témoignage / perspective

Public Health Ethics in Times of Crisis: The Experience of the Quebec Public Health Ethics Committee During the COVID-19 Pandemic

Michel Désya,b, Bruno Leclercc, Julie St-Pierrea

Résumé

Abstract

Le présent texte vise à partager l’expérience du Comité d’éthique de santé publique (CESP) de Québec pendant la pandémie de COVID-19, et plus particulièrement sur les risques et les opportunités rencontrés pendant cette période. Nous discutons notamment de l’agilité du CESP, conférée par ses règles de fonctionnement et son processus structuré d’examen éthique, et de sa capacité à réagir rapidement pour répondre aux questions éthiques soulevées par les interventions de santé publique en temps de crise. Nous nous concentrons sur les défis liés à l’autonomie du CESP, en particulier sa capacité à répondre en temps opportun à des préoccupations éthiques critiques.

The aim of this text is to share the experience of the Quebec Public Health Ethics Committee (CESP) during the COVID-19 pandemic, and more specifically on the risks and opportunities faced during that time. In particular, we discuss the agility of the CESP, conferred by its operating rules and structured ethical review process, and its resulting ability to react quickly to address the ethical issues raised by public health interventions in times of crisis. Our focus is on the challenges that come with the CESP’s autonomy, specifically its capacity to address critical ethical concerns in a timely manner.

Mots-clés

Keywords

comité d’éthique de santé publique, Québec, COVID-19, pandémie

public health ethics committee, Quebec, COVID-19, pandemic

Affiliations

a Secrétariat Général, Institut national de santé publique du Québec, Montréal, Québec, Canada

b Département de médicine sociale et préventive, École de santé publique de l’Université de Montréal, Montréal, Québec, Canada

c Département des lettres et humanités, Université du Québec à Rimouski, Rimouski, Québec, Canada

Correspondance / Correspondence: Michel Désy, michel.desy@umontreal.ca

introduction

When the Public Health Act was overhauled in 2001, the Quebec government created a public health ethics committee, the Comité d’éthique de santé publique (CESP), to independently review proposed surveillance plans and certain population health investigations. The CESP is also mandated to give its opinion on any ethical issues that may arise in the application of the Public Health Act within the field of public health practice, including any action or plan related to health promotion and protection, as well as disease prevention. Since 2009, the CESP has been bound to the Institut national de santé publique du Québec (INSPQ) through its Board of Directors, who has responsibility for its composition and operating rules. The CESP’s opinions aim to advance debates about public health actions that have a significant impact on the targeted population. The CESP’s composition reflects a deliberative democratic ethos, incorporating three public representatives, an ethicist, a legal expert, and three public health professionals. This structure ensures that ethical deliberations are informed by diverse perspectives, including lay voices, normative frameworks, and scientific realities. Though its opinions are non-binding, they are published online to stimulate public debate and exert argumentative pressure on policymakers. The legislator’s establishment of the CESP aligns with a deliberative ethical perspective, which contributes to critical analysis of issues aimed at fostering democratic debate.

Challenges

The COVID-19 pandemic had a significant impact on public health authorities worldwide, as well as on the CESP. Maintaining operations, efficiency, and agility were the main challenges faced by the committee.

Continuity during times of crisis

The onset of the COVID-19 pandemic in March 2020 paralyzed the CESP’s operations. Between March and June 2020, all committee meetings were suspended due to the unavailability of public health professionals required for quorum, many of whom were redeployed to frontline pandemic response efforts. Concurrently, requests for ethical reviews from the Ministry of Health and Social Services (MSSS) stalled, reflecting a system-wide prioritization of acute crisis management over ethical deliberation. Given the high number of ethical issues linked to the COVID-19 pandemic, CESP practices were reviewed, notably its membership. In the summer of 2020, under the guidance of the INSPQ Board of Directors, the CESP’s internal regulations were amended, introducing two substitute members to ensure quorum during absences. This reform, though modest, restored the committee’s capacity to address urgent issues, such as ethical reviews of surveillance protocols. By August 2020, the CESP resumed operations, albeit with a backlog of delayed requests. The inclusion of substitutes not only mitigated operational paralysis but also underscored the importance of structural flexibility in maintaining continuity during crises.

