As of the time of writing, New Zealand is one of the only countries that has succeeded in eliminating COVID-19. This paper will examine the role that bioethics played in reaching this achievement.

Ashcroft wrote a polemic discussing the role of bioethicists in determining how to distribute World Health Organization funds to combat the AIDS epidemic in Africa (Ashcroft 2008). He reported that the only agreement the group of international bioethicists reached was on the importance of good process. His view was that, in the absence of reaching substantive decisions, this made bioethics redundant. Following the severe acute respiratory syndrome (SARS) coronavirus epidemic in 2003, Thompson et al. (2006, 2) outlined the importance of bioethics input:

… the SARS experience in Toronto taught health care organisations, the costs of not addressing the ethical concerns are severe: loss of public trust, low hospital staff morale, confusion about roles and responsibilities, stigmatization of vulnerable communities, and misinformation.

They developed a framework guided by ethical decision-making processes and informed by ethical values. Like Ashcroft they emphasized the importance of fair process. Where Ashcroft felt the role of bioethics should be to make substantive decisions, Thompson et al. described a role for bioethics of developing a framework of values and principles. The aim was to articulate values that were already commonly accepted “in the community of its intended users” (Thompson et al. 2006) and it was to be used to inform decision-making. They described this as an exercise in applied, practical ethics. Following the SARS epidemic, the New Zealand National Ethics Advisory Committee (NEAC) published in 2007 the document “Getting Through Together: Ethical Values for a Pandemic.” These were based around the Canadian example, with a focus on process and values (see National Ethics Advisory Committee 2007, 4-5 under “Table 1: Ethical values to inform how we make decisions” and “Table 2: Ethical values to inform what decisions we make”).

Table 1 Ethical values to inform how we make decisions
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Table 2 Ethical Values to inform what decisions we make
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Some of the values expressed in the pandemic document also appear in the Public Health Association code of ethics (Public Health Association of New Zealand 2012, 5) with a slightly different translation, including:

Manaakitanga is 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. In doing so, all parties are elevated and our status is enhanced, building through humility and the act of giving.

Whanaungatanga underpins the social organisation of whanau [family], hapu [subtribe] and iwi [tribe] and includes rights and reciprocal obligations consistent with being part of a collective. It is the principle which binds individuals to the wider group and affirms the value of the collective. Whanaungatanga is inter-dependence with each other and recognition that the people are our wealth.

As with Toronto, this was an exercise in practical/applied ethics; a description of the values of the “community of intended users.” A significant difference between the New Zealand framework and the Toronto framework was the inclusion of Māori ethical concepts. Māori, the indigenous people of New Zealand, comprise around 16 per cent of the population (Statistics New Zealand 2018). There has been a significant Māori cultural renaissance in New Zealand over the past forty years (Taonui 2017), that has led to a broad acceptance that Māori values are an essential part of ethical decision-making in New Zealand. The NEAC “National Ethical Standards for Health and Disability Research and Quality Improvement” (National Ethics Advisory Committee 2019) and the code of ethics of the NZ Public Health Association (Public Health Association of New Zealand 2012) each have two sets of principles that sit alongside each other: a Māori list and a generic list. There is a lot of overlap but also some distinctive differences between the lists. While this analysis is based on there being a distinct Māori community, in reality there has been much merging of cultural values; the development of an AotearoaFootnote 1/New Zealand culture. There is increasing use of Māori language within the mainstream media and many Māori cultural practices are being adopted by the wider Aotearoa/New Zealand community, the most famous being the Haka performed by the rugby All Black team before a match.

After the 2009 H1N1 influenza pandemic, the New Zealand Pandemic Influenza Plan (NZPIP) was developed, and updated in 2017 (Ministry of Health 2017). The plan was written with influenza as the main focus, but it was noted that the plan would be applicable for other respiratory infections such as, for example, SARS. Ethical issues were top of the key issues list in the NZPIP (Ministry of Health 2017, 15):

People are more likely to accept difficult decisions if decision-making processes are open and transparent, reasonable, inclusive and responsive, with clear lines of accountability. Decision-making processes are also more likely to be acceptable if they are based on agreed, core ethical values.

It also noted that:

Some pandemic programmes must be implemented swiftly if they are to be effective, and some will have ethical components that need to be considered in real time. It will not always be effective to rely on usual processes.

In short, the foundational principles of the “Getting Through Together: Ethical Values for a Pandemic” document (National Ethics Advisory Committee 2007) are deeply embedded in the current New Zealand Pandemic Influenza Plan.

The New Zealand Response To COVID-19

In responding to COVID-19, a clear delineation was made between the science on which actions were based (represented by Director General of Health Dr Ashley Bloomfield), the ethical foundation on which decisions were based (that were embedded in the planning), and the politics of what was likely to be possible (led by Prime Minister Jacinda Ardern).

