Ethical preparedness

Much was said at the outset of the pandemic about how thoroughly well prepared the United Kingdom’s health service was for the outbreak. We now know that this wasn’t true, a decade of austerity having had a significant deleterious impact on our public services. That those in the NHS have nevertheless managed to cope as well as they have is tribute to their commitment and dedication to the service. It is also now widely known that a series of official exercises were conducted before 2019 that imagined various pandemic scenarios. Their recommendations have only recently come to light, and it is possible to see how many of these – such as in respect of a possible crisis in care homes – were, for whatever reason, not given priority.

Jeremy Farrar’s and Anjana Ahuja’s insider account of the progress of the pandemic, Spike, is a remarkable and chastening narrative of missed opportunities, catastrophic delays, and executive failures, alongside the exemplary courage and extraordinary hard work of the scientists who did their very best to work out research-based solutions to the impossible task facing frontline health workers. Its final chapter is a superb summary of the various preparations we might make to do better in the next pandemic. And we know there will be one.

At one point the authors say that they ‘wish that ethical considerations had been built into the UK’s coronavirus response right from the beginning ‘ (p. 229). The Nuffield Council could not agree more. From the outset of the pandemic we have consistently challenged the lack of discussion about ethical issues in decision making. Time and again, in making crucial decisions – whether on how to prioritise COVID and non-COVID healthcare needs when both were arguably equally urgent, whether and how to mandate vaccination, the priority rules for receipt of the vaccine, the idea of an acceptable level of avoidable deaths – the ethical considerations at stake have rarely been publicly articulated or recognised by political leaders.

Ethical preparedness

If these important issues are to be taken seriously next time around, we need what we, building on valuable work by others, are calling ‘ethical preparedness’. This means being ready as a society not just to deal practically and efficiently with a pandemic, but to do so in a way that is ethically appropriate and fully justified.

What then does ethical preparedness mean? There is still a great deal of work to do to explore the full scope of such a concept. However, drawing on the lessons from COVID, we suggest the following three elements are likely to play an important role:

1. Clarity on moral principles and values

First, there needs to be clarity regarding the moral principles and values that are to underpin policy responses. It is sometimes thought that in a public health emergency the normal moral rules, for example relating to fairness or human rights, do not apply, and that ‘anything goes’ in order to preserve lives at all cost. In our own Research in global health emergencies report, however, we argue that the ‘moral compass’ remains consistent; what may need to change is the practical ways in which its values are realised. So, for example, what seem to be draconian restrictions on free movement and personal liberty may be temporarily justifiable by the need to control an untreatable and highly contagious disease, but such measures bring with them duties to ensure that everyone has access to essential goods (for example through ensuring adequate compensation for those prevented from working), and that the impacts of the restrictions are not unfairly borne by those who are already most disadvantaged.

Throughout the pandemic, the Government appeared to subscribe to one moral rule that what was right was what produced the greatest overall benefit in terms of lives saved, captured in the mantra of ‘protect the NHS’ and ‘save lives’. Yet, there is broad agreement that, even in a crisis, doing the right thing (which in the exigencies of any particular situation may be simply the least bad thing) must take account of fairness. For instance, the Council and many others have consistently highlighted the disproportionate impact the pandemic, and the policy response to it, has had on certain social groups. Those already disadvantaged and suffering poorer health because of their economic situation have suffered still further as a result of COVID. If we as a society are genuinely concerned about this, then our national response should aim not just for an overall reduction of harm but also for inequalities to be mitigated and reduced.

Doing the right thing also means taking proper account of individual rights – to liberty, to privacy, and to living by one’s own beliefs, while recognising that, at times, and to the least degree possible, those rights may need to be limited for the safety and wellbeing of others. This difficult balancing act of reducing harm, tackling unfair health inequalities and minimising measures that are coercive or implemented without people’s consent, is described in the Council’s ‘stewardship model’ for public health. This was published in 2007 and has been widely used and adopted in the intervening years.

2. Clear, authoritative ethical guidance

A second element of ethical preparedness is ensuring that procedures, institutions, and regulations are in place so that ethical guidance can be provided in a clear, determinate, authoritative, and unambiguous fashion.

In the early months of the pandemic, there was much justified criticism of the confusing plurality of guidance being offered to front-line staff on such matters as deciding which patients should be prioritised for treatment. Such guidance came from official bodies, professional organisations, and academics, but not from the Government. The confusion led those making the critical decisions to worry as to what they should do, and, crucially, to be concerned that they might be subsequently liable to censure, discipline or worse, for those decisions they had to make under great pressure.

It is clear that much more needs to be done to harness the many different sources of ethical expertise and advice available nationally. We have been working recently with UKRI to gain a better understanding of the complex UK bioethics landscape, and look forward to engaging with policy makers and other stakeholders over how this diverse expertise can best be convened and made available to feed into policy considerations.

3. Ethical policy making and public engagement

A third element of ethical preparedness is making sure that the Government understands and articulates that ethical considerations need to be an integral part of policy-making, and actively engages the public in exploring the competing values and interests at stake. The Government must be seen to make ethically robust policy and the public must be involved and see that this is what is being done. Transparency of policy making, including explicit recognition of the values that are informing policy decisions, is the essential key to trust between Government and public. Yet this Government insisted that it was led by science, even though science, while providing crucial evidence, cannot itself provide an answer to policy questions that concern competing interests and values.

The public are highly capable of grasping moral matters. Indeed, they are quick to criticise a Government for prioritising self-interest over the public good. What is fair or unfair in particular contexts, and what it means to recognise and protect competing rights, are more difficult matters. Yet that is why it is so important to create the conditions under which there can be public discussion of ethical issues. The Nuffield Council has consistently stressed the importance of public engagement with, and public discussion of, key bioethical subjects – including highlighting how this is of even greater, not lesser, importance in times of emergency.

Non-ideal conditions

A final thought. Being ethically prepared and being practically prepared for a pandemic are interconnected. Having to make the best possible, even if not ideal decisions in difficult circumstances should not be taken to imply that those circumstances – scarce resources, existing disadvantage, poorer health outcomes for some – are simply facts of nature. They are the result of longstanding policies and official inaction that are open to moral scrutiny. If we make choices in what philosophers and economists call non-ideal conditions, we need to recognise why they are not the best and what can be done now to ensure they are better next time.

Being ethically ready for the next pandemic, or any other public health crisis, is a real priority. We need to take steps now to recognise this and to ensure we are properly prepared for the next emergency. A public dialogue commissioned through our partnership with the UK Pandemic Ethics Accelerator has identified key themes to be addressed in future policy making, including:

• addressing the inequalities that COVID has exposed and exacerbated;
• building trust and transparency into government policies and actions; and
• involving the public in policy-making.

We will be taking up these themes, among others, in work with national ethics bodies around the world in 2022, and in our contributions to international discussions, such as the forthcoming WHO agreement on pandemic preparedness.

No-one welcomes the prospect of another pandemic, or indeed of another public health emergency of any kind. But we know that the question is when, not if, the next one will arise. At the least, we should ensure we are prepared to meet its ethical challenges.