Ethics of Paid Sick Leave for the COVID-19 Pandemic and Beyond
Ontario COVID-19 Bioethics Table: Public Health Measures Workstream Brief
Public health ethics principles support the provision of paid sick leave as a public health response to COVID-19. There is evidence that paid sick leave protects workers from infectious risk exposures in workplaces, enables workers who currently cannot comply with quarantine and isolation measures, and mitigates the disproportionate effect of such measures on workers who cannot work from home.1–3 During outbreaks, paid sick leave enables workers to quarantine and isolate without being unduly penalized financially. This is especially crucial for workers who are forced to choose between protecting co-workers and supporting themselves and their families. In the immediate post-pandemic phase, paid sick leave is an important measure to ensure smooth economic recovery, which is essential for the public’s health. As a preventive strategy, permanent paid sick leave is a pandemic preparedness measure aimed at ensuring timely, effective, and fair implementation of quarantine and isolation.
How can government minimize harms from COVID-19 and ensure that the workforce can comply with public health measures without undue burdens being placed on workers, their families, and the economy?
Key goals of the COVID-19 pandemic response are to reduce transmission, prevent workplace outbreaks, enable business continuity, and promote social and economic well-being. To meet these goals, a key strategy is to provide the workforce with the necessary tools to respond to public health mandates for quarantine and isolation. Policies that encourage return to work, worker retention and stability in the workforce will support economic recovery.2,4–8 Provincially mandated paid sick leave is one of the key tools to achieve these goals.
Disadvantaged workers are overrepresented among essential workers and those deemed necessary for societal functioning but are the least able to afford to take days off work for quarantine and isolation, putting their coworkers at elevated risk of contracting COVID-19.9 Women are employed in occupations associated with significantly higher average risks of exposure to COVID-19 than men.10 Workers in low-wage occupations experience greater risk of exposure to COVID-19 at work compared to those in medium and high-income occupations. In Ontario, the highest proportion of SARS-CoV-2 infections are in neighbourhoods with the highest proportion of essential workers.11–13
Although the federal Canada Recovery Sickness Benefit (CRSB)14 provides $450 after taxes per week for up to two weeks to those who are required to quarantine/isolate, it is not a viable replacement for guaranteed paid sick leave for several reasons. First, the amount of the benefit is insufficient to replace lost wages (less than minimum wage)15, which may mean workers feel it necessary to continue to work; second, the application process is difficult to access for those who do not speak English or French and for those who are not able to apply online; third, receipt of the benefit is often delayed, leaving the worker unable to pay their bills; and fourth, it does not provide any job security.13 CRSB is also a temporary measure that may not continue into the deconfinement stage of economic recovery from COVID-19 where quarantine and isolation will continue to be essential parts of the test, trace, isolate measures that keep the economy safely running.
To reduce transmission and achieve economic recovery, there is a need for governments to minimize direct and collateral harms incurred by workers and their families who comply with public health measures. In addition to mitigating the spread of COVID-19, paid sick leave protects workers’ incomes, jobs and individual health. But it is also essential for economic recovery to ensure business continuity, reduce absenteeism related to ongoing or reemergent outbreaks and to ensure job security.2,4,5 Providing paid sick leave to Ontario workers is a public health preventive measure that is an efficient means of coping with rising health demands as a consequence of the effects of the pandemic on mental health and deferred care not related to COVID-19.4,16,17 A more robust, provincially mandated paid sick leave policy will ensure economic resilience now and in the recovery phase because employer-given sick pay is received faster, protects jobs, and is applied automatically to a worker’s paycheck without having to make a special application to the CRSB.
Ethical Rationale for Paid Sick Leave
A number of widely accepted public health ethics norms18–20 are relevant to the policy discussion of paid sick leave. These ethical considerations help to justify the implementation of paid sick leave in Ontario as a public health measure aimed at reducing mortality and morbidity, reducing COVID-19-related health inequities linked to the social determinants of health21, and in aiding economic recovery and stability. The implementation of permanent paid sick leave as a pandemic preparedness strategy is also supported by these norms.
The following ethical considerations should inform policy and broader public discussions of paid sick leave.
- Protection of the public from harm
In a pandemic, measures should be taken to protect the public from infectious, social, and economic harms.
