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Abstract

While the world was facing a rapidly progressing COVID-19 second wave, a policy paradox emerged. On the one side, much more was known by Autumn 2020 about the mechanisms underpinning the spread and lethality of Sars-CoV-2. On the other side, how such knowledge should be translated by policymakers into containment measures appeared to be much more controversial and debated than during the first wave in Spring. Value-laden, conflicting views in the scientific community emerged about both problem definition and subsequent solutions surrounding the epidemiological emergency, which underlined that the COVID-19 global crisis had evolved towards a full-fledged policy “wicked problem”. With the aim to make sense of the seemingly paradoxical scientific disagreement around COVID-19 public health policies, we offer an ethical analysis of the scientific views encapsulated in the Great Barrington Declaration and of the John Snow Memorandum, two scientific petitions that appeared in October 2020. We show that how evidence is interpreted and translated into polar opposite advice with respect to COVID-19 containment policies depends on a different ethical compass that leads to different prioritization decisions of ethical values and societal goals. We then highlight the need for a situated approach to public health policy, which recognizes that policies are necessarily value-laden, and need to be sensitive to context-specific and historic socio-cultural and socio-economic nuances.
COMMENT
The COVID-19 wicked problem in public health
ethics: conicting evidence, or incommensurable
values?
Federica Angeli 1, Silvia Camporesi 2& Giorgia Dal Fabbro3
While the world was facing a rapidly progressing COVID-19 second wave, a
policy paradox emerged. On the one side, much more was known by Autumn
2020 about the mechanisms underpinning the spread and lethality of Sars-CoV-
2. On the other side, how such knowledge should be translated by policymakers
into containment measures appeared to be much more controversial and
debated than during the rst wave in Spring. Value-laden, conicting views in the
scientic community emerged about both problem denition and subsequent
solutions surrounding the epidemiological emergency, which underlined that the
COVID-19 global crisis had evolved towards a full-edged policy wicked pro-
blem. With the aim to make sense of the seemingly paradoxical scientic dis-
agreement around COVID-19 public health policies, we offer an ethical analysis
of the scientic views encapsulated in the Great Barrington Declaration and of
the John Snow Memorandum, two scientic petitions that appeared in October
2020. We show that how evidence is interpreted and translated into polar
opposite advice with respect to COVID-19 containment policies depends on a
different ethical compass that leads to different prioritization decisions of ethical
values and societal goals. We then highlight the need for a situated approach to
public health policy, which recognizes that policies are necessarily value-laden,
and need to be sensitive to context-specic and historic socio-cultural and socio-
economic nuances.
https://doi.org/10.1057/s41599-021-00839-1 OPEN
1University of York Management School, University of York, York, UK. 2Department of Global Health and Social Medicine, Kings College London,
London, UK. 3School of International Studies, University of Trento, Trento, Italy. email: federica.angeli@york.ac.uk
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Competing goals and conicting values in the COVID-19
wicked problem
At the time of writing (November 2020), while the world is
facing a rapidly progressing COVID-19 second wave, and
governments are rushing towards the reintroduction of
restrictive measures, the consensus that almost monolithically
surrounded the lockdown decisionsor slight variations of the
same formulain Spring 2020, is visibly breaking apart. Roughly
6 months into the pandemic, a paradox emerges. On the one
hand, we have more evidence about the mechanisms under-
pinning the transmission, morbidity and mortality related to
Sars-CoV-2. On the other hand, how such knowledge should be
translated into containment policies is subject of erce debates. In
particular, a polarization of views started to emerge within the
scientic community, vividly illustrated by the Great Barrington
Declaration (Kulldorff et al., 2020; Lenzer, 2020) on the one side
and the John Snow Memorandum (Alwan et al., 2020; John Snow
Memorandum, 2020) on the other side. The Great Barrington
Declaration was authored by Dr. Sunetra Gupta (University of
Oxford), Dr. Jay Bhattacharya (Stanford University), and Dr.
