Ethical guidance during the Covid event

Sources, effectiveness and barriers to influencing policy

by Gary Sidley

This is the second report describing an ongoing 12-month research project investigating the UK Government’s use of behavioural science ‘nudges’ in their Covid communications strategy to promote compliance with restrictions and the subsequent vaccine rollout. The initial report – detailing the ubiquitous deployment of nudges into the Covid messaging and the likely sources of behavioural science expertise used in the development of the posters, slogans and videos – can be found here, and a summary here. An academic journal article, drawing on information contained in both reports, can be accessed through this link: https://ahpb.org/index.php/gary-sidley-article/

Introduction

Since early 2020, the people of Western democracies have endured heightened levels of state-sponsored propaganda, involving a range of ‘non-consensual persuasion’ techniques intended to aggressively promote the official Covid narrative while suppressing alternative viewpoints. An important element of this campaign has been the deployment of behavioural science strategies – or ‘nudges’. Throughout the Covid event the UK Government, in keeping with many other countries, drew on these interventions to strengthen their public health communications and thereby increase compliance with the pandemic restrictions and subsequent vaccine rollout. These psychological methods of persuasion often operate below people’s conscious awareness and frequently rely on inflating emotional discomfort to change behaviour. As such, the state’s use of these techniques on its own citizens has evoked ethical concerns among both psychological specialists and the general public. 

Attempts to initiate an open debate about the moral acceptability of a government deploying behavioural science methods to lever obedience with current edicts have, to date, been unsuccessful, with state-employed experts in positions of influence denying responsibility for the genesis of the more controversial (for example, fear-inflating) communications and/or displaying a reluctance to address the associated ethical questions. Consequently, it remains uncertain as to which individuals, or forums, within the government infrastructure determined the tone and content of the Covid communication strategy. Nor is it clear to what extent (if any) the stakeholders involved incorporated ethical considerations into the decision-making process.

This report – primarily relying on work done in months three and four of the project – aims to answer the following questions:

1. What sources of ethical expertise (individuals and groups) were nominally available to the Government during the Covid event?

2. What ethical guidance was offered during the Covid event that could potentially have been utilised to inform the appropriate development of nudge-infused messaging? 

3. What degree of influence did this ethical commentary achieve with regard to shaping government messaging during the Covid event?

4. What were the barriers to effective ethical input into the decision-making processes around messaging during the Covid event?

Methodology

Using the UK’s controversial ‘Look them in the eyes’ messaging campaign as a case study, the methods used to access relevant information have included: in-depth online searches using terms such as ‘Covid-19 messaging – ethics of’, ‘Covid communications – ethical input’, and ‘Ethical guidance during Covid pandemic’; scrutiny of the ‘What do they know’ database of the responses to historical Freedom of Information (FOI) requests, using the key words ‘Covid-19’ and ‘ethics’; inspection of the notes and minutes of government scientific and ethical advisory groups that were active during the Covid event; original FOI requests to government departments; and an exploration of the documented outputs of individual ethical experts, both within and outside of the government infrastructure.

Sources of ethical guidance during the Covid event: What have our research efforts revealed so far?

1. There was a substantial resource of ethical expertise embedded within the government infrastructure

From the beginning of the Covid event until October 2022, there was an active group of specialists dedicated to contributing an ethical perspective into government decision-making processes. This forum was known as the ‘Moral and Ethical Advisory Group’ (MEAG). Co-chaired by Jonathan Montgomery (Professor of Healthcare Law at University College London) and Jasvir Singh (Faiths Forum for London), the group was formed in October 2019 and met on 30 occasions. Its membership comprised ethical experts, social scientists, and representatives from UK religious and secular communities. 

The central purpose of the MEAG was to offer advice to the Government on health and social care issues. However, it is apparent from the group’s terms of reference that the expectation – at least in the initial phase of its existence – was that it would be reactive to ad hoc requests arising from health-related issues that required a speedy response. A more influential role was only envisaged in the ‘longer term’ when MEAG aspired to ‘advise proactively on issues that might be relevant to emergency preparedness planning more generally’. Further clarification of the group’s purpose was provided by co-chair, Professor Montgomery, in a meeting on the 22^nd April 2020 when he said, ‘MEAG exists to discuss issues and prompt further consideration from policymakers, rather than necessarily be able to provide definitive answers.’ 

One ethical specialist in the MEAG, Professor Michael Parker, was notable for his presence within other intra-governmental forums. Parker, a Professor of Bioethics at Oxford University, describes his research interests as being in the area of ‘collective action, individual responsibility, and the common good in infectious disease response’ in relation to ‘global health emergencies’. During the Covid event, in addition to his participation in the MEAG, Parker was also an advisor on the Scientific Pandemic Insights Group on Behaviour (SPI-B) – a subgroup of SAGE, composed mainly of behavioural and social scientists, that advised the Government on its Covid-19 communications strategy – and was therefore well placed to raise ethical questions about the content and tone of the pandemic messaging. 

Parker has acknowledged his wide-ranging presence in various expert groups throughout the Covid event. In a lecture he gave on the 23^rd May 2022, he said, ‘I’ve attended more than 100 main SAGE meetings, and an equal number, at least, of meetings of various SAGE subgroups … My guess is that I have put in more than a thousand hours over those two years.’ In the same presentation, he suggests that the level of ethical scrutiny available to the Government during the Covid event was distinctive, maybe unique, describing the period 2020 to 2022 as, ‘one of the most sustained and intensive periods over which a government has had access to timely ethics advice on policy evolving in real time’.

Clearly, during the Covid event, there was an ample resource of ethical expertise embedded within the government infrastructure, sufficient – one might think – to influence policy.

2. There were a range of ethical organisations outside of the government infrastructure who were actively offering advice

While the resource of ethical expertise within formal government advisory groups could be described as sufficient, in addition there were a range of organisations offering ethical guidance outside of the government infrastructure. Four institutions fall into this category, albeit with overlapping membership, aims and sources of funding.

