Since the outbreak of COVID-19, lockdowns have been used across much of the world as a primary public health measure. In this virtual seminar held on the 8th November 2021, the panel discussed the ethics and justifications of lockdowns and restricting population movement worldwide. To watch it please visit our seminar page here.
Voo Teck Chuan, Assistant Professor, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Martina Di Folco, MSc (Res),Policy and Engagement Officer, Oxford COVID-19 Government Response Tracker (OxCGRT), Blavatnik School of Government, University of Oxford, Oxford, UK
Ruipeng Lei, Professor of Bioethics, Executive Director, Centre for Bioethics, Vice Dean, School of the Humanities, Huazhong University of Science and Technology, China
Roberta Andraghetti, Regional Advisor – International Health Regulations, PAHO Health Emergencies Department, Pan American Health Organization (PAHO), Washington DC, USA
In contexts where there is high COVID-19 vaccination coverage, can broad restrictions, including lockdowns, be justified?
What are the ethical considerations associated with the use of targeted restrictions and lockdowns (e.g., of unvaccinated populations; of vulnerable populations)?
With profound inequities in vaccination coverage internationally, what are the ethical considerations associated with the continued use of travel restrictions?
Dr Andraghetti began the seminar, by highlighting a struggle within bioethics. Practitioners have to manage the tension between clinical ethics which apply to the individual, and public health ethics which apply to populations. In regard to the question of whether COVID-19 restrictions, including lockdowns can be justified in settings with high vaccination coverage, she argued the answer must be conditional yes. However, restrictions must be evaluated against specific criteria including the intensity of transmission, the specific epidemiologic situation, and health service capacity. Fundamentally, restrictions depend on the risk tolerance of local and national authorities in the context of a pandemic response. In regard to the second question of targeted restrictions, Dr Andraghetti noted the World Health Organisation is investigating the use of individualised public health measures based on immunity status. These measures should be based in affected settings which already have robust public health measures in place, and work under the assumption that the risk of infection from a vaccinated individual is lower than an unvaccinated individual. Once again, before implementation, authorities should consider whether this type of measure is proportionate, inclusive, and the extent to which it infringes on the rights of non-vaccinated individuals. Finally in regard to travel restrictions, Dr Andraghetti first asked can travel-related public health measures ever be classed as restrictions. Despite the semantic confusion, the overall health and wellbeing of affected communities should be the main consideration. A risk-based approach should be taken in developing travel public health measures and this relates again to individual and national risk-tolerance. Given the fact some countries have limited access to vaccines, Dr Andraghetti was against the introduction of proof of vaccination against COVID-19 as an exclusive condition for travel but it could be utilised as a single measure among many, which may work in some contexts, but not others. Dr Andraghetti concluded by arguing public health practitioners and bioethicists should continue to work together and manage this fundamental tension between clinical ethics and public health ethics for the foreseeable future.
Professor Ruipeng Lei’s presentation examined restrictions in relation to China’s strategy of managing COVID-19. She argued despite the changing global landscape, which includes the introduction of high-efficacy vaccines, ethical challenges remain. China’s strategy aims to eliminate the virus, whenever and wherever it’s found. This is achieved by using public health interventions which include vaccines, contact tracing, targeted lockdowns, and surveillance. However, the fundamental ethical issue is that protecting public health also infringes on individual freedom. Like Dr Andraghetti, Professor Lei believes the two values must be balanced. With this in mind, five principles should guide public-health decision making: utility, proportionality, necessity, least infringement, and transparency. The two aims of China’s ‘clearing-zero’ strategy is to prevent the virus from making contact with humans; this can be done via hand-washing, avoidance of mass gatherings, and sterilisation of the environment. The other aim is developing a vaccine which would lead to herd immunity and act as an immune barrier to the virus. Because the outcome of vaccines is still not clear, the first aim remains important. She acknowledged health restrictions do limit individual freedom, however, they also adhere to the five public health principles and are useful and necessary to prevent and limit the transmission of the virus. As a result they are justified. Drawing on her experience as resident of Wuhan, Professor Lei argued restrictions on balance are ethical. If transmission in a city is so wide, the virus can spill over to other cities. Wuhan’s successful reopening at the time of writing indicates that they also work.
