Journal of Bioethical Inquiry, Volume 17, Issue 4, December 2020
Guest editors: Michael Chapman, Paul Komesaroff, Ian Kerridge, and Ross Upshur

Recent Developments

Neera Bhatia

Whittington Hospital NHS Trust v XX [2020] UKSC 14: The Cost of International Commercial Surrogacy Recoverable as Damages: A Step in the Right Direction?

Symposium: COVID-19 – Lead essay

Michael Chapman, Paul Komesaroff, Ian Kerridge, and Ross Upshur

Inside the pandemic

Symposium: COVID-19 – Overviews and Provocations

• “ We” Are In This Together, But We Are Not One and the Same, Rosi Braidotti Abstract
  The COVID-19 pandemic is a man-made disaster, caused by undue interference in the ecological balance and the lives of multiple species. Paradoxically, the contagion has resulted in increased use of technology and digital mediation, as well as enhanced hopes for vaccines and biomedical solutions. It has thereby intensified humans’ reliance on the very high-tech economy of cognitive capitalism that caused the problems in the first place. This combination of ambivalent elements in relation to the Fourth Industrial revolution and the Sixth Extinction is the trademark of the posthuman condition. This essay explores this condition further, offering both critical and affirmative propositions for moving forward.
• The New Fear of One Another, Alphonso Lingis Abstract
  The COVID-19 contagion makes us fear anyone and everyone. Fear those with whom we are quarantined. Fear those confined in institutions. Doctors and nurses, who nonetheless care for us, know the most intense fear.
• The Appointment in Samarra: A New Use for Some Old Jokes, Slavoj Žižek Extract
  In my past work, I used—at least a dozen times—the old joke about a man who believes himself to be a grain of seed and is taken to a mental institution where the 18 doctors do their best to finally convince him that he is a human being. When he is cured—convinced that he is not a grain of seed but a man—and allowed to leave the hospital, he immediately comes back trembling with fear. There is a chicken outside the entrance door and he is afraid that it will eat him.
• The Left Reflects on the Global Pandemic and Speaks to Transform!, Gayatri Chakravorty Spivak Abstract
  The structure of this intervention is deliberately schizo-analytic: “and then—,” and “then—.” They are preparatory notes for a webinar by Transform! Europe on the COVID, arranged before the global explosion of Black Lives Matter. I question the top-down philanthropy of the bourgeois Left. I take the Rohingyas as bottom-line victims. I speak from two hometowns—Calcutta and New York. I ask the bourgeois Euro-U.S. Left not to monolithize the Global South. Many examples of how “India” is constructed are given. From New York, the United States is declared a failed state. Trump’s delinquencies are mentioned. It is argued that the only remedy at present is human behaviour and the typical U.S. character is not ready to practice this. This empirical fact shows the failure of the Kantian Sublime and reminds us that Kant thinks that the human moral will comes in to protect us from a hugely frightening natural phenomenon only by “subreption,” the same impulse that says that following steps provided by institutional religion will absolve us. Class and caste are taken into consideration throughout. I mention that as a coronavirus convalescent, I am donating plasma regularly.
• Interview: Mourning Is a Political Act Amid the Pandemic and Its Disparities (Republication), Judith Butler & George Yancy Abstract
  This conversation between a feminist and a critical whiteness scholar addresses the politics of vulnerability to COVID-19 and the questions of what it means to mobilize and learn from private grief and mass mourning and the role of academia and intellectuals in the current crisis.
• Engaged Ethics in the Time of COVID: Caring for All or Excluding Some from the Lifeboat?, Paul James Abstract
  If good ethics is the process of ongoing dialogical deliberation on basic normative questions for the purpose of instituting principles for action, then the COVID crisis, or any crisis, is not a good time for developing ethical precepts on the run. Given dominant ethical trends, such reactive ethics tends to lead to either individualized struggles over the right way to act or hasty sets of guidelines that leave out contextualizing questions concerning regimes of care. Good people will find themselves suggesting strange things, from setting up lifeboat scenarios to supporting structural racism. This essay argues against both these paths—crisis-ridden agonism or algorithmic resource-allocation—and turns instead to a form of ethics of care which takes its departure from older forms of ethics, while recognizing that modern and postmodern challenges no longer allow their grounding in animated relations, natural rights, or cosmological truths.

