Maxwell J. Smith, PhD is a Bioethicist and Assistant Professor at Western University in London, Ontario, Canada. His interests lie in public health ethics, social justice, and infectious disease ethics. In this interview with the Magazine’s editor Divanshu Sethi, he discusses the relation of ethics in public health, what is lacking in our policymaking in the current COVID-19 pandemic, and what complications he sees in the future.
Before we begin on the coronavirus pandemic, can you tell me how you got interested in public health policy? And why ethics is an important part of the field?
I did an undergraduate degree in bioethics at the University of Toronto in the wake of SARS, which happened to hit Toronto particularly hard. Being an epicentre of that outbreak, scholars in Toronto were uniquely positioned to reflect on the issues, including ethical issues, that we face in the context of infectious disease outbreaks. When I decided to pursue graduate studies in bioethics, the H1N1 influenza pandemic hit. It was evident that despite the field of bioethics having been around since the 1960’s/1970’s, relatively little attention had been paid to ethical issues that emerge in the context of public health. Issues regarding the use of restrictive public health measures (e.g., quarantine), setting priorities for the allocation of resources during major surges in demand, obligations of health care workers to provide care during outbreaks, and the global governance of pandemics were all issues that hard hitherto received scant attention. This is what initially got me interested in exploring public health ethics further, and particularly the ethics of pandemic preparedness and response.
The 2002-04 SARS outbreak infected over 8,00 people from 29 countries.
What particular COVID-19 issue have you been occupied with lately?
There are two. How to implement a fair system of triage for critical care resources is one issue that has occupied me and many ethicists at this time. The other issue regards the justificatory conditions that should be met to scale back social distancing and other restrictive public health measures. It occurs to me that the most vulnerable in our society were largely left inadequately protected during this first wave of the virus (e.g., long-term care homes, homeless shelters, etc.) due to significant under-funding prior to the pandemic. Any move to now scale back social distancing and other restrictive public health measures cannot make this same mistake – every effort must be made to protect those most vulnerable to this pandemic if the scaling back of restrictive measures is to be ethical. Lately, I’ve been occupied with how this might be done in an ethical manner.
Going through various epidemics over the recent decades like SARS, H5N1, H1N1 etc. there was still a lack of immediate global and local cohesion during the coronavirus outbreak. Why do you think there is still asymmetry in our responses to such epidemics? And what is missing in our policymaking?
One thing that plagues outbreak preparedness and response is our apparent inability to learn our lessons from past outbreaks. SARS, H5N1, H1N1, Ebola, MERS-Co-V, and Zika have all highlighted the moral failures manifest in our societies – failures that contribute to our lack of preparedness. These moral failures include profoundly inadequate public health and primary health care infrastructures as well as an inability to take seriously our obligations of global justice and solidarity. These outbreaks repeatedly demonstrate that we have shared vulnerabilities to infectious diseases, and that we in turn have shared responsibilities. We tend to remember this when we are in the midst of an outbreak, but soon forget and fail to take necessary steps that will engender greater solidarity to collectively mitigate these threats.
The most vulnerable are the hardest hit in a pandemic. Etienne Laurent/EPA
Decision making in a crisis like this could be complicated and challenging. Especially when there are competing ethical values. What frameworks or areas can one look into when considering a particular policy decision?
Many ethical frameworks have been developed which can inform decision-making in this context. The World Health Organization, for instance, has produced many guidance documents and frameworks that cultivate the lessons from previous outbreaks. One such guidance document is the WHO’s 2016 ‘Guidance for Managing Ethical Issues in Infectious Disease Outbreaks’. The challenges discussed in that document reflect many of the challenges we are now grappling with, e.g., how to allocate scarce medical resources, how to implement restrictive public health measures in an ethical manner, and whether physicians and other health care workers have a duty to care during a pandemic. Another influential framework which has been incorporated into many pandemic plans is one developed following SARS in Canada, called ‘Stand on Guard for Three: Ethical Considerations in Preparedness Planning for Pandemic Influenza’. Finally, some guidance has more recently been produced to inform the COVID-19 response. My colleagues and I recently published a paper on the fair allocation of scarce medical resources in the time of COVID-19 in the New England Journal of Medicine.