Efficiency in producing opinions

The process of developing and implementing policies to protect the health of the population was significantly impacted by the COVID-19 pandemic and ethical support for decision-making was constrained by this timeframe (1). The urgency of the pandemic necessitated radical departures from the CESP’s traditional workflows. The rapid evolution of the epidemiological situation and the resulting health measures put in place during the pandemic, as well as the pressure on health services to meet the increased demand for care, required an accelerated response to ensure the relevance of the CESP’s work. Prior to the crisis, the committee’s process involved request intake, evidence synthesis, deliberation across 2-3 monthly meetings, and publication after a 60-day embargo. The pandemic rendered this timeline untenable. In response, the CESP adopted streamlined workflows. Ad hoc working groups – composed of committee members, INSPQ staff, and external consultants – accelerated opinion production.

It should be noted that when the analysis of the health and social impact of population measures is carried out in real time, the resulting ethical opinions may need to be updated with a view to informing the public debate on the application of the measure. In this context, the CESP updated its Opinion on the compulsory vaccination of healthcare workers against COVID-19 (2) in 2021 to respond to the evolving situation. Publication timelines were also compressed: the mandatory 60-day embargo was reduced to under a week for critical opinions. Consequently, the Update to the Opinion on Mandatory COVID-19 Vaccination for Healthcare Workers (3) was published within five days of finalization to inform urgent policy debates.

Agility

From 2020 to 2022, no request was made to the CESP by public health authorities in connection with the COVID-19 pandemic, despite the major ethical issues associated with public health measures (e.g., curfew, wearing of masks). In the spring of 2020, professionals and members of the CESP and the Commission de l’éthique en science et en technologie (CEST) took the initiative of publishing two documents examining ethical issues raised by the pandemic (4,5). The first outlined an ethical framework to shed light on the dilemmas raised by the pandemic, while the second dealt with decision-making under a context of scientific uncertainty in the period following the first curfew imposed by the authorities in Québec in the spring of 2020. These documents provided a normative scaffold for subsequent deliberations.

In the autumn of 2020, recognizing that the public health authorities had not formally engaged in consultation with the CESP regarding the ethical dilemmas arising from the global pandemic response, and the CESP’s desire to contribute to public discourse on these matters, the committee resolved to assume the responsibility of directly addressing some of these issues. Article 19.3 of the INSPQ Act grants the CESP authority to “give its opinion on any ethical question arising from the application of the Public Health Act.” (6) This provision proved indispensable during the pandemic, enabling the committee to address issues absent formal requests from authorities. The CESP’s self-referral capacity contributes to important debates surrounding fundamental ethical issues and to democratic life in general. The effectiveness of public health actions can be enhanced by strengthening the ethical justification of public health measures; and the legitimacy and social acceptance of public health actions can be established through the CESP’s contribution to deliberative rigour in public discourse. The CESP issued three opinions in this manner: two regarding to the vaccination of healthcare workers (2,3) and one concerning immune passports (7). Before it was published, another opinion was dropped because the policy that was its subject matter had been withdrawn (8).

Risks and opportunities

The CESP’s autonomy, while a strength, carries inherent risks. The underutilization of self-referral could have eroded public trust, particularly if the committee remained silent on contentious issues. Proactive engagement, however, reinforced its legitimacy. The CESP enjoys autonomy in selecting topics and conducting its review in an independent manner, which is the cornerstone of its work. In the context of the CESP’s decision to address critical ethical issues during the pandemic, the rigorous, public, and falsifiable nature of its review process was fundamental to the CESP’s legitimacy and its interventions in the public sphere (9).

In 2022, the committee formalized its self-referral process to mitigate risks. Topic selection now requires alignment with the committee’s mandate and demonstration of significant societal impact. A risk assessment phase, involving consultation with the INSPQ’s Governance and Ethics Committee, evaluates political and scientific sensitivities. Transparency protocols ensure that all self-referral rationales are published alongside opinions, fostering accountability. At the conclusion of this risk assessment, the committee has the option to either proceed or not with the examination of the selected topic. This is very important from a risk management standpoint, because the CESP’s publications during the pandemic received significant media attention, something it had never received before.