Symposium: COVID-19 – Society and the Lifeworld

• Fast Violence, Revolutionary Violence: Black Lives Matter and the 2020 Pandemic, Claire Colebrook Abstract
  The 2020 pandemic cannot be divorced from the problem, pace, and spectacle of race, both because of the racial rhetoric regarding the origins of the violence and because of the subsequent racial injustice in the distribution of healthcare. This paper adds the concept of fast violence to Rob Nixon’s “slow violence” to look at the intersection between the climate of the planet and the climate of racial injustice.
• COVID-19 Ethics—Looking Down the Muzzle, Grant Gillett Abstract
  Public health and pandemic ethics frequently concern themselves with organizing principles, utility, and public policy. But the effects of pandemics, and the impact of measures to control them, are experienced by individuals and families. This is particularly true for those who are most vulnerable to COVID19—the elderly and “infirm.” So while ethics must assist in articulating the policies that will determine the allocation of resources during this and future pandemics, it must, at the same time, be alert to the intimate narratives of the infection. This is an account from someone looking down the muzzle of COVID-19.
• Hope and Optimism: A Spinozist Perspective on COVID-19, Genevieve Lloyd Abstract
  This essay discusses hope and optimism with reference to current rhetoric around COVID-19. It draws on Spinoza to suggest that much of that rhetoric rests on questionable assumptions about the supremacy of human reason within Nature.
• Knowing How to Act Well in Time, Peter Wagner Abstract
  Numerous scholars in the social sciences and humanities have speedily analysed and interpreted the COVID-19-induced social and political crisis. While the commitment to address an urgent topic is to be appreciated, this article suggests that the combination of confidence in the applicability of one’s tools and belief in the certainty of the available knowledge can be counterproductive in the face of a phenomenon that in significant respects is unprecedented. Starting out from the plurality of forms of knowledge that are mobilized to analyse COVID-19 and its consequences as well as the lack of any clearly hegemonic knowledge, the article tries to understand how a limited convergence in the politico-medical responses to the crisis emerged, and speculates on what would have happened if this had not been the case. In conclusion, it is argued that this pandemic demands a greater awareness of the uncertainty of our knowledge and of the consequences of our actions, both in terms of being situated in time and of aiming at timeliness.
• Not all Bad: Sparks of Hope in a Global Disaster, Paul Komesaroff Abstract
  The focus of discussion about the ethical issues associated with the COVID-19 pandemic has been on the great suffering to which it has given rise. However, there may be some unexpected positive outcomes that also emerge from the global disaster. The rupturing of entrenched systems and processes, the challenging of certainties that seemed beyond question, and the disruption of the assumed consensus of modernity may contribute to a rediscovery of the challenges that compose an ethical life. Elements of such a process are evident in the surge of community support and mutual caring, of spontaneous acts of joyous solidarity, of suspension of past conflicts, and exploration of new forms of reconciliation. The experiences are tentative and the outcomes uncertain, but at least for a moment the hope of a new way forward has been raised.
• The Phenomenology of Contagion, Annu Dahiya Abstract
  The lived experience of COVID-19 forcibly returns us to our bodies. This essay uses this (for most, sudden) return to embodiment to consider how our senses, as well as our “sense” of space, have been reoriented by this pandemic. It turns to certain strands within feminist philosophy that have questioned the privileged place vision has been accorded in the history of Western thought, as well as to mid-twentieth century phenomenologist Maurice Merleau-Ponty’s aim to rediscover the world of perception by philosophically centering the body, as touchstones to put forth a phenomenology of contagion. Contagion makes us confront our phenomenological and embodied experience of tactility. This focus on tactility undermines the philosophical hierarchy of the senses that accords sight as the most “noble” of the senses in Western canonical thought. While COVID-19 results in us rediscovering our bodies through touch in a moment of fear and panic, this essay considers how this rediscovery may be harnessed for different, possibly more just, futures.
• Sheltering at Our Common Home, Henk ten Have Abstract
  The current COVID-19 pandemic has reactivated ancient metaphors (especially military ones) but also initiated a new vocabulary: social distancing, lockdown, self-isolation, and sheltering in place. Terminology is not ethically neutral but reflects prevailing value systems. I will argue that there are two metaphorical vocabularies at work: an authoritarian one and a liberal one. Missing is an ecological vocabulary. It has been known for a long time that emerging infectious diseases are associated with the destruction of functioning ecosystems and biodiversity. Ebola and avian influenza viruses have been significant warnings. Obviously, this pandemic will not be the last one. As the planet is our common home, the major metaphor to explore is sheltering at this home.
• Invisible Enemies: Coronavirus and Other Hidden Threats, David Shaw Abstract
  To say that coronavirus is highly visible is a massive understatement in terms of its omnipresence in our lives and media coverage concerning it yet also clearly untrue in terms of the virus itself. COVID-19 is our invisible enemy, changing our lives radically without ever revealing itself directly. In this paper I explore its invisibility and how it relates and exposes other invisible enemies we are and have been fighting, in many cases without even realizing. First, I analyse the virus itself and how its stealthy nature has transformed our lives. Second, I describe how the invisible epidemic of social media sharing of fake news about the virus worsens the situation further. Third, I explore how the virus has revealed to us what really matters in our lives and has forced us to reevaluate our priorities. Fourth, I go on to explore the underlying structural weaknesses and disparities in society that have been exposed by the virus but previously remained unconsidered for so long that they too have become camouflaged, even if their effects are all too apparent; like the virus, neoliberal capitalism is an invisible enemy that has made prisoners of us all. I conclude by suggesting that the coronavirus pandemic represents a hidden opportunity to overcome perhaps the biggest invisible enemy of all: the moral distance that separates us from others. Only by rendering the rest of humanity morally visible to us can we overcome capitalism and stop treating other people as invisible enemies.
• The Rejuvenation of the Withering Nation State and Bio-power: The New Dynamics of Human Interaction, Abdul Wahab Suri Abstract
  The outbreak of COVID-19 comes at the time when a shrinking public sector healthcare is an acknowledged fact in post-colonial societies. The policies adopted by the apparatus of most nation states for the past thirty years or more reveal that providing healthcare to all sections of societies is not a priority. The gradual process of economic liberalization has established “market” as the only legitimate mechanism of the distribution of goods/services as per the efficiency principle. The financial markets are globalized in such a manner that nation states are constantly losing their capacity to perform redistributive functions. State withdrawal from the provision of welfare rights is undermining its moral authority to impose any normative imperative to the people who are being left alone at the mercy of market forces. But the spread of COVID-19 on a global scale has provided an opportunity to the nation state. With the help of healthcare systems, the State has reasserted itself as the ultimate archangel to define human beings and their respective status in the newly emerging nomenclature of the public sphere. In this paper, the rejuvenation of the nation state with respect to bio-power will be discussed in the postcolonial context.
• The Way We Live Now, John Wiltshire Abstract
  This is a personal account of one man’s experience of the months during which COVID-19 spread in Australia. Though personal, it aims to also be representative, so that readers will find in it reflections of their own experiences. Various social incidents are described, some in which social distancing is involved. The altering states of the author’s mind as time passes are carefully described in sequence, and the impact of continued anxiety and isolation on his mental well-being is presented as a form of madness, in one dramatic incident.