It was clear by mid-March 2020 that the option of no policy response had a high risk of large numbers of infections and deaths, and a collapse of the local health system. A choice had to be made as to what to do and our government decided to “Go hard, go early.” On March 26, 2020, a high level of community lockdown was imposed (Level 4), allowing only essential services to operate. Details of what each level entailed are published on the NZ government COVID-19 website. (New Zealand Government 2020). After one month at Level 4 restrictions, a decision was made to extend it for a further week before moving to Level 3. The basis of the decision was clearly signalled in advance and the extension was needed to ensure that capacity for contact tracing would be capable of managing the increased cases that might happen after restrictions loosened. These actions required a combination of the science (detail on contact tracing capacity, numbers of cases, amount of community spread), the ethical framework (described below), and the politics of whether the country would get behind the decision. The last two are of course linked in that if the ethical framework used is one that is shared by the community then it is more likely members will follow the rules. We moved to Level 2 on May 13 and finally to Level 1 on June 9 2020.

Good communication was a central element of the strategy. From mid-March until mid-May there were daily media briefings from the Prime Minister (PM) or other government ministers and the Director General of Health or other public servants.Footnote 2 I have selected some quotes from these briefings to illustrate the values articulated in ethical frameworks at work.

Unity/Kotahitanga

We have the opportunity to do something no other country has achieved—elimination of the virus—but it will continue to need a team of five million behind it. (PM Jacinda Ardern, April 16, 2020)

Reciprocity

Today, I can confirm that myself, Government Ministers, and Public Service chief executives will take a 20 percent pay cut for the next six months (PM Jacinda Ardern, April 15, 2020)

While acknowledging that the sum would make little practical difference to the government budget it was couched as an example of leadership and described alongside the sacrifices that many others had made.

Neighbourliness/whānaungatanga

Please be strong, be kind, and unite against COVID-19. (PM Jacinda Ardern, March 21, 2020)

We are seeking physical separation not social separation—reach out to people and most importantly be kind. (Director General of Health Ashley Bloomfield, March 29, 2020)

Throughout her briefings Prime Minister Ardern emphasized kindness and compassion. Particular emphasis was put on being kind to stressed supermarket workers and other front line staff.

Fairness

[The Ministry of Education] is also working with schools to identify students who do not have a device at home. It will deliver as many devices and materials as possible to students who will benefit the most. (Education package April 8th)

This was a clear commitment to addressing inequalities. An important argument in favour of elimination was that in the event that the virus spread the impact would be greater on more disadvantaged communities (Wilson et al. 2020).

Openness

Now, I share this with you because we have been open and transparent throughout this fight against COVID-19, and I personally believe really strongly that it is only fair. Since we are all in this together, we need to all keep working together for success, and that means us sharing with everyone the factors we’ll be taking into consideration and the data we use. (PM Jacinda Ardern, April 19, 2020)

The PM frequently emphasized the importance of transparency. She signalled in advance when big decisions would be made and what the basis of those judgements would be. There were several Facebook question and answer sessions with the public. The media had a lot of time for questions and answers after each release, that were answered clearly and with a commitment to find information if not immediately available … which was then followed through. The PM made it very clear that the goal was not just controlling the epidemic but overall well-being.

During that time, our focus has been to protect the health of New Zealanders. Alongside this, we’ve acted to cushion the economic blow as well… (PM Jacinda Ardern, April 19, 2020)

In their study of community responses to communication campaigns for Influenza A, Gray et al. identified that people wanted “messages about specific actions they could take … [and] transparent and factual communication where both good and bad news is conveyed by people who they could trust” (Gray et al. 2012). Public approval ratings suggest Prime Minister Ardern and Director General of Health Bloomfield mostly achieved this. Jacinda Ardern’s preferred Prime Minister rating on May 21, 2020, had gone up 21 per cent, to 63 per cent, the highest of any Prime Minister in the twenty-five years the poll has been conducted (Colmar Brunton 2020).

Google COVID mobility data showed that New Zealanders adhered to lockdown measures better than in most countries (Ritchie 2020). There was little in the way of enforcement required to achieve this. For a total population of five million, between March 23 and April 23, 2020 (during the Level 4 lockdown):

… police recorded 4,452 breaches of the Civil Defence Emergency Management or Health Act … 477 prosecutions, 3,844 warnings, 131 youth referrals. (Commissioner of Police, April 23, 2020 briefing)

The reality of steering through a pandemic is that there are myriad decisions to be made, in real time with insufficient information. There has been much debate in the media around these decisions. Many of the ideas raised have later been adopted as policy and there has been wide consultation with many sector groups. The approach taken of widely sharing available information as it comes to hand, having a clear sense of the ethical basis on which decisions will be made, and holding the trust and commitment of the population has been successful.

Conclusion

New Zealand is fortunate in its experience of COVID-19. We are a relatively sparsely populated island nation, although with a (previously) large tourism industry. The pandemic started far from our shores and we had time to make choices on how to respond. We have significant capacity in academic public health expertise but had to rapidly upscale our on-the-ground public health capacity to test and contact trace. We had developed a detailed pandemic plan with an explicit ethical framework. At the time of writing, New Zealand had avoided widespread infection and death. Bioethics articulated a framework that reflected the values and beliefs of the people who live here. Content specialist colleagues in clinical medicine, public health, modelling, economics, and many others interpreted the often uncertain information and provided good communications on which to base decisions. Our politicians, in particular Prime Minister, provided the leadership in making difficult decisions based on the ethical framework and scientific information, while building and maintaining the trust of the population necessary to implement them. Bioethics played an important role in eliminating COVID-19 from New Zealand.