Living Relational Ethics: A Case Study of a COVID-19 Asymptomatic Testing Programme in Higher Education

Abstract

Relational ethics gained increased attention as a guiding approach for public health during the COVID-19 pandemic. Highlighting the social features of viral transmission, such as shared risk, relational ethics emphasizes the importance of collective responses rooted in values of community solidarity, mutual obligation and equity. However, many discussions of relational ethics have remained largely normative rather than empirical in character. In this paper, we report a study of relational ethics in the context of a COVID-19 asymptomatic testing programme implemented at a UK university during the pandemic. Exploring how staff and students considered the exceptional ethical demands and dilemmas of the pandemic, we show that respondents discussed participation in the asymptomatic testing programme in relational terms. In particular, they emphasised the mutual dependencies of communal living, the risks of community transmission, expectations for institutional care and distributed responsibility to care for those most vulnerable to severe disease. Our empirical findings advance normative discussions of relational ethics by demonstrating the relevance of institutional context and social change, offering insights for future public health interventions premised on relational values.

Introduction

In recent discussions in public health ethics, scholars have called for a relational approach that highlights the ethical demands that emerge ‘within relationships and our commitment to one another’ during public health crises such as a pandemic (Austin, 2008: 11). Relational ethics draws attention to the moral responsibilities that derive from social interdependence and to values such as reciprocity, duty, trust, fairness and care (Austin, 2008; Kenny et al., 2010; Jennings, 2019). Even more fundamentally, it understands relationality to be an ontological condition of social life: we are always bound into mutual existence with proximate and distant others (Zigon, 2021). Drawing from this premise, those advocating for a relational approach in public health have stressed that responses to health crises should recognise the essential interconnectedness of social being and the mutuality of our needs, vulnerabilities and interests (Baylis et al., 2008; Jennings, 2019; Jeffrey, 2020; Redhead et al., 2023).

The principles of relational ethics gained particular immediacy during the COVID-19 pandemic, when our mutual dependencies were highlighted by the communicability of the SARS-CoV-2 virus (Hopkinson and House, 2021; Strong et al., 2021). Interconnected health outcomes were particularly stark when it came to disparities in risk across demographic groups (Wachtler et al., 2020; Magesh et al., 2021). Older people, those with compromised immunity, and the socio-economically disadvantaged were particularly vulnerable to disease, while others—including young, healthy people—tended to face lower risk individually but could contribute to transmission in the population at large (Davies et al., 2020; Goldstein et al., 2021). As a result, mitigation measures to reduce transmission required collective action that viewed the health of the individual as potentially consequential for community-level health outcomes and, especially, those most at-risk. Some argued that the ethical imperatives of the public health response mirrored the biological characteristics of the virus itself. In 2020, for instance, Dawson et al. (2020: 128) noted that, ‘Just as infection spreads through connection, our ethical response requires us to act together to ensure recognition of our common nature, needs and value’.

Much debate in public health ethics during the pandemic focused on the balance of individual versus communitarian rights and the tensions that can arise when the interests of those considered ‘at risk’ may not coincide with the interests of those who may be a source of risk (Goldhaber-Fiebert et al., 2020; Ayalon et al., 2021; Cook et al., 2021). Age was a particularly prominent feature of these debates, with some noting that the interests and needs of younger and older populations were portrayed in opposition to one another (Ellerich-Groppe et al., 2020; Ayalon et al., 2021). This conflictual framing represented, perhaps, epistemic biases in discussions of medical ethics that tend to pose population level interests and individual liberties in opposition (Dawson, 2022). These previous analyses of potential intergenerational differences raise the empirical question of how the norms of relational ethics were reflected in behaviours during the pandemic, particularly among young people.

Higher education institutions offer an important case study for this question, since they often play an important role in civic society (Goddard et al., 2016; Brennan et al., 2018). Early in the COVID-19 pandemic, higher education settings also represented a particular risk for viral transmission because students typically live in dense, shared accommodation. University campuses were recognised as potential hotspots for the transmission of COVID-19 (Cohen et al., 2020; Walke et al., 2020; Wilson et al., 2020), with consequences for students themselves and for possible onward transmission to surrounding communities (Walke et al., 2020; Yamey and Walensky, 2020; Lopman et al., 2021).

At the same time, relationships between higher education institutions and the communities in which they are based are often delicately balanced across multiple potentially competing priorities—in this case, an obligation to minimise community transmission while continuing to provide in-person education, in recognition of the academic, developmental and relational needs of students. During the pandemic, universities widely introduced mitigation measures, including testing and isolation programmes, to reduce risk of infection in student populations (Blake et al., 2021; Gillam et al., 2021; Hirst et al., 2021; Wanat et al., 2021; Warne et al., 2021). But how students and staff themselves conceptualised shared risk and responsibility when it came to testing has been less examined.