Established in London in 1991, the Nuffield Council on Bioethics claims to be the ‘leading independent policy and research centre, and the foremost bioethics body in the UK’ that provides advice on ‘ethical issues arising from developments in bioscience and health’. Since 1994 it has been funded jointly by the Nuffield Foundation, the Medical Research Council and Wellcome. The Nuffield Council believes it was influential during the Covid event; in its 2020 Annual Report it states that ‘The Council played a leading role in identifying and responding to pressing ethical issues, and was able to quickly produce high-quality work to support national and international responses to the pandemic.’ 

A second source of UK-based ethical expertise is the Oxford Uehiro Centre for Practical Ethics. Founded in 2002 and located in the Philosophy Faculty at the University of Oxford, the organisation comprises a group of academic researchers who aim to promote philosophical methods in ‘practical ethics’. On the centre’s website it states: 

Practical ethics should not only advance knowledge by deeper, rational ethical reflection and dialogue, it should change people’s hearts and so better their own lives and the lives of others.

Their specialists offer ‘ethics advice and consultancy for a wide variety of research projects and areas’.

The Wellcome Centre for Ethics and Humanities is also based at Oxford University. Established in 2017, the centre aims to ‘lead debate on the ethical requirements for scientific research & technological innovation’ and it investigates ‘the ethical aspects of advances in neuroscience, big data, genomics & global connectedness’. The Wellcome Centre regularly engages in collaborative work with the co-located Oxford Uehiro Centre.

The fourth, and most recently established, ethics organisation is the UK Pandemic Ethics Accelerator. It describes its central function as being to bring ‘UK ethics research expertise to bear on the multiple, ongoing ethical challenges arising during pandemics’ by providing ‘rapid evidence, guidance and critical analysis to decision-makers across science, medicine, government and public health’. Formed in May 2021, the Ethics Accelerator is a partnership between the Universities of Oxford, Bristol and Edinburgh, University College London, and the Nuffield Council on Bioethics. The source of funding is UK Research Innovation.

Not only do the geographical locations, workstreams, and sources of financing of these four ethics organisations overlap, but they share common membership. For example, Ilina Singh (Professor of Neuroscience at the University of Oxford) is a co-director at the Wellcome Centre, a ‘Distinguished Research Fellow’ at the Uehiro Centre, and a Principal Investigator at the Ethics Accelerator. Similarly, John Coggon (a Law Professor at the University of Bristol) is a Council Member at Nuffield while also performing the role of co-investigator at the Ethics Accelerator.

Overall, it is reasonable to conclude that, though there were four reservoirs of ethical expertise operating in the UK throughout the Covid event, they displayed significant similarities in relation to purpose and personnel.

3. Policy documents pre-dating the Covid event were available and potentially influential

In addition to the range of ethics experts active during the Covid event, there were at least three historical and well-known policy documents available to policy makers that could have been referred to when making decisions abouts Covid messaging.

The first – and arguably the most prominent – concerns pandemic influenza guidance. In 2007, the Cabinet Office and Department of Health collaboratively produced a report titled ‘Responding to pandemic influenza: The ethical framework for policy and planning’. This document was subject to two elaborations: the ‘Committee on ethical aspects of pandemic influenza’ (CEAPI) in 2011, and the GOV.UK’s ‘Guidance Pandemic Flu’ (published in 2013 and updated in 2017). These advisory papers cover similar ground, recommending that policymakers refer to the following principles when deliberating about decisions:

• RESPECT: Keeping people as informed as possible’; ‘respecting people’s personal choices about their treatment and care.

• MINIMISING HARM: [Considering] the physical, psychological, social and economic harm that a pandemic might cause.

• FAIRNESS: Everyone matters equally; There need to be good reasons to treat some people differently from others.

• WORKING TOGETHER: Working together to plan for, and respond to, a pandemic.

• RECIPROCITY: If people are asked to take increased risks, or face increased burdens … they should be supported in doing so.

• KEEPING THINGS IN PROPORTION: Those responsible for providing information will neither exaggerate nor minimise the situation and will give people the most accurate information that they can … decisions on actions that may affect people’s daily lives, which are taken to protect the public from harm, will be proportionate to the risk and to the benefits that can be gained.

• FLEXIBILITY: People will have as much chance as possible to express concerns about or disagreement with decisions that affect them.

• GOOD DECISION MAKING: Respect for this principle involves openness and transparency … involve people as much as possible in aspects of planning that affect them … take into account all relevant views expressed … good decisions should be rational & ‘based on evidence.

An additional flu-focused document – ‘Health & Social Care Influenza Pandemic Preparedness and Response’ – focusing on the operational aspects of pandemic response in the health and social care sectors – was published in 2012. While reaffirming the appropriateness of the 2007 ethical framework, a further key recommendation – directly relevant to government messaging during a pandemic – was to, ‘Take better account of information from behavioural scientists about how people are likely to think, feel and behave’.

A second source of historical policy guidance, accessible to decision makers during the Covid event, was the World Health Organisation (WHO) document, ‘Ethical considerations in developing a public health response to pandemic influenza’. Published in 2007, it covers a wide range of infection control activities (surveillance, isolation, quarantine, and social distancing) that can raise important ethical questions. Pertaining to messaging during a pandemic, the guidance emphasises the importance of: ‘trust; transparency; communicating to the public early; dialogue with the public; and planning’.

Thirdly, in 2017, the (now-defunct) Public Health England published a paper titled ‘Public Health Ethics in Practice’, one of the two co-authors being the previously mentioned Professor John Coggon. The document is structured around three case studies, one of which focuses on a pandemic scenario, and highlights some general principles:

• Ethics should not be viewed as an afterthought to be examined once policy adoption or intervention selections has taken place.

• [Ethics is] an integral component of public health decision making that should be incorporated into all aspects of policy & practice.

