We conducted a systematic literature review on the ethical considerations of the use of contact tracing app technology, which was extensively implemented during the COVID-19 pandemic. The rapid and extensive use of this technology during the COVID-19 pandemic, while benefiting the public well-being by providing information about people’s mobility and movements to control the spread of the virus, raised several ethical concerns for the post-COVID-19 era. To investigate these concerns for the post-pandemic situation and provide direction for future events, we (...) analyzed the current ethical frameworks, research, and case studies about the ethical usage of tracing app technology. The results suggest there are seven essential ethical considerations—privacy, security, acceptability, government surveillance, transparency, justice, and voluntariness—in the ethical use of contact tracing technology. In this paper, we explain and discuss these considerations and how they are needed for the ethical usage of this technology. The findings also highlight the importance of developing integrated guidelines and frameworks for implementation of such technology in the post- COVID-19 world. (shrink)

The global Covid-19 pandemic has resulted in social and economic disruption unprecedented in the modern era. Many countries have introduced severe measures to contain the virus, including travel restrictions, public event bans, non-essential business closures and remote work policies. While digital technologies help governments and organizations to enforce protection measures, such as contact tracing, their rushed deployment and adoption also raises profound concerns about surveillance, privacy and data protection. This article presents two critical cases on digital surveillance technologies implemented during (...) the Covid-19 pandemic and delineates the privacy implications thereof. We explain the contextual nature of privacy trade-offs during a pandemic and explore how regulatory and technical responses are needed to protect privacy in such circumstances. By providing a multi-disciplinary conversation on the value of privacy and data protection during a global pandemic, this article reflects on the implications digital solutions have for the future and raises the question of whether there is a way to have expedited privacy assessments that could anticipate and help mitigate adverse privacy implications these may have on society. (shrink)

There is growing interest in contact tracing apps for pandemic management. It is crucial to consider ethical requirements before, while, and after implementing such apps. In this paper, we illustrate the complexity and multiplicity of the ethical considerations by presenting an ethical framework for a responsible design and implementation of CT apps. Using this framework as a starting point, we briefly highlight the interconnection of social and political contexts, available measures of pandemic management, and a multi-layer assessment of CT apps. (...) We will discuss some trade-offs that arise from this perspective. We then suggest that public trust is of major importance for population uptake of contact tracing apps. Hasty, ill-prepared or badly communicated implementations of CT apps will likely undermine public trust, and as such, risk impeding general effectiveness. (shrink)

Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the (...) employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response. (shrink)

The COVID-19 pandemic presents unprecedented challenges to public health decision-making. Specifically, the lack of evidence and the urgency with which a response is called for, raise the ethical challenge of assessing how much (and what kind of) evidence is required for the justification of interventions in response to the various threats we face. Here we discuss the intervention of introducing technology that aims to trace and alert contacts of infected persons—contact tracing (CT) technology. Determining whether such an intervention is proportional (...) is complicated by complex trade-offs and feedback loops. We suggest that the resulting uncertainties necessitate a precautionary approach. On the one hand, precautionary reasons support CT technology as a means to contribute to the prevention of harms caused by alternative interventions, or COVID-19 itself. On the other hand, however, both the extent to which such technology itself present risks of serious harm, as well as its effectiveness, remain unclear. We therefore argue that a precautionary approach should put reversibility of CT technology at the forefront. We outline several practical implications. (shrink)

Digital tracing technologies are heralded as an effective way of containing SARS-CoV-2 faster than it is spreading, thereby allowing the possibility of easing draconic measures of population-wide quarantine. But existing technological proposals risk addressing the wrong problem. The proper objective is not solely to maximise the ratio of people freed from quarantine but to also ensure that the composition of the freed group is fair. We identify several factors that pose a risk for fair group composition along with an analysis (...) of general lessons for a philosophy of technology. Policymakers, epidemiologists, and developers can use these risk factors to benchmark proposal technologies, curb the pandemic, and keep public trust. (shrink)