In this article, we offer an empirical case study of a public health campaign implemented in response to COVID-19 in late 2020 at the University of Cambridge, UK. Our study collected views from university students and staff on an asymptomatic testing programme implemented as part of a strategy to monitor cases of COVID-19 and reduce transmission. Focusing on the ethical considerations raised by the testing programme, we show that study participants expressed awareness of the mutual vulnerabilities produced by the virus and a desire to act in solidarity with the needs of the broader community. Participation in the testing programme, as we will demonstrate, was informed by a principle of distributed responsibility, in which both individuals and institutions (especially the university) were seen to bear a moral obligation to protect at-risk members of the community at large. Moreover, the act of contributing to the testing programme itself helped to engender new forms of relationality. We argue here that these findings expand existing discussions of relational ethics by considering the institutional infrastructures and new relational imaginaries that support the enactment of values such as responsibility and solidarity.

Background to the Case Study

In the summer of 2020, the University of Cambridge developed an asymptomatic testing programme for COVID-19, which was aimed at helping the university re-open in-person after the pandemic-related disruptions of the previous academic year. The testing programme was developed in anticipation of the arrival of ∼18,000 students for the autumn term. Conceived as part of a multipronged approach to reduce risk to students, staff and city residents, it sought to detect cases early and prevent potential outbreaks among students living in college accommodation. The context was increased concern during Summer 2020 about the impact of students returning for in-person education, since August and September of that year had seen a steep rise in cases among young adults aged 17–21 (Public Health England, 2020), while the number of positive tests among people aged 50 or over appeared to stay the same or be declining (Office for National Statistics, 2020). A paper endorsed by the Scientific Advisory Group for Emergencies in September 2020 suggested that there was a ‘significant risk’ that higher education could amplify broader transmission rates and urged universities to develop clear test and trace policies (Task and Finish Group on Higher Education/Further Education, 2020). At this point in the pandemic, vaccination was not yet available and testing and isolation were key features of COVID-19 mitigation strategies. Self-administered lateral flow tests had not yet been authorized for at-home use (Mahase, 2020), so polymerase chain reaction (PCR) tests were the mainstay of identification for COVID-19.

As part of a broader ‘Stay Safe Cambridge Uni’ public health campaign, the University of Cambridge announced in early September 2020 that it would be implementing an asymptomatic testing programme for students residing in its colleges. The 31 colleges of the university are each separate self-governing institutions that provide students with accommodation and catering facilities and with academic and pastoral support. Colleges were responsible for administering asymptomatic testing programmes within their residential halls, with tests processed centrally at the Cambridge COVID-19 Testing Centre on the Cambridge Biomedical Campus (Brierley, 2021b). Starting on 5 October 2020, PCR testing was conducted weekly on a voluntary basis. Students were grouped into household testing pools of between 6 and 10 students and asked to self-administer a throat and nasal swab (Warne et al., 2021), with swabs from up to 10 students then immediately pooled in the same tube of viral testing medium. If a pooled test yielded a positive result, the members of that group were directed to administer individual confirmatory tests and to self-isolate. If these individuals’ tests were positive, students in the testing pool continued to self-isolate in their households for 14 days while receiving support (e.g. food deliveries) from college staff. The pooled testing method using student households reduced the capacity required to deliver a testing programme by 5-fold without compromising test sensitivity (Warne et al., 2021).

Student participation in the programme was encouraged through promotional slogans that emphasised the mutual benefits of testing: ‘Protect yourself and protect others’ and ‘I test to protect you, you test to protect me’ (Brierley, 2021a). Effective messaging for the Stay Safe Cambridge Uni campaign was informed by a survey of students and staff conducted by a professor from the Department of Psychology (University of Cambridge, 2020). The Vice Chancellor, in a video accompanying the campaign posted on social media, professed his hopes that this moment would be remembered as a time ‘when the community pulled together and rose to the challenge’ (Facebook, 2020). Over the course of the autumn term (between 5 October and 6 December 2020), 12,781 students living in college accommodation contributed swabs and participation rates remained over 75 per cent (Warne et al., 2021). Data from the programme suggested that a 31 per cent reduction in R0 (a mathematical term to indicate how contagious an infectious disease is) was attributable to asymptomatic testing in the autumn 2020 term (Warne et al., 2021).