Martin Kulldorff (Harvard University), and was written and
signed at the American Institute for Economic Research in Great
Barrington, Massachusetts, on October 4th 2020. The document
is co-signed by a further 44 medical and public health scientists
and medical practitioners working in the US, Canada, Israel,
Germany, India, New Zealand, and Sweden. The declaration
advocates against lockdown measures to favor a containment
approach based on a focused protection of the vulnerable, whilst
allowing the segments of the population nominally at lower risk
of COVID-related complications to resume normal life, thus
favouring population-level natural immunity. The John Snow
Memorandum was published in the Lancet on October 15th, 2020
as a reaction to the Great Barrington declaration, and was
authored by a team of 31 scientists from the UK, Switzerland, US,
Canada, Germany, France, Australia. The memorandums aim
was to lay out empirical evidence to justify restrictive lockdown-
like measures to prevent the uncontrolled spread of the virus and
the subsequent collapse of healthcare systems.
Such value-laden, conicting views about both problem de-
nition and problem solution are typical of policy wicked pro-
blems(Alford and Head, 2017), a construct that increasingly
applies to the COVID-19 global crisis. The pandemic has created
a context in which multiple urgent, interdependent societal goals
simultaneously exist, which generates a fundamental problem of
prioritization of one aspect over another (Camporesi and Mori,
2020). Such goals can be identied in the short-term reduction of
COVID-19 morbidity and mortality, the mitigation of long-term
social repercussions of containment policies (rising social
inequalities, mental health issues due to social isolation, inter-
generational conicts) and nancial adverse consequences, in the
form of severe economic recessions, and subsequent rise in
unemployment, poverty levels, and social tensions (Angeli and
Montefusco, 2020; Camporesi, 2020). We are currently witnessing
how such prioritization choices generate conicting stakeholder
views about what the problem is (e.g., catastrophic death toll vs
potential economic meltdown) and the related solutions (e.g.,
lockdown measures vs softer mechanisms of virus control). A
full-edged wicked problem has now arisen. However, while
wicked problems are normally associated with policy choices, the
polarization of views has now permeated the scientic commu-
nity and the very process of translation of evidence into policy
advice, therefore illustratingperhaps more than ever before
the evolution from value-free to value-laden science.
The prioritization of the shorter-term goals of reduction of
COVID-19-related morbidity and mortality in the Spring of 2020
rst wave resulted in a multiplicity of policy interventions
bundles in different countries. These interventions shared simi-
larities in the way they restricted individual freedoms (Camporesi,
2020) and varied in their combination of school closures, lim-
itations on pubsand restaurantsopening times, use of face
coverings, restrictions of socialization opportunities or individual
mobility (Angeli and Montefusco, 2020). Now, as evidence about
modes of contagion and manifestations of the disease accumu-
lates, the debate about how to use the scientic evidence to
inform policy has reached the stage of a polarized conict. The
shift away in narrative from the we are all in this together
(United Nations, 2020), to the focused protection(Kulldorff
et al., 2020) shows that the COVID -19 wicked policy problem
requires more in-depth ethical considerations. In this piece, we
offer an ethics-driven view of scientic advice for COVID-19
policy formulation, to illustrate how specic ethical prisms can
lead to differenteven polar oppositeviews on containment
policies. In this sense, we highlight the importance of ethics in
decision-making and in the process of translating evidence into
policy design (Oliver and Boaz, 2019). Our analysis also aims to
provide an interdisciplinary interpretative lens, as it addresses the
problem of how decision-makers attend to multiple objectives in
space and timea well-known area of research in management
studies (Cyert and March, 1963; Ocasio, 1997; Rerup, 2009), by
theoretically drawing on the eld of public health ethics (Abbasi
et al., 2018), and public policy formulation in the context of
wicked problems (Head, 2008; Waddell, 2016).