Symposium: COVID-19 – Global Perspectives

• Humiliating Whistle-Blowers: Li Wenliang, the Response to Covid-19 and the Call for a Decent Society, Jing-Bao Nie and Carl Elliott Abstract
  The question of whether China’s authoritarian response to COVID-19 was ethically justifiable will be debated for many years to come. But one feature of the Chinese response that should not be overlooked is its practice of silencing and humiliating the whistle-blowers who told the truth about the epidemic. In this article, we document the humiliation of Dr Li Wenliang (1986-2020), the most prominent whistle-blower in the Chinese COVID-19 epidemic. Engaging with the thought of Israeli philosopher Avishai Margalit, who argues that humiliation constitutes an injury to a person’s self-respect, we discuss his contention that a decent society is one that fights conditions which constitute a justification for its dependents to consider themselves humiliated. We explore the ways that institutions humiliate whistle-blowers in Western countries as well as in China.
• Rethinking the Central Role of Equity in the Global Governance of Pandemic Response, Oghenowede Eyawo and A.M. Viens Extract
  While the global governance of pandemic preparedness and response often touts the importance of equity as a moral value and policy goal, our reaction to the COVID19 pandemic should lead us to call this into question. On the one hand, we find the failure of omission—the progression of the COVID-19 crisis threatens to disproportionately impact low- and middle-income countries (LMICs) with vulnerable healthcare systems. On the other hand, we find the failure of commission—high income countries (HICs) battle to buy out ventilators, personal protective equipment, and diagnostic tests on the global market, which freezes out any real possibility of LMICs getting these resources. This lack of collective action is a moral failure that risks losing the gains made in promoting health and health equity globally, and risks calling into question the usefulness of equity-based arguments for responsible governance that were used to justify actions to achieve these gains. We argue that much of pandemic preparedness and response remains focused on the interests, resources, and capacities of HICs and, in the case of COVID-19, requires more than a one-size-fits-all approach.
• Science at Warp Speed: Medical Research, Publication, and Translation During the COVID-19 Pandemic, Wendy Lipworth, Melanie Gentgall, Ian Kerridge, and Cameron Stewart Abstract
  In response to the COVID-19 pandemic, there has been a rapid growth in research focused on developing vaccines and therapies. In this context, the need for speed is taken for granted, and the scientific process has adapted to accommodate this. On the surface, attempts to speed up the research enterprise appear to be a good thing. It is, however, important to consider what, if anything, might be lost when biomedical innovation is sped up. In this article we use the case of a study recently retracted from the Lancet to illustrate the potential risks and harms associated with speeding up science. We then argue that, with appropriate governance mechanisms in place (and adequately resourced), it should be quite possible to both speed up science and remain attentive to scientific quality and integrity.
• Learning Lessons from COVID-19 Requires Recognizing Moral Failures, Maxwell Smith and Ross Upshur Abstract
  The most powerful lesson learned from the 2013-2016 outbreak of Ebola in West Africa was that we do not learn our lessons. A common sentiment at the time was that Ebola served as a “wake-up call”—an alarm which signalled that an outbreak of that magnitude should never have occurred and that we are ill-prepared globally to prevent and respond to them when they do. Pledges were made that we must learn from the outbreak before we were faced with another. Nearly five years later the world is in the grips of a pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). It is therefore of no surprise that we are now yet again hearing that the COVID-19 pandemic serves as the “wake-up call” we need and that there are many lessons to be learned to better prepare us for future outbreaks. Will anything be different this time around? We argue that nothing will fundamentally change unless we truly understand and appreciate the nature of the lessons we should learn from these outbreaks. Our past failures must be understood as moral failures that offer moral lessons. Unless we appreciate that we have a defect in our collective moral attitude toward remediating the conditions that precipitate the emergence of outbreaks, we will never truly learn.
• In the Shadow of Biological Warfare: Conspiracy Theories on the Origins of COVID-19 and Enhancing Global Governance of Biosafety as a Matter of Urgency, Jing-Bao Nie Abstract
  Two theories on the origins of COVID-19 have been widely circulating in China and the West respectively, one blaming the United States and the other a highest-level biocontainment laboratory in Wuhan, the initial epicentre of the pandemic. Both theories make claims of biological warfare attempts. According to the available scientific evidence, these claims are groundless. However, like the episodes of biological warfare during the mid-twentieth century, the spread of these present-day conspiracy theories reflects a series of longstanding and damaging trends in the international scene which include deep mistrust, animosities, the power of ideologies such as nationalism, and the sacrifice of truth in propaganda campaigns. Also, the threats associated with biological warfare, bioterrorism, and the accidental leakage of deadly viruses from labs are real and growing. Thus, developing a better global governance of biosafety and biosecurity than exists at present is an urgent imperative for the international community in the broader context of a looming Cold War II. For such a governance, an ethical framework is proposed based upon the triple ethical values of transparency, trust, and the common good of humanity.
• A Global Ecological Ethic for Human Health Resources, Lisa A. Eckenwiler Abstract
  COVID-19 has highlighted with lethal force the need to re-imagine and redesign the provisioning of human resources for health, starting from the reality of our radical interdependence and concern for global health and justice. Starting from the structured health injustice suffered by migrant workers during the pandemic and its impact on the health of others in both destination and source countries, I argue here for re-structuring the system for educating and distributing care workers around what I call a global ecological ethic. Rather than rely on a system that privileges nationalism, that is unjust, and that sustains and even worsens injustice, including health injustice, and that has profound consequences for global health, a global ecological ethic would have us see health as interdependent and aim at “ethical place-making” across health ecosystems to enable people everywhere to have the capability to be healthy.
• Risk Communication Should be Explicit About Values. A Perspective on Early Communication During COVID-19, Claire Hooker & Julie Leask Abstract
  This article explores the consequences of failure to communicate early, as recommended in risk communication scholarship, during the first stage of the COVID-19 pandemic in Australia and the United Kingdom. We begin by observing that the principles of risk communication are regarded as basic best practices rather than as moral rules. We argue firstly, that they nonetheless encapsulate value commitments, and secondly, that these values should more explicitly underpin communication practices in a pandemic. Our focus is to explore the values associated with the principle of communicating early and often and how use of this principle can signal respect for people’s selfdetermination whilst also conveying other values relevant to the circumstances. We suggest that doing this requires communication that explicitly acknowledges and addresses with empathy those who will be most directly impacted by any disease-control measures. We suggest further that communication in a pandemic should be more explicit about how values are expressed in response strategies and that doing so may improve the appraisal of new information as it becomes available.