Since the outbreak of COVID-19, governments have turned their attention to digital contact tracing. In many countries, public debate has focused on the risks this technology poses to privacy, with advocates and experts sounding alarm bells about surveillance and mission creep reminiscent of the post 9/11 era. Yet, when Apple and Google launched their contact tracing API in April 2020, some of the world’s leading privacy experts applauded this initiative for its privacy-preserving technical specifications. In an interesting twist, the tech (...) giants came to be portrayed as greater champions of privacy than some democratic governments. This article proposes to view the Apple/Google API in terms of a broader phenomenon whereby tech corporations are encroaching into ever new spheres of social life. From this perspective, the advantage these actors have accrued in the sphere of the production of digital goods provides them with access to the spheres of health and medicine, and more worrisome, to the sphere of politics. These sphere transgressions raise numerous risks that are not captured by the focus on privacy harms. Namely, a crowding out of essential spherical expertise, new dependencies on corporate actors for the delivery of essential, public goods, the shaping of public policy by non-representative, private actors and ultimately, the accumulation of decision-making power across multiple spheres. While privacy is certainly an important value, its centrality in the debate on digital contact tracing may blind us to these broader societal harms and unwittingly pave the way for ever more sphere transgressions. (shrink)

This July 2020 issue of JME introduces a new section, “COVID-19 Current Controversies,” which will be a recurring section in each issue for the foreseeable future. This issue reflects on some of the most pressing ethical issues that have arisen roughly 6 months into the pandemic. Kathleen Liddell and colleagues examine important legal considerations at play in ventilator allocation decisions raised by the pandemic.1 They point out that ethics-based triage protocols that argue from the principle of “saving the most lives” (...) by withholding or withdrawing ventilators from certain patients could violate the law (U.K. and elsewhere). Patients’ legal rights are not suspended during this crisis, they remind us. The mere action of ventilator removal (extubation and proning) may constitute battery without consent, for example. Moreover, there may be problems with “evidentiary weakness” in some of the prognostic models used to inform such decisions. And, decisions that are inconsistent, subjective, and/or discriminatory may be deemed illegal. Those developing policies need to consider and consult various areas of law including criminal law (eg, murder, battery, negligence, manslaughter), human rights law, civil law (eg, battery, negligence, duty of care, consent), public and administrative law (eg, discrimination, case law), law on decision-making for incapacitated adults, professional regulations, and derogations from current law (eg, immunities and indemnities). Liddell et al offer 10 concrete, legally informed recommendations for those developing triage-policies to consider. Michael Parker and colleagues take on the issue of contact tracing using mobile apps and point out that such apps can enable people to emerge more safely from lockdowns, which provides a strong autonomy-based argument in favour …. (shrink)

Mobile applications are increasingly regarded as important tools for an integrated strategy of infection containment in post-lockdown societies around the globe. This paper discusses a number of questions that should be addressed when assessing the ethical challenges of mobile applications for digital contact-tracing of COVID-19: Which safeguards should be designed in the technology? Who should access data? What is a legitimate role for “Big Tech” companies in the development and implementation of these systems? How should cultural and behavioural issues be (...) accounted for in the design of these apps? Should use of these apps be compulsory? What does transparency and ethical oversight mean in this context? We demonstrate that responses to these questions are complex and contingent and argue that if digital contract-tracing is used, then it should be clear that this is on a trial basis and its use should be subject to independent monitoring and evaluation. (shrink)

The COVID-19 pandemic has led a number of countries to introduce restrictive ‘lockdown’ policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of (...) immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people’s civil liberties. We make tentative recommendations for the ethical introduction of immunity passports. (shrink)

