• Health Care Economics and Organizations

The editors of the JME are grateful to its authors, reviewers and readers for their efforts and attention to the important and novel ethical challenges of the COVID-19 pandemic. These efforts meant that the journal published a number of high quality articles analysing these issues and it has shaped subsequent discussions and debate in exactly the way that we strive for. Ultimately, outcomes such as impact, readership and contributing to knowledge are what matters most for a journal, but the imperfect metrics that journal performance is measured against matter too. So, the editors of the JME would also like to thank our authors, reviewers and readers for helping the JME score 5.9 in the most recent Clarivate Impact Factor (IF) rating. While that is not the highest IF in bioethics, it is worth mentioning that the highest citing paper from the bioethics journal with the highest IF, would have rated as the seventh most cited paper in the JME during this period. So, this latest rating reveals that the JME has had a very significant impact, readership and contribution to knowledge during the pandemic and we want to thank those who made this happen.

The ethical challenges of the pandemic have been a catalyst for exploring normative theories and concepts that make sense of and justify ethical positions about our pandemic response. At the same time, those communicating about what others should do during the pandemic have sought strategies for reaching people and distilling evidence based policy decisions. New Zealand’s Prime Minister Jacinda Ardern was quick to adopt simple and effective advice. In March 2020 she said

I have one final message. Be kind. I know people will want to act as enforcers. And I understand that, people are afraid and anxious. We will play that role for you. What we need from you, is to support one another. Go home tonight and check in on your neighbours. Start a phone tree with your street. Plan how you’ll keep in touch with one another. We will get through this together, but only if we stick together. Be strong and be kind.1

Despite Ardern’s appeal to citizens to support each other and leave any needed enforcement of lockdown restrictions to authorities, some people were enthusiastic about reporting lockdown transgressions, as was the case in most places.2 Nonetheless, the simple imperative to ‘be kind’ was effective at a time of crisis and was adopted elsewhere.

If a similar suggestion had been made in an ethics journal perhaps it might have been justified by an appeal to a principle such as solidarity, or a virtues based approach, an account of justice, or even as a way to maximize total utility. The simple imperative to ‘be kind’ makes sense on most ethical approaches and was effective simply on its own terms. Of course there are a number of ways of ethically justifying policy settings during the pandemic and in this issue of the JME, Stephen John and Emma Curran explore a contractualist justification for pandemic lockdowns.3

Whereas we might expect ‘reasonableness’ to be something that follows from a disposition to ‘be kind’, for a contractualist it is a method whereby we can test the permissibility of a course of action by asking whether it could reasonably be rejected by others who are impacted by that course of action.4 For example, there has been debate in the JME about selective lockdowns and whether it is permissible to have age targeted lockdowns so as to reflect the fact that some age groups are more at risk from COVID-19 than younger age groups.5 Rather than weighing costs and benefits, a contractualist might ask whether selective lockdowns could reasonably be rejected by groups impacted by that course of action. As John and Curran observe ‘…decisions about lockdown involve difficult judgments about the relative value of central human goods. Even worse, the expected costs and benefits of lockdown policies are spread unequally.’

The pandemic has highlighted and amplified health inequities in many countries and the normative tools medical ethics brings to bear on these issues should be up to the task.6 7 John and Curran claim that utility maximising approaches such as cost benefit analysis (CBA) have been found wanting during the pandemic, they say:

First, concerns about distributive justice seem central to debates both about COVID-19 in general, which has strikingly unequal patterns of morbidity and mortality, and, as noted, to lockdown specifically. A focus on aggregate outcomes is blind to these worries…CBAs… seem ill suited to capturing worries about structural and relational inequalities—say, stemming from race or class—expressed in the pandemic context.

John and Curran show how a contractualist emphasis upon the relative plausibility of objections to proposed lockdown measures captures issues that risk being lost if we opt for a CBA approach.

…although contractualism is focused on the complaints that generic individuals can make against principles, grounded on their own interests, the approach is well suited to tackle the kinds of worries about inequalities in risk of disease and inequalities in the effects of lockdown… In focusing our attention on those at the highest risk of ill health, our approach automatically places our attention on the most vulnerable members of society, and their claims against others.

It is important to be kind, but it is also important for medical ethics to draw on the best conceptual tools at our disposal. That’s particularly so when facing a set of new issues that bring into relief problems that our default approaches might neglect.