Symposium: COVID-19 – Voices from Different Places

• COVID-19 Pandemic: The Circus is Over, for the Moment, Philip Morrissey Abstract
  This critical essay responds to the COVID-19 pandemic and subsequent lockdown in Victoria from the perspective of a retired Aboriginal academic and reflects on personal responsibility, Indigenous history, and resilience.
• Fairness, Ethnicity, and COVID-19 Ethics: A Discussion of How the Focus on Fairness in Ethical Guidance During the Pandemic Discriminates Against People From Ethnic Minority Backgrounds, Alexis Paton Abstract
  Recent weeks have seen an increased focus on the ethical response to the COVID-19 pandemic. Ethics guidance has proliferated across Britain, with ethicists and those with a keen interest in ethics in their professions working to produce advice and support for the National Health Service. The guiding principles of the pandemic have emerged, in one form or another, to favour fairness, especially with regard to allocating resources and prioritizing care. However, fairness is not equivalent to equity when it comes to healthcare, and the focus on fairness means that existing guidance inadvertently discriminates against people from ethnic minority backgrounds. Drawing on early criticisms of existing clinical guidance (for example, the frailty decision tool) and ethical guidance in Britain, this essay will discuss the importance of including sociology, specifically the relationship between ethnicity and health, in any ethical and clinical guidance for care during the pandemic in the United Kingdom. To do otherwise, I will argue, would be actively choosing to allow a proportion of the British population to die for no other reason than their ethnic background. Finally, I will end by arguing why sociology must be a key component in any guidance, outlining how sociology was incorporated into the cross-college guidance produced by the Royal College of Physicians.
• Disability, Disablism, and COVID-19 Pandemic Triage, Jackie Leach Scully Abstract
  Pandemics such as COVID-19 place everyone at risk, but certain kinds of risk are differentially severe for groups already made vulnerable by pre-existing forms of social injustice and discrimination. For people with disability, persisting and ubiquitous disablism is played out in a variety of ways in clinical and public health contexts. This paper examines the impact of disablism on pandemic triage guidance for allocation of critical care. It identifies three underlying disablist assumptions about disability and health status, quality of life, and social utility, that unjustly and potentially catastrophically disadvantage people with disability in COVID-19 and other global health emergencies.
• Gambling With COVID-19 Makes More Sense: Ethical and Practical Challenges in COVID-19 Responses in Communalistic Resource-Limited Africa, David Nderitu and Eunice Kamaara Abstract
  Informed by evidence from past studies and experiences with epidemics, an intervention combining quarantine, lockdowns, curfews, social distancing, and washing of hands has been adopted as “international best practice” in COVID-19 response. With massive total lockdowns complemented by electronic surveillance, China successfully controlled the pandemic in country within a few months. But would this work for Africa and other communalistic resource poor settings where social togetherness translates to effective sharing of basic needs? What ethical and practical challenges would this pose? How would communalism be translated in special contexts to be useful in contributing to the ultimate common good? This paper uses examples from the current situation of COVID-19 in Kenya to address these questions.
• The COVID-19 Pandemic and Ethics in Mexico Through a Gender Lens, Amaranta Manrique de Lara & María de Jesús Medina Abstract
  In Mexico, significant ethical and social issues have been raised by the COVID-19 pandemic. Some of the most pressing issues are the extent of restrictive measures, the reciprocal duties to healthcare workers, the allocation of scarce resources, and the need for research. While policy and ethical frameworks are being developed to face these problems, the gender perspective has been largely overlooked in most of the issues at stake. Domestic violence is the most prevalent form of violence against women, which can be exacerbated during a pandemic: stress and economic uncertainty are triggers for abuse, and confinement limits access to support networks. Confinement also exacerbates the unfair distribution of unpaid labor, which is disproportionately assigned to women and girls, and highlights inequality in the overall labor market. Lack of security measures has resulted in attacks towards health workers, particularly female nurses, due to fear of contamination. Finally, resource results in lack of access to other health necessities, including sexual and reproductive health services. Research across all disciplines to face—and to learn from—this crisis should be done through a gender lens, because understanding the realities of women is essential to understand the pandemic’s true effects in Mexico and the world.
• Clever COVID-19, Clever Citizens-98: Critical and Creative Reflections from Tehran, Toronto, and Sydney, Laura Bisaillon, Mehdi Khosravi, Bahareh Jahandoost & Linda Briskman Abstract
  Our world suffers. Some people suffer more than others. Since the first part of 2020, ours is justly described as a time of uncertainty, threat, and upheaval. In this article, we offer reflections threaded narratively, told from the specificity of our societal contexts in Iran, Canada, and Australia. What might we learn in the present and anticipated future from people living chronically within conditions of uncertainty and immobility and also those experiencing uncertainty and immobility for the first time? We argue that reflexive comparative analysis bridging social and visual analysis, anchored in embodied conditions of such people, offers a way to learn from responses to COVID-19 while also being an exercise in ethical research practice. This reflection builds on and extends from our scholarly collaborations that have been ongoing since 2015. Our title recognizes this specific virus as stealthy. Importantly, our choice of words identifies resident Iranians—whose experiences were the original impetuses for this paper, and whose lives provide its empirical basis (98 is Iran’s country code)—as equally steely.
• Ethical Considerations for Restrictive and Physical Distancing Measures in Brazil During COVID-19: Facilitators and Barriers, Beatriz C. Thomé, Gustavo C. Matta & Sérgio T.A. Rego Abstract
  COVID-19 was recognized as a pandemic on March 11, 2020. Nine days later in Brazil, community transmission was deemed ongoing, and following what was already being put in place in various affected countries, restrictive and physical distancing measures that varied in severity across the different states were adopted. Adherence to restrictive and physical distancing measures depends on the general acceptance of public health measures as well as communities’ financial leverage. This article aims to explore and discuss ethical facilitators and barriers to the implementation of physical distancing measures within three dimensions: political, socio-economic, and scientific. Furthermore, we would like to discuss ways to ethically promote restrictive and physical distancing measures in a large and unequal country like Brazil. There is an urgent need for transparent, consistent, and inclusive communication with the public, respecting the most vulnerable populations and attempting to minimize the disproportionate burden on them.
• COVID-19 from Wellington New Zealand, Ben Gray Abstract
  This paper examines the role of bioethics in the successful control of COVID-19 in New Zealand. After the severe acute respiratory syndrome (SARS) coronavirus episode in Toronto researchers developed a framework of values and principles to articulate values that were already commonly accepted “in the community of its intended users,” to be used to inform decision-making. New Zealand subsequently developed its own framework that was embedded in its Pandemic Influenza Plan. These formed the basis of the New Zealand response to COVID-19. This paper illustrates the ways in which the bioethical framework was reflected in the decisions and actions made by the government.