Paid sick leave is an effective public health measure to contain the spread of infectious diseases by enabling citizens to follow quarantine and isolation mandates thereby reducing the burden of illness in workplaces.2,4,22 Economic stability and recovery are important for population health overall and the protective effects of paid sick leave will be important as the economy moves into recovery. Many Organisation for Economic Co-operation and Development (OECD) countries have implemented paid sick leave measures in response to COVID-19 that will extend beyond the current pandemic as a public health measure intended to protect against future health and economic harms from the next pandemic.4,23
Reciprocity requires that society supports those who face a disproportionate burden when protecting the public good. In a pandemic, measures to protect the public good impose a disproportionate burden on quarantined/isolated individuals and their families who may experience significant social, economic, and emotional burdens.18
Public health measures that restrict individual liberty and the ability to earn a wage require public compliance for them to be effective and ethical. There is evidence that lack of paid sick leave negatively impacts compliance with quarantine and isolation.8,9 Evidence from COVID-19 and past outbreaks like SARS demonstrate the economic impact of these on Ontario workers is often more than they can afford and puts their jobs at risk even though they are considered protective of the public overall.24 Public health measures such as quarantine/isolation impose burdens on workers that may be disproportionate, or difficult to meet and as a result a duty of support is owed to them.24 Provincially mandated sick leave that is accessible quickly and that eliminates or greatly reduces the financial costs of compliance with public health measures meets the duty of support for these workers who are protecting the public from COVID-19 spread and resultant economic harms. Small businesses that provide sick pay for their employees should also be appropriately compensated if the costs of doing so put their business in jeopardy. Many OECD countries have lowered the costs for employers through government subsidization.4 In Canada, Yukon has implemented the Paid Sick Leave Benefit rebate for workers who become sick, or who must quarantine or isolate and provides 10 days of wages per employee.2
Equity requires that measures be taken to prevent, minimize and redress health and other social inequities, including those created or exacerbated by public health measures such as quarantine and isolation.
Paid sick leave preserves the jobs of vulnerable/essential workers who cannot work from home and prevents harms related to loss of income while following public health measures.1,2 In Ontario it is estimated that there are 3 million essential workers who have worked more than 400 million hours in close proximity to other workers.12 The majority of COVID-19 workplace outbreaks have been borne by the manufacturing sector, forestry, agriculture, fishing and hunting ,transportation and warehousing and healthcare.3,13 Policymakers are urged to consider the health risks not only to workers but also to those with whom they live.25 US based studies have found that essential workers who cannot work from home are at increased risk of severe disease and death, and so are the people they live with.25. Compensating workers so they can follow quarantine and isolation protocols also reduces harm to fellow commuters on public transit co-workers by reducing their exposure to COVID-19 and respecting their right to a healthy and safe workplace and transportation system. Paid sick leave also increases job security1 and improves population health overall as low-wage, insecure work is correlated with poorer health status generally and worse occupational health and safety outcomes in particular.26
Proportionality requires that measures taken to mitigate the pandemic should proportionate to the actual level of risk, or critical need of, the community.
Paid sick leave for workers is an increasingly important public health measure to prevent workplace transmission and enable speedy economic recovery.1 As a public health measure, paid sick leave is a proportionate response to both health and economic threats posed by COVID-19. It is also a proportionate response to the increasing needs of marginalized workers as the pandemic continues and economic harms pile up and as entire families are becoming infected due to workplace exposures. As a preventive measure, paid sick leave is a measure proportionate with the need to maintain worker safety, productivity, and business continuity as deconfinement begins.
- Systemic resilience
Government has a moral imperative to anticipate population-level health harms and to balance efficiency with equity while doing so. Anticipating future public health threats and preparing for them is also an ethical requirement for good public health governance. This requires that we learn the lessons of this and past pandemics while preparing for future pandemics.
As we eventually move into the recovery phase of this pandemic, paid sick leave will continue to help control reemergent COVID-19 cases, reduce worker absenteeism overall by preventing the spread of this and other infectious diseases such as influenza, and will increase worker productivity overall.4,5 This will help ensure smooth economic recovery from COVID-19 as deconfinement continues. Data from this and other outbreaks shows that paid sick leave is an important strategy for public health containment as well as for economic stability and recovery.4,22,27 As an effective and efficient preventive measure, mandating paid sick leave for workers in Ontario will protect incomes, health, and jobs longterm.2,4 Preparing for future pandemics requires improving the adaptability of paid sick leave to the economic and health challenges posed by infectious diseases.4,23
Solidarity: paid sick leave signals a common purpose
Paid sick leave for Ontario workers will help to minimize mortality and morbidity, particularly for people in socially and economically vulnerable circumstances.21,23 It is also an important economic tool for ensuring the smooth economic recovery from this pandemic and for preparing for future infectious disease threats. In addition to the ethical considerations outlined above, there are other benefits to providing provincially mandated paid sick leave.
