A breach in the social contract: Limited participation and limited evidence in COVID‐19 responses

Abstract

Medically trained health professionals have been central to the development of policy responses to the coronavirus 2019 (COVID‐19) crisis. In their multiple roles—as clinicians, public health leaders, members of scientific advisory boards, and also as media pundits and health professionals—they have helped shape discourses of science‐based policy options during the first 2 years of the pandemic. In particular, health professionals as a collective voice insisted on the necessity of society‐wide measures of social control to curb the morbidity and mortality of the virus. These measures, in turn, informed the political and moral imagination of the political class, the media and the larger public. Yet, as emerging evidence suggests, measures of social control posed a serious and long‐term risk for health equity. In this discussion piece on the first 2 years of COVID‐related public health directives, we interrogate the tensions that advocating for extensive and protracted measures of social control can pose to the social contract between medicine and society, health equity and democracy. To illustrate these tensions, we discuss the public fallout between vocal members of the OSAT, an ad hoc biomedical‐led organization, and the Government of Ontario in light of the disagreement on the scope of ‘stay home’ orders to manage the third wave of the pandemic in the Spring of 2021 and, more recently, the mass protest against mass‐scale public health measures in Ottawa, Canada. We argue that while decision making under emergency conditions is a difficult task, the legitimacy of the social contract between medicine and society depends on medical experts’ judicious exercise of public health ethics principles. We offer a set of recommendations for building a more collaborative response to future health crises.

1. INTRODUCTION

For the past 2 years, biomedical experts have been central actors in the unfolding drama unchained by the coronavirus 2019 (COVID‐19) pandemic. In multiple roles as scientific experts, public health leaders and as frequent media pundits, members of this expert class have advocated for and implemented extensive measures of social control to curb the spread of the virus and its mutations. The most dramatic of these measures of social control is the ‘lockdowns*’, which were intended to manage COVID‐19 risk via widespread closures of economic, social, cultural and political life. These measures, however, cannot be understood as the simple translation of ‘scientific knowledge’ into easily applicable and measurable public health policy ³ —but as a tool of governance that requires the political assent of the population. This can be seen in the words of an academic speaking to the Canadian Broadcasting Corporation (CBC) on the issue of the upcoming seventh wave of mass infections projected for the fall of 2022 ‘… it's unlikely that we'll see a return of pandemic restrictions because public tolerance is very low’ but added ‘frankly, we don't need to do that’. ⁴ While it is clear that the political moment for these mass‐scale measures of social control may have passed—their unintended effects are likely to be felt for generations. ⁵ , ⁶ , ⁷ , ⁸

To be sure, in the early days of the crisis, in the absence of effective treatments and vaccines, such decisions to curtail the population's movements—with direct disruptions to civil liberties, access to education, health services and economic rights—may have been essential to curb the spread of the virus. Over the ensuing 2 years, these recommendations were variously followed and deployed by all levels of political leadership, and a reduction in morbidity and mortality was subsequently attributed to their deployment. ¹ , ⁹ However, there is a growing global awareness of the long‐term social, political, health and material costs of the deployment of lockdown measures. ² , ⁷ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ Measures to control the population as one of the central tools for managing the protracted nature of public health emergency posed by COVID‐19 have arguably become sedimented as a ‘go‐to’ tool in the imagination of experts, politicians and the general public—this can be seen in the expert cited by the CBC. As such, this tool has potentially obscured other more democratic and differently targeted mechanisms for dealing with the crisis. ¹⁶ , ¹⁷

In this discussion, we draw attention to the ethical and political implications of health professionals’, in particular medical professionals’, preferred courses of action playing a central role in the production of and advocacy for ‘radical measures of social control’ to manage the virus. ¹⁸ Trust is essential for the ongoing social contract between medicine and society, as well as for the effective implementation of evidence in health policy as laid out in the ‘Public Health Ethics Framework: A Guide for Use in Response to the COVID‐19 Pandemic in Canada’. ¹⁹ Within the context of advocacy for and uptake of ‘lockdowns’ as a public health policy option, we consider the contributing impact that emerging tensions between the health expert, the political class and society at large may have on the erosion of trust in social institutions (including medicine).