The case study we report here is a consultation on views and experiences of the asymptomatic testing programme at Cambridge. We respond to increasing calls for normative debates in public health and bioethics to be informed by empirical research, given growing evidence that empirical studies advance normative accounts by demonstrating how ethical principles are interpreted and translated in real world settings (Molewijk et al., 2004; Kon, 2009; Dunn et al., 2012). As part of this ‘empirical turn’ (Borry et al., 2005; Knight, 2016) in public health ethics, our discussion of the programme is concerned not with issuing normative statements on what is ethical, but rather with understanding how people grapple with pressing ethical demands within the contexts of their own values, interests and institutional constraints.

We offer two empirical contributions that can advance conversations around relational ethics. First, we demonstrate how institutional responsibility, scientific capacity and organizational infrastructure at the university—as described here—played a role in realising relational ideals. Second, we show how university students and staff continued to develop relational awareness of the social entanglements of university life as the programme was implemented through their participation in a collective disease mitigation measure. Our empirical approach therefore offers insights into how calls for relational ethical norms can be supported and where relational principles may encounter limitations in practice.

Methods

Following the introduction of the programme at the University of Cambridge, we developed a mixed-methods research project, consisting of consultation with students and staff, to understand the ethical issues associated with asymptomatic testing for students in higher education (THIS Institute, 2021). Data for our consultation were collected between 20 November to 11 December 2020, when the testing programme was available to all students living in college-owned accommodation. Data collection and analysis was primarily led by a multi-disciplinary research team from THIS Institute at the University of Cambridge, with varied backgrounds in social anthropology, medical sociology, healthcare improvement and clinical medicine. The project was designed to gather a breadth and depth of views from students registered at the University of Cambridge or staff employed by the university or a constituent college. A combination of qualitative and quantitative methods, including survey and interviews, was used to cross-validate and corroborate findings within the study. The survey included both closed-ended and open-ended free-text responses. Quantitative data from the closed questions were subject to descriptive analysis, while free text was analysed thematically. We also conducted semi-structured interviews for a more detailed exploration of ethical issues within the broader context of participants’ lives and experiences of the asymptomatic testing programme. These interviews offered deeper exploration of ethical issues and insight into topics raised in the survey. Our discussion of results below emphasises our analysis of longer-form interview and survey free-text responses. The consultation received approval from the University of Cambridge Psychology Research Ethics Committee (Application No: PRE.2020.138).

Data Collection for the Consultation

Email was used to invite students and staff to the consultation. Individuals who expressed interest were asked to register on Thiscovery (https://www.thiscovery.org/about), a secure online collaboration platform created and developed by THIS Institute. After providing written online informed consent, participants could choose between taking part in a semi-structured interview or a survey. Semi-structured interviews took place either online using audio–video software or by telephone. The three interviewers (AA, CC and MM) were experienced qualitative researchers at THIS Institute and had no relationship to the participants. The interviews were guided by an interview guide (Supplement 1). Questions covered the following topics: goals of the testing programme, choices regarding testing, access to testing, support for students, properties of the COVID-19 swab test, communication, confidentiality and data protection, risk of inequalities, support or opposition for the programme, suggestions for improving the programme, other concerns or ethical issues. These topics were informed by a provisional ethical framework that was developed by the study team based on a broad informal review of relevant literatures on public health ethics and screening programmes, and a previously developed ethical framework for COVID-19-testing in NHS workers conducted by our research institute (THIS Institute, 2020). The interview guide was refined through pilot interviews with three students. Changes included improving the clarity of the questions and optimising the order of the questions to enhance conversation flow. The interviews lasted for 30 to 60 min. Interview data were transcribed verbatim.

The online survey was administered using QualtricsTM software. It contained a mixture of open-ended, closed-ended and Likert-scale questions (Supplement 2). The questions were closely aligned with those used in the interview guide. An initial version of the survey was piloted with 10 students, after which small changes in question phrasings were made to enhance understandability. The survey took ∼15 min to complete. Before further analysis, the transcribed interviews and open-end survey data were anonymized for identifying information about individuals or organizations.