Conicting policy viewpoints: different priorities to different
values
Conicting values are commonplace in the context of managerial
decision-making (e.g., Levinthal and Marengo, 2020) and in
public health, especially in relation to the management of infec-
tious diseases (Ortmann et al., 2016). Compulsory vaccination
represents one emblematic example, in which individual freedom
is restricted to favor the public good, by way of boosting heard
immunity towards specic pathogens (Dawson et al., 2007).
Public health policies revolve, although often implicitly, around a
compass of three key values, namely utility, liberty, and equity/
equality. The principle of utility aims at maximizing a certain
value Xfor the greatest number of people. Public health policies
aim at maximizing population health. In the context of measures
aimed at the containment of disease outbreak, ensuring popula-
tion health translates into reducing the disease transmission,
morbidity and mortality, whether through vaccination, natural
herd immunity, or restrictive measures aimed at reducing/mod-
ifying citizenssocialization and interaction patterns, mobility and
hygiene practices. Liberty is generally understood as the freedom
to live ones own life free from interference from others. Although
there are two main understandings of liberty, a negative (liberty
to act free from interference), and a positive one (liberty to shape
ones own life according to ones own values, and to have the
opportunity to do so beyond and above the lack of others
interference) (Berlin, 1969) in the context of public health, liberty
is generally conceptualized as negative liberty. Equity/equality is a
value that is recognized as salient for public health policies, but
also of difcult operationalization and implementation. Egalitar-
ianism is the theory that aims at ensuring a fair distribution of
benets and harms across a given population, and hence to
maintain distributive justice. Equity and equality are often used as
synonyms in public health ethics, however, they point to different
even oppositeconcepts. Equity is a normative concept,
grounded in distributive justice, while that is not necessarily the
case for equality (i.e. not all health inequalities are unfair)
(Braveman and Gruskin, 2003). In the context of public health
policies, equity means equal opportunity and implies that
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resources should be distributed in ways most likely to produce a
fair distribution of harms and benets across all segments of the
population. This often implies that societal groups should not be
offered the same services (as it would be in the case of equal
treatment) but rather should receive differential care according to
their differential needs. We will focus in this piece on equity
rather than equality.
Even if not explicitly acknowledged, the values of utility, liberty
and equity underpin any public (health) policy decision, includ-
ing those aimed at containing the COVID-19 emergency.
According to a pluralistic approach to public health policy
(Selgelid, 2009b,2009a) these three values should all be con-
sidered as independent, socially legitimate public goals. Effective
public health policies are then tasked to nd creative ways to
pursue all of them at the same time, through trade-offs that are
socially and culturally acceptable. This is naturally easier said,
than done. What creates a broad spectrum of public policy
approaches in response to the COVID-19 pandemic is the dif-
ferent weight associated by different decision-makersand also
by scientiststo the three value dimensions of the ethical com-
pass, resulting in different trade-off points. The recently pub-
lished Great Barrington Declaration and John Snow
Memorandum exemplify two situations in which, provided the
same available scientic evidence, this is interpreted and trans-
lated by scientists into polar opposite advice with respect to
COVID-19 containment policies. We argue that such views can
be best understood in light of a different ethical compass that
leads to different prioritization decisions. We can assume that
signatories to both memoranda obviously want to reduce
COVID-19 morbidity and mortality, want to mitigate its socio-
economic repercussions, are concerned about restrictions of
personal freedom and increasing surveillance, appreciate the
differential impact of the policies across the population. However,
the signatories assign a different weight to each of the three values
of utility, liberty and equity, hence appraising the available sci-
entic evidence with a different, value-laden ethical prism. The
fact that the process of normative weighting assigned to empirical
data remains implicit creates a polarization that is only appar-
ently based on disagreements about empirical evidence.
The Great Barrington declaration takes a stance against
restrictive measures aimed at controlling the community spread
of the virus and instead proposes to focus policies and societal
resources towards focused protectionof the older demographics
notably those who are several times more likely to die from
COVID-19 or to suffer from long-lasting complications.
