Are we any better poised as a society to cope with COVID wave two in the period starting October 2020 than we were in the initial wave period March-August 2020? Have we the tools to assess the strengths and weaknesses of how we fared in the first wave? Can those tools be applied to shape the choices we make as citizens, as business owners and workers, and elected and appointed officials?
What Are We Learning
We must acknowledge that our involuntary exposure to the coronavirus pandemic is not yet done. We may be about to be taking a second heart-wrenching trek into the unknown. To date, that journey reveals the critical role of certain institutions and types of workers to our very survival. It draws into sharp focus the tensions between individual freedoms and collective responsibilities. Many people, vocations and enterprises have paid a terrible price when Mother Nature is dangerous and runs amok.
Over 65 EthicScan blog articles published over the past six months have identified areas of optimism as well as areas of concern. Through an ethics lens, we have come to appreciate the realm of specific ethical challenges: Who makes the decisions? What are the choices? Are we united in facing this challenge?
Does flattening the curve (leaving ICU beds free to treat the infected) represent our only or best choice? Which groups get the few specialized treatments or ICU beds? Should vulnerability, care-giving, region, age, or some other criteria be the main consideration here?
If we could reduce the overall rate of infection and mortality from COVID-19 by exposing a small minority of essential-care workers to almost certain infection, would that be justified on utilitarian grounds? How about residents of an under-populated region of a country with a currently low infection rate? Does “total harm minimization” (that is, the majority of society) mean that vulnerable small minorities should literally be sacrificed?
Prior Experience Measuring Ethical Performance
In 1988, EthicScan started producing for subscribers a series of ethical assessments of companies’ corporate responsibility performance for investors and consumers. These measures and sophisticated products were reports in a variety of formats and media, including individual companies’ industry sectors, and partnership screening reports drawn from public sources and a proprietary database.
Some of the lessons learned during that exercise were:
- Performance criteria must be measureable and transparent
- The definitions of a specific measure will change as technology, public media attention, and issues change (climate change, apartheid, conflict diamonds, etc.)
- The relevance of a specific criterion (such as number of women executives, reporting annually on environmental performance) also evolves as society changes
- No enterprise or institution scores well or conversely poorly across all criteria
- There is value in differentiating promise/policy/aspiration from practice, with an emphasis on reporting on the latter, to avoid greenwashing and promotional public relations
Could EthicScan try to extend these lessons and approach to assessing COVID-adaptation public performance?—that is, analyzing the ethical performance of governments, public-health agencies, professional associations, and other stakeholders as it relates to COVID-19? The following cautions would need to be applied:
- It would be vital to try and control against subjectivity or political bias
- Today’s decision-making environment is dramatically and abruptly changing, in large part because of unprecedented use of government emergency regulations and edicts
- Different jurisdictions can have different public-health metrics and standards
- There is much less full and open parliamentary discussion and review of decisions
- Ethical principles as well as expectations will vary depending upon whether the government is democratic or autocratic
Public-Health Policy Contextual Challenges
1. Disaster-Driven Over-Reaction
Decisions are largely being made by government with advice of public-health agency officials, both international and local. Several governments in the west have acted aggressively to promote social distancing, mask wearing, and pre-emptively shutting down businesses in order to explicitly flatten the curve—that is to prevent hospitals from being overwhelmed by COVID patients. Decisions in the first wave have heavily relied upon epidemiological predictions of deaths in the tens of thousands.
As it happened, our hospital-based medical system was not overloaded. Some observers say this was the result of widespread success with social distancing, clearing our IC hospital beds of non-essential patients, and wearing Personal Protective Equipment (PPE). Other observers have commented that Provinces like Ontario may have “over-flattened” the curve, and yet this this hasn’t saved lives. Indeed, aside from COVID deaths in lower numbers than forecast, there were thousands of intensive care beds reserved for COVID patients that remained unused, while victims of other diseases (heart, stroke, lung, liver, neurological, breast, prostate, et cetera) who had been prepped for procedures had their scheduled surgeries and other clinically-approved interventions postponed.
By-and-large, governments and public-health authorities in Canada focused exclusively on COVID-avoidance inside hospitals to the dis-benefit of an estimated 200,000 existing patients with other diseases who were prepped, tested and approved for scheduled essential and elective procedures. The results:
- a) Thousands were abruptly denied operations as hundreds of ICU operating rooms went unused; and other procedures cancelled. Hundreds died due to non-treatment of their original symptoms.
- b) These underused care providers were not redistributed to deadly locations like nursing homes, jails and other long-term care facilities that were the site of 75% of more confirmed cases.
2. Suitable, Unequivocal Benchmarks Are Not Readily Apparent
Disease transmission projections are best estimates based on assumptions. Typically ranges or alternate scenarios are forecast based on those assumptions. Who could know for example that the number of COVID-19 deaths would be 10,000; a much lower number than the higher end projections of 60,000-80,000?
If governments and health-planning associations in various locations essentially behave in a similar way, it is impossible to say whether or not a decision was avoidable or could have been different. Can we say with certainty that governments helped flatten the curve so effectively that beds weren’t needed? What specific causal role was played by closing cross-border traffic, or large acceptance of the need for social distance, or the non-symptomatic nature of carriers? Can the costs in terms of people dying because they were denied other disease procedures and treatments be said to be justifiable? Can the reason for those deaths due to the denial of medical procedures (such as heart or lung or kidney or thyroid) properly be coded as a death by omission attributable to an exclusively COVID pre-occupation mentality?
