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Over the past week, countless Americans across a dozen states have taken to the streets to protest lockdown regulations that have been put in place to prevent the spread of this coronavirus. Wielding signs reading “Give me liberty or give me covid” and “We want out of the coop”[1], their message is clear - they are protesting the sudden restrictions on their freedom and autonomy. These protests have led to significant tension throughout the US, the country which is currently the epicentre of the pandemic, with healthcare professionals blocking roads[2] to prevent protesters from causing mass traffic jams, so that they can continue to risk their own lives treating people in intensive care due to the virus. This conflict stems from the transformation of the attitude towards the US healthcare system, which has pivoted from being an almost entirely privatised system to increasingly wide-spread  state-mandated public health policies virtually overnight. Whilst the protests in the US are the most extreme example of the divide between healthcare independence and public health responsibility, this is currently a ubiquitous dichotomy for all of us, whether we are aware of it or not. The COVID-19 pandemic is causing the world to radically transform its attitude towards public health and national protection in a time of crisis, however the almost universal establishment of state-enforced health policies is leading some to rethink the more general perception of the ‘autonomy vs paternalism’ question in medical ethics. Could a post-COVID-19 world see an increase in paternalistic policies in public health?

Modern conceptions of paternalism are derived from the political and moral philosopher John Stuart Mill’s principle that power should only be exercised over another free person if their actions are going to cause harm to someone else. This principle has greatly informed social policy in general, but it has obvious and immediate consequences for how a state should handle healthcare. In this context, medical paternalism has meant that state-wide campaigns and policies tend to focus mainly on illnesses that can bring harm to those without the illness. Of course, walking around with an infectious disease, potentially spreading it to others, falls well within the limits of this definition. 

However, regardless of the circumstances, deciding whether acting in a paternalistic manner is justified requires a careful judgement of the associated moral considerations. Most notably, paternalism exerted as an exercise of power over another is clearly a breach of consent. Huge efforts are directed towards preserving consent in the realm of medical treatment and research, as well as in all other aspects of life, that overruling consent in any context must have extremely solid moral foundations. Furthermore, the routes via which paternalism is exercised around the world is completely dependent on the accompanying social and political architectures associated with different countries. This has never been made more obvious than during the current COVID-19 pandemic, with worldwide responses to the virus being directly correlated to where a state falls on the spectrum of laissez-faire governing to complete totalitarianism. 

Prior to the current COVID-19 pandemic, the largest paternalistic public health campaign in the UK has been the nationwide anti-smoking efforts. Movements such as “Stoptober” [3] have helped over 1 million people to quit smoking. Actions like this, together with public posters spreading anti-smoking messages, raised taxation of cigarettes and reduced health benefits for patients with smoking-related illnesses, can all be considered to be in line with the UK Government’s belief that they have a right to exercise influence over their population in the interest of public health. 

One of the most controversial examples of paternalism in public health in recent years has been the introduction of the Soft Drinks Industry Levy (SDIL), or the “Sugar Tax”, acting as a deterrent from the consumption of unhealthy drinks.  This case is particularly illuminating as the conflict surrounding the introduction of such a policy highlights the core moral objection against medical paternalism — these policies are a clear restriction on an individual’s autonomy. This is precisely the argument currently being raised against state-mandated quarantine in the US, and it is the counterargument often used against broad public health campaigns across time and space. The reason Mill presented his notion of paternalism in a relatively soft manner, whereby power can only be exercised when an individual’s actions will cause someone else harm, is intended to preserve an individual’s right to act autonomously when it comes to their own health. 

The importance of autonomy in medical ethics today is considered a direct consequence of the many cases of unethical coercion and abuse carried out in the name of health treatment and research throughout the twentieth century. Experiments on inmates in Nazi concentration camps, the Tuskegee syphilis experiment, where African American male patients were unknowingly given placebos rather than treatment, and Project MKUltra, also known as the CIA mind control program — such cases underscore the importance of consent. Such instances have shifted discourse in medical ethics away from paternalism and towards a belief that consent should always be given. The importance of consent can thus be interpreted as a formal effort to preserve the autonomy of the individual, preventing coercion and abuse by medical professionals. This is precisely the argument given by the philosophers Onora O'Neill and Neil Manson (2007) in their consideration of contemporary attitudes towards consent in bioethics. In the case of the current COVID-19 pandemic, it seems as though state-wide restrictions to autonomy in the name of a paternalistic protection needs to be justified in light of nearly a century worth of efforts directing medical research and treatment towards consent and autonomy. 

Of course, it seems entirely justified for a government to enforce isolation in the interest of the health of the entire population. It can be argued that the majority of people believe that, in the interest of public health, it is not only permissible, but downright necessary, for a state to exercise power over others in such circumstances. This is because moral considerations of paternalism often coincide with discussions on what has been dubbed the principle of “do no harm”, or non-maleficence.  There exists an understanding that it is a medic’s duty to prevent harm from coming to their patient. A similar argument can be made in support of a whole government’s use of paternalistic measures in the context of public health — one of the chief roles of a state-wide authority is to protect its citizens. In this sense, the government is bound by duty to its people to protect them from harm. It is clear that this is one of the main driving forces supporting paternalistic policies, not only in a time of crisis but during periods of normality too, as illustrated by anti-smoking and sugar tax campaigns. 

Whilst it seems as though much of the world will be forever changed by the unprecedented events of the last few months, one of the most radical shifts might be in our attitude towards the state-wide responsibility to maintain public health in spite of an individual's right to autonomy. This could completely alter the landscape of medical ethics, which has consistently been built through international scholarship since the mid twentieth century. Healthcare bodies in the future will undoubtedly refer to the current pandemic as a chief example of how paternalism saves lives, supporting the expansion of the boundaries of what we think is acceptable for our states to tell us what to do. Nevertheless, the most important impact of paternalistic healthcare policies during this pandemic was in showing us how necessary a coordinated effort is when mitigating a global threat. For the time being, a recognition that we are all mutually reliant in terms of compliance with public health policies should suffice to maintain our upkeep of government advice, even if it does mean a surrendering of our autonomy. 




Charlotte Zemmel is a 3rd year Natural Sciences undergraduate at Newnham College and is currently the physics subject editor of Bluesci magazine.


References:

  1. US faced with protests amid pressures to reopen
  2. Coronavirus: Healthcare workers block anti-lockdown protest in Colorado
  3. Stoptober Overview