Bioethics has developed approaches to address ethical issues in health care, similar to how technology ethics provides guidelines for ethical research on artificial intelligence, big data, and robotic applications. As these digital technologies are increasingly used in medicine, health care and public health, thus, it is plausible that the approaches of technology ethics have influenced bioethical research. Similar to the “empirical turn” in bioethics, which led to intense debates about appropriate moral theories, ethical frameworks and meta-ethics due to the increased (...) use of empirical methodologies from social sciences, the proliferation of health-related subtypes of technology ethics might have a comparable impact on current bioethical research. This systematic journal review analyses the reporting of ethical frameworks and non-empirical methods in argument-based research articles on digital technologies in medicine, health care and public health that have been published in high-impact bioethics journals. We focus on articles reporting non-empirical research in original contributions. Our aim is to describe currently used methods for the ethical analysis of ethical issues regarding the application of digital technologies in medicine, health care and public health. We confine our analysis to non-empirical methods because empirical methods have been well-researched elsewhere. Finally, we discuss our findings against the background of established methods for health technology assessment, the lack of a typology for non-empirical methods as well as conceptual and methodical change in bioethics. Our descriptive results may serve as a starting point for reflecting on whether current ethical frameworks and non-empirical methods are appropriate to research ethical issues deriving from the application of digital technologies in medicine, health care and public health. (shrink)

Zusammenfassung In der öffentlichen Debatte über die Corona-Warn-App kann der Solidaritätsbegriff als wichtiger, aber inhaltlich umstrittener normativer Bezugspunkt gelten. So stehen hier unterschiedliche Solidaritätsrekurse mit heterogenen Voraussetzungen, normativen Implikationen und praktischen Konsequenzen nebeneinander, die einer medizinethischen Untersuchung bedürfen. Vor diesem Hintergrund ist es Ziel des Beitrags, _erstens_ die Bandbreite der Verwendungsweisen des Solidaritätsbegriffs in der öffentlichen Debatte zur Corona-Warn-App anschaulich zu machen sowie _zweitens_ die Voraussetzungen und normativen Implikationen dieser Verwendungsweisen herauszuarbeiten und einer ethischen Bewertung zu unterziehen. Dazu stelle ich (...) nach einer kurzen Einführung in die Corona-Warn-App und einer Vergegenwärtigung der Grundzüge des Solidaritätskonzepts vier Beispiele aus der öffentlichen Debatte zur Corona-Warn-App dar, die mit Blick auf die zugrundeliegende Identifikation, die Solidaritätsgruppe, den solidarischen Beitrag sowie das normative Ziel erhebliche Unterschiede aufweisen. Sie unterstreichen die Notwendigkeit weiterführender Maßstäbe, um ihre Legitimität zu bewerten. Dazu greife ich auf vier normative Kriterien einer kontextsensitiven, moralisch gehaltvollen Solidaritätskonzeption zurück (Solidaritätsoffenheit, gestaltbare Inklusivität, Angemessenheit des solidarischen Beitrags, normative Abhängigkeit) und evaluiere auf dieser Grundlage die vorgestellten Solidaritätsrekurse ethisch. Für alle dargestellten Solidaritätsrekurse lassen sich in der Folge kritische Rückfragen formulieren. Dabei werden einerseits die Potenziale und Limitationen von Solidaritätsrekursen in öffentlichen Debatten deutlich. Andererseits werden Schlussfolgerungen möglich, wann eine Tracing-App tatsächlich als solidarische Technologie zur Pandemiebekämpfung verstanden werden kann. (shrink)

In this paper, we examine the practice and promises of digital phenotyping. We build on work on the ‘data self’ to focus on a medical domain in which the value and nature of knowledge and relations with data have been played out with particular persistence, that of Alzheimer's disease research. Drawing on research with researchers and developers, we consider the intersection of hopes and concerns related to both digital tools and Alzheimer's disease using the metaphor of the ‘data shadow’. We (...) suggest that as a tool for engaging with the nature of the data self, the shadow is usefully able to capture both the dynamic and distorted nature of data representations, and the unease and concern associated with encounters between individuals or groups and data about them. We then consider what the data shadow ‘is’ in relation to ageing data subjects, and the nature of the representation of the individual's cognitive state and dementia risk that is produced by digital tools. Second, we consider what the data shadow ‘does’, through researchers and practitioners’ discussions of digital phenotyping practices in the dementia field as alternately empowering, enabling and threatening. (shrink)