Initial Data Analysis

Initial data analysis for the study focused on examining the views of relevant stakeholders to guide the generation of an ethical framework on asymptomatic testing of students in higher education institutions. This included analysis of interview data and open-end survey data using an approach broadly based on the framework method (Gale et al., 2013). This qualitative analysis method was selected based on the project’s need for rapid analysis focused on identifying commonalities and divergences among participants’ responses. The framework method is not aligned with a particular epistemological, philosophical, or theoretical approach, but intended as a flexible tool that can be adapted for use with various qualitative approaches that aim to generate themes (Gale et al., 2013). Originating in large-scale social policy research, it facilitates multi-disciplinary qualitative analysis of studies including interview and other types of textual data, based on the principle that findings can be systematically organised into specified categories, including those that are pre-specified. The analysis for the ethical framework started with three independent analysts from RAND Europe familiarising themselves with the interview transcripts, followed by initial deductive coding of three transcripts using pre-defined codes based on a provisional framework that was also used to inform the interview guide. Following initial coding, the multi-disciplinary research team from THIS Institute worked with analysts from RAND Europe to agree upon a final set of codes to apply to all transcripts:

• Goals of the programme

• Choices about testing

• Balancing and distributing risk, harms, burdens and benefits

• Relationships between stakeholders: reciprocal responsibilities and solidarity

• Isolating

• Properties of the test

• Privacy, confidentiality and information-sharing

• Communication

• Other

The ‘Other’ code was used as a pragmatic catch-all for content that did not align with the study’s core analytic focus or recur across participants. These data were reviewed but did not warrant the creation of additional codes, as they tended to be tangential (e.g. brief reflections on unrelated university policies or general pandemic experiences) and did not contribute substantively to the ethical framework that was the original focus of analysis. Analysts from RAND Europe and THIS Institute then produced a matrix with interview quotes associated with one or more codes. AA, CC and MM generated summaries for each code, including illustrative quotes. The open-ended survey data were analysed similarly to the interviews, using a separate matrix and coding summaries for these data. Descriptive statistics were calculated in Microsoft Excel for the closed-ended survey questions, with Likert-scale questions visualised using diverging stacked bar charts (Heiberger and Robbins, 2014). The three data types (interview, open-ended and closed-ended) were then arrayed to facilitate systematic analysis across themes. This array informed discussions among the multi-disciplinary research team from THIS Institute regarding patterns arising across the analyses, enabling iterative review to generate themes while giving equal priority to the three different types of data (Creswell et al., 2003; Fetters et al., 2013).

Data Analysis for This Article

Following initial data collection and analysis for the study, the research team from THIS Institute produced an ethical framework (Figure 1) for asymptomatic COVID-19 testing among students in higher education institutions (THIS Institute, 2021).

Figure 1.

Ethical framework for asymptomatic COVID-19 testing of student in higher education institutions.

Members of the team also identified the potential for further exploration of two prominent cross-cutting themes across the data: (i) views on choice and (ii) conceptions of responsibility and duty of care. A separate article (Cox et al., 2022) explored the first of these themes, focusing on mandating participation in testing programmes (and other options, such as incentives or penalties) among students and staff, and concluding that maintaining the voluntariness of testing was the most ethically sound policy in this context. The analysis we present here discusses findings relating to the second theme: that of responsibility and duty of care, with a specific focus on the extent to which relational considerations featured in how participants experienced the testing programme. It seeks to advance normative discussions of relational ethics by showing how norms are negotiated within the real-world context of a public health crisis.

Results

The dataset included 26 semi-structured interviews and 213 survey responses. Participants included 208 undergraduate and postgraduate students (189 completed surveys and 19 participated in interviews) and 31 members of academic and non-academic staff (24 surveys and 7 interviews). Our analysis of participant responses showed that participation in the asymptomatic COVID-19 testing programme was largely motivated by relational norms, including conceptions of shared risk, discourses of moral obligation and a sense of community solidarity built within student households, colleges and with the broader public. These are presented thematically as ‘relational solidarity’, ‘distributed responsibility’ and ‘ritualising societal contribution’.

Relational Solidarity: Sharing Risk and Protecting the ‘Wider Public’

In both interviews and open-text survey responses, participants described their heightened awareness of shared risk in, and posed by, the student population. Their accounts suggested a consciousness of how their actions might affect not only those in their households, but also others in a (largely) unseen and diffuse wider public. The asymptomatic testing programme appeared, in these accounts, to be important for developing an intimate sense of interdependent health outcomes.

I personally feel a sense of responsibility towards my household members in terms of being more careful when I am outside the house. [Survey 35, student]

I feel like the most important responsibility is to protect the wider public who are generally more vulnerable than the student population. As well as this, our university has a huge capacity for biological research so we have a responsibility to use that to battle the COVID-19 crisis [Survey 83, student]

Consistent with notions of relational solidarity, we found that participants recognised shared risks and common outcomes, both with their immediate peers and with some members of staff and the broader community.

