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Table 3 Illustrative data extracts- Thompson’s framework- ethical values

From: Understanding the school community’s response to school closures during the H1N1 2009 influenza pandemic

Ethical values:

Decision-makers must strive to:

Evidence of ethical values in study

Examples - positive

Examples - negative

Values which were strongly in evidence

Duty to provide care

– work collaboratively with stakeholders to establish practice guidelines

Strong: All groups took duty to care seriously; schools had a broader definition of duty of care.

[Do you think that closing the school was an appropriate response…]

 

At that time, yes I do. Yes. Because I think that, again, if it had spread – [but] I mean, I teach a Year 12 class and we simply cannot afford the time to be mucking around and just staying away, et cetera… [Teacher, school 3]

– develop fair and accountable processes to resolve disputes

“Well, I guess when we knew that it wasn’t even as strong as the normal flu or whatever so that seemed kind of stupid but then there was the other argument which was; what if it turns into something really bad”. [Student, school 2]

Protection of the public from harm

– weight the medical and moral imperative for compliance

Strong – good awareness of need to protect public from harm

“… I really thought some of the rules were totally ridiculous but I didn’t want to put others at risk … I did take the dog for a walk but I made sure I went on a route where I wasn’t going to come in contact with anyone because I can’t sit still for 24 hours…But I think it was more – like I wouldn’t have visited my brother because I didn’t want to put his kids at risk.” [Teacher, school 2]

 

– ensure public are aware of medical and moral reasons for public health measures

– ensure public are aware of benefits of compliance and consequences of non-compliance

– establish mechanisms to review decisions as public health situation changes

[So thinking about the fact that you stayed home for that whole week and sort of stuck to the regulations I guess, what sort of promoted you to do that? Why did you stick to the rules?]

“Um.... There wasn’t really any point for me going out anyway, you know. I’d rather stay home, just stick to what rules were set then…yeah, ‘cause if I did have the infection I didn’t want to spread it any more.” [Student, School 4]

Stewardship

– consider benefits to the public good and the fair distribution of benefits and burdens

Strong- serious efforts to minimise harm and use the pandemic for good ends

“Before I left to go home that day I scanned in all of my lesson plans and all the resources for my Year 12 classes, which I was most anxious about. And so I emailed those to all of my students, and I was in phone contact, I was on email, and I set them enough work to make sure they didn’t lose any time or we didn’t fall behind in our course......I didn’t mind doing that. … And with my Year 10s, I didn’t set them as much work, and I was available through email and I gave them my home phone number”. [Teacher, school 1]

 

Values for which evidence was mixed

Solidarity

– ensure good, open, honest communication

Mixed: Solidarity between PH officials and schools in some situations, but not all.

“Look, Communicable Diseases were fantastic. They were probably in the same spot we were....”. [Principal, school 3l]

“Effectively the only thing we really got told was to … try not to go to public places etc . . . a few of us [were] going out to dinner on Saturday night, so we cancelled that, then found out [a school leader] went to the football that Friday night. [The school leader] said that some information had come through later that we didn't have to be as isolated. That wasn’t conveyed to staff in any way, shape or form, which I thought was pretty disgusting. . .” [Teacher, school 3]

– open collaboration in a spirit of common purpose between institutions

“I would say as the events unfolded that the communication … from the school was outstanding and from the Health Department who were here and giving information to the kids and to parents. There were daily phone calls to find out whether [our son] had shown any symptoms and when we were at work and he was at home on his own those phone calls were still there.” [Parent, school 1]

– share public health information

– coordinate delivery of health care and deployment of human and material resources

Lack of solidarity undermined School closures

Privacy

– disclose only private information relevant to achieve legitimate and necessary goals of public health

Mixed: good awareness of privacy issues but sometimes practices undermined this

“So, you know, we sort of, we really wanted to stress to the media that this is a human story It was about the dignity of the child that’s ill, and the dignity of all people that [have] swine flu…” [Principal, school 5]

“Oh, there was nothing subtle about it. Everyone knew that if you were the three students . . . that got the pink one [form], that meant it was really bad, and if you were the 27 kids that got the orange colour, then that meant it was really good . . . They are very attuned - the kids know . . . they pick it up straight away. . so they knew straight away…..yeah, the pink one - oh my god, I’m going to die. It was like, oh my god, that’s it; and then the bursting into tears stuff.... Because no one really knew”. [Teacher, school 4]

– release private information only if there is no less intrusive means to protect the public.

– provide public education to correct misperceptions about disease transmission

Equity

– preserve as much equity as possible between interests of those with influenza and others

Mixed: awareness of equity issues but sometimes practices undermined this

Some of the wording from the Department is very hard for families to understand. They would read something like a release and they would ring up and ask what does that mean? We would have to explain that means this. Why doesn’t it say that? It does but [not] someone whose third or fourth language is English. [Principal, school 3]

“Totally confused about the home isolation. We tried to clarify that through the web and realised how many families and parents don’t have [access to] the web”. [Principal, school 3]

– ensure procedural fairness in decision-making

“… the Year 12s … they obviously blamed the Year 10s for bringing it in and … then they all started hating us… The [student]who had it … had to have a couple of days off when [they were] better because [they] just couldn’t handle people…sneering at [them]…” [Student, School 1]

Individual liberty

– ensure restriction to individual liberty are proportional to harm, necessary and relevant to protecting public good, employ least restrictive means and are applied without discrimination

Mixed: range of views about whether restrictions on liberty were justified

They said there was a real concern. They were really concerned about it. Therefore you must take it with some seriousness. [School librarian, school 1]

“..He [stayed home] pretty well but I think he went down and had a hair cut at the local hairdressers and a couple of other things. I don’t think he mixed with many other students. But he went off and did his violin lesson as he normally does....As far as I was concerned, if he was symptom free, the risk of him transferring it was no greater than anyone else in the community.” [Parent, school 2]

Values for which there was little evidence or contrary evidence:

Proportionality

– use least restrictive or coercive measures to limit individual liberties or entitlements

Lacking: Most members of school communities thought the response was not proportional to the danger

 

“. . it would be the wrong thing to say it was a sop to the policy, but that’s what it turned out to be, because in reality we had one student who had minimal contact with a small number of students, and we shut the whole place down as a result of that.” [Principal, school 1]

– use more coercive measures only when less restrictive measures have failed to meet public health goals

Reciprocity

– ease burdens of stakeholders responding to public health measures

Lacking: little to no awareness of impact on individuals; stigmatisation

 

“… I did ring up a girlfriend and asked her to do some shopping she dropped things on the front verandah, knocked on the door, and went. [sigh] so it was a bit of a lonely time for me. When you’re on your own, to be totally isolated with no one. With no contact with anyone, except the telephone.” [School librarian, school 1]

Key value

Trust

– take steps to build trust with stakeholders before a crisis

Mixed: not strongly apparent in all schools, but where displayed school closures worked well

....it was difficult when I didn’t quite understand it, but then, we trusted fully with the Department of Health. They inspired a lot of confidence. I think they were fantastic with this. [Principal, school 5]

“. . . you don’t know how much PR was involved versus actual medical necessity . . when any government agency is making a decision…they need to be seen to be handling it in a controlled way . . . for fear of being criticised in the media for it.” [Teacher, school 2]

– ensure decision-making processes are ethical and transparent to affected stakeholders

“Someone got positive for swine flu in my grade. Everyone was a bit nervous but a lady came along and she told us it was alright and stuff. But yeah, the principal was saying, just everyone keep calm. [Student, school 3]