In terms of general trends in the social application of knowledge, there are a number of ways in which decision making has tended to gravitate away from those most immediately affected and toward institutions increasingly remote and insulated from feedback… Even within democratic nations, the locus of decision making has drifted away from the individual, the family, and voluntary associations of various sorts, and towards government. And within government, it has moved away from elected officials subject to voter feedback, and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary. These trends have grave implications, not only for individual freedom, but also for the social ways in which knowledge is used, distorted, or made ineffective.

Thomas Sowell¹

Introduction

In this article, I will explore how decision-making about treatment for health problems has moved away from clinicians and their patients, and has been taken over increasingly by governments and their associated bureaucracies. I will consider this in relation to the health service in Britain, and then look at the global response to Covid. I will finish by exploring the ethical issues with which authoritarian top-down control confronts Buddhists.

But I begin by drawing an analogy with a different type of human activity. This will serve to illustrate some important principles that also apply to health care (as well as other types of activity). The activity is that of driving and the rules that apply to it.

Driving, Regulation and Choice

In Britain, users of our road system must follow the laws governing road use, as described in the Highway Code. These laws prescribe which side of the road one must drive on, who has priority at a junction, and so on. They have to be learned and rigorously followed by any person who wishes to have a driving licence.

Let us suppose that, instead, there were no such laws governing road use — no Highway Code. Imagine that each person could choose on which side of the road to drive, that there were no speed limits, and that no one at a junction had any prescribed priority. This unregulated road system would likely result in chaos, with numerous accidents, traffic jams, and slow journeys.

In contrast, suppose that everything about using the road system was controlled: that drivers were subject not just to the Highway Code, but also to rules about who could drive, and when and where. Consequently, nobody could decide to get in a car, or use a bike or motorbike or even a bus, without permission, or having been ordered to do so. In such a system you would have to apply for permission to travel from one location to another at a specific time on a specific day. Imagine too that the rules governing individuals’ road use included quotas based on policies intended for the public benefit. Such policy-based restrictions might, for example, be concerned with whether the travel was associated with ‘essential’ activity, or how much it might contribute to global warming or the spread of disease, or the racial and gender characteristics of the person travelling. Obviously, such a system would seriously inhibit travel, personal freedom, and social interaction. It would be highly authoritarian, if not totalitarian.

Considering these two extremes — under-regulation and over-regulation — we can see that appropriate regulation will involve finding a middle way between the two: a way that enables people to travel as safely as possible, without unduly constraining their freedom to travel when and where they wish. With inadequate regulation, roads become more dangerous, and as a result people have less freedom to travel due to the high risks of simply being on the road. On the other hand, a rigid control-from-above approach, perhaps rationalised by over-zealous concerns about safety, equality, and the environment, would directly limit people’s freedom of choice and movement.

The existing road-system regulations, together with my hypothetical extreme counterexamples, illustrate that some degree of regulation is necessary for human activities to minimise harm and maximise freedom of choice. Of course, with road travel, there cannot be perfect safety, nor can everyone necessarily be allowed to drive to any specific destination they might unreasonably wish to go (such as onto the runway of an airport). But an effective and appropriate system of regulation is one that succeeds in reducing risk while maximising choice as far as possible.

This example suggests that in other areas of human activity — not just in road travel — there may be optimum systems of regulation that minimise risk and maximise choice. How much regulation, if any, is optimum in a given area will depend on many factors. There may be areas where no regulation is optimum and others where it needs to be strict. For example, one could consider trade and the regulation of markets with regard to freedom, regulation and over-control. However, here I want to look at another aspect of human activity, namely health care. I am going to discuss the degree to which health professionals are allowed to use their clinical judgement in their work, and to run surgeries and hospitals which function well in supporting effective clinical work.

Health Care, Regulation and Choice

An unregulated health system would let anyone practise who wanted to call themselves a health professional. Anybody would be allowed to set up institutions and businesses, and to practise and make money, even if the treatments they offered were ineffective or harmful. Such an unregulated system would also allow people to sell any products as medicines, and to perform whatever procedures they claimed were effective in treating illness and injury. The nineteenth-century marketing of ‘snake oil’ as a health panacea was an example. A hypothetical contemporary equivalent would be if doctors today were allowed to offer blood-letting to cure diseases, or exorcism to treat mental health problems.