• Venenum, Virus, Fear, and Politics, Zvi Bekerman Abstract
  This article presents a short reflection on the confluence between politics and pandemics as they are reflected in Israel in March and April 2020.
• It Didn’t Have to be This Way: Reflections on the Ethical Justification of the Running Ban in Northern Italy in Response to the 2020 COVID-19 Outbreak, Silvia Camporesi Abstract
  In this paper I discuss the ethical justifiability of the limitation of freedom of movement, in particular of the ban on running outdoors, enforced in Italy as a response to the COVID-19 outbreak in the spring of 2020. I argue that through the lens of public health ethics literature, the ban on running falls short of the criterion of proportionality that public health ethics scholars and international guidelines for the ethical management of infectious disease outbreak recommend for any measure that restricts essential individual freedoms, such as the freedom of movement. The public health ethics framework, however, falls short of explaining the widespread public support that the running ban has had in Italy. I discuss possible factors which could explain the public support for the ban in Italy. Finally, I raise the question of what societal implications the abandonment of the public health ethics framework based on proportionality might have. I conclude that if it is the case, as the history of pandemics teaches us, we will experience further waves of COVID-19 outbreaks, it becomes very important to raise these questions now, with an eye towards informing public health policies for the management of future COVID-19 outbreaks. This discussion should not become politicized along the lines of liberal pro-lockdown/conservative anti-lockdown. Instead, we should reflect on the trade-offs of lockdown policies according to a pluralist framework, in which COVID-19 related deaths are not the only possible value to pursue.
• Synergistic Disparities and Public Health Mitigation of COVID-19 in the Rural United States, Kata L. Chillag & Lisa M. Lee Abstract
  Public health emergencies expose social injustice and health disparities, resulting in calls to address their structural causes once the acute crisis has passed. The COVID-19 pandemic is highlighting and exacerbating global, national, and regional disparities in relation to the benefits and burdens of undertaking critical basic public health mitigation measures such as physical distancing. In the United States, attempts to address the COVID-19 pandemic are complicated by striking racial, economic, and geographic inequities. These synergistic inequities exist in both urban and rural areas but take on a particular character and impact in areas of rural poverty. Rural areas face a diverse set of structural challenges, including inadequate public health, clinical, and other infrastructure and economic precarity, hampering the ability of communities and individuals to implement mitigation measures. Public health ethics demands that personnel address both the tactical, real-time adjustment of typical mitigation tools to improve their effectiveness among the rural poor as well as the strategic, longer-term structural causes of health and social injustice that continue to disadvantage this population.
• Heralding the Digitalization of Life in Post-Pandemic East Asian Societies, Calvin Wai-Loon Ho, Karel Caals & Haihong Zhang Abstract
  Following the outbreak of what would become the COVID-19 pandemic, social distancing measures were quickly introduced across East Asia—including drastic shelter-in-place orders in some cities—drawing on experience with the outbreak of severe acute respiratory syndrome (SARS) almost two decades ago. “Smart City” technologies and other digital tools were quickly deployed for infection control purposes, ranging from conventional thermal scanning cameras to digital tracing in the surveillance of at-risk individuals. Chatbots endowed with artificial intelligence have also been deployed to shift part of healthcare provision away from hospitals and to support a number of programmes for self-management of chronic disease in the community. With the closure of schools and adults working from home, digital technologies have also sustained many aspects of both professional and social life at a pace and scale not considered to be practicable before the outbreak. This paper considers how these new experiences with digital technologies in public health surveillance are spurring digitalization in East Asian societies beyond the conventional public health context. It also considers some of the concerns and challenges that are likely to arise with rapid digitalization, particularly in healthcare.
• COVID 19 and Australian Prisons: Human Rights, Risks, and Responses, Cameron Stewart, George F. Tomossy, Scott Lamont & Scott Brunero Abstract
  Australian prisons are overpopulated with people suffering from numerous health problems. COVID-19 presents a significant threat to prisoner health. This article examines the current regulatory responses from Australian state and territory governments to COVID-19 and a recent case which tested the human rights of prisoners during a pandemic.
• Social Justice for Public Health: The COVID-19 Response in Portugal, Luís Cordeiro-Rodrigues Abstract
  The COVID-19 pandemic requires emergency policies to be put in place in order to avoid a global health catastrophe. At the same time, there has been an increasing preoccupation that argues urgent policies for public health neglect social justice. By looking at Portugal’s successful confinement case during the pandemic, I argue that ethically driven social justice policies are not just compatible but also an instrumentally important element in addressing this pandemic in an effective way. The Portuguese case study suggests that enhancing social justice towards socio-economically vulnerable groups correlates with the prevention of the spread of COVID-19; these benefits to public health can be explained by the fact that those policies create social distancing and less exposure to the COVID-19 virus and other contagious diseases and also remove disincentives to the use of healthcare services.
• What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France, Kristina Orfali Abstract
  In today’s pandemic, many countries have experienced shortages of medical resources and many healthcare providers have often been faced with dramatic decisions about how to allocate beds, intensive care, or ventilators. Despite recognizing the need for triage, responses are not the same everywhere, and opinions and practices differ around what guidelines should be used, how they should be implemented, and who should ultimately decide. To some extent, triage issues reflect community values, revealing a given society’s moral standards and ideals. Our goal is to study two countries which share many common features—Italy and France—as they deal with the pandemic, revealing the moral organization of medicine and healthcare, the power structures, and the nature of the disruptions in each context.
• Preserving Bodily Integrity of Deceased Patients From the Novel SARS-CoV-2 Pandemic in West Africa, Peter F. Omonzejele Abstract
  The outbreak of the novel coronavirus pandemic, otherwise known as COVID-19 brought about the use of new terminologies—new lexical items such as social distancing, self-isolation, and lockdown. In developed countries, basic social amenities to support these are taken for granted; this is not the case in West African countries. Instead, those suggested safeguards against contracting COVID-19 have exposed the infrastructural deficit in West African countries. In addition, and more profoundly, these safeguards against the disease have distorted the traditional community-individuality balance. The enforcement of social distancing, self-isolation, and lockdown has made it impossible for West Africans to drift to their ancestral homes and villages, as is usually the case in times of crisis, with attendant consequences for communal life and traditional burial rites. This could be one of the reasons why some COVID-19 patients are escaping from isolation centres, since to die in such centres violates their bodily integrity at an ontological level.

Symposium: COVID-19 – Bioethical Debates

• Antibodies as Currency: COVID-19’s Golden Passport, Katrina Bramstedt Abstract
  Due to COVID-19, the fragile economy, travel restrictions, and generalized anxieties, the concept of antibodies as a “declaration of immunity” or “passport” is sweeping the world. Numerous scientific and ethical issues confound the concept of an antibody passport; nonetheless, antibodies can be seen as a potential currency to allow movement of people and resuscitation of global economics. Just as financial currency can be forged, so too is the potential for fraudulent antibody passports. This paper explores matters of science, ethics, and identity theft, as well as the problems of bias and discrimination that could promulgate a world of pandemic “golden passports.”
• Dignity, Autonomy, and Allocation of Scarce Medical Resources During COVID-19, David Kirchhoffer Abstract
  Ruth Macklin argued that dignity is nothing more than respect for persons or their autonomy. During the COVID-19 pandemic, difficult decisions are being made about the allocation of scarce resources. Respect for autonomy cannot justify rationing decisions. Justice can be invoked to justify rationing. However, this leaves an uncomfortable tension between the principles. Dignity is not a useless concept because it is able to account for why we respect autonomy and for why it can be legitimate to override autonomy in times of critical care resource shortages. Dignity affirms the worth of the human individual as a meaning-making embodied subject, who is always in relationship to others, the world, time, and transcendence, and who realises their dignity through their moral behaviour. Such an understanding means people should be helped to make morally right decisions about their own treatment, which may include forgoing potentially beneficial treatment for the good of others. Respect for dignity does not require fulfilling the morally wrong choices of one who insists on treatment at the expense of others. Dignity also protects the discretion of clinicians to make decisions appropriate to their competence by prohibiting the application of broad-based criteria such as age.
• Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of “Duty” for Health Practitioners, Linda Sheahan and Scott Lamont Abstract
  From the ethics perspective, “duty of care” is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the “duty of care” from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of “duty” in their response to COVID-19.
• Advancing Global Health Equity in the COVID-19 Response: Beyond Solidarity, Stephanie Johnson Abstract
  In the coming weeks and months SARS-CoV-2 may ravage countries with weak health systems and populations disproportionately affected by HIV, tuberculosis (TB), and other infectious diseases. Without safeguards and proper attention to global health equity and justice, the effects of this pandemic are likely to exacerbate existing health and socio-economic inequalities. This paper argues that achieving global health equity in the context of COVID-19 will require that notions of reciprocity and relational equity are introduced to the response.
• Coronavirus Human Infection Challenge Studies: Assessing Potential Benefits and Risks, Euzebiusz Jamrozik, George Heriot & Michael Selgelid Abstract
  Human infection challenge studies (HCS) have been proposed as a means to accelerate SARS-CoV2 vaccine development and thereby help to mitigate a prolonged global public health crisis. A key criterion for the ethical acceptability of SARS-CoV2 HCS is that potential benefits outweigh risks. Although the assessment of risks and benefits is meant to be a standard part of research ethics review, systematic comparisons are particularly important in the context of SARS-CoV2 HCS in light of the significant potential benefits and harms at stake as well as the need to preserve public trust in research and vaccines. In this paper we explore several considerations that should inform systematic assessment of SARS-CoV-2 HCS. First, we detail key potential benefits of SARS-CoV-2 HCS including, but not limited to, those related to the acceleration of vaccine development. Second, we identify where modelling is needed to inform risk-benefit (and thus ethical) assessments. Modelling will be particularly useful in (i) comparing potential benefits and risks of HCS with those of vaccine field trials under different epidemiological conditions and (ii) estimating marginal risks to HCS participants in light of the background probabilities of infection in their local community. We highlight interactions between public health policy and research priorities, including situations in which research ethics assessments may need to strike a balance between competing considerations.
• Ethical Challenges in Clinical Research During the COVID-19 Pandemic, B.E. Bierer & S.A. White & J.M. Barnes & L. Gelinas Abstract
  The sudden emergence of the COVID-19 pandemic brought global disruption to every aspect of society, including healthcare, supply chain, the economy, and social interaction. Among the many emergent considerations were the safety and public health of individuals including patients, essential workers, and healthcare professionals. In certain locations, clinical research was halted—or terminated—in deference to the immediate needs of patient care, and clinical trials focusing on the treatment and prevention of coronavirus infection were prioritized over studies focusing on other diseases. Difficult decisions were made rapidly; flexibility and reconsideration were necessary, however, not only because the intensity and severity of infection varied over time and by locale but also because knowledge of the disease and understanding of its treatment (and prevention) grew. Here we discuss the ethical challenges in decision-making and competing ethical tensions during the pandemic in an effort to advance future preparedness.
• Beyond Duty: Medical “Heroes” and the COVID-19 Pandemic, Wendy Lipworth Abstract
  When infectious disease outbreaks strike, health facilities acquire labels such as “war zones” and “battlefields” and healthcare professionals become “heroes” on the “front line.” But unlike soldiers, healthcare professionals often take on these dangerous roles without any prior intention or explicit expectation that their work will place them in grave personal danger. This inevitably raises questions about their role-related obligations and whether they should be free to choose not to endanger themselves. In this article, I argue that it is helpful to view this situation not only through the lens of “professional duty” but also through the lens of “role-related conflicts.” Doing so has the advantage of avoiding exceptionalism and allowing us to draw lessons not only from previous epidemics but also from a wide range of far more common role-related dilemmas in healthcare.
• We Need to Talk About Rationing: The Need to Normalize Discussion About Healthcare Rationing in a Post COVID-19 Era, Neera Bhatia Abstract
  The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight—and as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare.
• Justice, Wellbeing, and Civic Duty in the Age of a Pandemic: Why We All Need to do Our Bit, Johan C. Bester Abstract
  This article presents an argument related to justice obligations during a pandemic and explores implications of the argument. A just society responds to a serious threat to the well-being of its people such as a viral pandemic to mitigate the impact of the pandemic on the well-being of its members. This creates identifiable societal obligations which are discharged by the institutions and individuals within society that are situated to do so. There are therefore identifiable obligations resting on various societal institutions, such as government, churches, schools, and corporate institutions, as well as obligations resting on individuals. Should an institution or individual fail to act in ways consistent with these social obligations, they perpetrate an injustice on society and its members.
• Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research, N. Straiton, A. McKenzie, J. Bowden, A. Nichol, R. Murphy, T. Snelling, J. Zalcberg, J. Clements, J. Stubbs, A. Economides, D. Kent, J. Ansell & T. Symons Abstract
  Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Symposium: COVID-19 – Clinical Implications