According to the signatories, this approach would also favor the
development of herd immunity, hence further shielding the older
people from the possibility of contracting the disease. This
position has sparked a strong reaction from the signatories of the
John Snow Memorandum, which highlights instead that the herd
immunity arguments based on the assumption that natural
infection from the virus will boost lasting protective immunity are
awed and lack supporting evidence. Moreover, the uncontrolled
spread of Sars-CoV-2 within communities would lead to an
excessive burden on healthcare systems and workers, and com-
promise the diagnosis and treatment of several acute and chronic
conditions, with long-lasting-negative repercussions. As a con-
sequence, the John Snow Memorandum argues that it is impor-
tant to extend social distancing, targeted restrictions of mobility
and socialization, face coverings and strengthened hygiene prac-
tices to the whole population.
With its emphasis on focused protectionthe Great Barring-
ton declaration prioritizes values of liberty and equity, as it views
the wide imposition of restrictive measures as violating individual
freedom in a way that is unfair to the less vulnerable individuals,
such as the young generations. The herd immunity argument
widely decried by the scientic community (Aschwanden, 2020)
and public opinion alike (The Guardian, 2020)is highly con-
troversial, and mostly for an ethical rather than a scientic rea-
son. The technical possibility that a population develops natural
protection from the infection exists, however, for Sars-CoV-2 it is
unclear what the threshold is as this depends on the transmission
rate and how long the immunity could last (Fontanet and
Cauchemez, 2020). Although from a technical point of view the
pursuit of (short-term) herd immunity is not, in theory, an
unattainable policy goal, there is widespread societal consensus
that it would be an unacceptable policy goal from an ethical point
of view, in the absence of improved patient management and in
the absence of optimal shielding of individuals at risk of severe
complications. In the absence of these two key factors, current
modeling of transmission dynamics predict that letting Sars-CoV-
2 epidemic run its course without non-pharmaceutical interven-
tions (i.e., social distancing, facemasks, heightened hygiene
measures) would lead to catastrophic consequences in terms of
death toll, both direct from COVID-19, and indirect, due to the
overwhelming burden on the healthcare systems (hospital capa-
city) (Brett and Rohani, 2020).
The signatories of the John Snow Memorandum are in fact
more concerned with utility, namely the short-term reduction of
COVID-19-induced mortality and morbidity and the long-term
health outcomes of delayed treatments. Interestingly, by pro-
blematizing the denition of vulnerableindividuals, John Snow
supporters implicitly defend the egalitarianism of their position,
as evidence is still scant around the reasons underpinning the
wide individual variation in COVID-19 adverse outcomeswith
some developing grave complications until death and other
showing only mild symptoms or remaining completely asymp-
tomatic. Concluding that everyone is equally at risk, the John
Snow Memorandum implicitly assumes that it is fair for restric-
tive measures to be applied to everyone, therefore leaning towards
a solution geared towards equality rather than equity. Instead, the
Great Barrington Declaration implicitly proffers that vulnerability
to the virus is only one aspect that should be taken into account.
Vulnerabilities within the population instead should be specied
taking into account vulnerability towards negative repercussion of
the economic recessionssuch as BAME minorities in the UK
(Institute for Fiscal Studies, 2020), as well vulnerability towards
the negative effects of lockdown-induced isolation and alienation,
as in adolescents (Lee, 2020). The prioritization of short-term
gains in terms of physical health with respect to impeding longer
term socio-economic disadvantage and mental health con-
sequences therefore becomes less straightforward.
