Not only benefit: equity and fairness in states’ responses to COVID-19

By Nic Aagaard, Lynley Anderson, Neil Pickering

A range of important ethical considerations that have arisen due to the emergence of the novel coronavirus COVID-19. A potentially important part of the international response is the role of National Ethics Committees (NECs). NECs are generally advisory committees, offering ethical comment to governments and other institutions, and setting out values and principles upon which to base policy. The World Health Organisation (WHO) has supported a number of meetings of representatives of NECs over the past four years at both an international and regional level.

On the 6th of April the WHO convened an international meeting of representatives of NECs from around the world to share the ways in which countries are addressing the ethical concerns raised by the COVID-19 pandemic.  More than 130 people attended by Zoom.

The acknowledged ethical challenges we face at this time include the allocation of oftentimes scarce resources such as Personal Protective Equipment (PPE), or Intensive Care Unit (ICU) beds, which require health care workers to decide between people, with the personal and ethical implications of these actions. Other concerns arise in the light of the public health response, which looks to utilise contact tracing and Artificial Intelligence, and other forms of digital technology, requiring a balance between concerns for privacy and preventing harm to others. There are also other issues related to the consequences of self-isolation and the effect that is having on families especially with regards to mental health and domestic violence statistics.

In addition, nations are looking for ways of treating COVID-19 and the development and research of vaccines that will be crucial to addressing this pandemic.  Being able to respond rapidly to research protocols will be a centrally important to ethics committees asked to review COVID19 related research.

At the meeting, the New Zealand National Ethics Advisory Committee (NEAC) reported on its response to COVID-19.  NEAC’s functions include providing ethical scrutiny of research and health service activities. NEAC published “Getting Through Together: Ethical Values for a Pandemic” in 2007. NEAC commenced review of this document this year, even before COVID-19 was recognised as a global pandemic. In line with the values in this document, NEAC recognised the significance of a process engaging with a wide range of stakeholders.  A meeting was held to establish and build relationships between the ethics groups (national and clinical), clinical groups, other health officials involved in prioritisation and equity and Māori leadership beginning with organisations with wide national representation.

A key determination for NEAC’s work is to ensure any COVID response does not perpetuate inequity (as required in the 2007 document, but expanded upon greatly in its application).  This provides an ethical justification for inclusion of equity and fairness alongside a focus on consequences measured in terms of benefit or risk reduction (as literature states any interventions or tools should have as an ethical underpinning). But as NEAC has recognised, there is a strong likelihood of tension between these ethical underpinnings.  In a pandemic where there are serious threats to lives, the tension appears at its sharpest.  For example, pre-existing ill-health and social deprivation may increase the likelihood of contracting the disease and reduce the capacity to recover.  These pre-existing conditions are already more prevalent in some groups than in others.  The aim to save as many lives as possible may tend to focus resources where these pre-existing conditions are less prevalent, whereas equity considerations seek to take into account the existing unfairness in directing the use of resources.

Making an ethical case to include equity at the heart of ethical thinking is a divergence with much of the literature that has been published to date, which have been described as adopting utilitarian maximisation outcomes as being in the public interest (and effectively an assumption). NEAC are planning on developing this further to guide clinical and public health initiatives across New Zealand.

 

Authors: Nic Aagaard1, Lynley Anderson2, Neil Pickering2 3

Affiliations:

1 Ministry of Health New Zealand

2 Bioethics Centre, Dunedin School of Medicine, University of Otago

3 Chair, National Ethics Advisory Committee (NEAC) New Zealand

Competing interests: None

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