A final thought worth noting is that ethical frameworks and guidance documents can only take us so far. The decisions that must be made during a pandemic will be incredibly difficult, involve competing values and interests, and must be made in severely time-constrained environments. Consequently, every effort must be taken to ensure that decision-making during a crisis like this proceeds according to fair processes – processes that are transparent, inclusive, and which promote accountability.
In the coming months, what dilemmas and complications you see with our public health policies? Especially in those areas where the healthcare capacity will be tested.
I think we’ll see our greatest test of solidarity yet. We’ve seen very well-resourced countries with well-resourced health systems which have been severely affected by this pandemic. As the virus circulates through under-resourced countries with severely under-resourced health systems, we could see significant morbidity and mortality. While well-resourced countries are in many cases deploying everything they can to get this pandemic under control within their own borders, it will still be important to help those less privileged to respond and recover. Given the challenge that every country is faced with currently, this will require an unprecedented degree of solidarity.
A second issue regards when it is ethically appropriate to scale back or ‘relax’ social distancing measures and other restrictive public health measures (e.g., travel restrictions). This question presents a dilemma because it raises competing interests and priorities. On the one hand, many scientists would like decision-makers to rely upon epidemiological data to tell us when it might be appropriate to begin easing up on these measures; when the epi curve shows a steady decrease in infections, perhaps some of these measures can be relaxed. On the other hand, there is a strong economic narrative that relies upon a risk-benefit calculation about when these measures should be relaxed in order to ‘re-open’ the economy. Yet, what is largely missing from these discussions is the extent to which the most vulnerable in our society will be protected when any action is taken to relax these measures.
A final issue regards the inequities that will have been created or exacerbated by this pandemic. Significant inequities are already entrenched in our society. This pandemic will in many cases disadvantage the already disadvantaged, and this may have implications for those populations for many years to come. It will be critical that we take action during our response and recovery to ensure that the least advantaged are well-supported so that they are not disproportionately disadvantaged.
Maxwell J Smith. “I think we’ll see our greatest test of solidarity yet.”
What kind of changes have you seen in your field of study? And in what ways do you think medical ethics and health policymaking will be affected by this crisis?
One thing that I have been noticing is the extent to which ethics has been ‘mainstreamed’ during much of this pandemic response. There is a common tendency for ethical considerations to be implicit or only brought to the table in an explicit way far along into decision-making processes. Yet, it seems that this pandemic is making evident to all the fact that every decisions we make as a society has a fundamentally ethical nature. The decision we make involve value judgements, affect different population groups disproportionately, and essentially involve questions about what is considered ‘right’ or ‘good’. This highlights the centrality of ethics to public health decision-making. My hope is that this ‘learning’ will be extended into decision-making long after we’ve recovered from this pandemic.
For our readers, could you recommend some papers and articles to understand better the nature of public health policy and its response to pandemic diseases?
To better understand the nature of ethics in public health policy and pandemic response, I would recommend the following:
Maxwell J. Smith and Ross E.G. Upshur. (2019). Pandemic Disease, Public Health, and Ethics. In Oxford Handbook of Public Health Ethics, ed. Mastroianni AC, Kahn JP, Kass NE. New York, NY: Oxford University Press.
Maxwell J. Smith and Ross E.G. Upshur. (2015). “Ebola and Learning Lessons from Moral Failures: Who Cares about Ethics?” Public Health Ethics, 8(3): 305-318.
World Health Organization. (2016). ‘Guidance for Managing Ethical Issues in Infectious Disease Outbreaks’.
Nuffield Council on Bioethics. (2020). Research in Global Health Emergencies.
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith MJ, Phillips JP. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. doi:10.1056/NEJMsb2005114