3. Punish the Healthy by Quarantining Everyone
Throughout recorded human history, those afflicted by diseases like leprosy and plague reportedly were killed, ostracized, and shunned, in large part to protect the rest of the population. In the case of this current COVID-19 epidemic, however, the decision was made to presumptively label all businesses and residences as vectors of illness. All individuals and residences—healthy or not—have been targeted with joblessness, de-densification, and sanitation solutions.
Some commentators say this quarantining everyone response reduces collective population exposure to the virus. Others call this punishing the healthy. There were no proactive public-health policies proposed or at least publicly debated or voted upon to target known probable unsafe and vulnerable workplaces or long-term care facilities or shelters where the vulnerable were located.
4. No-one Has a Crystal Ball or the Right Answer
We simply don’t know enough about the coronavirus. Because the virus manifests in different ways, are there internationally, actual, separate strains of a mutating disease? Can you become immune to it? Can it re-infect you multiple times? How many people have it but are asymptomatic? Do we know how many non-symptomatic people have recovered from it? Faced with so many unknowns, it is both easy and impossibly unfair to criticize policy decisions and action choices in hindsight.
There any many “known unknowns”:
- (a) the possibility of being re-infected;
- (b) the possibility of actual ground-zero cases outside China in December 2019;
- (c) how many victims have been affected asymptomatically and do not show up in the statistics?
- (d) when will we have an effective vaccine?
- (e) whether it is possible that we may never have a vaccine; and
- (f) the proportion of some COVID-diagnosis populations show symptoms other than the clinically-accepted respiratory ones.
A Proposed Measurement Framework
In collaboration with a small group of volunteer consultants, EthicScan has assembled a prototype measurement framework that we will be testing in the fall of 2020. Knowledge-bearing collaborators are welcome to participate in the testing phase, which will represent a total of ten hours per person over six months.
|Criteria||Principle||Number of Measures|
|1. Public health and safety||A. Ensure patients with COVID-19 symptoms are given the best care (not necessarily treatment) possible||10|
|B. Minimize risk to affected health-care providers of being exposed to COVID-19||9|
|C. Implement infection policies, consistent with previous evidence-based decisions||13|
|D. Prevent patients from coming to preventable harm while waiting for a diagnosis of their illness||9|
|2. Evidence-Based Decision-Making||A. Alignment and support of decisions provincially and federally1||5|
|B. Policies reflect the best available evidence and ensure assumptions made are well grounded and defensible||5|
|C. Implement health policies, consistent with previous evidence-based decisions||9|
|D. Messages sent from federal/province/health authorities are clear and consistent and provide reasons why the decision has been made||5|
|E. Enhance public trust in the federal/ province /health region||1|
|3. Respect democratic rights including accountability and transparency||A. Offer clarity about what interventions will and will not be offered and the rationale for these decisions||3|
|B. Minimize restriction or coercion as much as possible commensurate with the level of risk to broader wellbeing||6|
|C. Respect for the privacy rights of patients and their families||2|
|4. Economic Well being||A. Enhance resiliency of job creation and employment maintenance/recovery||10|
|B. Provide economic adjustment support for dislocated workers||5|
|C. Implement economic policies, consistent with previous evidence-based decisions||12|
|D. Provide well-being benefits for vulnerable populations||2|
|5. Duty of care to protect the vulnerable||A. Engage patients suspected to have COVID-19 and their families in a way that is respectful and mindful of power dynamics and life circumstances||6|
|B. Ensure all patients who present with COVID-19 symptoms receive a consistent level of care, regardless of where they present||3|
|C. Implement service policies, consistent with previous evidence-based decisions||7|
|D. At-risk vulnerable patients receive appropriate and timely care||5|
|6. Protect essential care givers/ workers||A. Assist care givers to understand their responsibility (duty) to provide care and live up to this even when it involves exposure to some risk of harm||2|
|B. Enable care providers to treat each other with kindness, care and compassion||1|
|C. Implement caregiver policies, consistent with previous evidence-based decisions||3|
|7. Quality of Life||A. Ensure decisions about care are made based on the values and beliefs of patients and public||2|
|B. Implement quality of life policies, consistent with previous evidence-based decisions||6|
|C. Enhance quality of life||3|
There is a need to have independent, apolitical and evidence-based measures of COVID-adaptation choices. EthicScan has been conducting workshops with all manner of industry executives to assess the national and international literature on Trends Forecasts and Outlooks for health care and Scenario Development and Testing for industry sectors. EthicScan is searching out infectious disease specialists, health policy analysts, and other professionals to help develop these metrics in Canada, the U.S., and the U.K. in the fall of 2020.
Five EthicScan “planning for recovery” series blogs:
Miller Thomson – COVID-19: The power of the government in a public health emergency:
Just Security – Emergency Powers in the Time of Coronavirus…and Beyond:
Wired.com – What Emergency Declarations Can (and Can’t) Do in a Pandemic:
Slaw, Canada’s Online Legal Magazine – Yes, We’re in an Emergency and Yes, We Still Have a Social Contract:
The Chronicle Herald – PETER MCKENNA: Is COVID-19 killing human rights protections, too?
BC Centre for Disease Control – COVID-19 Ethical Decision-Making Framework: