As part of the current COVID-19 pandemic, countries around the world have put in place several strict movement restrictions to prevent the spread of the virus. As of April 2020, about 3.9 billion people in 90 countries were living at home. The discourse on the ethical issues raised by such limitations, while historically rich, is lacking when it comes to pragmatic policy considerations of policymakers. Based on the existing literature, we present a unified framework of ethical principles – pragmatic considerations – policy indicators that can be flexibly applied in different countries and contexts to assess the ethical merits of movement-limiting policies. Our framework includes 11 unique but related ethical principles (harm, justification, proportionality, least restrictive means, effectiveness of benefits, reciprocity, transparency, relevance, fairness, responsibility, cost and feasibility). We mapped each ethical principle to answerable questions or pragmatic considerations to generate 34 policy indicators. These policy indicators can help policymakers and health professionals decide on ethically sound movement restrictions, monitor progress, and systematically evaluate the restrictions imposed. As an example, we used the framework to assess the ethical compliance of the first two phases of India`s largest national lockdown (March-May 2020). Political indicators have shown ethical failures in terms of proportionality, supply efficiency and accountability for India`s lockdown, which is expected to be subject to further restrictions. The framework is useful in ensuring that public health interventions restricting exercise in different parts of the world during the ongoing pandemic and possible future outbreaks are ethical.
The presence of possible ceiling and flooring effects is an important limitation in the current application of the frame. These effects result from the use of dichotomoized indicators. Categorical indicators, such as dichotomoized indicators, are used because they facilitate application, interpretation and comparison. In the future, discrete responses or ordinal responses with layers could replace dichotomization to avoid potential floors and ceilings. In addition, we used the arbitrary threshold “at least half of the indicators are positive” to decide whether the ethical principle was respected. Although 23 of the 31 dichotomous indicators received a “yes” answer in our analysis, the relative proportion of indicators in the principles suggests that several ethical principles were not fully or partially met. Changing this threshold may lead to qualitatively different conclusions. We tried to demonstrate the ease of application of the framework, so we did not test the findings across different thresholds. Future studies could select different thresholds deemed appropriate for the current scenario or, better yet, arrive at a set of conclusions sensitive to the different thresholds. While this may increase analytical complexity, studies could also assign different weights to indicators or use other aggregation methods more appropriate for the assessment in question.
Finally, we applied the framework to national containment in India, which simplifies subnational socioepidemiological heterogeneities and does not take into account differences within the state or other measures at the local level. However, with more detailed data, investigators and decision-makers at each level of the administrative hierarchy can tailor the framework to the geographic administrative unit (e.g., state or district or community containment zone) of interest. Such an application must use political indicators at different levels of decision-making, i.e. analyses at the state level would take into account national and state guidelines on movement restrictions. A very ancient approach to ethics holds that ethical action should be compatible with certain ideal virtues that ensure the full development of our humanity. These virtues are dispositions and habits that enable us to act according to the highest potential of our character and in the name of values such as truth and beauty. Honesty, courage, compassion, generosity, tolerance, love, loyalty, integrity, fairness, self-control and prudence are examples of virtues. The ethics of virtue requires of every action, “What kind of person will I become if I do this?” or “Is this action consistent with my best action?” The ethics of voluntary and imposed movement restrictions have already been discussed for outbreaks of infectious diseases and other biological hazards. In 2001, Barbera and colleagues18 examined ethical considerations for a large-scale quarantine for bioterrorist threats. They focused mainly on needs assessment, feasibility and cost-effectiveness. These ethical considerations for large-scale quarantines18 could arguably be adapted to lockdowns in the context of the current COVID-19 pandemic.
In the context of the 2003 severe acute respiratory syndrome outbreak, Upshur discussed ethical principles such as harm, proportionality, reciprocity and transparency (see Table 1) as necessary justifications for public health interventions,19 and applied them to imposed and voluntary quarantines.20 In 2007, the WHO report on the influenza pandemic discussed the ethical principles to be followed by governments in the event of 21 Beyond those proposed by Upshur This report also highlighted social justice, freedom, confidentiality, fair trials, efficiency and accountability as requirements for the ethical imposition of restrictions. In 2015, the Presidential Commission on Bioethics listed ethical considerations for restrictive measures in response to public health planning for the Ebola outbreak. [22] The Commission`s report recognized that ethical implementation should address considerations of harm, reciprocity, least violation, proportionality of evidence-based measures (such as charity and non-malevolence), justice and fairness. and ensuring equitable benefit-sharing among socio-economic strata. In 2016, WHO published general guidelines for the ethical management of infectious disease outbreaks.23 Recommendations for movement restrictions included the justified basis for imposing restrictions (known harm and evidence-based action), least restrictive means, cost considerations (effectiveness of benefits), ensuring humane conditions (mutual benefits), financial and social management consequences, protection of due process (fair trial), fair application (fairness and, for example, distributive justice) as well as communication and transparency. The second problem is that different lenses can lead to different answers to the question “What is ethical?” Nevertheless, each individual gives us an important insight into the decision-making process of what is ethical in certain circumstances. Respect for persons implies two ethical considerations: (1) individuals will and should be treated as autonomous actors, and (2) persons with limited autonomy due to youth, illness, mental retardation or limited freedom (e.g. prisoners) should be afforded additional protection. The principle of respect for persons means recognizing the authority of an individual`s preferences and decisions about his or her life. In the context of research, the principle of respect for individuals is expressed first and foremost in informed consent, according to which individuals should normally have the opportunity to decide whether or not to participate in research.
It is the responsibility of researchers to disclose information about a study in language understandable to potential subjects so that they can provide valid and voluntary informed consent. These disclosures generally include the purpose of the research, the research procedures, the risks, the expected benefits (if any) to the subject, the ability to ask questions and receive satisfactory answers, and a statement that participation is voluntary and that the subject has the right to withdraw from the study at any time for any reason. In recent years, public health interventions restricting autonomy and freedom have sparked necessary ethical debates and policies, and COVID-19-related movement restrictions, such as lockdowns, have revived this ethical dilemma. [33] For a detailed discussion of the IDD, see Australian Human Rights Commission, Federal Discrimination Law (2011), Chapter 5, at www.humanrights.gov.au/our-work/legal/federal-discrimination-law-2011 (accessed April 5, 2015).