Contextualizing values and policies in time and space
In dealing with a highly complex situationa wicked problem
such as the COVID-19 pandemic, it is important to understand
how valueshence societal goalsare formulated and under-
stood, and the inuence of temporality. The value of utility can be
specied short-term, as the reduction in the number of COVID-
19-related deaths at a given time. However, a more encompassing,
forward-looking view will also consider the total number of
COVID-19-induced deaths in the medium-long run. The need to
prioritize COVID patients in the hospital will necessarily lead to
other collateral deaths because of missed appointments and
delayed surveillance or surgeries (Maringe et al., 2020). Economic
recession is widening inequalities and increasing poverty levels
(Kirby, 2020; Van Lancker and Parolin, 2020), while the mental
health repercussions induced by isolation especially in young
people might lead to forms of addiction and depression (Lee,
2020). While deaths from the infectious disease are short-term,
indirect casualties that will occur down the line need to be taken
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into account. Public health policies cannot afford the myopic
mistake of discounting the future, a well-known individual cog-
nitive bias (Trout, 2007). The public health ethics framework also
demands that the management of infectious diseases outbreaks
follows the key principle of proportionality in restricting indivi-
dual freedoms to promote the public good (World Health
Organization, 2020). This means that, as epidemiological and
clinical evidence becomes more conclusive on the diseases
transmission, prevention and diagnosis patterns (Manigandan
et al., 2020), on the variability of health outcomes (Chen et al.,
2020), on the effect of non-pharmaceutical interventions to
reduce community spread (Li et al., 2020), and on the long-term
consequences of lockdown measures such as school closures
(Bayham and Fenichel, 2020; Viner et al., 2020), the same
restrictive policies might not be as suitable, justied or acceptable
as they were in the early stage of the pandemic. This principle is
implicit in the Great Barrington declaration.
What degree of personal infringement of liberty is justied?
This is where ethics comes in. Expert groups will offer a range
of possible ethically justied policies, but, we argue, it is the
policymakerstask to do the normative weighting and to decide
which policy approach is best suited to the local socio-eco-
nomic, socio-cultural and socio-political context (Angeli and
Montefusco, 2020). While in some national settings the Great
Barrington Declaration proposal could be more attuned to the
existing social dynamics, individual mindsets, healthcare
infrastructure and economic development, in other contexts
the prescription of the very same proposal would not be
applicable nor recommended, while the solutions proposed by
the polar opposite John Snow Memorandum could be more
suitable. For example, a policy of focused protection is not
practical in settingssuch as Italywhere intergenerational
exchange is very high, grandparents often babysit grand-
children and even share living space with younger generations.
Afocused protection approach, which also aims at achieving
high levels of community spread of the disease in less vul-
nerable societal segments, will likely lead to higher burden on
the healthcare system, which is only sustainable in settings
where healthcare infrastructures are strong and widely acces-
sible, and focused protection of vulnerable segments of the
population (i.e shielding) is feasible. In a similar way, restric-
tions to individual freedom are more difcult to implement in
countries where personal liberty is culturally highly valued,
and where utilityintended as the public goodcomes sec-
ond. A case in point is the use of face coverings, which, despite
mounting evidence related to the importance of the measure to
prevent COVID-19 transmission (Cheng et al., 2020;Lyuand
Wehby, 2020), remains highly debated (Martin et al., 2020). It
is not by chance that more individualistic cultures such as the
United States, the United Kingdom or the Netherlands
(Hofstede, 1983), have seen a more patchy and less widespread
imposition of such measures (Royal Society, 2020; Statista,
2020), combined with higher societal resistance and rising
social tensions (CNN, 2020).
Finally, questions of equity and justice. Public health measures
aimed at containing an infectious disease outbreak should take
into account to what degree the measures are disproportionately
affecting certain groups of the population. This is where the
concept of vulnerability comes in and where it can be used to
operationalize the equity principle. Dening who qualies as
vulnerable is difcult, but by no means impossible, as research
ethics literature demonstrates. One approach that we think could
be well suited here is the layered approach to vulnerability (Luna,
2019, 2014), which is context dependent, and dynamic. One could
identify, for example, the following three layers of COVID-19
related vulnerability:
A biological axis: likelihood of developing severe/critical
symptoms after contracting COVID-19. Evidence widely
supports that older people and people with pre-existing co-
morbidities are at higher risk of COVID complications;
Socio-economic axis: likelihood of being severely affected
by restrictive measures. Studies have highlighted how
disadvantaged groups and communities (such as BAME
minorities in the UK) are disproportionally more severely
hit by the economic crisis ensuing from lockdown
measures;
Mental health axis: likelihood of developing severe mental
health repercussions related to containment policies.