Paid sick leave builds a sense of common purpose in society when viewed as an important public health measure. It also can help build public trust in government, which is essential for public health compliance. A recent poll of Ontarians commissioned by Unifor and conducted by Ottawa-based EKOS Research Associates Inc. demonstrated strong public support for paid sick leave. Residents in Ontario were polled between April 7 and April 12, 2021 and 70 percent of Ontarians support five days of paid sick leave, and 64 percent support 10 such days for workers in the province.28 We are not all in this together unless we protect the income and jobs of society’s most economically and medically vulnerable. Paid sick leave provides reassurance to workers that their wellbeing and dignity are being respected; it also represents what we would all need if we were in the same position.
Stopping COVID-19 requires a collective effort. Providing paid sick leave is a critical example of a public health measure that builds a sense of common purpose between workers, between workers and employers, between businesses and the public and between the public and government. Finally, when public trust in government is increased through compensatory mechanisms aimed at reducing unequal burdens on vulnerable members of society it is beneficial for other aspects of outbreak response such as vaccine uptake and compliance with stay-at-home-orders.
Public health ethics principles support the use of robust paid sick leave as a public health measure aimed at reducing mortality and morbidity amongst society’s most vulnerable workers and their families. It is also a proportionate and efficient response to the challenges facing the economy as the pandemic moves into the recovery phase and beyond. Paid sick leave is not just for pandemic response but can also help us ensure that we are prepared for the next pandemic.
- Asfaw A, Rosa R, Pana-Cryan R. Potential Economic Benefits of Paid Sick Leave in Reducing Absenteeism Related to the Spread of Influenza-Like Illness. J Occup Environ Med. 2017 Sep;59(9):822–9.
- Ontario Ministry of Health Research, Analysis and Evalutation Branch. Paid sick leave benefits during the COVID-19 pandemic: evidence synthesis briefing note. Ontario; 2021 Feb.
- MacEachen E. Personal communication on preliminary results from ongoing IRSST funded research: Cote, D. MacEachen, E., Laberge, M., Majowicz, S., Meyer, S., Dube, J. Sick leave and social distancing in the age of precarious employment: Understanding workplace conditions and choices to prevent COVID-19 transmission. 2021.
- OECD. Paid sick leave to protect income, health and jobs through the COVID-19 crisis [Internet]. 2020 Jul [cited 2021 Mar 4]. (OECD Policy Responses to Coronavirus (COVID-19)). Available from: https://www.oecd.org/coronavirus/policy-responses/paid-sick-leave-to-protect-income-health-and-jobs-through-the-covid-19-crisis-a9e1a154/
- US Department of Labor. Families First Coronavirus Response Act: Employee Paid Leave Rights | U.S. Department of Labor [Internet]. 2020 [cited 2021 Apr 23]. Available from: https://www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave
- Pichler S, Ziebarth NR. The Pros and Cons of Sick Pay Schemes: Testing for Contagious Presenteeism and Shirking Behavior [Internet]. Rochester, NY: Social Science Research Network; 2015 Nov [cited 2021 Mar 4]. Report No.: ID 2689852. Available from: https://papers.ssrn.com/abstract=2689852
- Smith LE, Potts HWW, Amlôt R, Fear NT, Michie S, Rubin GJ. Adherence to the test, trace, and isolate system in the UK: results from 37 nationally representative surveys. BMJ. 2021 Mar 31;372:n608.
- Madad S, Nuzzo J, Bourdeaux M. The Missing Piece In America’s COVID-19 Isolation And Quarantine Strategy: Wraparound Services | Health Affairs Blog [Internet]. Health Affairs Blog. 2020 [cited 2021 Apr 23]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20201207.458415/full/
- University of British Columbia. Ability to work from home and paid sick leave benefits by precarious employment and socioeconomic status [Internet]. Partnership for Work, Health and Safety; 2020 Jun. Available from: http://pwhr.sites.olt.ubc.ca/files/2020/09/GSS-COVID-19-Research-Brief-2020.pdf
- Smith P, Mustard C. Issue briefing: Incidence of COVID-19 transmission in Ontario workplaces. Toronto: Insititute for Work and Health; 2021 Jan.