Ms Martina Di Folco, spoke about University of Oxford’s COVID-19 Government Response Tracker. The ‘OxCGRT’ provides a systematic, cross-national, cross-temporal measure of how government response to COVID-19 has evolved over the last two years. It is also designed to answer two research questions: firstly, what leads governments to adopt different policies? Secondly, what effects do government responses have, and how do effects vary in different populations, countries and contexts? OxCGRT has 23 indicators in closure and containment, economic response, health systems and vaccine policies, which are recorded on an ordinal scale to capture not just the presence of, but also degree of government response. In regard to the eight closure and containment indicators, which range from school and university closures, to stay at home requirements, the analysis showed that in 2020, there was a global trend in the first months of the pandemic with almost all countries implementing stringent policies at the same time regardless of local conditions. Stay at home orders spiked early, particularly in the northern hemisphere, but as the pandemic shifted into spring, they dropped off, and compliance began to fall. By 2021, divergent responses began to emerge. For example the UK lockdown policy is marked by increasing desensitisation. The first lockdown was implemented at 1000 cases, the second at 20,000, and the third at 25,000. Alternatively Australia has become hypersensitised. The first lockdown was implemented at 330 cases, followed by a second at 63, and a third at 20. Overall however, most countries follow a path of decreasing sensitivity in regard to lockdowns. Ms Di Folco argued in the context of restrictions in areas of high vaccination coverage, we first need to define what constitutes a high vaccination rate, and factor in regional disparities, incidence, immunity over time, and healthcare capacity. If pandemics are a global phenomenon, it doesn’t matter if a country has a high vaccination rate, because the virus could arrive from abroad, and reach the most vulnerable anyway. It could also mutate enough to make vaccinations less effective. As a result, a global effort is needed to tackle the pandemic, and move beyond it.
Questions and Answers
The panel then addressed several questions from the audience members which are outlined below.
We know some governments what to achieve higher vaccination rates. Are vaccine mandates an ethical tool to achieve this, and how can we ensure human rights are not violated?
Ms Di Folco talking more broadly about civil liberties, argues that some countries are using emergency legislation to boost powers and thereby creating inequalities and violating human rights. This makes it difficult to make a blanket statement for or against mandates because all countries are different. Ms Di Folco argues that as long as the pandemic continues, and large communities remain unvaccinated restrictions of some sort will inevitably continue. Professor Lei again argued we need to learn to balance the values of public health and individual liberty, stating that there is always a trade-off. She argued ethics isn’t simply about the identification of right and wrong, but sometimes the choice between the lesser of two evils. She argued that theoretical ethical analysis is always retrospective. Reactive decision-making in a public health emergency is more difficult and this needs to be taken into account when evaluating restrictions. Dr Andraghetti, argued all decisions are multi-faceted, and therefore governments require the input of bioethics committee who should have an expanded role in decision-making process.
Will China’s Clearing Zero strategy isolate it from the rest of the world?
Professor Lei said the ‘Clearing Zero’ strategy will likely discontinue at some point. However, the timing of this is more difficult. It is not easy to transfer from one approach to the other, and any policy change, must happen gradually. She also noted that adverse effects of any strategy needs to be monitored more carefully.
How much are restrictions related to political pressures from residents in a particular country? And to what extent should these be balanced and weighed against scientific and ethical considerations?
Ms Di Folco argued that at the beginning everyone was scared, and so most governments acted emotionally and closed up everything, even against WHO’s own IHR regulations. Dr Andraghetti’s disagreed with this saying the IHR regulations were poorly applied but do in fact contain a list of measures which allow for restrictions in certain situations. In her opinion, lockdowns were less an emotional response, and more a precautionary principle, which should have been recommended by the World Health Organisation to begin with. If the primary scope of WHO is to reduce the internationalization of diseases while being known as the cornerstone of public health law, it must make clear in the context of emergencies that restrictions can be applied.