Professor John Coggon, University of Bristol
- The prominence of health protection rationales to justify regulatory and policy measures during the covid-19 pandemic has logically drawn attention to health harms, including collateral harms, that have also been created.
- ‘Health/health trade-offs’ present complex ethical challenges that apply across sectors, and which cannot be well resolved through a single measure or standard of evaluation.
- Public debate is needed to evaluate health impacts across government policy, with attention to the sources, natures, and distribution of health costs across society.
The rationales for government interventions to limit the spread of coronavirus have been preventing disease and death from covid-19 itself, and avoiding broader harms that would occur if the health and care systems became overwhelmed. However, such measures have also created health risks, including collaterally, with health benefits to some being achieved through the cost of health harms to others (health/health trade-offs). The subtlety and complexity of the value judgments in this regard must be acknowledged. We should not suppose that we can reduce our evaluations to “health versus the economy”. Indeed, because economic decline leads to catastrophic, and avoidable, health harms we need to aim for shared gains in economic and public health protections. And we also need to see how direct health protection goals may create their own health challenges, and how health benefits and harms arise across social sectors and policy domains.
Some examples help explain the point. Since the implementation of coronavirus restrictions in March 2020, health harms have arisen in impacts on access to healthcare, with waiting list times rising and people being reluctant to seek medical help. Beyond the healthcare sector, we have seen health harms of lockdowns, for example, in the impacts on children’s development, education, and mental health. And overall, there have been unequal health impacts both in who has suffered the greatest harms of covid-19, and the harms caused by measures taken in response to it: for instance because of socioeconomic disparities, structural racism, gender, and disability.
To exemplify why ethical analysis of such matters is morally complex, consider Lord Sumption’s provocative argument that we should assign different values to different lives – by reference to the likely healthy years a person has to look forward to – to establish what (if any) coronavirus restrictions might be justified. The idea rests on two premises: that law and policy should provide that everyone is not of equal worth; and that a single scale can be applied to account for what makes life valuable. The position is problematic both for its moral assumptions and for using a single metric to evaluate policy. It is unsurprising that there was a significant backlash against Lord Sumption’s comments. But the questions that they were addressing do not go away.
So how might we approach them? The idea of health/health trade-offs presents an important reference point to help frame our ideas. Lawyer economist Cass Sunstein wrote an essay on this in the 1990s, addressing the problem “when the diminution of one health risk simultaneously increases another health risk.” Professor Sunstein’s analysis highlights three particular points of difficulty for government decision-making:
- Governments have to make decisions based on limited information;
- Decision-makers within government suffer selective attention: a particular decision-maker will generally be focused on particular problems, without regard to the complex whole of which those problems are just a part;
- There are qualitative distinctions in risks to health: depending on the source or nature of a risk, different levels or forms of government attention should be given to it.
The social and ethical realities of health/health trade-offs are such that the aim should not be to find a single measure to assess them: for example, a cost/benefit analysis of tolerable health risks, or a prioritisation tool such as quality adjusted life years. Professor Sunstein notes that: “People care not simply about how many lives are saved, but also about whether risks are involuntarily incurred, especially dreaded, inequitably distributed, potentially catastrophic, faced by the current or by future generations, and so forth.”
Looking at health inequalities across sectors shows how and why the sources of different sorts of health risks matter, and why it matters to look at who is impacted and how. Mehrunisha Suleman explains, for instance, how and why we should be concerned about the disproportionate impact of the pandemic on women across the UK; and amongst women those who experience further inequalities, for example, by virtue of disability or being from a minority ethnic community. Even for an individual person, health is a complex value: something that is good for your physical health may harm your mental health. Looking, then, across communities and across time, account must be given to who enjoys health benefits, when, and at what costs; including costs to others.
In developing, administering, or evaluating public health policies, ethical analysis is about much more than weighing up numbers of deaths given one scenario versus numbers of deaths given another, or assuming that all equal risks to health will, or should, be treated as equally problematic. The value judgments are complex. They call for recognition of health in all policies. And they require public debate on what matters when making the value judgment calls. From education and employment to trade and travel, ethical questions about protecting health and harming health should be at the heart of government decision-making.
This work is part of the Public Health and Health Inequalities workstream of the UK Pandemic Ethics Accelerator.
Professor John Coggon, Centre for Health, Law, and Society, University of Bristol Law School, 8-10 Berkeley Square, Bristol, BS8 1HH, UK
About The Accelerator
The UK Pandemic Ethics Accelerator is a new initiative that brings UK ethics research expertise to bear on the multiple, ongoing ethical challenges arising during pandemics. We provide rapid evidence, guidance and critical analysis to decision-makers across science, medicine, government and public health. We also support public debate on key ethical challenges
The UK Pandemic Ethics Accelerator receives core funding from the Arts and Humanities Research Council as part of UKRI’s covid-19 funding. Grant number AH/V013947/1.