• For public health policies and interventions to be ethically justified, they must be defensible by reference to political theory.

• Ethical guidance must be context specific … task specific … and level specific.

In conclusion, it is clear that, throughout the Covid event, there were multiple sources of ethical expertise and ethical guidance that could have been utilised during the development of the nudge-infused Covid messaging. But in actuality, what did these sources contribute to the decision-making process?

Ethical guidance that was offered during the Covid event: What have our research efforts revealed so far? 

1. None of the sources of ethical expertise raised specific questions about the Government’s nudge-infused messaging

A comprehensive inspection of the outputs of ethical experts during the Covid event revealed that there was no direct reference to the appropriateness and acceptability of the messaging used to promote compliance with the Covid restrictions and subsequent vaccine rollout. Given the sizeable academic literature addressing the ethical questions associated with behavioural science techniques (for example, Sunstein, 2016; Schmidt & Engelen, 2020), the critiques of their deployment during the Covid event (for example, HART, 2022), and the public’s ‘negative sentiment toward behavioural science and its policy counterpart’, this omission is surprising.

The MEAG met on 23 occasions between March and November 2020. Inspection of the minutes of these forums shows that they discussed a range of topics – including the Coronavirus Bill, prioritisation in intensive care, shielding policy, and antibody certification – but there was no explicit mention of behavioural science nudges and very little reference to Covid communications in general.

With regard to expert ethics groups operating outside of the government infrastructure, their outputs also neglected consideration of the moral questions associated with the state’s use of behavioural science strategies. However, there are a couple of instances where their statements could be construed as – perhaps inadvertently – relating to nudge-infused communications. Thus, on the 18^th May 2022, 40 Parliamentarians met with academics (from the Pandemic Accelerator and the Nuffield Council) and patient representatives to discuss the theme of ‘Building Public Values into Pandemic Recovery & Preparedness’. One of the presenters at the event, Professor Dame Theresa Marteau (Director of the Behaviour and Health Research Unit at Cambridge University), proposed that ‘Trust in scientific advice is fostered by scientists communicating in ways that aim to inform (not persuade)’. Although not stated explicitly, such an assertion seems to question the ethical appropriateness of communicators resorting to – often-covert – nudge techniques as a means of promoting compliance with pandemic restrictions.

Another rare example of ethical experts directly referring to behavioural science strategies during the Covid event is contained in a Nuffield Council policy briefing (dated 17^th May, 2022) titled ‘Ethical tools for decision-makers: Responding to public health threats’. While emphasising the importance of three values (reducing suffering, treating everyone with respect, and fairness), the authors propose a ‘Ladder of public health intervention’ in which the third most coercive rung is described as, ‘Present safer behaviours as a social default’. They go on to define the aim of this type of intervention as ‘to help create an environment where acting to protect others is presented as the norm and is seen to be valued’, and refer to wearing a face mask as an illustrative example. Clearly, what is being described here is a ‘normative pressure’ nudge that exploits the fact that an awareness of the prevalent views and behaviours of fellow citizens can exert pressure on us to conform. Although the policy briefing does not discuss the ethical questions arising from these types of interventions, their high ranking on the coercion/intrusiveness ladder implies that such issues warrant debate.

2. No ethical advice was sought during the development of the controversial ‘Look them in the eyes’ campaign

Perhaps partly as a result of experts’ neglect of ethical commentary about nudge-infused communications, it appears that those tasked with developing the Covid-19 messaging (involving videos, posters, and slogans) did not seek a specialist ethical perspective on their outputs. 

This provisional conclusion can reasonably be drawn from a Cabinet Office response to our FOI request that asked for details about any specialist ethical input into the making of the adverts and videos used in the ‘Look them in the eyes’ communications campaign. Arguably the most powerful – and controversial – package of Covid-19 messaging in the UK, this campaign involved a series of close-up images of acutely unwell patients wearing surgical masks and ventilation masks, and a voice-over saying, ‘Look them in the eyes and tell them you are doing all you can to stop the spread of coronavirus’. From a behavioural science perspective, the ‘Look them in the eyes’ initiative could be viewed as adding guilt and shame (the emotional mediators of ego nudges) to the previous reliance on fear-inflation (see Research Report 1, p 10, for further details).

The reply from the Cabinet Office to our FOI stated that ‘Ethical approval on government campaigns is not a standard requirement’ and there was a reliance on ‘audience testing via insight research to inform development and ensure accuracy of message take-out’. The Cabinet Office went on to say that ‘Research findings did not indicate that additional, non-standard approvals – such as ethical approval – were required’. 

This FOI response also provided details of what their ‘insight research’ involved. Apparently, the process is centrally managed by a ‘specialist market research recruitment agency, accredited to ISO20252’ deploying ‘a network of recruiters across the UK’. In this instance – the testing of the ‘Look them in the eye’ communications – the research involved ‘six 90-minute focus groups, each consisting of six respondents’. The participants were asked ‘to provide their opinions on the proposed campaign materials’. The conclusion to be drawn from this information is unequivocal: Apart from the exceptional circumstances where members of the general public on their six-person audience panels proactively raised specific ethical concerns about an advert, no ethical advice would be sought. And, given that the ‘Look them in the eyes’ campaign is widely regarded as the most provocative UK example of Covid messaging, it seems doubtful that other communication campaigns – such as the ‘All in, All together’ newspaper project – would have incorporated ethical consideration of their materials either.

Placing these findings in a wider context, recent revelations by the ‘Us For Them’ campaign group (Kingsley et al., 2023) indicate a fundamental neglect of ethical oversight across the broad range of Covid communications. In the drive to promote the Pfizer vaccine to children and young adults, the Government did not even follow the basic advertising guidance regarding the targeting of minors, instead claiming exemption from legislative rules relating to the promotion of medicines on the grounds that their messaging did not constitute advertisements. In light of this level of evasion of fundamental governance, the absence of ethical input into the ‘Look them in the eyes’ initiative is less remarkable.