This paper explores ethical debates associated with the UK COVID-19 contact tracing app that occurred in the public news media and broader public policy, and in doing so, takes ethics debate as an object for sociological study. The research question was: how did UK national newspaper news articles and grey literature frame the ethical issues about the app, and how did stakeholders associated with the development and/or governance of the app reflect on this? We examined the predominance of different ethical (...) issues in news articles and grey literature, and triangulated this using stakeholder interview data. Findings illustrate how news articles exceptionalised ethical debate around the app compared to the way they portrayed ethical issues relating to ‘manual’ contact tracing. They also narrowed the debate around specific privacy concerns. This was reflected in the grey literature, and interviewees perceived this to have emerged from a ‘privacy lobby’. We discuss the findings, and argue that this limited public ethics narrative masked broader ethical issues. (shrink)

The success of digital COVID-19 contact tracing requires a strategy that successfully addresses the digital divide—inequitable access to technology such as smartphones. Lack of access both undermines the degree of social benefit achieved by the use of tracing apps, and exacerbates existing social and health inequities because those who lack access are likely to already be disadvantaged. Recently, Singapore has introduced portable tracing wearables (with the same functionality as a contact tracing app) to address the equity gap and promote public (...) health. We argue that governments have an ethical obligation to ensure fair access to the protective benefits of contract tracing during the pandemic and that wearables are an effective way of addressing some important equity issues. The most contentious issues about contact tracing apps have been the potential infringements of privacy and individual liberty, especially where the use of apps or other technology (such as wearables or QR codes) is required for access to certain spaces. Here we argue that wearables, as opposed to apps alone, will make a digital contact tracing mandate more practical and explain some conditions under which such a mandate would be justified. We focus on Singapore as a case study that has recently deployed contact tracing wearables nationally, but also reference debate about wearables in Australia and New Zealand. Our analysis will be relevant to counties trialling similar portable tracing wearables. (shrink)

Several digital contact tracing smartphone applications have been developed worldwide in the effort to combat COVID-19 that warn users of potential exposure to infectious patients and generate big data that helps in early identification of hotspots, complementing the manual tracing operations. In most democracies, concerns over a breach in data privacy have resulted in severe opposition toward their mandatory adoption. This paper examines India as a noticeable exception, where the compulsory installation of such a government-backed application, the “Aarogya Setu” has (...) been deemed mandatory in certain situations. We argue that the mandatory app requirement constitutes a legitimate public health intervention during a public health emergency. (shrink)

The COVID-19 pandemic will generate vexing ethical issues for the foreseeable future and many journals will be open to content that is relevant to our collective effort to meet this challenge. While the pandemic is clearly the critical issue of the moment, it’s important that other issues in medical ethics continue to be addressed as well. As can be seen in this issue, the Journal of Medical Ethics will uphold its commitment to publishing high quality papers on the full array (...) of medical ethics. At the same time, JME aims to be a premiere home for ground-breaking scholarship on the ethical issues raised by COVID-19. Toward this end, we have a number of papers that are freely available online and for which production has been fast-tracked.1–5 A challenge for authors who want to write about the pandemic is the rapidly evolving nature of the situation and the time it takes for journal content to be reviewed and published, even when fast-tracked. For that reason, all authors who would like to submit a paper on the pandemic can also submit a post to the JME blog prior to submitting a full paper to the journal. Those interested in writing for the JME blog should contact one of its editors, Hazem Zohny or Mike King. Over the last 3 weeks, 30 high-quality commentaries on the pandemic have been posted to the blog. These posts are circulated widely via the JME Twitter and Facebook feeds and have stimulated significant …. (shrink)

Disasters and public health emergencies raise a variety of ethical dilemmas, often including those that require balancing the best interests of individuals against those of groups or communities. The on-going COVID-19 pandemic provides examples of these ethical conflicts, as do other recent outbreaks. Decisions and actions in this context must address different ethical issues, ranging from those directly related to autonomy, consent, privacy and confidentiality to those related to interventions and technologies, such as efficacy, effectiveness, safety and fair access. This (...) paper aims to identify ethical conflicts with complex resolutions involving aspects related to values, rights and needs of individuals and the collective, and to suggest how such challenges could lead to more positive experiences and outcomes when confronted in future emergencies. (shrink)

