UK Pandemic Ethics Accelerator – Reflections from the Public Health and Health Inequalities workstream

The UK Pandemic Ethics Accelerator brought together ethics experts from across the UK, following the onset of the Covid-19 pandemic, to consider key ethical questions and to offer support to policy makers. In this blog, John Coggon, who led the public health and health inequalities workstream, reflects on its work.

Questions of public health and ethics have long been on policy makers’ agendas. Successive governments have recognised problems of avoidable ill health and the entrenched reality of unfair health inequalities between different groups and communities; even while we have not seen any sort of political consensus on how best to tackle matters of health and inequity. This lack of consensus made matters all the more challenging when the Covid-19 pandemic hit the UK: public decision-makers faced multiple complex ethical questions at speed. The decisions that they made – and did not make – have been defining of significant immediate and ongoing questions of social justice.

As nations struggled to respond to the novel virus, they had to balance weighty, and often competing, ethical concerns. These covered the health costs of policy decisions: questions of how to measure the need to protect people from the coronavirus itself against the need to protect against other threats to health, including the health harms of health protection measures themselves. And they spanned questions of what value we should place on health in relation to other goods such as economic security or individual freedoms – although all of these are, in many ways, connected.

The policy decisions were extremely difficult, but they were rendered more so by the fact that they were being taken in contexts in which health inequalities were already inherent – meaning that susceptibility to risks of harm from the virus and from its mitigations was not shared equally.

How governments chose to respond also laid bare another set of questions – around procedures and processes – including where responsibility for policy decisions should lie; the basis on which decisions should be made. They shone light on the challenges of identifying what information is considered and who should be consulted; and what are the appropriate levels and methods of explanation, transparency, and scrutiny.

Within the UK, the pandemic made clearer than ever the reality that our opportunities to enjoy good health are not equally shared and that long-standing norms, structures, and institutions have entrenched these inequalities. Public policy decisions throughout the pandemic continued to distribute its benefits and costs unequally – with some communities and groups bearing a disproportionate burden not just of ill health but also of loss of other values, such as freedom, relationship, and economic security.

As the pandemic progressed, the work undertaken within the public health and health inequalities workstream sought to offer ethical expertise and insights in support of answering the key questions being faced by public policy makers.

We explored the trade-offs the pandemic forced upon policy makers who were seeking to protect health and argued that public debate was need to support decision makers in balancing different priorities. We sought to do so with recognition of the complex diversity of ways that people, experts, and governments might place importance on particular health problems and threats. We also explored the impact of specific pandemic policies on health – for example the pausing of non-Covid biomedical research.

A key focus of our work was on understanding health disparities in the UK, recognising that many of these pre-existed the COVID-19 pandemic, even while they were exacerbated and/or made more visible by it. Our health is created and held collectively – as a shared asset – but it is not distributed equally. Our work focussed on where differences in health outcomes and opportunities for good health were unfair and avoidable. This involves looking back, and trying to learn from our past experiences as public health policies are developed for the future; for example in government healthy weight strategies.

We also considered the need for subtlety in our understanding of inequalities and how policy responds to these. The pandemic revealed inequalities across many different axes: from racial disparities in health; to the impact of increased gendered expectations around care; the impact of digital exclusion among low income children on education; the treatment of older people in care homes; the approach taken to disabled people in developing triage guidance and more. The pandemic also saw a rise in food poverty, domestic violence and child abuse.

Looking across these axes of inequality, we have made the case for an intersectional approach – avoiding viewing things through a single lens such as race or gender, but rather looking at how and why different characteristics may overlap to create greater instances of unfair, avoidable inequality. As well as providing a framework to provoke ethical evaluation of intersectionality in relation to personal characteristics, we have set out a framework for thinking about different aspects of inequality against considerations of place and public health decision-making.

Overall, we have added to arguments that ethically-informed policy would be built on understanding and addressing the upstream causes of inequalities – the ‘causes of the causes.’ Throughout our work we have argued that policy makers need to listen to the marginalised and muted voices of people with lived experiences of inequalities stemming from, or worsened by, the pandemic. This should be part of a broader commitment to engaging with people and publics around issues of ethical complexity to understand their values and priorities in balancing different competing needs, and drawing their insights and perspectives into a wider ecosystem of ethical deliberation and engagement.