The assembling of a controversial, Canadian‐based social protest movement comprised of disparate political agendas and consolidating against ‘public health mandates’ under the moniker ‘the Trucker Convoy’ in the spring of 2022 in Canada's capital city, Ottawa, signals, that such an erosion may well be underway. Those trained in a healthcare profession or public health need to be aware that even well‐intended and sound scientific interventions when applied universally may have unintended political effects in society, and consequently, on their own social status as sanctioned experts. With this cautionary note in mind, and with an understanding that experts’ participation in decision making under acute urgency is a difficult task, we present a respectful, yet critical analysis of professional power during future crises, and provide suggestions for the reflexive application of that power. To do this analytical work, we provide a brief review of the concept of ‘social contract’ between medicine and society, and then explore its implications for sustainable and participatory public health ethics and decision‐making processes.

2. FROM UNCERTAINTY TO DISAGREEMENT

The initial lack of understanding of the virus’ infectivity, morbidity and mortality, and the absence of effective public health surveillance, treatments and vaccines, necessitated the rapid development and implementation of ‘radical measures of social control’ across the world. These complex and variable interventions constituted a type of generalized population‐level quarantine‐like set of policy options that restructured all economic sectors and limit citizen's civil liberty. ²⁰ They were instantiated with the assent of political institutions, including the Ontario Human Rights Commission.† In their multiform presentation and deployment, these interventions have been loosely labelled as ‘lockdowns’. The interventions were intended to protect both populations waiting for the development of effective vaccines and treatments, as well as preserve health systems’ upsurge capacity. ¹⁶ , ²¹ Although these policies were associated with a reduction in the transmission of the virus, resulting in fewer virus‐related hospitalizations and deaths, ²² the overall impacts of such a policy on morbidity and mortality due to economic downturns, widespread loss of education opportunities and delayed medical treatments in the years to come is unknown. ²³ Worrisome signs of their effects on the social determinates of health, however, is emerging. ²⁴ , ²⁵ , ²⁶

Lockdown measures became centrepieces in numerous liberal democratic governments’ tool kits to manage health system capabilities since the start of the pandemic. This approach, however, began to be met with certain levels of resistance by the beginning of Year 2 of the crisis. Consider the Ontario (Canada) government's attempt to reinstall measures during the ‘third wave’ of infection (in the Spring of 2021). Facing the sharpest upsurge of infections and hospitalizations to that date, the Government appealed to ‘general’ scientific‐health consensus as justification for additional restrictive measures (e.g., banning all outdoor activities) and included expanded police powers. While members of the Ontario Science Advisory Table (OSAT), a nongovernmental volunteer advisory board formed by clinicians and researchers, did not recommend the closure of parks, they did support the continuation of strict limitations to economic and social life. The OSAT also recommended the implementation of social benefits, such as paid sick leave to facilitate the isolation of people with COVID‐19 symptoms. ²⁷ These worker‐focused suggestions were based on explicitly epidemiological logic (i.e., from the desire to reduce transmission and hospitalizations specifically related to COVID‐19). The general public, media pundits and some health experts (including some members of the OSAT itself), rapidly rejected the Ontario government's expanded policy, suggesting that closures of amenities in parks, for example, were not backed by science. Police forces across the province refused to comply citing concerns over violations of civil liberties, ²⁸ forcing the government to partially backtrack. ^{29 ,} ‡

It could be argued that under a climate of fear, these well‐intended recommendations nurtured a ‘strong‐hand’ approach to policy making; the violations of civil and political rights that such approaches may promote can have long‐lasting social and political consequences. One year later, these unintended effects took a dramatic turn when the Canadian Federal government invoked the Emergencies Act in the Spring of 2022, effectively suspending a host of civil and political rights to stop and dismantle a very small, peaceful but controversial (allegedly led by ‘right‐wing’ actors) and vocal opposition to 2 years of socially restrictive public health measures. This event is an important reminder that even the most technical and ‘data‐driven’ scientific claims, whether made by laboratory sciences, public health or medicine, ³¹ , ³² once in the public sphere as public policy become amenable to public interpretation, contextualization and contestation by multiple social actors. ³³ In other words, public health, together with medicine and science itself, are not value neutral, but profoundly social and political in terms of their relevance and their effects ³³ , ³⁴ , ³⁵ , ³⁶ —as recognized long ago by Rudolf Virchow. ³⁷

