By G. Owen Schaefer and Angela Ballantyne

Should you download an app that could notify you if you had been in contact with someone who contracted COVID-19? Such apps are already available in countries such as Israel, Singapore, and Australia, with other countries like the UK and US soon to follow. Here, we explain why you might have an ethical obligation to use a tracing app during the COVID-19 pandemic, even in the face of privacy concerns.

 

How it works

Contact tracing apps could take a variety of forms, but the most prevalent idea is to leverage Bluetooth technology. The app logs whenever two users are in close proximity for a sufficient period of time. That data normally remains secured and dormant – until a user is diagnosed with COVID-19 by relevant health authorities. Following a positive test result, the authority would, with the  user’s consent, access the app’s data in order to contact other members of the pubic who have downloaded the tracing app and recently been in close contact with the infected individual. These contacts would be advised to self-isolate and abide by the prevailing public health guidelines.

The app serves to automate and accelerate traditional contact tracing. Such tracing is essential to contain outbreaks like COVID-19. By identifying contacts more rapidly, people potentially exposed to COVID-19 will self-isolate more quickly – in turn reducing the risk that they will pass the virus on to other people. Modelling by researchers at the University of Oxford suggests that widespread use of such an app as a complement to existing contact tracing measures could effectively stop rapid spread of COVID-19. However, where such apps are available, uptake has been too low to realize their full potential. For instance, in Singapore, TraceTogether has been downloaded by around 1 million individuals – impressive, but at less than 20% of the total population, it is far short of the coverage required for contact tracing apps to be effective at containing disease spread (Australian officials have said they are aiming for 40% of their population to download the app).

Even if the app has a modest impact on reducing COVID-19 spread, there is a compelling ethical imperative to download and use the app, on the basis of two moral principles: beneficence and reciprocity.

 

Beneficence

Beneficence is the obligation to do good for others, to act with charity and kindness, to enable others to further their legitimate interests, often by preventing harms or mitigating threats.  For example, if you are walking past an unknown toddler drowning in a pond, you are morally required to reach in and save the toddlers life. The extent of the duty to help others depends on the likelihood your action will actually improve the person’s wellbeing, and the degree of risk to you that the action entails.

It is difficult to calculate the precise societal benefit generated by one individual downloading a tracing app, as that depends on a number of uncertain variables: the likelihood a user will be diagnosed with COVID-19, the viral reproduction rate, the severity of the disease, the likelihood the app’s contact tracing would prevent further people from being infected and experiencing harm. Nevertheless, on balance, the benefit of widespread use of the app is likely to be substantial. COVID-19 has already had a devastating effect on global well-being; contact tracing has substantial potential to save lives, and apps are a promising means to accelerate and improve contact tracing.

COVID has placed enormous pressure on health systems and public services. Contact tracing apps are also beneficial because they can conserve the human and financial resources currently required to undertake rapid and aggressive contact tracing via other methods.

If contact tracing apps are effective, countries may be able to lift lockdown orders sooner – as of this writing it is estimated that around 4.5 billion people around the world are forced or advised to stay at home. In the long run, easing social distancing measures sooner with the assistance of contact tracing apps will be conducive to promoting personal freedom and well-being, and reducing the dual burdens of both COVID-19 disease and lockdown.

 

Risks

The risks to users of downloading the app are primarily privacy related. The production and storage of data always has potential vulnerability to malicious hacking, even with robust protections. Moreover, there is a potential for authorised users – governments or private companies that operate the app or have access to its data – to use the data for secondary purposes not directly related to disease containment, such as law enforcement, immigration or marketing. The app then raises the spectre of the rise of the surveillance state as a potential legacy of COVID-19.

Several strategies have been implemented to mitigate these risks. Bluetooth data of momentary contacts with other app users is, on its own, not very sensitive, and unlikely to result in identity theft or other personal harms in the instance of a data breach. Secondary uses are more worrying, but may be addressable by several governance structures which have been proposed as ethical conditions for contact tracing apps’ responsible deployment, including: effective legal/regulatory limits on how the data can be used; independent oversight; and algorithmic transparency.

In fact, many people already co-operate with much more intrusive obligations to restrict movement and work in order to contain COVID-19.  Any potential personal harm from downloading a contact tracing app is much less serious than abiding by advice that confines people to their homes and effectively prevents many from earning a living.  Downloading the app entails minimal risk relative to the anticipated benefit.

 

Reciprocity

Frontline healthcare workers are rightly being praised for their hard work and personal self-sacrifice. By continuing to care for patients during this crisis, including many who have COVID-19, they expose themselves to substantial risk of transmission. In addition, overloaded systems have made the healthcare environment often stressful and exhausting, physically as well as mentally. Healthcare workers’ efforts have led many, including former US President Barack Obama, to exhort individuals to abide by social distancing measures for the sake of the well-being of healthcare workers.

The rationale is essentially one of reciprocity: as a population we substantially benefit from the sacrifices of healthcare workers through continued provision of essential medical care, not only for COVID-19 but also all the usual ailments that continue to arise.

This rationale extends to contact tracing apps. Using the apps exposes us to some degree of privacy risks. But solidarity with those who have made sacrifices for us demands that we be willing to make sacrifices in turn. Many of these sacrifices are already being undertaken – particularly the use of social distancing, which has had widespread negative impacts on people’s employment, ability to socialize, and mental health. In fact, the risks and intrusion of using a contact tracing app are arguably far less than these social distancing measures.

If moral exhortations to social distancing are justified on grounds of beneficence and reciprocity, then the less burdensome use of contact tracing app is an even stronger obligation.

 

Vulnerability and unequal distribution of risk

Marginalized populations are both hardest hit by pandemics and often have the greatest reason to be sceptical of supposedly benign State surveillance. COVID-19 is a jarring reminder of global inequality, structural racism, gender inequity, entrenched ableism, and many other social divisions. During the SARS outbreak, Toronto struggled to adequately respond to the distinctive vulnerabilities of people who were homeless. In America, people of colour are at greatest risk in several dimensions – less able to act on public health advice such as social distancing, more likely to contract the virus, and more likely to die from severe COVID if they do get infected. When public health advice switched to recommending (or in some cases requiring) masks, some African Americans argued it was unsafe for them to cover their faces in public. People of colour in the US are at increased risk of state surveillance and police violence, in part because they are perceived to be threatening and violent. In New York City, black and Latino patients are dying from COVID-19 at twice the rate of non-Hispanic white people.

Marginalized populations have historically been harmed by State health surveillance. For example, indigenous populations have been the victims of State data collection to inform and implement segregation, dispossession of land, forced migration, as well as removal and ‘re‐education’ of their children. Stigma and discrimination have impeded the public health response to HIV/AIDS, as many countries still have HIV-specific laws that prosecute people living with HIV for a range of offences.  Surveillance is an important tool for implementing these laws. Marginalized populations therefore have good reasons to be sceptical of health related surveillance.

The catch here is that “pockets of suffering that are unfair, unjust and preventable cannot be addressed if they are not first made visible.” Data is necessary to show the differential impact of COVID-19 in order that mitigation strategies can be implemented. For example, cell phone data in the United States (US) was used to show that high income demographic groups have been able to reduce their geographic movement more significantly than lower income groups.

This differential burden suggests that those with the greatest ethical obligation to use contract tracing apps are non-marginalised populations. Whether marginalized populations have a similar obligation is a more open question. The privacy risks to them are generally greater, but insofar as COVID-19 has disproportionately negatively affected such populations, the benefits to such populations are also potentially greater.

We are told that staying home saves lives. Using contact tracing apps is also likely to save lives, as well as human and financial resources currently required to undertake contact tracing. Health providers and frontline workers take on increased risks every day to serve and protect the public. On the grounds of beneficence and reciprocity we, especially those of us from more privileged groups, have an ethical obligation to use these apps.

 

Authors and affiliations:

Owen Schaefer is a Research Assistant Professor, working under the Science, Health and Policy-relevant Ethics in Singapore (SHAPES) initiative at the Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore

Angela Ballantyne is a Visiting Senior Research Fellow, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore; and Associate Professor of Bioethics, Department Primary Health Care and General Practice, University of Otago (currently on leave)

Competing interests: We have no competing personal or financial interests with regards to the content of this post.

Acknowledgements: We would like to acknowledge and thank the following people for their helpful advice: Michael Parker, Vikki Entwistle and Katherine J. Skene.