Discussion

Three fundamental challenges associated with expedited ethical assessments during crises are elucidated by Yeh and Lee (1). First, despite the rapid nature of opinion generation, inevitable delays can still impede the timely development and implementation of critical policies that are crucial for disease containment or mitigating the consequences of a public health emergency. Second, the public nature of opinions, often presented alongside other documents, regulations, policies, and similar materials addressing the same concerns, presents a potential source of confusion or misuse. This can adversely affect the efficacy of disease prevention initiatives, individual health behaviours, and overall health outcomes. Lastly, the implementation of rapid ethics reviews may necessitate additional administrative inputs, including dedicated funding and human resources.

In response to the first issue raised by Yeh and Lee, it is important to acknowledge that, while there is potential to enhance the efficiency of opinion development, there will always be a delay associated with the ethical review process for the proposed measures. By optimizing the production process and facilitating communication between the review committee and the relevant authorities, these delays can be effectively mitigated. The emphasis on timeliness underscores the significance of public health authorities seeking the advice of committees with the mandate to provide ethical assessments during a pandemic. Their recommendations should be considered when formulating and implementing health measures, both legally and otherwise. Notably, even without prior consultation, the CESP provided its initial opinions on the vaccination of healthcare workers and the issuance of immunity passports well before these measures were formally considered. In this context, anticipation played a crucial role.

Regarding the second issue, during the pandemic, several journalists erroneously equated the CESP with the INSPQ, which is its designated responsible institution. This resulted in a misrepresentation of the CESP’s independence in its ethical review process and recommendations. Given its comprehensive expertise in public health, the INSPQ experienced heightened demand during the pandemic. Consequently, the confusion between the institution and the independent ethics committee for which it is responsible posed a persistent challenge throughout the pandemic. The CESP’s opinions garnered significant media attention, which facilitated the promotion of their ethical contributions to public discourse due to this misunderstanding. However, to prevent confusion, it is crucial that the role and characteristics of a committee like the CESP be consistently emphasized and clarified as necessary, particularly during periods of heightened media visibility.

Yeh and Lee’s third challenge was not encountered by the CESP, as it was already in place prior to the pandemic, with a budget and human resources. This situation suggests that the form of institutionalization of ethics that links the CESP to the INSPQ can be advantageous, and it can attain its full potential during an emergency if the CESP’s services are promptly requested by the relevant authorities. However, the CESP lacks both the mandate and the resources to conduct extensive public consultations on specific cross-cutting issues related to crisis management during a pandemic situation, particularly concerning the observance of the Quebec Charter of Human Rights and Freedoms. Should such a necessity arise at the conclusion of the post-pandemic assessment, Quebec possesses the requisite institutions (e.g., the Commissaire à la santé et au bien-être), academic expertise needed to facilitate such consultations and, if necessary, the capacity to develop novel normative guidelines to prepare for the next pandemic.

Conclusion

Indeed, Yeh and Lee’s analysis (1) is corroborated by pertinent observations made by the CESP during the pandemic. First, any period of public health crisis can disrupt the regular activities of a committee working in this or a related field, particularly for committees operating in the domains of public health and/or other health-related ethical considerations. It is paramount to ensure that ethics advisory committees can maintain their normal operations during times of crisis. Second, such committees must be able to provide their opinions in an expedited manner to ensure their relevance in a dynamic decision-making environment. Lastly, if given the opportunity and their input is not otherwise sought, committees should proactively analyze significant ethical issues that fall within their expertise, even if this entails taking an uncomfortable position. As outlined in Wilson’s et al. typology (10), the CESP and other committees serve as a critical ally to those responsible for public health decision-making (i.e., the MSSS). Integrating ethical justification into public health practice leads to its enhancement. The CESP’s experience during the COVID-19 pandemic exemplifies both the challenges and opportunities for achieving this objective within the context of a public health emergency.

