Public health ethics framework: A guide for use in response to the COVID-19 pandemic in Canada
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The public health threat posed by the COVID-19 pandemic has led all levels of government to take unprecedented measures to help slow the spread of COVID-19 and thereby minimise serious illness, death and social disruption resulting from the pandemic. Difficult choices are being made in a context of considerable uncertainty, as knowledge about COVID-19 and the impact of unprecedented public health measures evolves rapidly. Examples include decisions about allocation of scarce resources, prioritization guidelines for vaccines and medical countermeasures, curtailment of individual freedoms, and closing or re-opening public spaces, schools and businesses. Recognizing the fundamental ethical nature of these choices can help decision makers identify competing values and interests, weigh relevant considerations, identify options and make well-considered and justifiable decisions.
This Framework is intended for use by policy makers and public health professionals making public health decisions in the context of COVID-19.
This document is a guide to support ethics deliberation and decision-making in the public health response to the COVID-19 pandemic, including the transition to a new normal. It is based on several guidance documents and frameworks developed in Canada and internationally. Section 1 articulates ethical principles and values for public health authorities to consider, and Section 2 sets out a framework to help clarify issues, analyse and weigh relevant considerations, and assess options, in order to support decision making in real situations.
Ethical values and principles
Trust and Justice are the two key guiding values that underpin this framework. The ethical principles and procedural considerations that follow contribute to upholding and promoting trust and justice. Given that it may not be possible in some circumstances to uphold all values and principles equally, it will be important for decision makers to explain how they prioritised them, and to justify the trade-offs made in each situation.
Trust is the foundation upon which rest all relationships, whether between persons, persons and organisations, or citizens and government. Trust is essential to the success of the response to COVID-19. The effectiveness of many public health measures depends on the active cooperation of the public, and such cooperation is more likely if the public trusts the advice of public health authorities. Evidence that public health measures are achieving their intended outcomes, or alternatively, timely and transparent explanations of why they have not, also help to maintain and promote public trust. Without this trust, individual choices could contribute to the spread of COIVD-19 within the community. In the current context of uncertainty, being open, truthful and transparent in decision making and communication is essential to establishing and promoting trust.
Justice entails treating all persons and groups fairly and equitably, with equal concern and respect, in light of what is owed to them as members of society. This does not mean treating everyone the same, but it does mean considering who benefits and who is burdened by measures, avoiding discrimination, and minimising or eliminating inequities in the distribution of burdens, benefits, and opportunities to preserve health and well-being. In the context of COVID-19, it also means carefully considering the impact of decisions and their implementation on those who have the greatest needs, are especially vulnerable to injustice or are disproportionately affected by the pandemic and public health response measures, both in Canada and in the global context. A conscious and deliberate questioning of assumptions is essential in ensuring that responses and decisions do not reproduce the biases and stereotypes that are further entrenching inequalities in this pandemic.
Respect for persons, communities and human rights
Respect for persons and communities means recognizing the inherent human rights, dignity, and unconditional worth of all persons, regardless of their human condition (e.g., age, gender, race, ethnicity, disability, socioeconomic status, social worth, pre-existing health conditions, need for support). This entails recognizing the unique capacity of individuals and communities to make decisions about their own aims and actions, and respecting the rights and freedoms that form the foundation of our society. The right to autonomy is not absolute however. In the context of the response to COVID-19, respecting autonomy may entail: recognizing the importance of public consultation and of explaining the basis of decisions; providing information in a manner that is truthful, honest, timely and accessible; and providing individuals with the needed personal supports and the opportunity to exercise as much choice as possible when this is consistent with the common good. Respect for communities requires considering the potential impact of decisions on all communities and groups that may be affected, and respecting the specific rights of, and responsibilities towards, Indigenous Peoples.
Individuals, organizations and communities have a duty to contribute to the welfare of others. In the context of COVID-19, public health authorities’ decisions and actions should promote and protect the physical, psychological and social health and well-being of all individuals and communities to the greatest extent possible. They should also consider the specific needs of, and duties towards, those who are marginalised, disadvantaged or disproportionately affected by response measures.
Public health authorities have an obligation to avoid causing undue harm and, given that some harm is likely unavoidable, to minimise risk of harm and to reduce suffering associated with COVID-19 and public health response measures. This requires taking into consideration the variety of harms and suffering that may result from the current pandemic (such as ill health, increased anxiety and distress, isolation, social and economic disruption), as well as the differential impact of these harms on different groups and populations.
