Opportunities and challenges for ethicists advising public health authorities during the COVID-19 pandemic

Maxwell J. Smith, PhD, Western University, London, Ontario, Canada (maxwell.smith@uwo.ca)
 
The COVID-19 pandemic has raised a number of distinctive and profound ethical challenges. It is therefore unsurprising that public health authorities have turned to ethicists for advice when developing and implementing policies and measures in their pandemic response. This has created many opportunities for ethicists to enhance the moral quality of public health decision-making; however, it has also raised a number of challenges, both substantive and procedural. This blog summarizes a recent PHEPREN webinar which engaged the experiences and perspectives of ethicists who have played key roles in advising public health authorities in four countries during the COVID-19 pandemic. Webinar speakers included Dr. Alena Buyx (Technical University Munich and German Ethics Council, Germany), Professor Florencia Luna (Director of the Bioethics Program at FLACSO (Latin American School of Social Sciences), Principal Researcher at CONICET, Argentina), and Dr. Maxwell J. Smith (Assistant Professor and Co-Director of the Health Ethics, Law, & Policy (HELP) Lab, Western University, Canada), and was chaired by Professor Michael Parker (Director of the Wellcome Centre for Ethics and Humanities and the ETHOX Centre, University of Oxford, United Kingdom).
 
Opportunities
The COVID-19 pandemic has generated widespread awareness of the ethical dimensions of public health activities. Consequently, in many cases the value of ethical reasoning and guidance has been acknowledged by public health authorities, which has created opportunities for ethicists to directly influence decision-making at local (e.g., hospital), national (e.g., national government), and international levels (e.g., World Health Organization). In some instances, this awareness was not present prior to the pandemic and unique opportunities emerged to establish bodies to systematically examine emerging ethical issues in this context (e.g., in the case of Argentina’s National Ad Hoc Commission on Ethics and Human Rights). In other cases, this awareness was simply amplified. The guidance that ethicists have had the opportunity to offer has included the generation of ethical frameworks for the overall pandemic response or for specific ethical issues such as lockdowns, as well as the provision of ad hoc advice to decision-makers, including leaders of national governments. This has required ethicists to consider the ways in which advice ought to be tailored to different scales and contexts of decision-making.
 
While there was no blueprint for precisely how ethics should be engaged in this context or how ethicists should optimally provide guidance, as a field, ethics was well-prepared for many of the questions that ethicists were asked to comment on. For instance, much has been previously written about the ethics of critical care triage in the context of a major surge in demand, and much work has been done in the domain of public health ethics, which has sought to address questions of inequities in the contexts of public health emergencies and in the balancing of individual liberties with the public good. While the COVID-19 pandemic has no doubt presented unique challenges and nuanced familiar ones, ethicists have been well-positioned to make meaningful and helpful contributions to pandemic response efforts.
 
Challenges
As advisors to public health authorities during this pandemic, ethicists have been asked to participate in the rather unique ecology of decision-making that exists within an incident command and control structure. Where the value of ethicists’ expertise has been acknowledged and incorporated into these decision-making structures, it is critically important that ethicists help to address issues that authorities consider relevant or have prioritized. At the same time, it is imperative that ethicists preserve their capacity to be critical, defend positions and priorities that they view as ethically important, and bring issues or priorities to the attention of decision-makers that they might otherwise not be aware of. This is often a fine balance.
 
In many instances, ethicists engaged by public health authorities have accepted a significant responsibility insofar as they have felt they must represent or at least raise the relevant perspectives of an entire field (i.e., bioethics) in their role. Moreover, because many other disciplines have not been engaged by public health authorities in a manner similar to the way in which ethicists have, ethicists have at times felt as though they should raise, if not seek to represent, the perspectives from other critically important disciplines in the humanities and social sciences. This challenge has been addressed in part by making clear whose perspectives are missing from discussions and by crowdsourcing these important perspectives, i.e., reaching out and drawing upon the expert perspectives of colleagues in relevant disciplines.
 
A related challenge regarding the scope of ethicists’ roles in advising public health authorities regards the sheer number of ethical issues that deserve attention in pandemic response. Where experts in epidemiological modelling, critical care, or supply chain logistics have a set of skills and expertise that apply to specific areas of the pandemic response, ethicists might be, and often have been, asked to comment on any and all issues given the fundamentally ethical nature of many decisions that must be made during a pandemic. This presents a significant challenge in terms of priority setting and bounded rationality. These challenges are exacerbated by the fact that, by and large, ethicists advising public health authorities in this context have done so with extremely limited bandwidth. In many if not most cases, ethicists have been asked to serve in these roles while continuing their full-time jobs as academics, clinical ethicists, or otherwise.
 
Finally, the challenges that ethicists have experienced have of course largely been addressed in an online environment with impossibly short timelines given the urgency with which decisions must often be made. This has frustrated processes for including diverse perspectives, reconciling divergent viewpoints, and incorporating dissenting voices—elements that are all normally difficult to address even with ample time and face-to-face meetings.
 
The work that ethicists have engaged in when advising public health authorities during this pandemic no doubt represents some of the most challenging work that we have been, or will be, faced with. Yet, I think I speak for most when I say that if we have been at all successful in enhancing the moral quality of public health decision-making, it will be worth it.

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