• An Ethics Framework for Making Resource Allocation Decisions Within Clinical Care: Responding to COVID-19, Angus Dawson, David Isaacs, Melanie Jansen, Christopher Jordens, Ian Kerridge, Ulrik Kihlbom, Henry Kilham, Anne Preisz, Linda Sheahan, George Skowronski Abstract
  On March, 24, 2020, 818 cases of COVID-19 had been reported in New South Wales, Australia, and new cases were increasing at an exponential rate. In anticipation of resource constraints arising in clinical settings as a result of the COVID-19 pandemic, a working party of ten ethicists (seven clinicians and three full-time academics) was convened at the University of Sydney to draft an ethics framework to support resource allocation decisions. The framework guides decision-makers using a question-and-answer format, in language that avoids philosophical and medical technicality. The working party met five times over the following week and then submitted a draft Framework for consideration by two groups of intensivists and one group of academic ethicists. It was also presented to a panel on a national current affairs programme. The Framework was then revised on the basis of feedback from these sources and made publicly available online on April 3, ten days after the initial meeting. The framework is published here in full to stimulate ongoing discussion about rapid development of user-friendly clinical ethics resources in ongoing and future pandemics.
• Building an Ethics Framework for COVID-19 Resource Allocation: The How and the Why, Angus Dawson Abstract
  This paper expands on “An Ethics Framework for Making Resource Allocation Decisions within Clinical Care: Responding to COVID-19,” which is also published in this special issue of the Journal of Bioethical Inquiry. I first describe and explain the steps we took to develop this framework, drawing on previous experience and literature to explain what frameworks can and cannot do. I distinguish frameworks from other kinds of guidance and justify why our framework takes the form it does. Our key aim was to help answer practical questions faced by frontline clinicians. I then explain some of the normative issues that shape the content of the framework itself. Here, I engage critically with the resource allocation literature and justify the particular positions that we take in the framework. Although we undertook this work to address resource allocation decisions anticipated during the unfolding COVID-19 pandemic, it will also serve as an example for others who wish to design practical ethics frameworks for other bioethical issues that will emerge in the future.
• Systems of Care in Crisis: The Changing Nature of Palliative Care During COVID-19, Michael Chapman, Beth Russell, Jennifer Philip Extract
  Evident within the many lessons that the novel coronavirus (COVID-19) pandemic has taught us is the fragility of the systems that enable us to care for each other. Care systems, the dynamic interconnections and processes involving care providers and care recipients, result in the practices that we recognize as “care.” These systems emerge from the needs of human bodies, the recognition and response to these needs by people and communities, the communication that supports these connections, and the meaning attributed to this care. These care systems are complex and develop through relationships and interactions (Hodiamont et al. 2019). We cannot understand them or predict their movement just by focusing on the individual parts (such as the people) involved (Glouberman and Zimmerman 2004). They are also adaptive. These care systems are influenced by and respond to the changes that occur within and around them, sometimes resulting in the emergence of new behaviours and approaches. Response can lead to some systems becoming more resilient to change and to other disrupting or even dispersing. How care is provided within and through these systems varies. But such systems remain an omnipresent shifting and often unnoticed tapestry of connections and structures engendering our experience (Maturana and Varela 1980).
• Family Presence for Patients and Separated Relatives During COVID-19: Physical, Virtual, and Surrogate, Teck Chuan Voo, Mathavi Senguttuvan, Clarence C. Tam Abstract
  During an outbreak or pandemic involving a novel disease such as COVID-19, infected persons may need to undergo strict medical isolation and be separated from their families for public health reasons. Such a practice raises various ethical questions, the characteristics of which are heightened by uncertainties such as mode of transmission and increasingly scarce healthcare resources. For example, under what circumstances should non-infected parents be allowed to stay with their infected children in an isolation facility? This paper will examine ethical issues with three modes of “family presence” or “being there or with” a separated family member during the current COVID-19 pandemic: physical, virtual, and surrogate. Physical visits, stays, or care by family members in isolation facilities are usually prohibited, discouraged, or limited to exceptional circumstances. Virtual presence for isolated patients is often recommended and used to enable communication. When visits are disallowed, frontline workers sometimes act as surrogate family for patients, such as performing bedside vigils for dying patients. Drawing on lessons from past outbreaks such as the 2002-2003 SARS epidemic and the recent Ebola epidemic in West Africa, we consider the ethical management of these modes of family presence and argue for the promotion of physical presence under some conditions.
• Imagining and Preparing for the Aftermath of the COVID-19 Pandemic: A Justification for Taking Caring Responsibilities into Consideration when Allocating Scarce Resources, Christopher F.C. Jordens Abstract
  Various models have been used to “emplot” our collective experience of the COVID-19 pandemic, including the epidemiological curve, threshold models, and narrative. Drawing on a threshold model that was designed to frame resource-allocation decisions in clinical care, I offer an ethical justification for taking caring responsibilities into consideration in such decisions during pandemics. My basic argument is that we should prioritize the survival of patients with caring responsibilities for similar reasons we should prioritize the survival of healthcare professionals. More generally, the pandemic reveals the fundamental importance of informal care and affords an opportunity to raise questions of justice relating to it.
• COVID-19, Moral Conflict, Distress, and Dying Alone, Lisa K. Anderson-Shaw & Fred A. Zar Abstract
  COVID-19 has truly affected most of the world over the past many months, perhaps more than any other event in recent history. In the wake of this pandemic are patients, family members, and various types of care providers, all of whom share different levels of moral distress. Moral conflict occurs in disputes when individuals or groups have differences over, or are unable to translate to each other, deeply held beliefs, knowledge, and values. Such conflicts can seriously affect healthcare providers and cause distress during disastrous situations such as pandemics when medical and human resources are stretched to the point of exhaustion. In the current pandemic, most hospitals and healthcare institutions in the United States have not allowed visitors to come to the hospitals to see their family or loved ones, even when the patient is dying. The moral conflict and moral distress (being constrained from doing what you think is right) among care providers when they see their patients dying alone can be unbearable and lead to ongoing grief and sadness. This paper will explore the concepts of moral distress and conflict among hospitalstaff and how a system-wide provider wellness programme can make a difference in healing and health.
• Ought Conscientious Refusals to Implement Reverse Triage Decisions be Accommodated?, Nathan Emmerich Abstract
  Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment—that is, when withdrawal of treatment is arguably in the best interests of patients—and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage.
• Healthcare Professional Standards in Pandemic Conditions: The Duty to Obtain Consent to Treatment, Sarah Devaney, Jose Miola, Emma Cave, Craig Purshouse & Rob Heywood Abstract
  In the United Kingdom, the question of how much information is required to be given to patients about the benefits and risks of proposed treatment remains extant. Issues about whether healthcare resources can accommodate extended shared decision-making processes are yet to be resolved. COVID-19 has now stepped into this arena of uncertainty, adding more complexity. U.K. public health responses to the pandemic raise important questions about professional standards regarding how the obtaining and recording of consent might change or be maintained in such emergency conditions, particularly in settings where equipment, medicines, and appropriately trained or specialized staff are in short supply. Such conditions have important implications for the professional capacity and knowledge available to discuss the risks and benefits of and alternatives to proposed treatment with patients. The government’s drive to expedite the recruitment to wards of medical students nearing the end of their studies, as well as inviting retired practitioners back into practice, raises questions about the ability of such healthcare providers to engage fully in shared decision-making. This article explores whether the legal duty on healthcare practitioners to disclose the material risks of a proposed medical treatment to a patient should be upheld during pandemic conditions or whether the pre-eminence of patient autonomy should be partly sacrificed in such exceptional circumstances. We argue that measures to protect public health and to respect autonomous decision-making are not mutually exclusive and that there are good reasons to maintain professional standards in obtaining consent to treatment even during acute pressures on public health systems.
• What Matters? Palliative Care, Ethics, and the COVID-19 Pandemic, Linda Sheahan & Frank Brennan Abstract
  As is often the case in clinical ethics, the discourse in COVID-19 has focused primarily on difficult and controversial decision-making junctures such as how to decide who gets access to intensive care resources if demand outstrips supply. However, the lived experience of COVID-19 raises less controversial but arguably more profound moral questions around what it means to look after each other through the course of the pandemic and how this translates in care for the dying. This piece explores the interface between the pandemic, ethics, and the role of palliative care. We argue that the ethical discourse should be broader, and that the principles that underly the discipline of palliative care provide a solid ethical foundation for the care of all patients through the coronavirus pandemic.
• Telling the Truth to Child Cancer Patients in COVID-19 Times, Lynn Gillam, Merle Spriggs, Clare Delany, Rachael Conyers & Maria McCarthy Abstract
  A notable feature of the COVID-19 pandemic is that children are less at risk of becoming infected or, if infected, less likely to become seriously unwell, so ethical discussions have consequently focused on the adult healthcare setting. However, despite a lower risk of children becoming acutely ill with COVID-19, there nevertheless may be significant and potentially sustained effects of COVID-19 on the physical, psychological, and emotional health and wellbeing of children. Focusing on the context of children’s cancer care, and specifically bone marrow transplant (BMT), we describe some of these effects and then address one specific ethical challenge that arises. That is the question of what and how much to tell children whose cancer treatment has been changed because of COVID-19. Drawing on our previous work on the ethical reasons for telling the truth to younger children (aged 5-12) we link different ethical reasons to the different types of information that could be given to children in this context. We argue that children should be given an explanation of the changes that they will directly experience, including some changes to the process of their actual medical treatment; but not about increased risk associated with these changes, unless they specifically ask for this information.
• Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach, Cameron Stewart, Paul Biegler, Scott Brunero, Scott Lamont, George F. Tomossy Abstract
  The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).

