intervention, the stronger the justification and the clearer the evidence required. For example, compulsory quarantine, or asking people to ‘self-isolate’ in their homes for long periods of time, are significantly more intrusive than encouraging people to practise good hygiene and avoid direct contact such as shaking hands, and hence require greater justification. It is unlikely that intrusive measures will be proportionate if less intrusive means are likely to be as effective.
Contact-tracing, isolation of people with confirmed disease, and quarantine of those with close contact to diagnosed patients, are all well-established and evidence-based public health measures for responding to infectious disease outbreaks. As such, their use in outbreaks such as the current COVID-19 pandemic can readily be justified, despite the impact on the individuals concerned. In the absence of an effective vaccine, these are also the only methods available for containing outbreaks. There is, however, little or no evidence to date on the impacts of closing down whole cities or regions, as happened in Hubei province in China, and increasingly in other countries such as Italy and Spain. Such interventions go well beyond standard quarantine practice in that they apply to large numbers of healthy individuals, as well as to those who are either already ill, or have increased risk of infection through close contact with known cases. A WHO representative in China was cited as describing such ‘lock-downs’ as ‘unprecedented’ and beyond current WHO recommendations, while commending the commitment of authorities in China to contain the virus. Research designed to evaluate the impact of such lockdowns will be very important in helping determine both their effectiveness and their social costs in areas such as mental health, jobs and livelihoods, and hence the proportionality of the use in their future.
In addition to considering the likely impact on personal liberties, other negative effects of potentially effective interventions also need to be taken into account when considering proportionality of response, including the scope for significant impact on business, and hence on people’s livelihoods (especially for those whose situation is precarious). In emergencies, there is a risk that the suffering directly arising out of the emergency (in this case the health effects of COVID-19) is automatically prioritised over existing causes of suffering. In making judgments about the proportionality of interventions in response to the emergency, it is essential that governments also keep in view other, often equally pressing, needs. England’s Chief Medical Officer, Chris Whitty, has emphasised that an important part of the current approach of household isolation and avoidance of unnecessary social contact, is to reduce the pressure on the NHS and avoid the risk of ‘indirect deaths’ – deaths from non-COVID-19-related reasons – resulting from health services being overwhelmed.
A number of challenging trade-offs are emerging in consideration of possible interventions in the Delay phase of the Government’s action plan. Closing schools not only disrupts children’s education – for some, at a critical time for exams that influence future career options – it also has a substantial impact on the workforce, with many parents unable to work because of childcare responsibilities. This in turn could lead to serious staffing shortages in key services, including the NHS and social care. Alternatively, it could lead to grandparents taking on childcare responsibilities – even though older people are those who are at greatest risk of suffering severe disease from the virus. Advice to older people to stay at home and avoid social contact, or prohibition on outside visitors coming into care homes, may reduce the risk of the most vulnerable groups becoming infected – but may also have significant consequences with respect to people’s mental health and general well-being, especially if such restrictions continue over an extended period. This is of particular concern given the pressures that are likely to be experienced in the social care system, and the risks that (despite the encouragement of personal and community solidarity, as described below) some vulnerable individuals may find themselves without adequate support and social contact. Such consequences should form an important part of the risk-benefit analysis in determining the extent to which proposed benefits will indeed contribute to the reduction of suffering.
Public justification and maintaining trust
Trust is essential in order to maintain support on the part of the general public for the measures proposed: without such trust, compliance with those measures is likely to be low. Clear and trustworthy public communication on the part of governments, providing transparent and convincing justifications for the decisions taken, is particularly important in helping create and maintain such trust. Recent challenges to Government policy on the part of a number of scientists highlight the importance of clear public justification – for example through publishing the modelling assumptions that underpin the advice provided by expert committees, and being frank about what is, and is not known, and about how the difficult trade-offs involved are being approached.
A crucial part of such public justification includes clarity as to the overall aims of the Government’s public health strategy, as illustrated by the concerns arising out of uncertainty as to whether or not ‘herd immunity’ to COVID-19 is an aim, or simply a side-effect, of Government policy. If the pressures on health services reach the point when prioritising or rationing care becomes unavoidable, it will similarly be important for decision-makers to develop fair and impartial criteria for allocating scarce healthcare resources that can be seen to be publicly justifiable.
Fair and respectful treatment
The manner in which public health interventions are introduced and managed is also ethically significant. While it may in some circumstances be proportionate to restrict people’s liberties (even in quite draconian ways, such as through extended quarantine), this must be done in a way that shows respect for them as individuals – of equal moral worth with all others. At a personal level, this requires courtesy and honest, respectful communication between those acting on behalf of the state and the individuals concerned. It also places a duty on the state to make sure that those who are effectively deprived of their liberty do not suffer in other ways as a result. The appreciation showed to NHS staff and others at Arrowe Park by the group of UK residents quarantined after returning from Wuhan demonstrated how important kind and respectful treatment had been on a personal level – and also for gaining wider public trust.13Treating people with respect also involves providing them with clear and timely information about the development of the pandemic and potential risks to individuals, to enable them to make choices about the conduct of their own lives (for example about social interaction) in situations not covered explicitly by public health measures.
Solidarity: ensuring just sharing of burdens
The state has a strong duty, founded in solidarity, to ensure that those who are asked to bear burdens in order to protect others (for example, self-isolating with minor symptoms), are supported in ways that ensure they do not suffer materially. This moral duty is reinforced by the practical consideration that if people cannot afford to pay their bills, they are unlikely to comply with the proposed restrictions.
The importance of ensuring that those who are unable to work because they are self-isolating are able to afford their daily living expenses has been raised in recent parliamentary debates.14 In response, the Government has announced that statutory sick pay (SSP) will be paid from the first day of illness (rather than the fourth); that those self-isolating should be eligible even if they are not currently ill; and that Universal Credit will be payable to those workers who do not qualify for SSP. Concerns have nevertheless been raised as to the adequacy of these benefits, which in most cases will fall far short of normal earnings for those concerned. Campaigners are calling for further measures to protect vulnerable private tenants, including rent freezes and protection from eviction, particularly in the light of action by some banks to offer mortgage ‘holidays’ to homeowners unable to meet mortgage payments because of COVID-19. The needs of others who may be particularly vulnerable to the impacts of COVID-19, such as refugees and undocumented migrants, also need to be taken into account.
In the light of the latest advice for people to stay away from any places where close social contact is unavoidable, such as restaurants, cinemas, theatres, pubs, and clubs, considerable concern has been expressed about the impact on business – especially as these businesses have not directly been instructed to close, which might have enabled them to claim on their insurance. There have been calls for further financial support from Government, amid fears that thousands of businesses may close for good.
States have particular duties in solidarity towards healthcare workers, given the additional burdens they bear on the front-line of care, and the additional risks to which they are exposed. The World Health Professions Alliance has highlighted the urgent need to ensure that such workers have access to crucial personal protective equipment, as well as the importance of ensuring they have adequate breaks during and between shifts, and support services in recognition of the burden on their psychological health.
Solidarity is also important at international level: emergencies such as the COVID-19 pandemic illustrate very clearly how inter-connected and interdependent nation states are. Financial and logistical support for less well-resourced countries will be essential in order to ensure that the global pandemic is brought under control. The research required to develop effective treatments and vaccines also depends on international collaboration, and on adequate funding from both governments and philanthropic organisations.