The students are aware that they are at low risk of morbidity and […] risk of mortality. So, they know they’re doing it altruistically to prevent the spread elsewhere, both for the staff and the local population, but also the risk of taking it home to their families. [Interview 26, staff].

I know the residents and people living in [Cambridge] may be older or more exposed and bringing students back is kind of, that felt really, in my head I felt really guilty about that. […] I think there is a general kind of [perception] at the moment that students are irresponsible; young people don’t care about the virus. And, actually, despite it being a very banal and everyday task, the fact that so many students […] are doing the swab and participating in this programme kind of indicates that we do care about it. [Interview 24, student].

Mutual protection was a central feature of messaging for the Stay Safe Cambridge Uni campaign, so it is unsurprising that this theme was central to how students and staff framed the ethical demands of the programme. However, participants’ responses show that a generalized framework for solidarity was adapted within the relational contexts of university life. The distinctive concerns posed by dense student accommodation and intergenerational cohabitation in a small city introduce additional considerations for conventional discussions of relational solidarity. We expand on these below.

Distributed Responsibility: Testing as a Duty of Care and a Duty to Care

The role of the university in operating the testing programme was a critically important feature of participants’ responses. Many survey respondents agreed that the university had a responsibility to reduce the transmission of the virus in the wider population (79 per cent agreed or strongly agreed), suggesting that the programme gave expression to an institutional duty to serve both students and the public good. Some emphasized in open-end survey responses and interviews the university’s obligations to the broader community, composed of people with varying degrees of vulnerability. Their accounts referred to concentric circles of responsibility encompassing individuals, their colleges, the city and indeed, society at large. It was situated within a broader ethical demand to, in the words of one survey respondent, ‘all be doing our bit to slow transmission and protect the vulnerable…’ [Survey 23, student].

I mean, there’s the good neighbour business about not wanting the […] students to infect the whole of the town, that’s very important, of course, looking after your neighbours. That’s what we all have to do, isn’t it? Take responsibility for our health, and not just for our own sake but because it affects everyone else. [Interview 23, staff]

[…] the unique thing about college accommodation as well is, you’re living in a community where you are interacting daily with cleaners, with maintenance staff, with fellow academics, all from different age groups and vulnerable groups. And so, it’s not just students cordoned off in halls of residence; there’s that community element. […] I think the general consensus among students is like, this, you know, swabbing ourselves each week, is a necessary thing that we do, not to protect our own health but to protect this institution of the university, operating in quite a small city centre. And so, I think, from a personal point of view, I think, yeah, universities do have that responsibility but, from a student point of view, I don’t feel like that responsibility is to me as the student, but rather to this community that [the university] uniquely finds itself in. [Interview 24, student]

Participants identified the infrastructure provided by the programme as critical in enabling participants to more effectively protect vulnerable members of the community (mostly unconnected to the university) and prevent strain on healthcare systems.

[…] if the student body coming back led to an increase in COVID which led to an increase in local healthcare demand that would be quite significant for the local population. So, actually I do really feel there was a duty of care to make sure the actions of the university in bringing back students were not going to overburden the local healthcare framework. [Interview 18, staff]

Importantly, the testing programme was also regarded as part of a set of mutual obligations between the university as an institution and its students. Most survey respondents agreed that the university had a responsibility to run a testing programme to reduce transmission in the student population (81 per cent agreed or strongly agree) and to limit disruptions to educational opportunities (82 per cent agreed or strongly agreed). Participants linked the duty of care to the university’s role as an educator and a landlord. For example, student participants emphasised that they had been encouraged by the university to return in-person for the term and therefore that the university was responsible for establishing precautionary measures to keep them safe.

[…] when you first get here, the first thing [the colleges] say is we have a duty of care to you, we'd like you to register with a GP that is in the city rather than where you come from, just because it's their job pastorally to keep us safe with regards to providing us with housing and health services, mental health services, all of that. So, it's just another facet of keeping us all safe […] as our landlords, for people that are particularly living in college, it's just a duty of keeping everyone healthy. [Interview 6, student]

Participants also noted that residential colleges had broad responsibilities for students who test positive. They highlighted the importance of support for the practical challenges of isolation or quarantine (e.g. meal delivery and laundry pick-up), and other physical, educational, emotional, psychological and social needs.

Yeah, I guess they do need to have the responsibility to help students who test positive, if they need to go into isolation, help them out with that […] keep them physically safe in terms of what happens if someone is positive, there needs to be a lot of good advice on what to do if you get back a positive response. And then also maybe a responsibility to take care of everyone’s mental health as well, because obviously if you’re getting tested and if you would be positive, there’s also that stigma associated with getting a positive response. So, I think that’s something that they should be responsible for as well. [Interview 25, student].