- Chagla Z, Ma H, Sander B, Baral SD, Mishra S. Characterizing the disproportionate burden of SARS-CoV-2 variants of concern among essential workers in the Greater Toronto Area, Canada. medRxiv. 2021 Mar 26;2021.03.22.21254127.
- Watson T, Kwong J, Kornas K, Mishra S, Rosella L. Neighbourhood characteristics associated with the geographic variation in laboratory confirmed COVID19 in Ontario, Canada: a multilevel analysis. medRxiv [Internet]. 2020 Apr 10; Available from: https://www.medrxiv.org/content/10.1101/2021.04.06.21254988v2.full.pdf
- Health Services Region of Peel. Briefing note: paid sick days and supports for essential workers. [Internet]. 2021 Jan. Available from: https://peelregion.ca/advocacy/paid-sick-leave/briefing-note.pdf
- Canada Revenue Agency. Canada Recovery Sickness Benefit (CRSB) [Internet]. 2020 [cited 2021 Apr 23]. Available from: https://www.canada.ca/en/revenue-agency/services/benefits/recovery-sickness-benefit.html
- Government of Ontario. Your guide to the Employment Standards Act: Minimum wage. [Internet]. [cited 2021 Apr 23]. Available from: https://www.ontario.ca/document/your-guide-employment-standards-act-0/minimum-wage
- CAMH. Mental Health in Canada: COVID-19 and Beyond [Internet]. Toronto: Centre for Addiction and Mental Health; 2020 Jul. Available from: https://www.camh.ca/-/media/files/pdfs—public-policy-submissions/covid-and-mh-policy-paper-pdf.pdf
- Conference Board of Canada. Health Care Cost Drivers in Canada Pre-and-Post Covid-19 [Internet]. 2020 Sep. Available from: https://www.canadaspremiers.ca/wp-content/uploads/2020/10/CBOC_impact-paper_research-on-healthcare_final.pdf
- Thompson AK, Faith K, Gibson JL, Upshur RE. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006 Dec;7(1):1–11.
- Upshur REG. Principles for the Justification of Public Health Intervention. Can J Public Health. 2002 Mar;93(2):101–3.
- Dawson A. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press; 2011. 210 p.
- Public Health Ontario. COVID-19 – What We Know So Far About… Social Determinants of Health [Internet]. Toronto; 2020 May. Available from: https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2020/05/what-we-know-social-determinants-health.pdf?la=en
- Stearns J, White C. Can paid sick leave mandates reduce leave-taking? Labour Econ. 2018 Apr 1;51:227–46.
- Decent Work and Health Network. Before it’s too late: how to cloe the paid sick days gap during COVID-19 and beyond [Internet]. Ontario; 2020 Aug. Available from: https://d3n8a8pro7vhmx.cloudfront.net/dwhn/pages/135/attachments/original/1604082294/DWHN_BeforeItsTooLate.pdf?1604082294
- Singer PA, Benatar SR, Bernstein M, Daar AS, Dickens BM, MacRae SK, et al. Ethics and SARS: lessons from Toronto. BMJ. 2003 Dec 6;327(7427):1342–4.
- Selden TM, Berdahl TA. COVID-19 And Racial/Ethnic Disparities In Health Risk, Employment, And Household Composition: Study examines potential explanations for racial-ethnic disparities in COVID-19 hospitalizations and mortality. Health Aff (Millwood). 2020 Sep 1;39(9):1624–32.
- Shaw WS, Main CJ, Findley PA, Collie A, Kristman VL, Gross DP. Opening the Workplace After COVID-19: What Lessons Can be Learned from Return-to-Work Research? J Occup Rehabil. 2020 Sep 1;30(3):299–302.
- Simpson J, Albani V, Bell Z, Bambra C, Brown H. Effects of social security policy reforms on mental health and inequalities: A systematic review of observational studies in high-income countries. Soc Sci Med. 2021 Mar 1;272:113717.
- Akrit M. Ontarians strongly favour paid sick days, poll finds. Toronto Star [Internet]. 2021 Apr 16 [cited 2021 Apr 20]; Available from: https://www.thestar.com/news/gta/2021/04/16/ontarians-strongly-favour-paid-sick-days-poll-finds.html
For further scientific evidence in support of paid sick leave for COVID-19, please see the Ontario COVID-19 Science Advisory Table brief on paid sick leave.
Further information about the Ontario COVID-19 Bioethics Table.