As COVID-19 continues to spread, a variety of COVID-19 tracking apps (CTAs) have been introduced to help contain the pandemic. Deployment of this technology poses serious challenges of effectiveness, technological problems and risks to privacy and equity. The ethical use of CTAs depends heavily on the protection of voluntariness. Voluntary use of CTAs implies not only the absence of a legal obligation to employ the app but also the absence of more subtle forms of coercion such as enforced exclusion from (...) certain social and work activities. The protection of individual rights to voluntary use can be enhanced through an ethics by design approach in the development of CTAs that treat the introduction of CTAs for what it is: a complete novelty that is being tested for the first time in democracies. (shrink)

This paper seeks to investigate and assess a particular form of relationship between the State and its citizens in the context of the COVID-19 pandemic, namely that of obedience to the law and its related right of protest through civil disobedience. We do so by conducting an analysis and normative evaluation of two cases of disobedience to the law: (1) healthcare professionals refusing to attend work as a protest against unsafe working conditions, and (2) citizens who use public demonstration and (...) deliberately ignore measures of social distancing as a way of protesting against lockdown. While different in many aspects, both are substantially similar with respect to one element: their respective protesters both rely on unlawful actions in order to bring change to a policy they consider unjust. We question the extent to which healthcare professionals may participate in civil disobedience with respect to the duty of care intrinsic to the medical profession, and the extent to which opponents of lockdown and confinement measures may reasonably engage in protests without endangering the lives and basic rights of non-dissenting citizens. Drawing on a contractualist normative framework, our analysis leads us to conclude that while both cases qualify as civil disobedience in the descriptive sense, only the case of healthcare professionals qualifies as morally justified civil disobedience. (shrink)

In April 2020, close to the start of the first U.K. COVID-19 lockdown, the U.K. government announced the development of a COVID-19 contact tracing app, which was later trialled on the U.K. island, the Isle of Wight, in May/June 2020. United Kingdom surveys found general support for the development of such an app, which seemed strongly influenced by public trust. Institutions developing the app were called upon to fulfil the commitment to public trust by acting with trustworthiness. Such calls presuppose (...) that public trust associated with the app can emerge if the conditions for trustworthiness are met and that public trust is simplistic, i.e., linearly the sum of each member of the publics’ individual – U.K. government trust relationship. Drawing on a synthesis of the trust literature and fifteen interviews with members of the public trialling the app on the Isle of Wight, this paper aims to explore what trust mechanisms and relationships are at play when thinking about public trust in the context of the U.K. COVID-19 app. We argue that public trust is a complex social phenomenon and not linearly correlated with institutional trustworthiness. As such, attention needs to widen from calls for trustworthy infrastructures as a way to build public trust, to a deeper understanding of those doing the trusting; in particular, what or whom do people place their trust in when considering whether using the app and why. An understanding of this will help when trying to secure public trust during the implementation of necessary public health measures. (shrink)

Mobile phone-based applications (apps) can promote faster targeted actions to control COVID-19. However, digital contact tracing systems raise concerns about data security, system effectiveness, and their potential to normalise privacy-invasive surveillance technologies. In the absence of mandates, public uptake depends on the acceptability and perceived legitimacy of using technologies that log interactions between individuals to build public health capacity. We report on six online deliberative workshops convened in New South Wales to consider the appropriateness of using the COVIDSafe app to (...) enhance Australian contact tracing systems. All groups took the position (by majority) that the protections enacted in the app design and supporting legislation were appropriate. This support is contingent on several system attributes including: the voluntariness of the COVIDSafe app; that the system relies on proximity rather than location tracking; and, that data access is restricted to local public health practitioners undertaking contact tracing. Despite sustained scepticism in media coverage, there was an underlying willingness to trust Australian governing institutions such that in principle acceptance of the new contact tracing technology was easy to obtain. However, tensions between the need to prove system effectiveness through operational transparency and requirements for privacy protections could be limiting public uptake. Our study shows that informed citizens are willing to trade their privacy for common goods such as COVID-19 suppression. But low case numbers and cautionary public discourses can make trustworthiness difficult to establish because some will only do so when it can be demonstrated that the benefits justify the costs to individuals. (shrink)