Ethical reflections on the COVID‐19 pandemic: The epidemiology of panic

In many of the more relaxed civilizations on the Outer Eastern Rim of the Galaxy, the Hitch‐Hiker's Guide has already supplanted the great Encyclopaedia Galactica as the standard repository of all knowledge and wisdom, for though it has many omissions and contains much that is apocryphal, or at least wildly inaccurate, it scores over the older, more pedestrian work in two important respects. First, it is slightly cheaper; and secondly it has the words DON'T PANIC inscribed in large friendly letters on its cover. (Douglas Adams, The Hitchhiker's Guide to the Galaxy)

The world has been preparing for a pandemic, most likely to be caused by a novel strain of influenza or a newly emerged respiratory virus, for decades.1 However, the unpredictable nature of a pandemic means that, when it does occur, it tends to induce panic. Tellingly, the letters spelling ‘panic’ form the beginning and end of the word pandemic.

A pandemic also raises multiple ethical considerations. The COVID‐19 pandemic illustrates many features of a pandemic, such as uncertainty, shifting circumstances and rapidly changing recommendations. The responsible planning and allocation of resources becomes a major consideration if the health service is unable to sufficiently cope with the number of sick patients to give them all optimum care.

While resource allocation will be crucial, here, we would like to concentrate on questions of decision‐making regarding public health measures in the face of an evolving pandemic. The Nuffield Council on Bioethics2 has emphasised that:

• Public health measures should be evidence‐based and proportionate.

• The aims of interventions should be clearly communicated to the public.

• Coercion and intrusion into people's lives should be kept to a minimum.

• People should be treated as moral equals, worthy of respect.

• The respect due to individuals should never be forgotten when interventions such as quarantine and self‐isolation are implemented.

• Solidarity is crucial.

Public health measures designed to limit spread of a virus – in this case, the novel coronavirus called SARS‐CoV‐2 because its closest relative is the coronavirus that caused the SARS epidemic – often impinge on valued civil liberties. Home isolation, which may be recommended to limit exposure and spread, has been shown to have significant effects on mental health, causing post‐traumatic stress that may be prolonged for years.3 There are fears that home isolation will increase the risk of domestic violence. Furthermore, restrictions on activities will often have major economic implications for individuals, families and society. The rationale for imposing restrictions, such as those on travel and movement, is the common good: individuals benefit from not being infected, but the very function of society depends on being able to cope with the amount of disease, which in turn depends on the rate of spread of infection.

It has been suggested that the core components of an ethical decision‐making process are fairness, inclusiveness (engaging all relevant stakeholders), transparency, reasonableness, accountability and responsiveness (timeliness).4, 5 However, in a pandemic, the benefits of engaging the public's opinion are arguably outweighed by the need to follow expert advice on how to manage a complex, rapidly evolving infectious disease in a way that best balances issues that may conflict, such as population health and individual civil liberties. Experts in the context of a pandemic are epidemiologists, infectious disease specialists, public health specialists and modellers. A wise government forms a committee drawing on the very best experts in these disciplines, experts who are highly trained, keep up with the latest research literature better than the rest of us and are in close touch with the leading international experts. In Australia, the Chief Medical Officer (CMO), Dr Brendan Murphy, chairs the Australian Health Protection Principal Committee (AHPPC). The government is bound in legislation to follow the advice of the CMO during a pandemic, and the CMO leans heavily on the advice of the AHPPC. The CMO is accountable for the decisions and recommendations he makes to the government. With regard to the transparency of decision‐making, the AHPPC recommendations are posted regularly on the Department of Health website,6 with explanations of the rationale for the recommendations. The need for continuous oversight and frequent changes of recommendations make widespread consultation impractical and even problematic. The names of the experts are not provided because experience tells us that, when passions are running as high as they are now, experts would face abuse and even death threats on social media, which are not conducive to providing the best advice. In this case, transparency conflicts with our obligation to protect the mental health and welfare of our experts.

One aspect of a society that values and preserves civil liberties is that members of the society can voice their dissatisfaction with decisions and decision‐makers fearlessly. But in a pandemic, who should we trust if not the best experts available to us? Yet every day, we have quasi‐experts arguing that the government is being remiss in not acting sooner, for example, by not closing schools immediately. Closing schools is effective and important in influenza pandemics because children are the major spreaders of influenza. The reason the AHPPC did not recommend earlier school closure is that there is no good evidence that children are major transmitters of SARS‐CoV‐2, in contrast to influenza, and there are big social and financial implications of closing schools. Yet some private schools have decided to ignore the AHPPC advice and close, which is a puzzling and confusing message, likely to raise anxiety levels rather than lower them.7

It is unwise to compare the course of COVID‐19 in Australia with the differing course the pandemic has taken in different countries, given the enormous differences in epidemiology, speed of introducing preventive measures, level of testing and also the emphasis each country puts on civil liberties. However, media commentators and a number of health professionals apparently think they know better than the AHPPC and are quick to suggest we should be doing more. However, ‘doing more’ has implications on infringements of civil liberties and raising societal levels of anxiety. The uneducated use of emotive words such as ‘exponential’ to describe the current situation threatens to increase worry exponentially. It is no wonder that the confused public engages in panic buying when, instead of trusting the expertise of those in key decision‐making positions, so many people express their own anxiety by reinforcing and promoting messages that are bound to increase the anxiety of others.

Solidarity and collective responsibility are at a premium during a pandemic. Angela Merkel has spoken in statesmanlike, poignant terms to her people about how a democracy best responds to such a crisis.8 In a milieu of uncertainty, there is no certainty about what will happen next. Baseless reassurance is futile, but trust in those who know better than us is paramount in preventing an epidemic of panic.