John Coggon: How do we ensure the proper place and visibility of value judgements in public health policy and practice?

The following is an edited version of John Coggon’s remarks at a UK Pandemic Ethics Accelerator event on 23rd May 2022, discussing the place of values in public policy during a pandemic

Photo of John Coggon

Professor John Coggon is Professor of Law in the Centre for Health, Law, and Society at the University of Bristol Law School. He is also a member of the University of Bristol’s Population Health Science Institute and Centre for Public Health, an Honorary Member of the UK Faculty of Public Health, and a member of the Nuffield Council on Bioethics. In this piece, he reflects on the contributions to this collection – which are drawn from an event hosted on 23rd May, 2022, by the UK Pandemic Ethics Accelerator, on which he is a co-investigator.

The Covid-19 pandemic has laid bare all manner of questions of ethics and social justice. These include substantive ethical questions: for instance, what weight should be given to the value of protection from the coronavirus as compared with other threats to health, including those that would directly follow from coronavirus restrictions or from the prioritisation of SARS-CoV-2 over alternative health concerns; or how should the protection of health be weighed against the protection of other values, such as economic security or freedom of association? They include procedural ethical questions: who should make such decisions, on what (lawful) basis, with regard to what considerations, having consulted which people and groups, and with what degree and forms of explanation, transparency, and scrutiny? And they take place against a practical background of unequal susceptibility to risks of harm: both the direct harms of the virus itself; and the configuration of risks that result from measures to mitigate (or not) those harms.

Within the UK, the pandemic has shown, with renewed force, how social norms and institutions determine people’s unequal opportunities to enjoy good health. It has also let us see how public decision-making influences the spread of benefits and costs of being part of a shared society; of who may flourish and who may suffer in the face of threats to population health and to other values, such as freedom, happiness, and relationships of love and care. And it has demonstrated – for better and for worse – both how ethical values are inescapable aspects of public policy and decision-making, and that there are significant, real-world challenges to making ethics visible within our political and public structures.

The central place of ethics and value judgements

Since the possible impacts of Covid-19 became clear in early 2020, governments, public agencies, and other actors and organisations have had to make a wide range of decisions. These have included failures to act, as well as the implementation of political and legal interventions whose profundity is without precedent: most strikingly through emergency legislation restricting freedoms and limiting people’s rights across the UK, passed rapidly and with little scrutiny. At all stages, ethical values have been central: pandemic decision-making is characterised by questions of trade-offs and prioritisation, and of conflicts both between competing values, and the competing interests of different groups and communities.

Despite such obviously and heavily ethical context, ethical discourse and debate in the UK was – and felt- muted. Early in the pandemic, the Nuffield Council on Bioethics – a collaborator on the UK Pandemic Ethics Accelerator – published an excoriating statement calling for basic standards of democratic governance. Yet there has remained a tendency, particularly within Westminster, to frame difficult decisions as ones that are simply led by “the science”. A sound – or as sound as possible – evidence base is, of course, essential to good decision-making. But there are values at play when a Minister decides which science to follow. And there are value judgements in weighing up the costs and benefits of doing so, and in understanding whether and how this acceptably bears on people’s basic rights.

The Ethics Accelerator was developed to assist in this fraught environment. And part of that work entails reflection. To that end, we brought together a range of experts in a conference on 23rd May, 2022 to explore, examine, and explain how value judgements did, do, can, and should feature in public decision-making and policy. We asked how ethics has been incorporated, or not, in practice and planning during the pandemic, and how approaches in the future should be informed. Since the conference, we are delighted to have been able to draw together the speakers’ contributions as a series of written papers.

What does it mean to bring ethics to public health decision-making?

Ethics presents an unavoidable context to the pandemic and pandemic decision-making. And throughout the pandemic, bodies – including the Nuffield Council on Bioethics – have applied themselves to sharing ethical analysis and guidance. Government departments, public agencies, and influential organisations have also sought and published ethical advice. And formal mechanisms for including ethical deliberation were developed within the UK’s political decision-making structures: notably, through Moral and Ethical Advisory Groups and the participation of a bioethics expert in the Scientific Advisory Group for Emergencies.

But what places does, and should, ethical expertise have in public decision-making; with what forms of transparency; are these matters appropriately understood and explained; what works well; and where do we find problems or challenges? These are vital questions to address as we respond to the continuing pandemic, and as we plan for the future. To contribute to that endeavour, the collected papers present insights from a range of stakeholders whose professional positions and experiences lend valuable lessons. We hear about “in the room” advisory roles; experiences of speaking directly to decision-makers. And we see how different forms of “outside the room” scrutiny and analysis fit into the picture: scrutiny, for instance, from the media, law, and expert groups; and the generation and promotion of advice, guidance, and evaluation from academic and other stakeholders. Of course, the contributors to the collected essays are not the only people with a perspective on the matters that we investigated, but their insights span a range of disciplines and experiences during this critical period.

Voices from the UK’s ethics ecosystem

Across their contributions, we see explicit reference to the idea of the UK’s ethics ecosystem. There is no shortage of ethics expertise in the UK, whether understood narrowly as a sub-discipline in philosophy, or as a broader collection of applied areas of inquiry as reflected in the multi-disciplinary field of bioethics. However, bringing this wealth of ethical expertise and insights into public decision-making can present challenges. Some of these relate to competing priorities: for example, concerns for transparency may come into tension with demands for candour. Some relate to contingencies and political will – even political courage – or a lack of it.

The idea of an ethics ecosystem allows us to imagine multiple roles for ethics: explaining, advising, providing scrutiny, aiming for meaningful inclusivity, communicating (sometimes complex) reasoning, critically exploring justifications, and so on. It also allows us to see that there will not be just one role or remit for ethical input. Our contributors span different points of professional expertise, but also have contributed to shared efforts in the pandemic from different positions relative to society, professional groups, and the government. We hope that readers will take their own lessons from the different reflections, with a view not just to learning about past practices, but also to assuring our policy and decision-making systems and structures are better prepared for the future.