Reçu/Received: 23/08/2024

Publié/Published: 28/04/2025

Conflits d’intérêts

Conflicts of Interest

Aucun à déclarer

None to declare

Édition/Editors: Hazar Haidar & Aliya Affdal

Les éditeurs suivent les recommandations et les procédures décrites dans le Core Practices de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.

The editors follow the recommendations and procedures outlined in the COPE Core Practices. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.

references

1. Yeh MJ, Lee PH. Ethical preparedness for health policymaking and implementation during public health emergencies: the role of rapid ethical assessment. Health Security. 2023;21(5):371-78.
   2. CESP. Avis sur la vaccination obligatoire des travailleurs de la santé contre la COVID-19. Québec: INSPQ; 2021.
   3. CESP. Mise à jour de l’avis sur la vaccination obligatoire des travailleurs de la santé contre la COVID-19. Québec: INSPQ; 2021.
   4. Désy M, St-Pierre J, Leclerc B, Couture-Ménard M-E, Cliche D, Maclure J. Cadre de réflexion sur les enjeux éthiques liés à la pandémie de COVID-19. Comité d’éthique de santé publique & Commission de l’éthique en science et en technologie. Québec: INSPQ; 2020.
   5. Désy M, Bernier N, St-Pierre J, Leclerc B, Couture-Ménard, M-E, Maclure J. Enjeux éthiques de la pandémie de COVID 19 : précaution et déconfinement. Comité d’éthique de santé publique & Commission de l’éthique en science et en technologie. Québec: INSPQ; 2020.
   6. Loi sur l’Institut national de santé publique du Québec, LQ 1998, chapitre I-13.1.1, art 19.3.
   7. CESP. Avis sur les passeports immunitaires. Québec: INSPQ; 2021.
   8. CESP. Rapport d’activités 2021-2022. Québec: INSPQ; 2022.
   9. Filiatrault F, Désy M, Leclerc B. Le processus d’examen éthique du Comité d’éthique de santé publique et son cadre de référence. Comité d’éthique de santé publique. Québec: INSPQ; 2017.
  10. Wilson J, Hume J, O’Donovan C, Smallman M. Providing ethics advice in a pandemic, in theory and in practice: A taxonomy of ethics advice. Bioethics. 2024;38(3):213-22.

## Références

MJ, Lee PH. Ethical preparedness for health policymaking and implementation during public health emergencies: the role of rapid ethical assessment. Health Security. 2023;21(5):371-78.

2CESP. Avis sur la vaccination obligatoire des travailleurs de la santé contre la COVID-19. Québec: INSPQ; 2021.

3CESP. Mise à jour de l’avis sur la vaccination obligatoire des travailleurs de la santé contre la COVID-19. Québec: INSPQ; 2021.

4Désy M, St-Pierre J, Leclerc B, Couture-Ménard M-E, Cliche D, Maclure J. Cadre de réflexion sur les enjeux éthiques liés à la pandémie de COVID-19. Comité d’éthique de santé publique & Commission de l’éthique en science et en technologie. Québec: INSPQ; 2020.

5Désy M, Bernier N, St-Pierre J, Leclerc B, Couture-Ménard, M-E, Maclure J. Enjeux éthiques de la pandémie de COVID 19 : précaution et déconfinement. Comité d’éthique de santé publique & Commission de l’éthique en science et en technologie. Québec: INSPQ; 2020.

6Loi sur l’Institut national de santé publique du Québec, LQ 1998, chapitre I-13.1.1, art 19.3.

7CESP. Avis sur les passeports immunitaires. Québec: INSPQ; 2021.

8CESP. Rapport d’activités 2021-2022. Québec: INSPQ; 2022.

9Filiatrault F, Désy M, Leclerc B. Le processus d’examen éthique du Comité d’éthique de santé publique et son cadre de référence. Comité d’éthique de santé publique. Québec: INSPQ; 2017.

J, Hume J, O’Donovan C, Smallman M. Providing ethics advice in a pandemic, in theory and in practice: A taxonomy of ethics advice. Bioethics. 2024;38(3):213-22.