UK Pandemic Ethics Accelerator – Reflections from the Prioritisation workstream

The UK Pandemic Ethics Accelerator brought together ethics experts from across the UK during the Covid-19 pandemic to consider key ethical questions and to offer support to policy makers. In this blog, Dominic Wilkinson, Julian Savulescu and Jonathan Pugh, who led the prioritisation workstream, reflect on its work.

Throughout the SARS-CoV-2 pandemic, the UK Government (like all governments around the world) faced challenging prioritisation questions – not just around how to allocate scarce medical resources such as ventilators and vaccines, but also about which values we should prioritise.

The Ethics Accelerator prioritisation team sought to respond to this by offering rapid ethical guidance and concrete suggestion, based on systematic analysis of the moral values at stake, and the application of robust, rigorously studied ethical principles. Through our work we brought out the ethical questions embedded in crucial policy decisions in this pandemic, and the disingenuity of the Government’s mantra that it was “following the science”.

Below we explore three examples of key policy issues which were considered during the pandemic. While robust scientific evidence was crucial for making justifiable policy decisions in these cases, questions of policy cannot be determined by purely scientific considerations.

Mass Testing – In the COVID-19 pandemic, the government received considerable criticism for their testing strategy, due to the large amount of public funding channelled into tests that had relatively low degrees of accuracy in pilot trials. Later, the government was also criticised for its reliance on these tests in re- schools.

As debates continued about mass testing we published peer-reviewed ethical analysis of mass testing in the Journal of Medical Ethics. We highlighted the competing moral values that need to be weighed in making decisions around testing. We noted the public health costs of the false reassurance that might come from false negative results, and the harms of unnecessarily restricting liberty among individuals who receive false positive results. This work enabled us to develop an ethically grounded criticism of the government’s decision to rely solely on lateral flow tests in re-opening schools.

Embedding ethics support and analysis into the policy decision-making for future mass testing strategies would help to ensure that moral costs are appropriately acknowledged in policy outcomes, and that the justification for restricting freedom following a positive test result can be better articulated and communicated to key stakeholders.

Vaccine Prioritisation – The advent of effective vaccines had huge implications for public responses to the COVID-19 pandemic, however it also raised complex ethical questions around how they should be distributed. The UK government largely followed the advice of its Joint Committee on Vaccination and Immunisation (JCVI) which set out two-phased guidance on prioritisation. However this left significant ethical questions unaddressed. The first phase outlined nine priority groups which, together, represented 99% of preventable mortality from Covid-19. The second phase continued to prioritise in accordance with age, in adults under the age of 50. However, this strategy overlooked various other risk factors that were more salient in an individual’s mortality risk profile in those under the age of 50, including occupational exposure to the virus. Although the JCVI highlighted these risks in their guidance, they also noted that “Priority occupations for vaccination are considered an issue of policy, rather than for JCVI to advise on”. It appears that the JCVI’s remit was limited to advice on scientific matters and did not extend to matters of policy. However, this is a somewhat artificial distinction; the scientific data that is determined to be relevant to the functioning of such committee is itself an ethical judgment.

Prior to the announcement of Phase 2 of the JCVI’s vaccine prioritisation guidelines, we produced a rapid review of the different international approaches to vaccine prioritisation, and their ethical justification. We also published peer-reviewed journals arguing that the JCVI’s focus on vulnerability in the first phase of prioritisation may not have been ethically warranted, and that there should be limits to the extent to which citizens should be able to choose one vaccine over another. We also published a rapid review on childhood consent for vaccination in children, and peer reviewed journal articles addressing general ethical issues relating to consent for vaccination, and arguing that vulnerable individuals in other countries should have been prioritised for vaccination over children in affluent countries. We also produced a rapid review on the extent of the government’s obligations to donate vaccines to other countries prior to initiating a booster programme.

The experience of the pandemic suggests a need for the JCVI to engage more explicitly with ethical questions. Bringing ethics expertise into the committee would help to ensure that it would be in a better position to advise on scientific data that may be potentially relevant to the vaccine policy decision-making in future pandemics.

Vaccine Mandates The question of vaccine mandates arises when policy makers need to ensure the highest possible vaccine uptake, particularly among certain high-risk populations with high exposure to others such as healthcare workers. However, the government’s decision-making process on this matter during the Covid-19 pandemic did not operate smoothly.

As questions around vaccine mandates were considered in the UK, we provided a rapid ethics review of the literature concerning the ethics of measures to increase vaccine uptake, which we used to inform two written evidencesubmissions to two separate government consultations on proposals to introduce vaccine mandates in the healthcare sector. In the first we explained why a vaccine mandate can only be ethically justified if it is a necessary and proportionate public health measure, and outlined what would have to be the case for the proposed mandate to satisfy these criteria. In the second, on the basis of ethical arguments we outlined in the Journal of Medical Ethics, we recommended that any vaccine mandate in the healthcare sector should include an exemption for those who could provide proof of natural immunity. Finally, we also produced peer-reviewed ethical analysis of the moral differences between coercing and merely incentivising vaccination, which included a recommendation for a payment-for-risk model for increasing vaccine uptake.

In practice these issues were not fully considered and the processes for policy making were flawed. Policy on vaccine mandates was announced prior to a consultation, and the proposal was later dropped in response to strong opposition, and concerns about staff retention. These debates starkly illustrate how key ethical values can conflict in public health policy; while vaccine mandates may promise a considerable public health benefit, they also involve a significant infringement of individual liberty. Embedding ethical expertise into policy decision-making for such mandates would help to ensure a smoother decision-making process, lend ethical as well as scientific legitimacy to any proposed policy, and enhance public communication of the rationale for mandates.

Our experience across the pandemic demonstrates a need for ethical analysis to be embedded in policy-making decisions, particularly during pandemic situations, but also more broadly. The UK Government’s attempt to shelter behind the idea of ‘following the science’ in pursuing its policies, reduced opportunities to explicitly and transparently ground decision in key moral principles and to utilise existing ethical frameworks and expertise to support deliberation.