In order to promote well-being and minimise harm, the following must be considered when weighing options:
- Effectiveness: there should be a reasonable likelihood that the proposed decision or action will achieve its goals, and that its implementation is feasible. If scientific evidence is available, the proposed action or decision should be supported by the evidence;
- Proportionality: potential benefits should be balanced against risks of harm. Measures should be proportionate to the relevant threat and risks, and the benefits that can be gained. If a limitation of rights, liberties or freedoms is deemed essential to achieve an intended goal, the least restrictive measures possible should be selected, and imposed only to the extent necessary to prevent foreseeable harm;
- Reciprocity: those who are asked to take increased risks or face greater or disproportionate burdens in order to protect the public good should be supported by society in doing so, and the burdens they face should be minimised to the greatest extent possible;
- Precaution: scientific uncertainty should not prevent decision makers from taking action to reduce risks associated with COVID-19. The continued search for scientific evidence should nonetheless be a goal.
Because individuals are part of a greater whole, whether an organization, a local community, a nation or the global community, collective action in the face of common threats is justified. Helping each other and working together to plan for, respond to, and recover from, the pandemic is important because the pandemic affects all of society. It implies strong links between all jurisdictions within Canada, and at the international level.
Ethical decisions are based on the best information available and a solid, shared understanding of what values, principles and considerations are important. A good decision-making process helps to build trust, to increase legitimacy and acceptability of decisions, and to effectively implement them. Its hallmarks are:
- Accountability: decision makers are answerable to the public for the type and quality of decisions made or actions taken;
- Openness and transparency: decisions are made in such a way that stakeholders know, in a full, accurate and timely manner, what decisions are being made, for which reasons, and what criteria were applied, and have the opportunity to provide input;
- Inclusiveness: groups and individuals who are most likely to be affected by a decision are engaged in the decision-making and planning processes to the greatest extent possible;
- Responsiveness: decisions are revisited and revised as new information emerges;
- Intersectionality: an intersectional lens is applied to deliberation and decision making.
This framework consists of five steps. It sets out questions to guide the systematic analysis of ethical issues – using the values and principles articulated in Section 1 – and the assessment of options, in order to support decision-making.
Step 1: Identify the issue and gather the relevant facts in order to clearly understand the problem
- What is the issue that needs to be addressed?
- What are the relevant facts, scientific evidence and other contextual factors? What misinformation surrounds the issue? What is not known?
- Who is affected by this decision? How can all stakeholders be engaged throughout the decision-making process?
- How do the different stakeholders view the issue, and what are their concerns?
Step 2: Identify and analyse ethical considerations, and prioritise the values and principles that will be upheld
- What ethical values, principles and considerations are involved in this issue?
- Are any of these values and principles in conflict?
- Which of these values or principles are most important?
Step 3: Identify and assess options in light of the values and principles
- What are the options (including doing nothing)?
- In light of the prioritised values and principles, what are the pros and cons of each option (e.g. potential benefits, harms, fair and equitable distribution, relative impact on disadvantaged individuals or groups, intended and unintended consequences, level of certainty about effectiveness, respect for rights and interests)?
- What uncertainties exist for each option?
Step 4: Select best course of action and implement
- Which option best aligns with the prioritised values and principles?
- Are the decision makers and stakeholders comfortable with the decision?
- Who will implement the decision? How can it be implemented fairly?
- How, when and by whom will the decision be communicated?
Step 5: Evaluate
- What are the lessons learnt from implementation of the decision?
- Were the results of the decision consistent with the objectives? Were there any unintended consequences? Did its implementation create or exacerbate inequalities?
- Should the decision be revisited?
- World Health Organization, Guidance for Managing Ethical Issues in Infectious Disease Outbreaks (2016)
- UNESCO International Bioethics Committee and World Commission on the Ethics of Scientific Knowledge and Technology, Statement on COVID-19: Ethical Considerations from a Global Perspective (2020)
- Public Health Agency of Canada, Framework for Ethical Deliberation and Decision Making in Public Health: A Tool for Practitioners, Policy Makers and Decision Makers (2017)
- Alberta Health, Alberta's Ethical Framework for Responding to Pandemic Influenza (2016)
- British Columbia Ministry of Health, COVID-19 Ethical Decision-Making Framework (2020)
- Northwest Territories Health and Social Services Authority, Territorial Ethical Decision-Making Framework (2019)
- Québec, Comité d'éthique de la santé publique et Commission de l'éthique en science et en technologie, Cadre de réflexion sur les enjeux éthiques liés à la pandémie de COVID-19 (2020) (in French only)
- University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group, Stand on Guard for Thee: Ethical considerations in preparedness planning for pandemic influenza (2005)
- Trillium Health Centre, IDEA: Ethical Decision-Making Framework (2013)
- Status of Women Canada, Government of Canada’s Approach: Gender-Based Analysis Plus (2018)
The Public Health Ethics Framework: A Guide for Use in Response to the COVID-19 Pandemic in Canada was developed by PHAC’s Public Health Ethics Consultative Group and its Secretariat with input from the Canadian Pandemic Influenza Task Group, the Federal/Provincial/Territorial Special Advisory Committee on COVID-19 and the COVID-19 Disability Advisory Group. PHAC greatly appreciates the time and effort that all contributed to this endeavour.
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