Even more striking were some of the official attempts to justify the imposition of these emotionally disturbing images and messages on the British populace. One justification – as detailed on the MullenLowe website – was their belief that 20% of the population underestimated the risk of Covid-19, and they wanted to ‘make the risk real for those who were unsure or didn’t believe it’. A subsequent Cabinet Office response to our FOI request in August 2023 confirmed that the ‘Look them in the eyes’ initiative was developed with the not-frightened-enough subgroup in mind, the stated objectives of the communications being:

To continue the ‘Stay Home’ campaign, encouraging people to stick to the rules
and take personal responsibility for their behaviours.

To make those people who are ‘unsure’ of the coronavirus risks, or who believe
the risks are exaggerated to reappraise their behaviour and not bend the rules.

The focus on ‘Risk Sceptics’ requires a shift in gear:
from ‘Authoritative Command’ (Phase 1a & b)
to a more emotionally triggering ‘People to People approach (Phase 2).

Most importantly, it proves to be effective in forcing reappraisal of behaviour even among those who currently believe that risks are exaggerated; directly prompting them to seriously consider their ‘small transgressions’ or ‘stretching’ of the rules.

Another Cabinet Office justification for the tone and emotional power of the ‘Look them in the eyes’ campaign, based once again on their own qualitative research, was that people were generally less frightened of the virus in January 2021 as compared to the time of the first lockdown in March 2020. An FOI response (on the 6^th October 2023) conveyed details of the official thinking:

… level of perceived risk & concern is not as high as March 2020. March a shock to the system but now have learned to live alongside Covid.

Younger can be more fatalistic, strong belief in personal strength and ability to recover/experience less severe symptoms.

Strong evidence of Covid fatigue across the sample. They have settled into their own level of ‘acceptable behaviour’ and perceived risk that fits with their lifestyle, their specific needs & circumstances.

Significant & visible difference in behaviour & attitude between the two lockdowns. More people on the streets, more businesses open, more traffic on the roads. Fearful but much less panic this time around.

The challenge is in overcoming people’s established ways of managing their lives within the lockdown rules as by & large they believe they are mostly compliant.

Thus, three official justifications for inflicting this emotionally disturbing content on the British populace were: the presumed existence of a subgroup of ‘risk sceptics’ who were not sufficiently frightened of the prospect of developing the Covid-19 illness; younger people were less alarmed and held stronger beliefs in their powers of recovery should they contract the SARS-CoV-2 virus; and the observation that, in January 2021, many people felt less frightened (as compared to the March 2020 lockdown) and had made corresponding adaptations to their life styles. Each of these justifications can be challenged on the grounds of irrationality, dubious ethics, or both.

MullenLowe, the advertising agency that produced the ‘Look them in the eyes’ adverts, worked on the assumption that one in five of the population had underestimated the risk of Covid-19, and therefore it was desirable to ‘make the risk real for those who were unsure or didn’t believe it’.

It is unclear as to the source of this risk estimate. And, given that Covid-19 had already been recognised to be a mild disease in all but a small minority of cases – with an infection fatality rate (IFR) of less than 0.15% for those under 60 years of age (Ioannidis, 2021) – it is doubtful whether one can validly identify a subset of the population as complacent. Furthermore, even if a ‘not-frightened-enough’ subgroup could be reliably distinguished, it is ethically problematic to use the existence of this minority as justification to scare and shame everybody, most of whom (as a result of the media-driven nudge operation) would, by this stage, be overestimating their levels of personal risk. Strategically opting to further frighten and shame the already overly fearful is an action that would be very difficult to defend on moral grounds.

Similarly, referencing younger people’s invulnerability beliefs as a rationale for releasing these emotionally-disturbing videos and posters can also be criticised as being both irrational and unethical. For the researchers involved in developing and disseminating the ‘Look them in the eyes’ material, the fact that younger people had a 

stronger belief in [their] personal strength and ability to recover/experience less severe symptoms (FOI response 6.10.23).

partly justified the tone and content of their campaign. Yet, this assumed belief is a perfectly rational one: healthy individuals under the age of 30 were at no appreciable risk of dying of Covid-19. The IFR for 20 to 29-year-olds was 0.0088% and, for the under 19s, 0.0013% (Ioannidis, 2021). In the context of the multiple risks faced in day-to-day life, these levels are negligible; anyone who implies otherwise is exhibiting a severe form of risk aversion.

The third justification from the ‘Look them in the eyes’ creators – that people were less scared than in March 2020, and had adapted their behaviour so as to function within the restrictions – is, arguably, even more disingenuous. To view as negative the observation that many had ‘learned to live alongside COVID’, and had ‘settled into their own level of “acceptable behaviour” and perceived risk that fits their lifestyle’ (FOI response 6.10.23)  – and to use this as a valid reason for scaring and shaming them – is both perverse and ethically indefensible. A more rational interpretation of these behavioural changes would be that people were increasingly making their own individualised, balanced risk assessments, and making pragmatic decisions about how best to function in difficult circumstances and get on with their lives.

3. Although overlooked, much of the general ethical guidance produced during the Covid event was relevant to the specific ethical concerns about nudge-infused messaging

Ethical questions arising from the Government’s ubiquitous deployment of behavioural science-infused messaging were detailed in an earlier report (see Research Report 1, p5). In brief, four aspects of the Covid-19 communications can be viewed as problematic: the methods per se; the absence of informed consent; the contentious goals; and the lack of transparency. Much of the expert ethical commentary documented during the Covid event, although not explicitly addressing the issue of nudge-infused messaging, had relevance to one of these four ethical concerns. Some illustrative examples will now be described.

• The methods per se

Concerns about the methods relate to the acceptability of a government using techniques on its people that increase emotional discomfort and lead to widespread collateral damage. Strategically evoking fear, guilt, and shame to promote compliance is ethically questionable, as is the harnessing of peer pressure to achieve conformity. Ethical commentary of relevance to these concerns was typically couched in terms of ‘respect’ and the ‘harms’.