School closures and extended lockdown periods have
increased mental health issues in the population, with
children and adolescents at particularly high risk.
Age, gender and race remain transversal axes here, as the
approach rejects applying the label of vulnerability to specic
groups. That does not mean that is impossible to dene who is
vulnerable, contrary to the John Snow memorandum positions.
However, who counts as vulnerable to COVID-19 will change
depending on the context, over time and through what layers one
decides to look at this question. While in the rst COVID-19
wave the priority has been given to the biological axis, the
attention is, in the second COVID-19 wave, importantly shifting
towards socio-economic and mental health aspects.
With the purpose of illustrating the longitudinal evolution
over time of value prioritization, and its cross-sectional, cross-
country variation, we have selected a number of containment
measures that can reect how the values of liberty, equality and
utility are incorporated into scientic advice and then translated
into policy. Restrictions to individual freedom can be appreciated
for example through the presence of restrictions to jogging
activities; the presence of a ban on amatorial sports activities; the
extent of face coverings obligations, the restrictions on household
mixing, and whether a social bubble is allowed. The value of
equity can be operationalized into whether the measures have
been prescribed to the whole population indistinctively or whe-
ther there has been a differential application to more or less
vulnerable sub-groups, or taking into account the different
morbidity and mortality levels across regions. This aspect can be
appreciated by considering whether restrictions have been
imposed nationally or following a regionalization rationale;
whether face coverings have been prescribed also to children
under 11, notably less amenable to infect, get infected and
develop severe symptoms from COVID-19; whether specic
measures have been adopted to strengthen protection of older
demographics; whether youth sport activities have been allowed;
whether business closures have been imposed indistinctively or
have instead followed an occupational health risk assessment.
Finally, utility can reect into governmentsadvocacy practices,
namely the presence of a stay-at-home advice, the emphasis of
COVID-19 as a burden for healthcare workers and systems, the
clear and frequent communication of COVID-19 epidemic
progression, the level of surveillance and sanctioning of non-
compliant individual behaviors. We have considered the pre-
sence/absence as well as the strength of the above aspects at the
highest point of rst and second wave of COVID-19, in Italy and
in the United Kingdom. As restriction levels, timing and the
combination varied across England, Scotland, Wales and
Northern Italy, we focused on England.
Table 1represents the comparison of measures between
COVID-19 rst and second wave in the two countries, as derived
from the original policy documents. Based on the nature of the
containment measures, and the effect to which they reected
values of equity, utility and liberty, we computed scores on each
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Table 1 Evolution of COVID-19 containment policies across the rst and the second pandemic wave (until December 2020) in Italy and in England (partial scores for each
dimension in brackets).
