Ruth Cunningham, Charlotte Paul, Andrew Moore
Public health responses to infectious diseases such as COVID-19 require us to draw on our common humanity and be explicit about our values. Recognising this will help us make good decisions in difficult situations so that, for example, the need to impose restrictive measures and to protect ourselves does not conflict with fairness, respect, and neighbourliness. In Aotearoa/NZ, Getting Through Together already provides a statement of shared values which can be used to guide a wide range of responses.
In response to Wilson and Baker’s timely piece on preparing for a potentially severe novel coronavirus (COVID-19) pandemic, Shanthi Ameratunga raises the spectre that ‘keeping it out’ could morph into ‘keeping them out’.
Her observation is a proper reminder that epidemics require us to draw on our common humanity as well as on our public health expertise in making the difficult decisions that are needed. We are at phase 1 and 2 of the New Zealand (Influenza) Pandemic Plan: ‘plan for it’, and ‘keep it out’ or border management. Soon we might be at phase 3 ‘stamp it out’ and then possibly phase 4 ‘manage it’, phase 5 ‘manage it post-peak’, and finally phase 6 ‘recover from it’.
Getting Through Together, written by the National Ethics Advisory Committee as part of pandemic preparedness was published by the Ministry of Health in 2007. This document explores the place of widely shared ethical values in managing each stage of a pandemic. It is highly relevant today. A clear statement of shared values will help in making difficult decisions now and in the days (and probably months) to come.
After wide consultation, the Committee arrived at two sets of values for decision-making: those informing how we make decisions (see Table 1) and those informing what decisions we make (Table 2). At each phase of our pandemic response, values should inform the making of important decisions.
Good decision-making includes following good processes (including being open to public scrutiny) and being explicit about the values that underlie decisions. Getting Through Together reminds us that such decision-making processes are important in conferring legitimacy on decisions, particularly when not all will agree with the decisions:
“A good decision-making process fosters trust and goodwill towards institutions such as hospitals, leading to greater acceptance and satisfaction and fewer complaints. … Good decision-making processes … show respect for people and ensure procedural fairness…Where the reasons for decisions are not apparent, trust in decision-makers may be undermined.”
The values and decision-making processes outlined in Getting Through Together offer support to decision-makers at all levels of society who face difficult choices. For example, at this phase, where the focus is on border control, decisions are being made on who is allowed into New Zealand. The World Health Organization has cautioned against border control actions that promote stigma or discrimination. Remembering and articulating the importance of upholding the values of kohitanga/unity and manaakitanga/respect in performing our public health functions to minimise harm will help us weigh the relative harms and benefits of our actions. Similarly, drawing on values of whānaungatanga or neighbourliness as well as fairness will help us in considering our border control responsibilities with respect to our Pacific neighbours.
We have already implemented restrictive measures, both quarantine and ‘self-isolation’.
Getting Through Together invokes the value of respect or manaakitanga in considering such restrictive measures, stating:
“When restrictive measures are required, the least restrictive measures possible should be used. … People subjected to restrictive measures such as quarantine may be deprived of their freedom of movement, but they should not be deprived of other rights. Quarantine measures can be implemented in ways that are respectful, supportive and fair, and cater for divergent needs.”
Similarly, reciprocity is crucial when people are subject to quarantine:
“This [quarantine] would be done for the good of others, not for the person’s good. Such people are required to bear an extra burden in the interests of others. Reciprocity can be expressed by ensuring people who are quarantined are given extra support and well looked after, in keeping with the extra burden they carry for protecting others.”
In New Zealand, Chinese people have already experienced stigma and discrimination associated with fear of the novel coronavirus. It is thus encouraging that at the Whangaparāoa Reception Centre, where 157 people from Wuhan are being held in quarantine for two weeks, the Ministry of Health understands its role in respecting the Chinese community. The Ministry of Health website includes this:
Dr Bloomfield says it has been important to try and continue routines for the guests, and that included marking Chinese New Year last night.
“Chinese New Year is an important cultural event and we organised this to honour that for both our guests with Chinese heritage and all others.”
This is exactly the respect and reciprocity we need.
With the potential that an increasing number of people will require isolation or quarantine if we enter the ‘stamp it out’ cluster control phase, the responsibility for providing this support will not remain with government agencies alone. We will need to recognise the values of neighbourliness and unity in coming together to support those whom we are asking to ‘self-isolate’ while well. Similarly, values must guide prioritisation decisions by health professionals who care for those who become ill, and guide consideration of what we owe to these professionals who care for the sick. Getting Through Together reminds us that the responsibilities for making difficult decisions go beyond the health sector and thus its guidance should be used by “a wide range of people, including health professionals, planners, policy makers, and members of the public and business communities.”
As Wilson and Baker point out New Zealand needs to prepare for a potentially severe pandemic; this must include improving hand and respiratory hygiene practices, making available personal protective equipment, and preparing for potential self-isolation. It must also include much more, through discussions at all levels of society about our shared responsibilities to each other, and how we can equip ourselves for making difficult decisions. Getting Through Together has already begun the work of making shared values explicit. We are familiar with using ethical values all the time in deciding how to behave, but what is different with a pandemic is that there can be many conflicts between our impulses to protect ourselves – to impose restrictive measures and to protect ourselves and our families – and the protection of our common humanity.
Explicitly drawing on our common values will help us all to get through this together. Dr Tedros, Director General of WHO, said this week: With the virus now in some 23 countries, international solidarity is of the utmost importance, because “we are all in this together, and we can only stop it together”.