In March 2020, the Nuffield Council on Bioethics published a paper titled ‘Ethical Considerations in Responding to the Covid-19 Pandemic’, that included the statement: ‘While individuals may be asked to make sacrifices for the public good, the respect due to individuals should never be forgotten.’ The same organisation returned to this theme in a 2022 paper in which they highlighted ‘treating people with respect’ as a guiding value of public health interventions. Similarly, the Department of Health and Social Care (DHSC) includes ‘respect’ as a key principle in their ‘ethical framework for adult social care’. The prominent American behavioural scientist, Professor Cass Sunstein, seems to be addressing the same construct in a 2021 interview with the World Economic Forum when he says that nudges should be ‘compatible with human dignity’ and ‘consistent with their (the people’s) values’.

With regard to the collateral damage associated with nudge methods, ethical commentaries focusing on the potential harms of pandemic interventions are pertinent. Addressing the ethical issues relating to the lifting of lockdown, Professor Michael Parker (Parker, 2020) described ‘minimising harms’ and ‘maximising wellbeing’ as fundamental values, two criteria that could reasonably apply to Covid-19 messaging. The same ‘minimising harm’ consideration was highlighted as a key principle in the previously mentioned ethical framework for social care (DHSC, 2021). Likewise, the Nuffield Council endorsed the importance of ‘reducing suffering’ as a guiding value in their 2022 article.

• The absence of informed consent

Obtaining the informed consent of the recipient before administering any medical or psychological intervention has always been a cornerstone of ethical clinical practice in liberal democracies. The apparent lack of any attempt to acquire the endorsement of the British people prior to the mass implementation of psychological methods of persuasion (nudge-infused messaging) can therefore be regarded as ethically problematic. 

Historically, Professor David Halpern – the President and Founding Director of the Behavioural Insights Team (BIT) – was unequivocal about the fundamental importance of obtaining consent prior to using nudge techniques. Halpern was a co-author of the influential MINDSPACE document, published in 2010, that detailed the range of nudges in the armoury of behavioural science. This seminal document states: ‘Policymakers wishing to use these tools … need the approval of the public to do so.’ Five years later, in his book, Inside the Nudge Unit, he is even more emphatic about the importance of consent: ‘If Governments … wish to use behavioural insights, they must seek and maintain the permission of the public’ (p375). Another prominent behavioural scientist, Professor Cass Sunstein, reinforced this viewpoint when, in a 2021 interview, he stated: ‘if the people don’t like them (nudges), they should be able to say, “We don’t want that one.”’

During the Covid event, much was written about the importance of public involvement in decision making around ethically contentious pandemic policies. As early as April 2020, the Nuffield Council issued a statement, titled ‘Covid-19 and the basics of democratic governance’, that asserts that ethical input ‘is a matter of fundamental democratic accountability’. The same document goes on to say that the UK ‘has a public that has much to say but no opportunity to say it’, and urges the Government to ‘invite a broad range of perspectives into the room, including wider public representation’. The Nuffield Council returned to the same issue in a January 2022 blogpost where they proposed that one of the three core aspects of ethical preparedness is ‘Ethical policy making and public engagement’.

The same theme was raised in a ‘Rapid Ethics Review’ by the UK Pandemic Ethics Accelerator in September 2021, proposing that ‘The government should decide how to make meaningful public engagement an institutionalised part of their future covid-19 policy.’ The Ethics Accelerator reiterated this recommendation in their meeting with parliamentarians in May 2022, where a key point emerging from the discussion was that ‘Engaging the public in ethical tensions would contribute to building public values into pandemic recovery and preparedness.’ At the same event, Professor Ilina Singh highlighted to MPs the missed opportunity to ‘use tried and trusted ways of engaging the public in considering ethical questions’. 

To summarise, a range of experts – ethicists and some behavioural scientists – have stressed the importance of considering the perspectives of ordinary people during policy decision making, a principle that is of considerable relevance to the state’s deployment of nudge techniques.

• The contentious goals

During the Covid event, behavioural science strategies were incorporated into government communications primarily to promote compliance with a range of unprecedented and poorly-evidenced restrictions. When these measures were imposed, there existed a body of empirical research concluding that lockdowns (for example, Chaudry et al., 2020; American Institute for Economic Research, 2020) and masks (for example, Centre for Disease Control & Prevention, 2020; Cochrane review, 2020) were of little to no benefit in reducing the transmission of a respiratory virus. But, inexplicably, in early 2020, well-established pandemic plans were discarded. The deployment of fear, shame, and peer pressure to realise compliance goals – goals that infringe on basic human rights and where the net benefits are highly questionable – can be viewed as ethically unsound.

Arguably, during the Covid event, the ethical commentary most pertinent to this issue of contentious goals was provided by the Wellcome Centre in a written statement to Parliament in July 2020. In this multi-authored document they highlight the ‘Siracusa Principles’ that provide an internationally agreed-upon basis for restricting human rights during exceptional circumstances. Two of the principles cited require that any such restrictions are ‘In the interest of a legitimate objective’ and ‘Based on scientific evidence’. While these principles arose from consideration of the restrictions (lockdowns, masks, etc.) per se, it is reasonable to suggest that they are equally applicable to the communication strategies implemented to achieve their realisation.

Four months earlier a Nuffield Council report, addressing the key issues to be considered when responding to a pandemic, had stated that ‘interventions should be evidence-based and proportionate’. In May 2022, the same body proposed that a key responsibility of the state was to ‘enable people to live healthy lives’, an aspiration that could be viewed as inconsistent with the strategic use of fear, guilt, and shame in the Covid messaging.

