A central ethical value in pandemic planning is kotahitanga – solidarity. If we do not do this together, we will not get through, writes Dr Ben Gray

The National Ethics Advisory Committee produced a document in 2007 titled Getting Through Together, ethical values for a pandemic.

This document was the result of wide consultation following the SARS epidemic and tried to answer the question what we, in Aotearoa/NZ, think is the right thing to do and how is the right way to do it.

It reflected the culture and beliefs of this country and, in particular, included significant Māori concepts such as kotahitanga, manaakitanga, and whānaungatanga. This document was embedded in the New Zealand Influenza Pandemic Plan 2017 and thus the public servants advising government on management would have been aware of it.

At the time that a pandemic strikes there is no time or resource to consult widely.

In a recently published paper, I argue that the existence of an ethical framework was an important element behind New Zealand’s successful response to Covid-19. I looked at the briefings from the Prime Minister and the Director-General of Health and mapped the extent to which the approach they took aligned closely with “Getting Through Together”:

– The team of five million is a direct reference to Kotahitanga … doing this together.

– Being kind is a reflection of Manaakitanga; behaviour that acknowledges the mana [prestige] of others as having equal or greater importance than one’s own, through expression of aroha [love], hospitality, generosity, and mutual respect.

– There has been a commitment to openness and transparency, particularly evidenced in the daily briefings during the early phase of the pandemic.

– Fairness and attention to inequality was an important reason why we did the hard lockdown. We recognised that if the virus spread in NZ it would disproportionately affect Māori and Pacific peoples.

A central ethical value in pandemic planning is kotahitanga or solidarity. If we do not do this together, we will not get through. Clearly the lack of unity in the USA is an important element behind the way the pandemic is playing out there. This requires us to be united behind our decision makers, the politicians, even though inevitably all of us at one time or another may not agree on the decisions made. Our politicians behaving the “right way” (the way most New Zealanders think is right) will enhance trust. The New Zealand Attitudes and Values Study conducted a survey before and after the Covid-19 level 4 lockdown. It showed that trust in the police, science and politicians increased and satisfaction in the government’s performance went up significantly. Clearly, the government and health officials managed to nurture kotahitanga during this phase of the pandemic.

One of the challenges of maintaining kotahitanga is how to manage criticism of the government approach. This was difficult for the National Party during the election campaign because on the one hand they needed to be seen as part of the “team of 5 million” but on the other hand their job as an opposition was to point out the problems that they saw; that is the job of politicians. I am sure this tension contributed to the outcome of the election.

The role of scientists and bioethicists is different from the role of politicians/decision makers.

The role of the scientist is to provide what we know about the issue in question. They are not decision makers and should try to avoid criticising the decision, as opposed to providing relevant information that affects the decision, as this can undermine solidarity. A good recent example of this was in the blog by Nick Wilson discussing the number of Covid-19 cases at the border. “This high failure rate is unacceptable from a border control perspective…as well as from an occupational health perspective”, an opinion backed up by scientific argument. He did not say that decisions to date were wrong. There are many other issues relating to the border that are not within his expertise; the effect on trade, the effect on sport, the logistics of managing the border and how many staff are available.

The National Ethics Advisory Committee responded to Covid-19 by producing an “Ethical Framework for Resource Allocation During Times of Scarcity”. The central part of the NEAC document is an ethical framework on resource allocation, and they acknowledge the need to update the 2007 pandemic planning document in the light of the Covid-19 experience. This is a good illustration of the role bioethicists can play, describing the values that are relevant to the decisions being made, and how many of those values might compete. Like the scientists they give advice but the public servants in the particular areas will advise the politicians who are accountable for the decisions.

The politicians need to listen, be prepared to change course in light of new information and behave in a way that enhances trust. Central to maintaining trust is respecting all views, being open about how decisions are made, and being responsive when unintended consequences of decisions are brought to light.

The rest of the team of 5 million need to be kind, respectful, inclusive and be able to place the needs of the whole community above our more narrow individual needs. Political debate is vital, none of the decisions are clear cut and all ideas are helpful. Conducting the debate respectfully and being able to live with difference is essential.

New Zealand has fared better than many in the Covid-19 pandemic. The combination of a clear ethical framework, good scientific advice and skilled, trusted politicians has served us well. This has significantly contributed to the population pulling together. Maintaining Kotahitanga is vital for our continuing successful response to the pandemic.

Dr Ben Gray is an Associate Professor in the Department of Primary Health Care and General Practice at the University of Otago, Wellington.

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