In contrast, a reasonably regulated system would encourage, allow and mandate suitable training for each of the various health professions. Training would be based upon the accumulated clinical experience and the empirical and scientific knowledge of those professions, and on the sciences and other fields of study that inform them. It would also allow those suitably qualified through such training to make clinical decisions based on their level of knowledge and experience. Those not suitably qualified would not be allowed to practise. Furthermore, in such a reasonably regulated system, the structure and functioning of the surgeries (local medical centres), hospitals, and other health organisations would be determined by the experience of clinicians and by the needs and opinions of their patients.

In contrast, an over-regulated health system would involve rigidly controlled organisation and management of hospitals, surgeries and other health organisations. The managers would be expected to follow structures and procedures dictated by a centralised bureaucratic authority, and not by local health professionals. These professionals and their organisations would also be expected to meet centrally set targets, ignoring local professional and patient opinions on what was needed.

Such an over-controlled health system might also have other unwelcome characteristics. Poor training, unfit for the purpose, might be forced upon practitioners. Professionals might be obliged to follow rigid treatment protocols instead of acting upon their own clinical judgment, knowledge and experience. Such rigidity would restrict the range of illnesses a specialist could treat or investigate, making it difficult to cross-refer to, or work cooperatively with, other specialities. The consequence would be impaired treatment, especially for those with complex co-morbidities.

Thus, like the three types of road system in my analogy, we can also imagine three types of health care system – under-regulated, appropriately regulated, and over-controlled. So, what about currently existing healthcare systems? How closely do they correspond to one of these three possible types? I will explore this question by looking at the health system in the UK.

The UK Health System

In the UK, it is noteworthy that over the last twenty to thirty years health professionals have become increasingly controlled from above. Politicians, bureaucrats and senior managers have imposed rigid procedures, undermining clinical practice. Typically, the senior managers are themselves restricted by control from above. Their organisations have also become increasingly controlled and regulated by the Department of Health and a network of centralised agencies.

It was not always like this in the NHS, as I can personally bear witness. In the 1980s, I was a founder-member of a community mental health team. The team was led by a consultant psychiatrist, who wisely took a serious interest in the team members’ opinions on how to provide an optimum service. All team members had suitable accredited training and years of experience. The team also consulted patients and local GPs on the sort of service they wanted. We adapted what we did in the light of their opinions. We had no team manager. Everything we did was based upon our own clinical knowledge, skills and experience, and informed by the views of our patients and local practitioners.

But by the 2000s, the NHS had changed profoundly. Within the mental health service where I was working by that time (not the one I mentioned above) we had to disband the ‘crisis team’ we had developed. The team members were subsumed into a new specialist service that covered a much wider geographical area. They were unhappy about the change, and predicted that the new service would not work, especially over the extensive rural area it was supposed to cover. They were proved correct. Implementation of the new service left many crises for us to deal with. After six months, the new service was itself in crisis, and the manager resigned. I myself left the NHS in 2004 because of this ethos of over-control, in which clinicians’ opinions were ignored.

Why and how had such a misconceived ‘reform’ been implemented? The government, in association and consultation with its chosen ‘experts’, had designed the new system on the basis of a study of just one such service in an inner-city area. It then stipulated that the same model must be used everywhere, regardless of the opinions of local clinicians. Our service managers did what they were told, despite clinicians’ disagreement.

During the same period that I was experiencing this over-regulation of a specific NHS service, I also began to feel concerned about a broader undermining of civil liberties in the UK by the government of the day. I was far from alone in this. Perhaps the issue received its widest public attention in 2007, with the release of Chris Atkins’ film ‘Taking Liberties’². But even a few years before that, in 2003, a booklet called ‘Total Politics – Labour’s Command State’ had been published ³. It showed me that others were concerned about the government’s over-control of public services in the same way that I was. The booklet pinpointed four features of such over-control: targets imposed by Whitehall, centrally controlled funding, bureaucratic audit and inspection, and rigid terms and conditions. The authors termed this four-pronged approach ‘command and control’. There was also a more detailed book called ‘Systems Thinking in the Public Sector’, published in 2008 by an occupational psychologist⁴. This also severely criticised command-and-control and the dysfunctional systems imposed by the British government on public services.