Italy England
Measures First waveDPCM
(March 9th, April 22nd)
Second waveDPCM
(November, 3rd) Red zone
regulations
First waveNational
restrictions March 26th
Second waveNational
restrictions November 5th
Liberty
Jogging permitted Partiallyonly in proximity
of ones home and in
adherence with social
distancing (2/5)
Yesjogging permitted in
adherence with social
distancing (5/5)
Yes, but limited to once a
day, either alone or with
members of the same
household (5/5)
Yesalone, with members of
the same household or one
person outside it, adhering to
social distancing (5/5)
Face coverings
mandatory only in
indoor settings
Noface coverings are
mandatory at all times both
indoor and outdoor (0/5)
Noface coverings are
mandatory at all times both
indoor and outdoor (0/5)
Yesface coverings
mandatory only indoor (also
outdoor in some venues
with reopenings) (5/5)
Yesface coverings
mandatory only indoor (5/5)
Amatorial sport
activities permitted
Noall sport competitions
suspended; trainings of
professional athletes
permitted (0/5)
Noonly competitions and
trainings at professional level
permitted (0/5)
Noall leisure and sports
activities are suspended (0/
5)
Partiallyall leisure and sports
activities are suspended/
allowed those that are part of
the normal educational
activities of schools; and for
training and competitions of
elite sportspersons (2/5)
Household mixing
permitted
Nomeeting members of
other households indoor/
outdoor is strictly
forbidden (0/5)
Nomeeting members of
other households indoor/
outdoor is strictly
forbidden (0/5)
Nohousehold mixing not
permitted (0/5)
Partiallysupport bubble
permitted (2/5)
Overall score 2/20 5/20 10/20 14/20
Equity of containment policies
Regionalized approach
to lockdown-like
decisions
NoGeneral lockdown
measures have been
imposed on March 9th on
the whole country
regardless of regional
variations (0/4)
Yesdifferential lockdown
measures have been imposed
in different regions
depending on regional
variations in infection
rates (4/4)
NoEngland, Scotland,
Wales and Northern Ireland
adopted the same lockdown
restrictions for the whole
respective national
territories (0/4)
NoEngland, Scotland, Wales
and Northern Ireland adopted
the same lockdown restrictions
for the whole respective
national territories (0/4)
Maintenance of face-
to-face educational
activities
Noall educational
activities have been
suspended (0/4)
Partiallyprimary schools
remain open, remote learning
introduced for secondary
schools (2/4)
Noschools, colleges and
universities shut down (0/
4)
Yesschool, colleges and
universities remain open (4/4)
No face coverings for
children below 12
Noface coverings are
mandatory for all children
above 6 (0/4)
Noface coverings are
mandatory for all children
above 6 (0/4)
Yesno face coverings for
children below 11 (4/4)
Yesno face coverings for
children below 11 (4/4)
Strengthened
protection for
older people
Mildlimitations on
visitorsaccess to RSAs (2/
4)
Strongpriority entrance in
supermarkets (only for some
regions); limitations to
visitorsaccess to RSAs (3/
4)
Mildsome indications for
additional shielding of older
adults (2/4)
Strongstrengthened
protection for clinically
vulnerable people(3/4)
Guidelines for
occupational risk
Noall non-essential
activities shut down (0/4)
Yesbusiness closures have
followed a rigorous risk
Noall non-essential
activities shut down (0/4)
Noall non-essential activities
shut down (0/4)
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Table 1 (continued)
Italy England
Measures First waveDPCM
(March 9th, April 22nd)
Second waveDPCM
(November, 3rd) Red zone
regulations
First waveNational
restrictions March 26th
Second waveNational
restrictions November 5th
assessment in different
industrial sectors
assessment analysis (e.g.,
hairdressers remain
open) (4/4)
Overall score 2/20 13/20 6/20 11/20
Utility emphasis
Presence of a stay-at-
home advice
Very strongthe decree
was renamed #iorestoacasa
because of the strong stay-
at-home advice (5/5)
Strongthe decree (Oct
24th) conveyed the message
that measures are drastic but
proportionate, and aim at
preserving (in decreasing
order of importance) public
health, jobs and the
economy, and individual
liberties (Domenico Arcuri
TV interview on 15/11/
2020) (3/5)
Very strongRegulations
renamed Lockdown
regulations;Stay at home;
protect the NHS; save
lives(5/5)
Strong—“Hands, Face,
Space(3/5)
Emphasis of COVID-19
burden to health
systems and workers
Very highcitizens clapping
from balconies to thank
healthcare personnel;
together we will make it
banners (5/5)
Highpictures of exhausted
nurses and doctors on social
media; testimonies on talk
shows (3/5)
Very highClap for our
Carers movement; Protect
the NHS(5/5)
HighFocus on healthcare
personnel who is still
recovering from rst wave (3/
5)
Frequent and
transparent
communication of
COVID-19 epidemic
progression to
the public
Very highregular and
transparent bulletin on
hospitalizations, death toll
and ICU occupancy.