To be sure, the tensions that arose in light of strict measures underscore the ways in which ‘science’, emerging and ever‐expanding evidentiary sources, social values and political expedience have intermingled in the policy responses to the COVID‐19 crisis. ³⁸ , ³⁹ A key issue was perhaps that health professionals and other biomedical experts were caught off‐guard by political actors’ intended or unintended misuse of health expert recommendations. We argue that such potential misuse of ‘science’ discourses, and what can be described as a ‘mission creep’ of the expert class of advisors who become vocal advocates for particular social solutions to a crisis, could have been and can be avoided by the application of accepted ethical principles. These principles include participatory decision‐making and the consideration of a broad array of biomedical and historical and emergent social evidentiary sources encompassing data pointing to the economic, political and social costs of medical interventions in society. The application of social justice principles (i.e., an examination of the unequal effects of policies on differently resourced populations) and the transparent and direct communication to the public ¹⁷ are also foundational. These ethical conventions have been developed in public health scholarship ⁴⁰ , ⁴¹ , ⁴² and by the Canadian Federal Government's Public Health Ethics Framework ¹⁹ for building levels of social trust necessary to confront acute health crises. The application of these ethical considerations bears direct relevance for health professions at large, and medicine in particular, since it is medical experts who are typically selected as public health leaders. This is so because to preserve the social contract between medicine and society, it is paramount for health professionals, as part of the expert class, to examine the ethical and socio‐political implications of health‐related policy recommendations that disrupt social, political and economic rights in moments of crisis.

3. THE SOCIAL CONTRACT

In a liberal society, the power given to medically trained professionals (alongside the state) to act under principles of beneficence to allocate material and social resources can be traced to medicine's social contract with society. ⁴³ As Cruess and Cruess ⁴⁴ suggest, the contract between medicine and society is constituted by the fulfilment of expectations from each party, and that the medical profession comes first as a copartner with society. The profession fulfils its role by providing responsible and evidence‐informed advice, decision making, and leadership in the provision of and allocation of scarce healthcare resources. ⁴⁵ Society—via the state and other social institutions—fulfils its role by bestowing upon the profession self‐regulation, autonomy and generous social and financial rewards, ⁴⁶ and in times of crisis, the regulation of society itself. ⁴⁷ The social contract confers epistemic privilege by endowing the medical professions with the capacity to determine what counts as a legitimate problem and the scientific basis for its definition. ⁴⁸ , ⁴⁹ This includes the ability to choose the types of data that count as evidence, and the context and the conditions of acceptability of something as scientific, as a fact, or as a data point that matters or not (in the context of healthcare concerns). ⁵⁰ , ⁵¹ More importantly, the social contract determines the voices authorised to address a problem within the scope of medicine and/or related to health. ⁴⁹ Times of crises, such as that instigated by COVID‐19, highlight the amount of power concentrated in the hands of medically trained public health experts.

4. MEDICINE'S POWER AND ITS UNINTENDED CONSEQUENCES

We are not suggesting here that the power conferred to the medical profession is good or bad. Our goal here is to draw attention to the fact that any evaluation of this capacity to enact regulations and manage society depends on a deep understanding of the social basis for the allocation of such power. To do so, we must denaturalize the conditions of possibility that produce the social assent that allows expert groups, like the medical profession, to decide on their own—without broader societal participation—the values and the forms of knowledge and evidence (episteme) to be included in health decision making in normal times. This is essential as these conditions can pave the way for uncritical obedience and mission creep under conditions of uncertainty, and also misuse of experts’ advice by political actors—especially in times of emergency or crisis.

Epistemic privilege bears potential problems when we account for issues of equity and access. A society's norms and values often reflect the preferences and interests of those in positions of privilege, which are dominated by the financially well off and the well‐rewarded professional elites. In a heterogeneous society, this hegemony in determining the authorized voices and sources of evidence can inadvertently further marginalize, silence and harm those without the necessary material and symbolic resources to contest the value preferences of those in positions of privilege. ⁵² Radical social interventions, such as lockdowns, can deepen existing health and social inequities ⁵³ , ⁵⁴ and create new ones, ⁵⁵ , ⁵⁶ , ⁵⁷ which vulnerable populations may not be able to resist or contest as even protest can be vilified or criminalized (e.g., the Canadian trucker convoy). Whether one agrees or disagrees with the leaders and the causes of a particular social movement, the long‐term consequences of the marginalization or criminalization of protest based on public health regulations require careful examination.

5. ETHICS: KNOWLEDGE, EVIDENCE AND SOCIAL RESPONSIBILITY

The government of Canada developed a ‘Public Health Ethics Framework: A Guide for Use in Response to the COVID‐19 Pandemic in Canada’ ¹⁹ to establish the values and principles that should guide public health decision making (see Table 1 below):

Table 1.

Public Health Ethics Framework: A guide for use in response to the COVID‐19 pandemic in Canada

‘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 minimize 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’ 19 https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/canadas-reponse/ethics-framework-guide-use-response-covid-19-pandemic.html

Abbreviation: COVID‐19, coronavirus disease 2019.