Drawing on these sources and on my own experience in the NHS, I want to outline here what I see as the crucial characteristics of command-and-control. They can be summarised in six inter-related categories:

• The inappropriate command, regulation and micro-management of services from above;
• the imposition of dysfunctional systems of management and organisational structure;
• rigidity in what practitioners are allowed to do, undermining their practical wisdom;
• the use of inappropriate (and at times, to be frank, ridiculous) ‘targets’ by which the functioning of an organisation is supposedly measured;
• the reliance upon selected and government-approved ‘experts’ and their recommendations, rather than allowing professionals to make appropriate choices;
• a disregard for ordinary people’s opinions, especially of those members of the public most affected by the service in question.

On the grounds of health and safety, such authoritarianism can be rationalised as necessary to prevent serious harm. Yet however well-meaning the intentions behind it might be, command-and-control itself can bring about not just poor performance but serious harm. In practice, financial considerations often take priority over clinical ones. Yet ironically, the dysfunctional systems themselves turn out to be very costly.

The simplest and most direct way I can support my critique is by quoting from various reports and studies published in the last couple of decades. With regard to the NHS, here are some key quotations from the ‘Total Politics’ booklet that I mentioned above.

Central targets have distorted clinical priorities and caused a collapse in staff morale. (p34)

First, doctors, nurses and local hospital managers have been stripped of much of the autonomy they enjoyed before this government came to power. No longer can they treat patients by reference to need alone. Instead, they must treat patients in a way that allows them to meet targets. (pp34-35)

Targets have also caused a massive increase in red tape, bureaucracy and waste in the NHS. (p36)

This booklet was published in 2003 by the Conservative Policy Unit as a critique of the policies of the existing Labour government. However, the critique of command-and-control cannot be dismissed as a party-political issue. The fact is that the same strategy has continued under subsequent coalition and Conservative governments. In 2016, The King’s Fund published ‘The Chief Executive’s Tale’, containing interviews with people who had been senior managers in the NHS⁵. In particular those senior managers were critical of the 2013 Health and Social Care Act, brought in by the Conservative / Lib. Dem. coalition government. Here are some excerpts:

There was barely a good word said during the interviews about the 2013 reorganisation of health and social care… more generally, the adjectives used about the 2013 changes were ‘disastrous’ and ‘catastrophic’. (p12)

The bureaucracy includes the targets and all the reporting up the line of endless key performance indicators. The micro-management from the centre. The huge number of regulators and the amount of information they demand, often the same information in different forms, and the massive amount of money being spent to feed that beast. (p15)

I remember sitting on one side of a table with six or seven of my team to talk about improving A&E [accident and emergency] performance, strengthening our quality strategy and reducing our avoidable mortality, and there were 38 people from other agencies sitting opposite demanding ‘where, why, how’, each of them marking our homework. Thirty-eight of them! From Monitor, from the commissioners, from the NHS England region, from CQC, Healthwatch and so on… (p16)

As well as initiating the authoritarian, target-driven, micro-management of the NHS, the Labour Government under Tony Blair also undermined many health workers’ autonomy by establishing the Health and Care Professions Council (HCPC). The HCPC oversees their legal right to practise, and regulates the criteria that must be met. Before the establishment of the HCPC, the professional bodies of the health care workers performed these functions for themselves. Subsequent governments have not overturned this. Thus, health professionals (other than doctors, whom the GMC oversees) are only permitted to practise if they continue to meet the criteria set by a bureaucratic quango, over which their professions have no control.

Another major development also undermined clinicians’ discretion and autonomy. This was the imposition of the ‘safeguarding’ process — a mandatory set of procedures stipulating what clinicians should report if patients mentioned a crime or ‘abuse’ committed by themselves or someone else. When I returned to the NHS a few years ago to do some part-time work, I was dismayed to learn of this system and its effects. I learned from colleagues that their reporting of such matters had harmed therapeutic relationships with the patients involved, and thereby hampered those patients in overcoming their health problems. Mandatory safeguarding procedures can be detrimental to patient care.

In such an over-controlled health system, there have been serious health scandals, revealing situations in which patient care has been consistently poor. For example, the ‘Mid-Staffordshire NHS Foundation Trust’ scandal showed neglectful and harmful practices at that Trust. The Francis Report (2013) presented an investigation of this⁶. It is a long, detailed and complex report investigating what happened at the Trust itself, and how the various regulatory agencies largely failed to respond well to the problems. Again, quotations from the report offer the simplest way to show clearly that the problems identified were the same as those pinpointed by the Total Politics booklet a decade earlier:

The focus of the system resulted in a number of organisations failing to place quality of care and patients at the heart of their work. Finances and targets were often given priority without considering the impact on the quality of care. This was not helped by a general lack of effective engagement with patients and the public, and failure to place clinicians and other healthcare professionals at the heart of decision-making. (Executive Summary, p65)

Trust management had no culture of listening to patients. There were inadequate processes for dealing with complaints and serious untoward incidents (SUIs). (Summary, p44)

Concerning the Department of Health (D.H.), the report states:

… evidence the Inquiry has heard shows that D.H. officials are at times too remote from the reality of the service they oversee. They need to connect to their patients and frontline staff more personally and directly. Nothing is more likely to focus the mind on the impact of decisions on patients than to listen to patients’ experiences. (p63)

The Francis Report also made serious recommendations about nursing, with poor nursing being a significant feature of the scandal:

There should be an increased focus on a culture of compassion and caring in nurse recruitment, training and education. Nursing training should ensure that a consistent standard is achieved by all trainees throughout the country. The achievement of this will require the establishment of national standards. (p76)

Practical hands-on training and experience should be a prerequisite to entry into the nursing profession. (p76)

Why had nurse training fallen away from such a compassionate, practical basis in the first place? Nurse training in the U.K. was originally practice based, but this approach changed when it was decided that a career in nursing should begin by undertaking a degree course. Another question is why ward ‘management’ had become separated from patient care, as illustrated by this comment from the report:

Nurse leadership should be enhanced by ensuring that ward nurse managers work in a supervisory capacity and are not office bound. They should be involved and aware of the plans and care for their patients. (p76)

Poor management theory and practice are discussed in the book ‘The Puritan Gift’⁷, which, amongst other things, describes how the ‘management’ taught in university business schools often became dissociated from domain knowledge (i.e. the practical skills, knowledge and wisdom of those doing the essential work). The book describes the negative effects of this in American health care but also touches on how nursing and hospital leadership in Britain were adversely affected by the imposition of such management practice.

With regard to the American health care system, the authors contrasted the management of hospitals under the earlier so-called ‘Nightingale System’ (with senior physicians and nurses in charge) with what replaced it:

In the Nightingale Hospital, the management of what is now called the ‘core competencies’ was strictly in the hands of medically qualified men and women – both physicians and nurses. In the post-Nightingale world after 1970, however, responsibility would be increasingly entrusted to a new breed of medically unqualified ‘professional’ managers remote from the ward floor… (p213).

The authors document the decline of nursing practice in America. They then briefly describe how nursing and hospital management in Britain were undermined by the Salmon Report, which replaced hospital matrons with ‘professional’ managers.

Overall, in the UK, it is clear that health care has been adversely affected by too much central command-and-control instigated by government. Associated with this is the prioritisation of notions of management over the domain knowledge of health professionals, and even the undermining of appropriate training.

As if all this were not bad enough, it is necessary now to point out that public health systems can get even worse.

Totalitarian Health Systems

I began with an analogy — a hypothetical over-controlled road system. Returning to that idea, it is possible to imagine an equally over-controlled (and highly dysfunctional) health system imposed by politicians. This would be one where people’s ability to see a health professional was strictly managed, where even their freedom to leave home, go to work, or mix with other people was controlled according to an official assessment of actual or potential health dangers. It sounds unlikely, doesn’t it? Surely no real government would implement such a system?

Unfortunately, it has already happened. Over much of the world, governments have responded to the Covid ‘pandemic’ by the imposition of such measures. The truth is that even with the early and more dangerous variants of the virus, Covid had an infection fatality rate comparable to a very bad flu season (though not equal to the worst, such as the 1918 flu pandemic — known as the ‘Spanish flu’). To offer another comparison, it was less than the measles fatality rate used to be⁸. But no government ever imposed a system of command-and-control for flu or measles.

Yet with the advent of Covid, all around the world, we saw the imposition by governments of highly authoritarian measures that seriously restricted people’s movements, their ability to work and their ability to meet others. Some governments also restricted the medications that could be used against Covid (discouraging and even banning the use of medications recommended by many frontline doctors as effective against Covid). They also forced a large percentage of the world’s population, including large sections of the public that were at minimal risk from Covid, to be injected with inadequately tested ‘vaccines’. Information, evidence, and opinions contrary to the demands and claims of this authoritarian system were also ignored or denigrated, rather than seriously considered.⁹ As this subject has been treated recently and extensively here in Apramada (in Achara’s series entitled ‘A Good Heart is not Enough’) I need not delve further into the details here.¹⁰

What I want to emphasise is firstly that the UK government’s response to Covid constituted an extreme instance of command-and-control from above. It has had a myriad of negative consequences, with serious adverse effects on the functioning of the economy, poverty levels, physical and mental health, and child development. It was also a response which transgressed the generally accepted ethical principles of public health practice, including the fundamental principle that ‘communities faced with epidemics … respond best and with the least anxiety when the normal social functioning of the community is least disrupted.’¹¹.