Frequent press
conferences (5/5)
Very highregular and
transparent bulletin on
hospitalizations, death toll
and ICU occupancy. Frequent
press conferences to explain
new measures (5/5)
Highweekly ONS report
since 31st March, frequent
press conferences (3/5)
Milddata and statistics
available on the UK
Government website, NHS and
ONS (2/5)
Sanctions on non-
compliant behavior
Very highfrom 400 to
1.000 Euro, up to 5.000
Euro for violation of
quarantine
April, 24th: 6.679 sanctions,
12 quarantine violations (5/
5)
Very highfrom 400 to
1.000 Euro, up to 5.000 Euro
for violation of quarantine
November, 17th:
1.117 sanctions, 30 quarantine
violations (5/5)
Highfrom £60 to
£960 FPN
March, 27thApril, 27th:
8.877 xed penalty notices
(FPNs) (3/5)
Very Highfrom £200 to
£6.400 FPN, larger parties up
to £10.000
March, 27thOctober, 19th:
20.223 FPNs (5/5)
Overall score 20/20 16/20 16/20 13/20
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dimension, for each country across the two waves, on a total of 20
points for each value dimension.
We then plotted the results in Fig. 1. The graphs highlight how
values are differentially embedded into containment policies
trough context- and time-specic trade-offs. The gure highlights
how two countries started from very different positions, with
measures in Italy in the rst wave almost entirely guided by utility
(public health) considerations, with strong restrictions of indivi-
dual freedoms and little appreciation of differences in vulner-
ability levels across populations and regions. In the second wave,
we notice the evolution of Italian policies towards more con-
sideration for liberty and equity value dimensions. England has
experienced a similar evolution, albeit starting from a much more
libertarian stance. Its policies show an evolution towards liberty
and equity considerations against a slight reduction of utility-
focused measures.
Conclusions
Public health policiesand particularly those aimed at the con-
tainment of a highly infectious disease such as COVID-19
revolve around a compass of moral values, which are often
implicitly given different weights by both policymakers and sci-
entic advisors. Both the understanding of these values, and the
normative weighing of the values will always necessarily be context
dependent, and dynamic. Public health policies should aim to
consider to what degree the proposed measures aimed to preserve
the public good are socio-culturally acceptable in restricting
individual freedom, in what way they disproportionately affect
certain groups of the population, according to what aspect of
vulnerability is most relevant. An approach of situated policy is
therefore most salient, which promotes policymaking that is
attuned with idiosyncrasies that are both spatial (the socio-cultural
and socio-economic local context) and temporal (given the rapid
evolution of COVID-related scientic evidence). A situated
approach to policymaking in the context of wicked problems
reects that there cannot be a one-size-ts-all approach to
COVID-19 public health policies.
Our analysis has aimed to propose an ethics-driven perspective
to better comprehend how evidence is used to inform policy-
making and how disagreement on policy can emerge within
scientic communities. In doing so, we have offered an inter-
disciplinary view at the intersection between management studies,
public policy and bioethics disciplinary boundaries. Whilst the
debate around evidence-based policymaking has been a core
focus of science and technology studies (Frickel and Moore,
2006), this commentary offers an alternative perspective that is
less concerned with the politics of sciencehence the inuence on
knowledge production of socio-political factors and power
dynamics (Hoppe, 2005)and is instead more focused on how
evidence is ltered through a situated ethical prism to inform
policymakersprioritization decisions. The recognition that pol-
icymaking is shaped by socio-contextual factors and that pol-
icymakers engage into processes of interpretation of evidence in
light of their knowledge, norms and values and towards their
economic and political goals is not new (Sohn, 2018). This
commentary suggests, however, that an ethical perspective is
salient to understand such processes, that interestingly affect not
only policymakers but also prominent representatives of the
scientic community. Our analysis thus highlighted how
evidence-based public health containment measures to address
the pandemic can be ethically justiable and understood through
a clear and transparent understanding of the values underpinning
policy decisions, and the evolution of acceptable trade-offs
over time.
Received: 20 November 2020; Accepted: 1 June 2021;
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