Why it matters
The need to balance individual autonomy and actions designed for the collective good is a well-recognised challenge in public ethics. The challenges of achieving the right balance have been the subject of much debate and controversy throughout the COVID-19 pandemic, when many policies were introduced with the aim of protecting and promoting public health. Some measures introduced to control transmission (including case isolation, household quarantine, and contact tracing) were described by Lawrence Gostin as among ‘the most complex and legally/ethically controversial public health powers.’
Especially controversial was the introduction of mass testing of asymptomatic people, and the isolation of individuals who tested positive (and their close contacts), but there has been little research on the views of stakeholders who were affected.
We asked over 200 staff and students at a case study university about their views on asymptomatic testing programmes, whether they thought that making participation mandatory was acceptable, and what they thought about the introduction of incentives or penalties.
The University of Cambridge introduced weekly asymptomatic COVID-19 testing for students in October 2020. Offered to all students living in college-owned accommodation at the time, it was based around “households”, with nasal swabs from individual students being tested in a pool. If a pooled sample tested positive, students within the household were asked to isolate while PCR testing took place. If any students in a household tested positive, they all had to isolate for 14 days. Participation was voluntary, with no penalties or incentives at the time of the study.
A total of 239 stakeholders took part in our study. 189 students and 24 staff completed surveys while 19 students and seven staff were interviewed between November and December 2020. This was before COVID-19 vaccinations were available .
What we found
Many participants felt there was an ethical obligation to take part in the testing programme, but many also felt also that getting tested was a moral choice that should not be forced. Nearly two-thirds of survey respondents agreed that asymptomatic testing should be voluntary at the level of the individual student. Reasons given included respect for personal liberty and individual choice. Even when some participants strongly supported the view that students should participate in testing, for example to protect others, they still felt it should be the individual’s choice.
When it came to making testing mandatory, only 28% of participants thought that it should be compulsory. Around two-thirds of respondents opposed penalties for not taking part; 31% strongly disagreed and 33% disagreed. While some believed that limited forms of restriction for those not participating in the testing programme might be acceptable, many felt that it undermined choice and risked creating hostility to the programme.
Most survey respondents supported the use of incentives (42% agreed, 33% strongly agreed) seeing small incentives (like a free coffee for taking part) as acceptable on the grounds that they would encourage uptake and thank participants for taking part. The choice of incentive was important, though; some participants explicitly stated that small incentives were more acceptable than large ones.
This study provides evidence to support the principle of the least restrictive means when encouraging participation in an asymptomatic student COVID-19 testing programme. The findings suggest that policies that support choice should be used in preference to those that restrict choice (such as making participation mandatory or penalising those who do not participate). Enabling students to make their own moral choices around participation may be the optimal strategy.