Public Health Ethics in a Pandemic

Ten years ago, we (re)published a historical pamphlet written during the 1665 Great Plague, by an anonymous inhabitant of London, entitled The Shutting Up Infected Houses (Anonymous, 2010; Verweij and Dawson, 2010). The author vividly argued against the practice of locking people up in their own houses as a means of preventing further disease transmission within the community. Many of those imprisoned in their own houses might not have been sick or infected at all. They were not treated as victims, but first and foremost, as a threat to others. The ‘quarantined’ families could only hope that they would be given some support in their home prison and not left there to die from hunger or thirst. The anonymous author argued that this policy created fear that was highly counterproductive: it would lead to the disease going underground, and people who experienced symptoms would rush out of the city, thus contributing to the spread of infection elsewhere. (By the way, the pamphlet also contains some recipes for homemade remedies to prevent and cure the plague. We recommend that you do not rely upon any of them during the infrequent plague outbreaks that still occur.)

Now, in 2020, we see a large variety of measures, everywhere in the world, with the aim of containing the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. These measures are not, perhaps, as arbitrary as those of 17th Century London. The choice of universal distancing measures and national and international lockdowns which apply to everyone, might even be seen as protecting, thus expressing some solidarity with the most vulnerable groups in our society, for whom the disease is most dangerous. It is also significant that in many countries the resources of the modern welfare state have not been used merely to oppress but also to support impacted individuals and populations. Notwithstanding this positive aspect, the quarantine and lockdown measures that have been taken, are unprecedented, dramatic and deeply affect people’s health and well-being. There is a long list of consequences, including: lack of social and physical contact with loved ones, loss of jobs and income, reduced access to medical care for non-COVID patients, schools closed for a long time with life-long impact on children’s opportunities etc. Universal measures impact upon everyone, but there will often be already disadvantaged groups who suffer the negative consequences of universal actions disproportionately.

In a large and novel pandemic such as the one we are currently living through, in the absence of a vaccine or adequate treatments, societies fall back upon some of the oldest and simplest forms of infectious disease control. Quarantine, isolation, physical distancing, the creation of barriers at borders are central because every contact might be a vehicle for transmission and infection. Many of us have been staying in our homes, through different degrees of voluntariness and compulsion. As a result, the societal life that we mostly take for granted, with its many opportunities for being together in a crowd at music, theatre, sporting and religious events, disappears. This situation allows us to see the significance of having adequate diagnostics, treatments and most importantly a vaccine, as the means to rebuilding economic and cultural life and meeting family and friends again. Yet the production of a vaccine raises many public health ethics issues that require discussion in the near future, including the consequences of a fast-track quest for a vaccine, the equitable distribution of what will initially be a scarce vaccine, and the implications of a global vaccination programme that will require a very high level of participation.

This issue of Public Health Ethics has two sections that fit well with current issues. The first is a selection of papers that directly deal with or are specifically relevant to the COVID-19 pandemic. They are concerned with a diverse range of topics including whether COVID-19 patients should be isolated together with their loved ones, whether there is a maximum level of acceptable risk in the context where a novel drug or vaccine is urgently needed, and how a step-by-step opening up of societies after confinement can be achieved in a responsible way. The section also contains a clarification of core ethical concepts often used in policy making, and a discussion of the role of ethical expertise in setting up a triage protocol.

The issue also has a section on immunization policies. Steven Kraaijeveld develops an ethically relevant taxonomy of types of vaccination. Although he does not discuss COVID-19 vaccination, it might be that his concept of altruist vaccination will appear to be applicable and relevant in this area. One can imagine that young people for whom the risk of COVID-19 is reduced may be a target group for effective (‘altruist’) vaccination programmes, thereby aiming, indirectly, to protect more vulnerable groups, especially the elderly. The other papers, by Pierik and by Rashi, are specifically about childhood immunization. Roland Pierik argues that governments must secure basic (not best) interests of children and strike a balance between precaution and proportionality. Tsuriel Rashi discusses vaccination from a Jewish ethical perspective. Both papers offer grounds for restricting and resisting the choice of parents to refuse vaccination for their children.

One might expect that a serious pandemic like SARS-CoV-2, given the mortality and morbidity it causes, and the burdens that infection control measures put on everybody, would largely silence anti-vaccination voices. However, this is not the case. Indeed, it seems that conspiracy theories that have been endorsed by such groups for some time may be embraced by larger groups who resist the public health measures taken in the name of COVID-19. These diverse groups share a conviction that governments and public health authorities seek unlimited power over individuals and that active resistance is needed to protect individual liberty. The question as to which policies may be legitimate and justified, raised by the anonymous author of the 1665 pamphlet mentioned above, will remain a central theme in public health ethics as applied political philosophy.

Since this journal was founded in 2008, we have seen public health ethics taking on a more and more prominent role in the larger field of bioethics, and this has only grown due to the current pandemic. Just as everyone on Twitter is now an (apparent) expert epidemiologist, everyone now seems to be a public health ethicist. The number of manuscripts submitted to our journal has doubled in the past half year. We see this as an important opportunity to strengthen both the discipline of public health ethics and, in turn, the journal Public Health Ethics. We are heartened by this lively interest in the issues but will remain committed to the highest academic standards for our journal. For this reason, we have decided to expand the editorial team of our journal. We are happy to announce that Lynette Reid (Dalhousie University, Canada) and Daniel Goldberg (University of Colorado at Denver, USA) have taken up roles as associate editors, joining James Wilson (University College London, UK) who has been an associate editor for several years. The team will be further broadened as necessary. We also welcome Beatrijs Haverkamp (Wageningen University, Netherlands) as our new book review editor. We extend our sincere thanks to the members of our editorial board, to all the reviewers that perform such essential work, and to our outstanding colleagues at Oxford University Press who ensure such high production standards.

Public Health Ethics has three issues per year, and so space is limited. However, the journal is committed to covering the whole range of issues across the field of the ethics of public health and prevention. Although ethical issues of importance during pandemics are likely to appear often in our table of contents, we look forward to receiving manuscripts on other topics. Just as COVID-19 should not dominate all policies and concerns in the field of public health, we should not neglect, in our journal, such important ethical themes as health inequalities, lifestyle choices, access to clean air, water and healthy food, malaria control, preventive mental health, occupational health ethics and screening programmes, etc. As in other parts of life, we can’t let the pandemic and proposed control measures determine each and every choice we make—indeed, that is also what public health ethics is about.