Despite the general consensus that responsibility—both personal and institutional—was a critical rationale for the asymptomatic testing programme, some respondents raised questions about the efficacy of ‘moral responsibility’ or ‘responsibility for the community’ in promoting participation.

A lot of emails that I get focused on the community… responsibility for the community. I’m not sure that works. I think an individual response saying […] okay, if you can’t go to the lab for two weeks [due to self-isolation], be aware of that because it might impact your place […] and you don’t comply with the self-isolation, you might be faced with a £1000 fine. Those things tend to scare people a lot more and scare them into compliance. And also realising the implications of their actions if they don’t comply. So, I think that works a lot better. [Interview 3, student]

I think the moral responsibility for students to test is something that we believe in as a college but it’s not something that the students necessarily believe in as individuals. And I think we’ve seen that by an increase in uptake when students are looking at going home and wanting to provide a negative test for that, which means to us, disappointingly, that means that they don’t feel the same moral obligation to protect the staff and their fellow students as they do to protect their families. [Interview 16, staff]

‘Ritualizing Societal Contribution’: Establishing Prosocial Action

Our study suggests that the asymptomatic screening programme was understood not just as a way of managing transmission in the student population, but also as a tangible reminder of the relationship between individuals and their community. As one respondent put it, the testing programme had the effect of ‘ritualizing societal contribution’ [Survey 4, student]—an evocative description that emphasises how habitual swabbing became imbued with ethical and affective significance and helped to instantiate a conception of community. As a consummate example of prosocial action, the testing programme emerged both a symbol and driver of relational norms. The alignments between self and collective that were illuminated by the biological realities of communicable disease were made explicit in discussions of community wellbeing.

So, I think taking part for me has also just been a thing that I’ve done because it’s good for not just me but also everyone else around me too. As well as that, I think it is also quite interesting to see what the general level is in the rest of the community, and that’s really necessarily affected by whether I test positive or not. [Interview 4, student]

[…] Communicating the results of [the testing programme] are very helpful, so sharing with people what the problem is, these are the results that have been generated from the asymptomatic versus the symptomatic. I think that’s very powerful, because then not only do people see that it’s happening, but they see the effects that it’s having, and they see the overall output. So, I think that has been really good. And there were communications where this was discussed, but emphasising your personal responsibility and the situation with regard to protecting the local community, the NHS, that I think again is an important message to get out. [Interview 18, staff]

The social effects of testing were felt even more immediately through the creation of household testing pools. Created for logistical purposes to carry out mass testing, household pools were typically based on proximity or shared use of a communal kitchen or bathroom. Pools might bring together students with no prior relationship across multiple flats and even buildings. These administratively designed units held the potential to take on immediate significance if a positive case was identified within a pooled sample, in which case individual students contributing their swabs might be collectively directed to isolate. Student participants described feelings of solidarity that formed within testing pools (with one characterising weekly testing as a ‘bonding type thing’ [Interview 13, student]). Participants also described the more challenging effects of the unprecedented social entanglements, shared risks and newfound obligations introduced by the household testing pools.

[…] in my pool there was only four people, but my kitchen was being shared by ten or eleven people. So, we had a situation whereby, for example, if one of us tested positive, then us four would have to self-isolate, but the people that we were sharing a kitchen with wouldn’t have to self-isolate […] Then they changed the groups again, and they’ve now put me […] in a different group […] it’s occurred to me that I’m being tested in a pool of people I’ve never even seen, so why should I have to self-isolate if one of them tests positive? On the same principle, someone that I shared a kitchen with might test positive and I would be free to continue going to labs and whatever. [Interview 10, student]

These reflections on the practical realities of asymptomatic testing emphasise how relationality can be viewed as constraint, especially when imposed institutionally in ways that contradict patterns of actually experienced social contact.

Discussion

Our study of students and staff at a case study university found that its asymptomatic COVID-19 testing programme intervened in university life not only by detecting cases and reducing the risk of transmission, but also by raising relational ethical considerations. The testing programme provided a concrete focus for broader concerns around community interdependency and collective wellbeing. It did so by rendering explicit the mutual dependencies between students, staff and the public, and by offering an infrastructure (both practical and discursive) for personal and institutional accountability. Our analysis suggests that relational ethical considerations were influential in guiding participation in the testing programme, which in turn countered narratives of intergenerational conflict and individually oriented behaviours. These findings complicate simplistic assumptions about the divergent interests of young, student populations and older or more vulnerable groups. They give expression to narratives of intergenerational solidarity and bear out the normative calls for relational ethics during public health crises.