The goals of interventions have also been considered by academic researchers when evaluating the ethics of nudges and other pandemic management strategies. For example, Jamrozick (2022), in his overview of the critiques of the ‘new normal’, wrote:

Ethical evaluations also require reviewing the best available empirical evidence regarding the expected benefits and harms … involved in a policy, as well as the likely distribution of these outcomes in the community.

Alluding to the increasingly common practice of referring to global betterment as justification for unprecedented interventions, Correa et al. (2022) make the crucial observation that ‘Knowing what is the greater good during this pandemic outbreak is the question no one has answered yet.’ 

• The lack of transparency

Many nudges impact upon their targets below their level of awareness and this covert mode of action lends weight to the accusation that they are manipulative. The importance of transparency – with regard to the full range of pandemic decision making – has been repeatedly endorsed by ethics specialists and researchers during the period 2020 to 2022.

In a rapid policy briefing in March 2020, the Nuffield Council proposed that ‘Interventions that interfere with personal liberties should be carefully and transparently justified.’ The following month they were unequivocal on this issue, asserting that the Government should:

Show us (the public) what it is doing and thinking across the range of issues of concern
Set out the ethical considerations that inform(ed) its judgements
Explain how it has arrived at decisions … and not that it is just ‘following the science’.

Some commentators have couched the transparency question in terms of ‘trust’. Subian et al. (2021) argued that a transparent and ethically legitimate framework for decision making can lead to ‘increased public trust in government and commercial entities for routine as well as crisis practice’. Similarly, following their workshop at Westminster in May 2022, the UK Pandemic Ethical Accelerator group concluded: ‘To build trust, transparency alone will not suffice; it is important to share justifications that align with public expectations’, and ‘It’s best to be honest with the public about what we do and don’t know.’

During the Covid event, some behavioural science scholars directly addressed the transparency issue with a specific focus on nudges. For example, Correa et al. (2022) suggested that nudges can be problematic when applied in ‘face-to-face interaction between doctor and patients’ where ‘influences on choice architecture are not so welcome and can be misinterpreted as manipulation’. They add that, in the hands of a ‘bad government’ nudges may be ‘manipulative and violate autonomy’ by encouraging decisions ‘in directions different from those that individuals would do rationally’. Sunstein (2021) was more succinct: ‘Nudges should satisfy certain constraints – that is, they should be transparent, not covert or hidden.’

4. There is a broad consensus among ethicists that their advice had minimal influence upon policy decisions during the Covid event

As already described, the sources of ethical expertise (both within, and outside of, the government infrastructure) offered no specific, targeted guidance to inform the development of the nudge-infused messaging during the Covid event. Although much of the documented ethical advice could be construed as indirectly addressing some of the prominent concerns surrounding the state’s use of behavioural science within its communications strategy, the evidence suggests that the processes involved in the production of emotive and controversial campaigns like ‘Look them in the eyes’ were ethics-free zones. Strikingly, however, many ethics experts have expressed the view that their services were underused, or their guidance ignored, resulting in their achieving minimal impact across the range of policy decisions.

An early ominous sign of policymakers’ marginalisation of ethical advice relates to the treatment of the MEAG. On the 22^nd April 2020, Professor Jonathan Montgomery (MEAG co-chair) confirmed that he would write to Professor Chris Whitty (Chief Medical Officer) to ask him to ‘consider commissioning MEAG to produce a framework to assist policymakers take moral and ethical issues into account when developing policy’. Surprisingly, this constructive offer was promptly rejected. The MEAG meeting notes of the 29^th April 2020 detail how Whitty had ‘advised against’ a documented ethical framework on the grounds that ‘this might crowd out the capacity of MEAG to consider detailed issues on which advice was being sought’. This response – that could reasonably be construed as a directive to only give ethical guidance when asked to do so – may have informed a MEAG member’s intriguing comment on a Nuffield blogpost in January 2022:

I think this is very much bound up with the abandonment of the influenza plan from 2007, which had a strong ethical component built into it from the start and a clear set of principles for decision-makers to use. There has been considerable resistance to the idea of ethical appraisal throughout the Covid pandemic. (My emphasis).

In addition to a passive, only-respond-when-asked, role being imposed on MEAG, some ethical specialists perceived that subsequent specific requests for advice were tokenistic. For instance, in December 2020, on the contentious topic of vaccine certifications, the MEAG ‘noted that many members considered that MEAG had been invited to advise at a very late stage of the process’. The same observation was made by participants in a stakeholder workshop (Pykett, 2022) where concern was expressed that ‘the role of the (ethics) committee had been to deliver on policy decisions already made’.

Many ethics experts have bemoaned their lack of influence during the Covid event. As early as April 2020, a statement by the Nuffield Council claimed: 

The Westminster Government does not seem to want to engage or take on board other views on any of these issues; nor is it evident that they are thinking about them, or taking advice on them from a social and ethical perspective … as far as we can see, neither the UK Government nor any of the devolved administrations have taken advice from their own Moral and Ethical Advisory Group.

This initial censure of the Government’s disregard of ethics was endorsed over two years later by Pykett (2022) when, in her analysis of key ethical moments in the pandemic, she concludes: ‘Ethical considerations have been simultaneously widespread in public debate, yet marginalised in policy responses.’

Similar criticisms have been expressed by the Pandemic Accelerator experts, for example, Professor John Coggin: ‘Ethical discourse in the UK was – and felt – muted’; Professor Ilina Singh: ‘We have struggled to make policy impact and to engage policy-makers’; and (more diplomatically) Professor Michael Parker: ‘There are a range of ways in which it could have been better, and there could have been more of it.’

Arguably the strongest condemnation of policymakers’ neglect of moral guidance during the Covid event was provided by Dr David Seedhouse (Honorary Professor of Deliberative Practice at Aston University) who wrote: 

One of the most troubling aspects of the Government’s response to the pandemic was its complete disregard for ethics …  a handful of people, quite out of their depth, were able to dismiss ethics – along with previous well-documented Government pandemic planning – with what seemed like a mere wave of the hand. (Seedhouse, 2022). 