But secondly the UK was not alone. This imposition of command-and-control in response to Covid occurred on a global scale. National governments did similar things at similar times, disregarding widely acknowledged principles of public health ethics, and in many cases overturning their own pre-existing public health guidelines for responding to a pandemic. Questions, therefore, need to be asked. How did such a colossal authoritarian command-and-control operation come about? How and why was it implemented? Who was ultimately responsible for it?

The Moral Dilemma

Those are questions too big and complex to explore here. Instead, I will end by highlighting the moral dilemma faced by those working in an over-regulated, authoritarian system. Such a system is not merely inefficient and wasteful. It actually causes harm. When this becomes clear to health professionals, they are inevitably presented with ethical problems. Should they continue to comply with demands of command-and-control, and become the agents of that harm? Or should they instead try to practise in accord with their conscience, perhaps in ways that the system forbids? Should they at least speak up in protest?

Whatever decisions health professionals might make, there will be consequences, not just for the patients but also for the professionals themselves. For example, some doctors who disagreed with the response to Covid have had their right to practise revoked. It is not easy to keep faith with one’s conscience if one loses the ability to earn a living, with a consequential loss of the ability to support a family financially. Others, while not losing their jobs, were denigrated and suffered reputational harm. In such a position many, perhaps most, will censor themselves and thereby go along with coercion.

Such dilemmas can arise for anyone with a conscience, but the specific form they take will depend upon one’s beliefs. For Buddhists, the dilemma is focussed on the first precept, which enjoins not harming others, but it also involves the speech precepts that enjoin truthful, kind and helpful speech. Misinforming patients, or withholding information that is important for their health, is not truthful or helpful. Nor is it kind. On the other hand, one might be guilty of slanderous speech if one denounces the ‘system’ without having taken pains to weigh up evidence and think through the arguments for oneself. Perhaps the tenth precept, which enjoins not clinging to wrong views — and thus implicitly the clarifying of our thinking — is relevant here too. Finding a path through competing ethical demands is not easy.

Mindfulness — that continuous critical awareness, cultivated by Buddhist practice, of what one is doing, feeling and thinking — is relevant here. It makes it more difficult for us to practise self-deception. There are psychological strategies that human mind can adopt to evade the kind of inner conflict that is generated by working in a command-and-control environment. For example, one may choose to stifle one’s doubts and accept the official doctrine, reassuring oneself it must be correct since it is endorsed by officially approved ‘experts’. Similarly, one could remain silent when doctors and scientists who disagree with the official line — including personal colleagues, perhaps — are denigrated and ‘cancelled’. One might even join in with the denigration. However, to adopt such strategies is actually to lie to oneself, thereby breaking the precept of truthful speech. Psychologically and spiritually, it is a form of self-harm. For Buddhists, the practice of mindfulness — especially of feelings, volitions and mental processes — offers protection against this.

For people with a conscience who find themselves trapped in a situation of command-and-control, perhaps the starting point is to take whatever pains are necessary to assure oneself of the truth — to clarify what is going wrong, and how things need to change. Once this is done, the possibilities for remedial action will also start to become apparent. But many people in a command-and-control situation drift on from day to day, beset by a feeling that things are not as they should be, but lacking the determination to bring their critique into sharp focus. In the third of his series of articles, ‘A Good Heart is not Enough’ (here in Apramada), Achara has set out a Buddhist epistemology, together with some specific suggestions, designed to ‘hone one’s truth-seeking ability’. Though aimed at policymakers in faith communities, most of the suggestions hold good for health professionals. They include, for example, the importance of not suppressing intuitions, and of learning how to test them, the cultivation of critical and quantitative thinking, and the need to build networks of knowledge and wise judgement. (9)

Conclusion

The issues of freedom, regulation and control are of central importance to human activities. Depending upon the type of activity, there is likely to be an optimum level of regulation that minimises harm and maximises freedom of choice. For some activities, having no regulation is likely to be optimal, whilst others need an appropriate level and type of regulation. Harm can come from under-regulation and from over-regulation. The latter is very much associated with political and bureaucratic over-control that deprives people of choices which should be theirs to make. As the increasing over-control of the NHS indicates, and the highly authoritarian response to Covid exemplifies, over-control can be destructive, in many ways. It is also the hallmark of totalitarianism, which, generally, severely limits peoples’ liberties and punishes non-compliance with the official narrative.  Thomas Sowell’s warning from 1980, which I quoted at the beginning, was prescient.