Symposium: COVID-19 – Surveillance and the Panopticon

• COVID-19—Extending Surveillance and the Panopticon, Danielle Couch, Priscilla Robinson, Paul Komesaroff Abstract
  Surveillance is a core function of all public health systems. Responses to the COVID-19 pandemic have deployed traditional public health surveillance responses, such as contact tracing and quarantine, and extended these responses with the use of varied technologies, such as the use of smartphone location data, data networks, ankle bracelets, drones, and big data analysis. Applying Foucault’s (1979) notion of the panopticon, with its twin focus on surveillance and self-regulation, as the preeminent form of social control in modern societies, we examine the increasing levels of surveillance enacted during this pandemic and how people have participated in, and extended, this surveillance, self-regulation, and social control through the use of digital media. Consideration is given to how such surveillance may serve public health needs and/or political interests and whether the rapid deployment of these extensive surveillance mechanisms risks normalizing these measures so that they become more acceptable and then entrenched post-COVID-19.
• Accelerating the De-Personalisation of Medicine: The Ethical Toxicities of COVID-19, Mark Arnold and Ian Kerridge Abstract
  The COVID-19 pandemic has, of necessity, demanded the rapid incorporation of virtual technologies which, suddenly, have superseded the physical medical encounter. These imperatives have been implemented in advance of evaluation, with unclear risks to patient care and the nature of medical practice that might be justifiable in the context of a pandemic but cannot be extrapolated as a new standard of care. Models of care fit for purpose in a pandemic should not be generalized to reconfigure medical care as virtual by default, and personal by exception at the conclusion of the emergency.
• Applying a Precautionary Approach to Mobile Contact Tracing for COVID-19: The Value of Reversibility, Niels Nijsingh, Anne van Bergen and Verina Wild Abstract
  The COVID-19 pandemic presents unprecedented challenges to public health decision-making. Specifically, the lack of evidence and the urgency with which a response is called for, raise the ethical challenge of assessing how much (and what kind of) evidence is required for the justification of interventions in response to the various threats we face. Here we discuss the intervention of introducing technology that aims to trace and alert contacts of infected persons—contact tracing (CT) technology. Determining whether such an intervention is proportional is complicated by complex trade-offs and feedback loops. We suggest that the resulting uncertainties necessitate a precautionary approach. On the one hand, precautionary reasons support CT technology as a means to contribute to the prevention of harms caused by alternative interventions, or COVID-19 itself. On the other hand, however, both the extent to which such technology itself present risks of serious harm, as well as its effectiveness, remain unclear. We therefore argue that a precautionary approach should put reversibility of CT technology at the forefront. We outline several practical implications.
• Pandemic Surveillance and Racialized Subpopulations: Mitigating Vulnerabilities in COVID-19 Apps, Tereza Hendl, Ryoa Chung, Verina Wild Abstract
  Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response.
• COVID-19 and Contact Tracing Apps: Ethical Challenges for a Social Experiment on a Global Scale, Federica Lucivero, Nina Hallowell, Stephanie Johnson, Barbara Prainsack, Gabrielle Samuel, Tamar Sharon Abstract
  Mobile applications are increasingly regarded as important tools for an integrated strategy of infection containment in post-lockdown societies around the globe. This paper discusses a number of questions that should be addressed when assessing the ethical challenges of mobile applications for digital contact tracing of COVID-19: Which safeguards should be designed in the technology? Who should access data? What is a legitimate role for “Big Tech” companies in the development and implementation of these systems? How should cultural and behavioural issues be accounted for in the design of these apps? Should use of these apps be compulsory? What does transparency and ethical oversight mean in this context? We demonstrate that responses to these questions are complex and contingent and argue that if digital contract-tracing is used, then it should be clear that this is on a trial basis and its use should be subject to independent monitoring and evaluation.

Related: Visit the COVID-19 symposium page for interviews with editors and authors on the JBI Dialogues podcast and other updates and reflections.