By Verina Wild, Alena Buyx, Samia Hurst, Christian Munthe, Annette Rid, Daniel Strech, Alison Thompson.
Clinical ethics consultations are a well established method to deal with ethically problematic situations in clinical care, even in emergency situations. But an emergency public health ethics consultation? This was unusual for most of us.
Public health authorities in many places of the world are now struggling with ethically complex decisions regarding their response to the SARS-CoV-2 pandemic. Surely, they are also reaching out to ethicists, asking for advice. We share our experience here so as to promote exchange with other public health ethicists who are actively consulting authorities at the moment. We are interested in knowing what questions are being asked; what answers are being produced; and what processes colleagues are using to respond to these consultation requests.
In our case, the requesting authority (State Institute for Health, Bavarian Health and Food Safety Authority) did not ask us for specific recommendations, but for ethical criteria on which to base their decisions. We therefore drew on well-established public health ethics frameworks and literature on pandemic ethics that we applied to the current SARS-CoV-2 pandemic (see our full response including references). The requesting authority was regional and is therefore not involved in nation-wide governmental decisions or international decision-making. This explains why our response only very briefly touches on national and global aspects, even if these are absolutely crucial in the overall pandemic response.
The authorities’ first question was whether saving lives should be the primary or only consideration in deciding about possible public health interventions. If there were other considerations, such as the burden of these interventions or the extent to which they limit individual freedom, the authorities wondered, how should they balance these considerations against saving lives?
The second question regarded the significant uncertainties about how effective different public health interventions would be in the context of the SARS-CoV-2 pandemic. If the interventions’ effectiveness could not be the main justification, what other ethical considerations could or should be considered?
The final two questions were about the ethics of conducting epidemiological research. Would it be ethically appropriate to conduct studies on diagnostic tests as part of the effort to scale up screening and testing? And what ethical considerations would be relevant for conducting cohort studies on disease outcomes and immunity over time?
In our replies, we emphasized that public health interventions should take a multi-sectoral perspective, taking not only health–including mental health and domestic violence– but also economic impact, educational attainment, and so on into account. We also highlighted the importance of considering effects on, for example, class and gender. At various places we urged the authorities to pay particular attention to social vulnerabilities and social justice, as it can be assumed that disadvantaged population groups will be burdened disproportionately both by the pandemic itself and any restrictive public health interventions. Because infections as well as interventions can reproduce and reinforce social vulnerabilities, in pandemic response must seek to maintain and stabilise social justice.
We further argued that evidence of the effectiveness of public health interventions should remain the primary ethical justification for choosing between possible measures, and that data collection about their effectiveness should be integral to any roll-out. We further proposed that data should be collected not only on SARS-CoV-2 and COVID-19, but also on the psychological, social, economic and other effects of the public health interventions taken.
In relation to epidemiological research, we strongly encouraged pursuing such research, but generally giving priority to public health interventions and clinical care if research risked competing for limited personnel or infrastructure to support the pandemic response. All research should use sound scientific methods, and the resulting data should be published fully, quickly and open access and widely disseminated.
Finally, our consultation process was as follows: The lead person who was approached by the public health authority created a Google doc with the questions and room for replies. She contacted a group of public health ethicists/pandemic ethicists and asked to fill in their thoughts. Within 24 hours, the document was filled with critical insights as well as references to relevant literature. The lead person drafted a response that all group members could edit and comment on–thanks to Google docs simultaneously and around the globe. This made it possible to provide the requesting authorities with a reply within two days that was based on international expertise.
We are pleased to report that the authorities found the document valuable and expressed the wish to establish a similar procedure for future ethics consultation requests. We, of course, agree that ad hoc public health ethics consultation can be of value and therefore set aside time to contribute to this process, while also trying to homeschool our kids, support family and friends in need, and attending to our regular work. All this was possible because of our commitment to provide ethical advice during a major global health emergency, our pre-existing work relationships, and a good dose of camaraderie and intellectual curiosity as to what others would say. However, if the capacity for ad hoc public health ethics consultation is to be established, resources, networks, standard operating procedures, and so on need to be developed similar to clinical ethics consultations.
Authors: Verina Wild1, Alena Buyx2, Samia Hurst3, Christian Munthe4, Annette Rid5, Daniel Strech6, Alison Thompson7
- LMU Munich, Germany
- TU Munich, Germany
- University of Geneva, Switzerland
- University of Gothenburg, Sweden
- The Clinical Center, NIH, USA
- Charité Berlin, Germany
- University of Toronto, Canada
Competing interests: None
Disclaimer: The views expressed here are those of the authors and do not necessarily reflect the policies of the National Institutes of Health or the U.S. Department of Health and Human Services. This work was supported by the Clinical Center Department of Bioethics, which is in the Intramural Program of the National Institutes of Health.