Also, ethicists have consistently suggested that a blinkered reliance on the recommendations of scientists was the major reason why policymaking remained an ethics-free zone. At an Ethics Accelerator conference in May 2022, Professor Coggan observed:

There has remained a tendency, particularly within Westminster, to frame difficult decisions as ones that are simply led by ‘the science’ … But there are values at play when a Minister decides which science to follow. And there are value judgements in weighing up the costs and benefits of doing so, and in understanding whether and how this acceptably bears on people’s basic rights. 

Professor Parker made a similar point in an October 2022 article on the Ethics Accelerator website:

To say that one can ‘follow the science’ or ‘follow the data’ is to fail to acknowledge that the making of value judgements about what matters morally is an unavoidable step in any policy-making process.

That science, and the corresponding policies, are not value-free has also been articulated by other commentators (for example, Fritz, 2020, and Nuffield Council, 2020). 

A specific example of where a purported reliance on science was used to deflect ethical evaluation is detailed by Pykett et al. (2022). Pykett describes how members of MEAG offered ethical input into the deliberations of the Joint Committee on Vaccination and Immunisation (JCVI) to help inform its decision making around vaccine prioritisation. However – as stated in the JCVI minutes of the 7^th May 2020 – the ‘Committee agreed that JCVI advice would be based on scientific principles from the available scientific evidence and this would not include detailed ethical considerations.’ 

This assumption – sometimes explicit, sometimes implicit – about the primacy of ‘the science’ in determining policy may bear significant responsibility for what Jamrozick (2022) describes as ‘an ethical crisis in public health’, where many pandemic interventions could be considered ‘unacceptable according to pre-pandemic norms of public health ethics’. Clearly, policy decisions throughout the Covid event have typically been made within an ethical vacuum. The changing pandemic guidance within Adult Social Care could be seen as symbolic of this state of affairs. The original Department of Health and Social Care document (updated in April 2021) comprehensively describes a broad ethical framework, promoting values such as respect, reasonableness and proportionality. However, this guidance was withdrawn on the 1^st April 2022 and ‘superseded’ by another document, titled ‘Infection prevention and control in Adult Social Care’ in which there is no mention of ethics at all.

The barriers attenuating the impact of ethical guidance on pandemic policy: What have our research efforts revealed so far?

1. There was a perceived lack of clarity regarding the identity, and location, of the political decision makers

One of the more prominent conclusions to emerge from the ongoing Covid-19 Inquiry has been the chaos and infighting at the heart of Government. This lack of coordination between ministers, advisors and civil servants may have contributed to the perception of some ethicists that it was often unclear as to where the key policy decisions were being made – undoubtedly, without this knowledge of where the power and influence lie, it is very difficult to introduce ethical values into the deliberation process. (With regard to nudge-infused communication, this barrier to introducing ethical principles into decision making would have been accentuated by the multiple pockets of behavioural science offering advice during the Covid event – see Report 1, section 4b, for further details.)

Two participants at the Pandemic Accelerator conference in May 2022 mentioned the problems associated with trying to offer ethical guidance without knowing the identity and location of the political decision makers. Professor Montgomery described how ‘It proved very difficult, at least early in the pandemic, to identify who was taking decisions. If you can’t identify who’s taking the decisions, it’s hard to offer advice in a timely manner.’ Professor Singh expanded on the same point, stating that ‘Transparency in reasoning and decision-making’ was an ‘area of improvement for this Government in the handling of the pandemic.’ She goes on to say: 

Another challenge is that we have had an ambiguous, or lack of, relationship with pandemic science leadership. We have had trouble identifying where the leadership was. It wasn’t just Chris Whitty and Patrick Vallance, there was leadership all the way down.

In her review of the ethical moments in the pandemic, Pykett et al. (2022) highlighted the same issue. After facilitating an online workshop on the 25^th March 2021, incorporating the views of four UK Government ethics advisors, she identified the need for ‘a clearer pathway … between advisory institutions and decision makers to ensure ethically-informed debate’.

2. The ethical advice offered was frequently fragmented and drawn from multiple sources

In the notes of the MEAG meeting of the 16^th March 2022 is the statement: ‘Members expressed concern that communications and guidance could be more joined-up.’ The same concern had earlier been raised, less diplomatically, by Fritz et al. (2020) who described ethical approaches in the first months of the pandemic as ‘piecemeal, confusing, and risks needless duplication’.

A more considered perspective on how fragmented ethical advice was a factor in mitigating its influence on policy is offered by Pykett et al. (2022). Referring to an ‘ethical adhocracy’ Pykett and her colleagues describe how, despite being ‘carefully covered behind the impression of a finely-tuned orchestration of expertise’, this unstructured system results in ‘decisions about values’ being ‘highly contingent … on opportunities and situations, with ambiguity and contestation’. Usefully, Pykett et al. consider the causes of this fragmentation and suggest one contributor could be ‘the ambiguity created by the perceived need to develop new ethical principles, guidance & frameworks rather than using well-established principles, such as those from the Committee on Ethical Aspects of Pandemic Influenza’. This suggestion chimes with the questionable way in which scientists and policymakers have been prone to assume that the challenges presented by Covid-19 required a completely different set of responses than previous pandemics.

3. Ethicists lacked visibility to policymakers

In their review, Pykett et al. observe that the MEAG was ‘underutilised’ and, after reading the group’s outputs, they were left with ‘a sense of an advisory body whose potential is not fully realised’. Members of the MEAG seemed to recognise their obscurity; the minutes of their meeting on the 9^th September 2020 state:

The Group explored a range of options to increase the visibility of MEAG and identify opportunities to add value by improving links with policy makers and securing greater influence over decision-making. To achieve this the group agreed to reach out proactively to senior civil servants in key policy areas.