Relational Awareness

Relational solidarity is characterised by a ‘willingness to be held accountable for others (especially the weakest and most disadvantaged in society), and [by] our awareness of mutual vulnerability and interdependence’ (Baylis et al., 2008: 205). This sense of relational solidarity (Baylis et al., 2008; Jennings, 2019) was prominent in how our study participants described the motivations of students taking part in the asymptomatic testing programme. Indeed, our empirical account contributes to these existing theoretical discussions by suggesting that asymptomatic testing helped to expose and produce new obligations, forms of care and constraints. This renewed consciousness of social embeddedness at a time when physical proximity became a source of risk helped to engender a relational awareness critical to participation in the programme.

In our study, students and staff reflected on how participation in the asymptomatic testing programme (and disease mitigation measures more generally) sensitised them to their social entanglements. While providing a nasal swab was necessarily a solitary activity, it served as a critical reminder of participants’ position within relational networks of friends and classmates, college staff, city residents and distant family. Testing directly facilitated sociality by enabling continued in-person learning, usual recreational activities and travel home during holiday breaks. The programme can therefore be viewed as one way in which new forms of relatedness and revised understandings of community took shape (Hopkinson and House, 2021; Strong et al., 2021).

Household pools created to enable asymptomatic testing on a mass scale offer a particularly clear example of this. If relational ethics is defined as a recognition of the interdependent qualities of social existence (Austin, 2008), then we might view the asymptomatic testing programme as marshalling those relational conditions towards reducing viral transmission. An individual’s sample was quite literally dissolved into a pooled test, thereby drawing individual students together as ‘biological entities’ (Dolezal, 2020: 1), all facing shared social consequences. These practicalities of pooled testing created impactful—if temporary—communities and, for some respondents, a sense of moral accountability or social belonging. Membership in a testing pool could also serve as a reminder of interdependencies when testing pools were misaligned with living arrangements or when members of a pool were directed to self-isolate. The underlying logics of pooled testing therefore produced, as much as they reflected, the conditions of collegiate living.

Asymptomatic testing also illuminated civic commitments that extended far beyond the university. For example, some participants expressed a concern with obligations that come with being a city resident and a good neighbour. Though the broader social effects of asymptomatic testing are beyond the scope of this study, our findings suggest compelling connections between the contribution of a test swab and the cultivation of community. Acting together simultaneously, even when it involves isolation, holds the potential to cultivate an imagined sense of community through an embodied sense of shared purpose (Ulfstjerne, 2020). Studies of public health campaigns, for instance, have noted how they often configure individuals as moral subjects in conceptions of the public good (Nordfeldt and Roalkvam, 2010). Accounts of blood donation have suggested that these contributions produce relations of reciprocity and mutuality (Titmuss, 1970; Valentine, 2005; Busby, 2006; Waldby, 2006). Understanding how a localised response such as asymptomatic testing for COVID-19 may have featured in biosocial re-imaginings of self and community will be a rich area for further study, with important implications for how future public health measures that make appeals to relational ethics might be operationalised.

Infrastructures for Solidarity

Our study also contributes to discussions of relational ethics by highlighting the infrastructures necessary to make the practice of relational ethics logistically possible for students living in college accommodation. It shows that the distribution of moral responsibility between individuals and institutions is an essential consideration for those advocating for a relational approach to public health ethics.

For instance, proponents of a relational approach to public health ethics note that taking responsibility for the wellbeing of others is an important expression of care and solidarity (Jennings, 2019; Jeffrey, 2020). However, discourses of personal responsibility can also initiate or exacerbate blame and stigma. For example, some universities in the United States in the summer of 2020 were reported to have responded to lapses in social distancing among students by holding them directly responsible for possible campus closures (Mangan, 2020; Marcus and Gold, 2020). A further risk of discourses of moral ‘responsibilisation’ is that they may place undue emphasis on individual behaviour and agency (Lupton, 1995; Brown et al., 2019) and so deflect attention from structural determinants and forms of social inequality (Rose, 2007; Shamir, 2008; Trnka and Trundle, 2017). When presented as an individualised ‘moral project,’ (Maunula, 2013: 20) mitigation measures could produce expectations for self-protection and bodily control that suggest infection is the result of irresponsible behaviour, even though, in pandemic conditions, the ability to fully control exposure to a virus like COVID-19 is limited. Discourses of moral responsibility that urge caution as a form of care are central to public health responses in a pandemic (Ellerich-Groppe et al., 2020; Hier, 2021), but a nuanced account of responsibility that captures its varied individual, collective and institutional demands is necessary to contextualize relational ethics within the power dynamics of real-world public health interventions.

