Table 1

Framework for ethical principles, considerations, and policy indicators for implementing, monitoring, and evaluating lockdowns and other movement-restrictive non-pharmaceutical public health interventions

Ethical principleDescription of principle as per the source referenceQuestions/considerations raised under the principleCorresponding policy monitoring and evaluation indicators
Harm/necessity
  • Warranted by previous medical and public health analyses18

  • Knowledge of measurable harm20 22

  • Presence of justifiable basis for harm21 23

  • Is there measurable harm due to the disease outbreak?

  • Presence of scientific evidence indicating harm (eg, human to human transmission, mortality)

  • Presence of decided metric for harm measurement (eg, death count, case count, case fatality ratio)

Justifiability
  • Reasonable expectation that it will have a significant impact; reliance on best available scientific evidence21

  • A justifiable basis for imposing restrictions, based on evidence, with continuous re-evaluation23

  • Scientific justification for the quarantine, plausible way to determine who should be quarantined18

  • Measures should be grounded in the best available scientific evidence22

  • Is there scientific evidence for the effectiveness of the restriction to prevent/reduce harm?

  • Is the appropriateness of the restriction being continuously re-evaluated as and when more evidence emerges and when the course of the outbreak changes (increase/decrease in cases)?

  • Is the restriction being withdrawn when new evidence suggests that the original rationale is no longer applicable?

  • Are the restrictions placed based on some valid parameters (eg, case counts in a locality) that can determine who is at the risk of harm?

  • Presence of prior peer-reviewed scientific publications on the effectiveness of restrictions

  • Successful historical precedent (any instance before)

  • Presence of a dedicated response team for review of literature, adequate data collection, impact evaluation and situational monitoring to continuously determine the effectiveness of the restrictions

Proportionality
  • Mandatory restrictions should only be instituted as a last resort; restrictions to be terminated when no significant benefit seen21 23

  • Restrictions should be proportional to the disease control goal20

  • The restriction should be accurately tailored to specific risks18

  • Is the restriction proportional to the potential harm?

  • Matching stringency of measures with the growth of cases and deaths in the epidemic*

Least restrictive means
  • Mandatory measures should only be instituted as a last resort21 23

  • Voluntary measures should come before mandatory ones20

  • Mentioned as the principle of least infringement, which suggests minimisation of impingement on individual liberties22

  • Is the least restrictive measure applied before other measures severely curbing individual and communal rights?

  • Are voluntary restrictions implemented before mandatory restrictions?

  • The number of steps between the least (eg, voluntary physical distancing at public places) and the most restrictive (eg, mandatory lockdown) measures

  • Whether sufficient time intervals are given for every set restrictive step to show maximum effect*

Utility efficiency
  • Potential benefits should outweigh the adverse effects18

  • Maximising aggregate benefits under fewest costs21

  • Do the probable benefits of the restriction outweigh the probable risks?

  • Are the restriction benefits achieved under the smallest costs?

  • Does the analysis of trade-off (eg, cost–benefit analysis) between loss of livelihood and other losses against deaths averted and cases averted show net positive benefit?*†

Reciprocity
  • Provide means of mitigating adverse effects; provide employment protection; address financial and employment consequences21

  • Ensuring humane conditions, addressing financial and social consequences23

  • Communication strategies should be designed to avoid stigmatisation (mentioned under communication and transparency)23

  • Society has a reciprocal obligation to individuals for curtailing their liberties20

  • The needs of detainees must be addressed18

  • Those who bear the burden of restrictive policies should be supported by society and public agencies22

  • Is the government reimbursing the individuals for curtailing their rights and for the loss of income/loss of livelihood due to restrictions?

  • Is the government placing relief mechanisms ensuring that the restricted individuals are not facing an undue burden?

  • Are measures being taken to avoid stigmatisation and discrimination of those under restrictions?

  • Are the societal groups less affected by the restriction taking care of those affected gravely by them?

  • Cost and population coverage

  • Presence of tax and loan payment concessions

  • Postponing non-essential routine activities (eg, examinations, sports events, etc)

  • Anti-discriminatory mass media practices

  • Guidelines in place for responsible news media reporting to avoid discrimination and reduce stigma

  • Presence of helplines to deal with mental health issues that may arise

  • Surveys for awareness among people about avoiding discrimination

  • Presence of grassroots ventures that help the impoverished groups

Transparency
  • Process and rationale of decision-making should be made transparent and public (mentioned as publicity of measures)21

  • Decision-makers should publicly explain the basis for decisions, including the uncertainties in decision-making23

  • Communicate clearly the justification for quarantine20

  • Are the policy decisions regarding restrictions and their rationale being continuously informed to the public in comprehensible ways?

  • Presence of press conferences in local languages

  • Frequency of press conferences

  • Presence of outreach methods and materials that are easy to understand, in local languages, and are widely distributed

  • Presence of a public record of justification for the quarantine that is conveyed to lay people in local languages

Relevance
  • Reasons, principles and evidence for the decision should be considered relevant by the affected stakeholders; develop strategies with community input21

  • Solicit community members’ views on restrictions (mentioned under communication and transparency)23

  • Are the restrictions being implemented with feedback from the community that is affected by them?

  • Presence of public opinion polls

  • Presence of people’s representatives in the decision-making process of dedicated response teams

Equity
  • Special attention to protecting vulnerable populations21

  • Equitable application of movement restrictions23

  • Rights and liberties of restricted individuals should be protected, disproportionate distribution of the benefits and burdens of PHI to certain individuals/groups should be prevented; mentioned as the justice and fairness principle22

  • Is there equitable distribution of the available resources for relief to the marginalised communities?

  • Is there a disproportionate burden of the restriction on vulnerable populations?

  • Presence of food and shelter security for the below poverty line and low-earning unorganised labour groups affected by the restrictions

  • Presence of domestic violence helplines for women and children

  • Availability of healthcare access for the chronically ill and elderly groups

Accountability
  • Provide individuals with legal recourse to challenge their isolation/quarantine; revisability; appeal mechanisms21

  • Due process protections; decision-makers should be held accountable for abuse of authority23

  • Allow for a process of appeal20

  • Are there measures in place for individuals to express grievances and challenge the restrictions?

  • Can the decision-makers be held accountable in case of losses (economic/health)?

  • Presence of grievance redressal and feedback portals

  • Presence of public platforms to challenge the restrictions by speaking to authority figures

  • Presence of laws that allow for a process of appeal

  • Uninterrupted and autonomous working of the judicial system for fast-tracking the restriction-related appeals

  • Mechanisms for demanding reparations in case of life and livelihood losses due to restriction

Cost and feasibility
  • Countries should review if their existing laws provide authority for actions that may be needed in a pandemic; mechanism in place for enforcement/regulation21

  • Feasibility of implementation and maintenance of quarantine18

  • Costs and practical constraints need to be taken into account23

  • Are financial and other resources available to carry out a restriction?

  • Does the country have legal and disciplinary systems in place to enforce the restriction?

  • Are there enough resources to provide food, shelter, counselling to the community during the period of restriction?

  • Presence of laws that allow the implementation of restriction

  • Presence of a police force for restriction (eg, confinement) implementation

  • Ability to create places of confinement for restricted (eg, quarantined/isolated) individuals

  • *These indicators depend on the intrinsic characteristics of the disease in question and need to be modified based on disease knowledge to be made dichotomous.

  • †This analysis incorporates the trade-off between total economic loss versus economic catastrophe averted in the form of saved lives. Such analyses routinely involve calculations over the value of statistical life or quality-adjusted life-years estimates.30

  • PHI, public health intervention.