Based on the feedback received from the participants at their workshop, Pykett and her collaborators speculate about the reasons for this invisibility. As for potential contributory factors, they implicate recent structural changes in the heart of Government: ‘The capacity for the civil service itself to provide sound, evidence-based and ethical policy advice to ministers had been hollowed out over the last decade.’ And, on a similar theme: ‘The increasing centralisation of policy strategy & advisory personnel in the Cabinet Office and Number 10 has led to the politicisation of ethical questions of government.’

At their workshop with parliamentarians in May 2022, ethicists from the Pandemic Accelerator emphasised the importance of making policymakers aware of the availability of ‘trustworthy processes’ that incorporate ‘research and reasoning tools’ so as to instil an ethical dimension into their deliberations. According to Professor Singh, one way of achieving this aim is to ‘collaboratively develop an open channel of communication and proactive infrastructure to enable ethics experts to work alongside policy makers’.

4. Ethicists believed they were constrained by being a member of a formal government advisory group

Despite a sizeable resource of ethical specialists embedded within the government infrastructure during the Covid event, they achieved minimal influence across the range of pandemic policy decisions and raised no concerns at all about the appropriateness and acceptability of nudge-infused messaging. Two such ethicists – Professors Montgomery and Parker – have said that they felt to some degree constrained by their membership of formal government advisory groups, thereby raising the possibility that such involvement could constitute another barrier to the provision of effective ethical guidance. 

Professor Jonathan Montgomery (a co-chair of the MEAG), in an article for the Pandemic Accelerator in May 2022, says:

If you’re an advisory body within the Department of Health and Social Care, as the Moral and Ethical Advisory Group was, you are bound by the framework of your terms of reference and accountability.

As previously described, the MEAG members may have been discouraged from proactivity by mentions of responding to ad hoc requests in the group’s terms of reference. Furthermore, as part of the Department of Health and Social Care, its early deliberations were, perhaps predictably, ‘limited to a clinical and biomedical focus’ (Pykett et al., 2022) rather than addressing broader societal issues.

The constraints of formal group membership are also described by Professor Michael Parker (a member of the MEAG and of various SAGE groups). In an October 2022 publication he expresses the view that ‘the role of senior adviser comes with some responsibilities’ and goes on to discuss the ‘difficult balance’ between his individual perspective (and written outputs) and his collective responsibility as a member of a forum. It can, however, be argued that Parker’s appeals to the constraints of formal membership of a government advisory body as a reason for his lack of influence is less convincing; as a participant in full SAGE meetings and the SPI-B subgroup (the latter a forum dedicated to advising Government on their communications strategy), it is reasonable to assume that he had every opportunity – or perhaps even an obligation – to proactively raise issues of ethical concern.

5. The limited experience of members of the advisory groups, together with the negative perceptions of SPI-B held by other key actors, may have attenuated the impact of ethical oversight

Participants in the online workshop facilitated by Pykett et al. (2022) drew attention to the narrow range of skills and experiences of members of the formal advisory groups as a possible reason for the neglect of ethical issues: 

There was one bioethicist on SAGE, and a handful of social/health psychologists, an architect, a legal scholar & an astrophysicist. The wider social science & humanities disciplines are almost entirely absent.

In addition, some of the workshop participants believed that ‘significant overlaps between people sitting on a range of different committees could be problematic’.

Perhaps of more significance to the lack of ethical oversight pertaining to the development of Covid-19 messaging were the negative views held by some politicians and senior civil servants towards members of SPI-B. For example, Dominic Cummins (Chief Advisor to Boris Johnson), when giving evidence to a Health and Social Care Committee in January 2021, described behavioural scientists as ‘charlatans’. A more restrained, though still negative, appraisal of SPI-B members was given by Lee Cain (Director of Communications under Boris Johnson) in his Covid Inquiry interview on the 31^st October 2023; Cain ‘didn’t find particularly helpful’ and ‘disagreed with’ the contributions of the behavioural scientists.

While such pointed criticism may be unjustified, it is clear that the actions of some SPI-B members did invite censure. Professor James Rubin (a co-chair of SPI-B) recently told the Covid-19 Inquiry how ‘the decision in June 2020 of multiple participants of SPI-B to join a subgroup of independent SAGE took me by surprise and put us in an awkward position’. The fact that eight behavioural scientists had become involved in independent SAGE – a group of zero-Covid advocates publicly critical of Government policies – would likely have tempered SPI-B’s influence on other key players. Indeed, as stated in Rubin’s transcript, Patrick Vallance (the Government’s Chief Scientific Advisor) at the time described it as ‘an odd thing to do & may cause problems … totally inappropriate’ and said that Government departments were ‘very wary’ of putting anything to SPI-B because of ‘leaks or misuse’. These actions of SPI-B dissidents would have ensured that – if they were to subsequently question the ethical basis of nudge-infused Covid messaging – their influence would likely be weakened.

The next steps

The initial report of this ongoing research project strived to identify the key players (behavioural scientists, civil servants, politicians and advertisement company personnel) who were responsible for the development of ethically dubious Covid messaging – that deployed fear, shame and scapegoating – to lever compliance with pandemic interventions. Building on this analysis, this document has: scrutinised the sources of ethical guidance available to policymakers during the Covid event; documented the advice offered that was potentially relevant to the ethical questions surrounding nudge-infused messaging; presented evidence that this guidance had minimal impact on the range of pandemic decisions, and no impact at all on the design of Covid communications; and listed the barriers that ethicists and academics believe may have been responsible for the minimal impact this ethical guidance had on policy.

Building on this knowledge base, the next steps of the research project will:
a) Provide a critical review of the academic literature discussing the ethics of nudging.
b) Conduct a gap analysis to highlight the key differences between ethical best practice in decision making around the state’s use of nudging and the reality of what happened during the Covid event.
c) Develop, and disseminate, a bespoke or modified set of ethical guidelines and /or processes to inform and constrain how the UK Government uses behavioural science in the future.

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