1. Thomas Sowell, ‘Knowledge and Decisions’ (1980), pp163-4
2. Taking Liberties
3. Total Politics – Labour’s Command State’; Greg Clark and James Mather, editors; Conservative Policy Unit.
4. Systems Thinking in the Public Sector; John Seddon; Triarchy Press, 2008
5. The Chief Executive’s Tale; Nicholas Timmins; The King’s Fund; 2016
6. Report of the Mid-Staffordshire NHS Foundation Trust Public Enquiry; Chair: Robert Francis Q.C., February 2013
7. The Puritan Gift; Kenneth and William Hopper; I.B. Tauris, 2009
8. WHO: “Before the introduction of measles vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and measles caused an estimated 2.6 million deaths each year.” https://www.who.int/news-room/fact-sheets/detail/measles. The world population in 1963 was 3.19 billion. In 2020 it was 7.76 billion.  So the pre-vaccine measles fatality rate would equate to 6.32 million per year for a world population the size of that in 2020. Estimated world Covid deaths for the first twelve months were approximately 3 million.  This Covid fatality level is equivalent to 38.65 deaths per 100,000 population.  Flu fatality rates have declined over the last hundred years and, for example, were approximately 10.2 per 100,000 in the USA in the 1940s, but could be more than that during subsequent flu pandemic years.  See: https://ajph.aphapublications.org/doi/10.2105/AJPH.2007.119933
9. See, for example, an article by Ramesh Thakur: https://brownstone.org/articles/agree-with-us-or-hold-your-tongue/
10. Achara’s series of articles ‘A good heart is not enough’ explores some of these issues. https://apramada.org/articles/a-good-heart-is-not-enough-part-1 and A Good Heart is not Enough – part 3 – Apramada
11. Public health ethics: critiques of the “new normal”, Euzebiusz Jamrozik, Monash Bioethics Review https://doi.org/10.1007/s40592-022-00163-7 Two quotes from this:

    “Donald Henderson (1928–2016) was a prominent medical epidemiologist who, among other achievements, led the successful World Health Organization (WHO) smallpox eradication campaign. In a 2016 paper on optimal public health responses to influenza pandemics, Henderson and co-authors identify an “Overriding Principle” (Inglesby, Nuzzo et al. 2006): ‘…communities faced with epidemics … respond best and with the least anxiety when the normal social functioning of the community is least disrupted…’  Many global responses to the recent coronavirus pandemic, including many of Australia’s policy responses, have failed to follow not only this “Overriding Principle” but also many other principles of public health ethics…”

    “Considering many of responses to the Covid19 pandemic in light of the principles of public health ethics leads to some sobering conclusions. During the pandemic, the moral value of health often became narrowly aligned with the avoidance of one particular virus while mental health and other harms increased, socioeconomic inequalities were exacerbated, and civil liberties were subject to sometimes draconian limitations. The interests of children were in multiple ways sacrificed, often with no strong justification, in the name of reducing harm from a virus that poses extremely low risks to healthy children. Inequality skyrocketed; the benefits of public health interventions and their economic effects overwhelmingly accumulated to the rich while the poor benefited little, were often harmed, and were sometimes placed at higher risk of infection. There was a lack of evidence that the benefits of many NPIs outweighed their harms, and a widespread failure to collect such evidence in an unbiased way. Transparency and legal checks on power were often limited. Policing was excessive. Rather than the “least restrictive alternative” populations experienced extreme levels of coercive control during lockdowns. Taken together, these failures risk undermining trust in public health and science, and the unchecked use of public health power (or prolonged states of emergency) risks undermining democracy itself. Policies instituted during the covid19 pandemic provide many important case studies for ethical analysis. This Special Issue includes extended analyses of policies including lockdowns, school closures, border closures, and the use of fear in public health. It is hoped that better understanding of what went wrong, ethically speaking, during the last few years, might help to inform more balanced and proportionate responses to future pandemics.”