Accordingly, our study offers a fresh perspective on ‘distributed responsibility’ for relational ethics. In contrast to the focus on the autonomous individual often associated with analyses of responsibilisation, participants articulated a relational conception of responsibility rooted in the interdependencies of collegiate living. They acknowledged the exceptional moral stakes of communicable disease, which is likely to affect the non-student population of the university and the local community most seriously. Responsibility was framed by participants as an acknowledgement of the moral demands of care: as ‘recognition and action motivated by one’s commitment to the welfare of the Other’ (Trnka and Trundle, 2017: 11; Tronto, 1993). Notably, this interpretation of personal duty was accompanied by expectations for reciprocity: students held the university administration responsible for supporting their wellbeing and access to educational opportunities and saw colleges as accountable for providing pastoral and practical care.

The asymptomatic testing programme was framed through a narrative of responsibility, but also, critically, facilitated expressions of solidarity by making them logistically possible (Prainsack, 2020). This suggests that participation in mitigation measures cannot solely be explained as individual altruism, but must also be supported and facilitated through institutional forms of care. This finding can contribute to new understandings of distributed responsibility by moving beyond discussions of individual responsibilisation. It supports a more rigorous consideration of the ‘collective conditions’ (Rose and Lentzos, 2017: 46) that allow responsibilities to be met in a public health response.

Limitations of the Case Study

Our case study has some limitations. It was conducted shortly after the asymptomatic testing programme was introduced in October 2020 and does not provide a longitudinal account of how asymptomatic testing and responses to it might have changed throughout the 2020–2021 academic year and through successive lockdowns in the UK.

Participants in the study may not have been representative of the full range of views among students and staff, and we were not able to gather perspectives from non-university affiliated Cambridge residents. As we were unable to assess patterns of non-response to the consultation, it is possible that our findings do not reflect the views of the wider university population. The study used a convenience sample, reflecting the need for a rapid approach during the early phase of the pandemic. That said, it was not the aim of the study to produce a representative account, but rather to explore how participants understood and articulated the ethical dimensions of participation in a specific testing programme. We also acknowledge that the collegiate structure of the University of Cambridge and the decentralised management of student welfare is somewhat distinctive among institutions of higher education.

Our consultation also does not address how participants came to hold their relational views. We initially inquired into the ethics of the testing programme, particularly the question of whether it constituted a responsibility or a duty of care incumbent upon the university (Supplement 1 and 2). This research focus helped to orient the interview and survey data around the moral obligations posed by COVID-19. Additionally, an emphasis on mutual care was central to the ‘Stay Safe Cambridge Uni’ campaign and broader public health discourse during the pandemic. These contextual factors make it difficult to isolate how participants developed the relational values expressed here—further investigation of that question was beyond the scope of our study. Nevertheless, we anticipate that our findings in this case study can offer broad insights into how individuals expect and receive care, and how they articulate obligations to their communities during a public health crisis.

Conclusions

Our study of university-based asymptomatic testing programme has found that the programme mobilised, gave expression to, and amplified conceptions of shared vulnerability and solidarity during the early part of the COVID-19 pandemic. Showing how students and staff interpreted the moral demands of the programme and articulated concerns that are aligned with the normative principles of relational ethics, this study found that public health interventions for transmissible disease can uncover, inform and produce new forms of relational awareness and moral demands for solidarity that are distributed between individuals and institutions.

We are now living with a markedly different public health approach to COVID-19, in which formal regulations and moral expectations around testing and other mitigation measures have fundamentally changed. However, this case study of a pandemic public health response emphasises the value of relational ethics in understanding and informing public health interventions. Responding to calls to integrate empirical research with normative inquiry in public health ethics, our study lends further analytical purchase to relational considerations such as solidarity and care (Knight, 2016; Redhead et al., 2024). It cautions against reducing moral responsibility to the individual and highlights instead the significance of institutional infrastructures and relational awareness for ethical practice during a public health crisis.

Supplementary Data

Supplementary data is available at Public Health Ethics online.

Funding

This study is funded by Mary Dixon-Woods’ National Institute for Health Research (NIHR) Senior Investigator award (NF-SI- 0617-10026), by the Wellcome Trust through a contract award for a project on ethical issues in COVID-19 testing, and by The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK. The views expressed in this article are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care, or the Wellcome Trust. The survey and interview consultation were approved by the University of Cambridge Psychology Research Ethics Committee.