As the framework suggests, the legitimate exercise of expertise is dependent on a careful balancing of multiple forms of evidence and the values that are to be prioritized in decision making under conditions of uncertainty. This process is analogous to clinical decision making, where deployment of expertise requires integration of multiple evidence sources in a way that is highly sensitive to context, resources and the values of patients and their families. ⁵¹

Decision making, especially under conditions of significant professional or scientific uncertainty, is not an easy task for any individual professional or even an entire professional group in ‘normal times’. For those medical professionals in positions of leadership (e.g., Chief Medical Officers) or advisory roles to government (e.g., the OSAT) during moments of crisis, consideration of the social determinants of health is paramount when constructing health policy. This is so because poorly constructed policy can negatively impact the income, education and public participation of already vulnerable groups not only in the short term but over generations, leading to a deepening of already existing inequities. Thus, the balancing of broader evidentiary sources (not one single matrix of risk whether biological or social) and values such as the health equity for differently resourced populations and across generational lifespan takes on history‐shaping consequences with profound sociopolitical implications. Having a clear understanding of the weight and value of both context and timescales in health decision making (e.g., emergency response vs. chronic illness), therefore, can help medically trained experts and advocates to set priorities that are informed by broad evidentiary resources and by values of transparency and participatory democracy, as the ‘Public Health Ethics Framework’ suggests.

6. EVALUATING DECISION‐MAKING PROCESSES IN TIMES OF UNCERTAINTY

At the time of their first implementation, ‘lockdowns’ were conceived as a strategy of last resort, intended as transitory due to their theorized differential cost on society. ⁸ The costs of these interventions have since gone from a set of measurable possibilities to measured empirical realities. ⁵² , ⁵⁸ , ⁵⁹ , ⁶⁰ Turning to the Canadian provincial case again, the OSAT, whose composition is dominated by medical and other health experts, has never made publicly available an evaluation of the short‐term gains of the social interventions (which are mathematical projections of infections and hospitalizations); it has recommended vis‐à‐vis the widespread short‐ and long‐term effects for the entire population. ⁶¹ , ⁶² We, therefore, need to ask socially and scientifically urgent questions about the ways in which medical and other health experts in positions of authority use, interpret and deploy decisions based on the available data.

7. RECOMMENDATIONS FOR BUILDING A MORE COLLABORATIVE RESPONSE

As COVID‐19 become less of an acute and more of a chronic problem (or as new infectious agents emerge), some measures of social control will most likely remain in place for years to come with profound sociopolitical implications. To be effective and equitable, decision‐making models need to shift from sole authoritative expertise to collaborative expertise as the Canadian ‘Public Health Ethics Framework’ suggests. The highly disruptive nature of COVID‐19 responses underscores the need for building robust health policy roadmaps that must be inclusive, participatory and centred on values of health equity across populations and across generations. To be clear, we need participatory and democratically debated ethical principles for public engagement during times of population‐level medical emergencies.

Medical professionals and biomedical experts need to work with other experts (e.g., social scientists and ethicists) and local communities to identify appropriate and equitable responses to public health threats. This will allow the allied group of professional and community experts to identify and specify a plurality of communal values, needs and risk tolerances to guide policies rather than centring policies privileging the risk‐averse character of the most worried, but also not as risk tolerant as the least worried members of society.

The social contract between medicine and society can be enhanced by medical experts’ reflexive awareness of the unintended effects of their expertise in policymaking. Weighing social benefits and consequences in a more inclusive or democratically driven process can allow for ownership of initiatives among diverse stakeholders. In turn, this can enable people to protect themselves and others from infectious diseases while also preventing the unintended exacerbation of social and material inequities together. This suggested recalibration of experts’ responses is of crucial interest as the world awakens to the realities of highly disruptive pandemics and its evolution into endemic conditions, which bring heavy costs in terms of human lives and deepens generation‐long disruptions to social development and health equity.

AUTHOR CONTRIBUTIONS

Jamie Cristian Rangel contributed to the conceptual mapping of the paper, writing of the first draft and subsequent editing; Rory D. Crath made a minor contribution to the conceptual mapping of the paper, revisions to the drafts and subsequent editing; Sudit Renade made some revisions to the drafts and subsequent editing.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Rangel JC, Crath RD, Renade S. A breach in the social contract: limited participation and limited evidence in COVID‐19 responses. J Eval Clin Pract. 2022;28:934‐940. 10.1111/jep.13775

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analysed in this study.