As the COVID-19 pandemic has expanded around the world, there has been a growing number of experts calling for the universal wearing of protective face masks.
Even in the absence of ‘gold standard’ research (eg. RCT), experts contend there is nonetheless sufficient evidence from other sources to justify recommending and even mandating the universal wearing of masks as one of a number of important tools for helping to reduce community transmission and spread of the disease (Chan 2020, p. 5).
A question of nursing ethics
The acknowledged benefits of wearing a face mask has not stopped a vocal minority of people (who otherwise should wear a mask) from claiming that wearing a mask is a ‘violation of their liberty’ and that they have a ‘right not to wear a mask’. For some, refusing to wear a mask has become a ‘political act’.
There have also been US media reports of people (including patients) conflating their ‘right’ not to wear a mask as tantamount to their right to make decisions about their medical care (‘My body, my choice’ – see https://www.vox.com/covid-19-coronavirus-us-response-trump/21326204/texas-coronavirus-rio-grande-houston).
Here the question arises of whether refusing to wear a mask in the absence of a lawful reason not to (eg. exemptions include having a medical or mental health condition, a disability, etc.) has a sound moral basis. In summary, do people have a genuine moral right to refuse to wear a mask when exemptions to mandatory requirements do not apply? The short answer is: No.
When examined from within an ethical framework it becomes clear that there is no meaningful sense in which people who should wear a mask can validly claim a moral right not to wear a mask and that they are mistaken in thinking they can.
As has long been established in the bioethics literature, a moral right is a special interest which ought to be protected for moral reasons (Johnstone 2019).
Prima facie there is no obvious basis upon which not wearing a mask can be characterised as a ‘special interest’ let alone one that ‘ought to be protected for moral reasons’. Anti-maskers might contend, however, that the special moral interest warranting protection in this case concerns their autonomy. But this too involves a mistake in thinking.
The nature and moral authority of autonomy is well established in the bioethics literature. As a concept, autonomy refers to a person’s independent and self-contained ability to decide. As an action-guiding principle, autonomy prescribes that, as a general rule, people ought to be respected as self-determining choosers provided that their choices do not interfere with the significant moral interests of others.
What proponents of the autonomy argument often overlook is that autonomy is not (and has never been) a stand-alone principle, that is, its exercise is constrained by other moral principles (eg. do no harm, do good, uphold justice, etc.) (Johnstone 2019).
Since decisions not to wear a mask contributes to the community transmission and spread of a devastating and potentially deadly disease, they stand unequivocally to interfere with the significant moral interests of others. Like passive smoking and unprotected sex, the failure to wear a mask threatens the health, wellbeing and even the lives of others.
Public health ethics
COVID-19 has highlighted our interdependency on others, our interpersonal obligations towards others, and the need for a robust ethical framework for decision-making during a pandemic.
Following the lessons learned from the SARS outbreak of 2003, the Joint Centre for Bioethics Pandemic Influenza Working Group (2005) produced its landmark report Stand on guard for thee, in which it outlined ten substantive values to guide ethical decision-making for a pandemic influenza outbreak.
Subsequently, the World Health Organization (WHO), with input from the Joint Centre group, launched its guidance document: Ethical considerations in developing a public health response to pandemic influenza (WHO 2007).
These documents present in-depth the cornerstones of public health ethics including the ethical principles of equity, utility/efficiency, liberty, reciprocity, and solidarity. They also discuss the challenges involved in balancing competing rights, interests and values. Common to both reports is the stance that in a public health crisis:
• restrictions to individual liberty may be necessary to protect the public from serious harm;
• to protect the public from harm, healthcare organisations and public health authorities may be required to take actions that impinge on individual liberty (Joint Centre 2005, pp. 6 & 7).
The need for solidarity
A key action-guiding principle in public health ethics is solidarity. In keeping with this principle individuals commit to being ‘firmly united by common responsibilities and interests, and undivided in opinion, purpose and action’ (WHO 2007, p. vi). Considering this, it is not merely disappointing but unconscionable that some people simply refuse to accept their mutual obligations towards their fellow citizens and to play their role in helping to stop the spread of COVID-19. Choosing not to wear a mask might make people feel ‘in control’.
The reality is, however, that so long as the virus is circulating through the community no-one can rest assured that they have control over their lives or that the ‘normalcy’ of our lives has returned.
Chan T K 2020. Universal masking for COVID-19: evidence, ethics and recommendations. BMJ Global Health 2020; 5:e002819.
Johnstone, M-J. 2019. Bioethics: a nursing perspective, 7th ed. Elsevier, Sydney
Joint Centre for Bioethics Pandemic Influenza Working Group (2005) Stand on guard for thee: ethical considerations in preparedness for pandemic influenza. University of Toronto Joint Centre for Bioethics, Toronto
World Health Organization (WHO) 2007 Ethical considerations in developing a public health response to pandemic influenza. WHO, Geneva
Dr Megan-Jane Johnstone AO is a retired professor of nursing who writes as an independent scholar. She is the author of the landmark book Bioethics: a nursing perspective (Elsevier, Sydney).
To be informed on the latest evidence on mask coverings head to the ANMF website- evidence brief on COVID-19: MASKS (PPE) AND NON-PPE FACE COVERINGS FOR MEMBERS OF THE PUBLIC
Fantastic summary of to wear or not to wear. It certainly clarifies the fores and against.
A really well researched, and well written article.
Demanding your “right” can have serious consequences for others.
Dr Johnstone was my lecturer at RMIT and in my post grad honours year. She is one of the most intelligent and inspiring teachers and writers, and pushed me to create writing that was well researched and communicated to it’s audience. She took the time to teach and I will always remember her for this.
It’s funny, you can make all the arguments you like but ultimately any mandate will be underwritten by state coercion. From where I stand, your ethical framework looks a lot like a rationalisation for a belief system. Moreover, there’s no explicit, unambiguous and quantifiable threshold or parameter that determines when individual liberty can be justifiably impinged and to what extent, rather the unelected and largely unaccountable experts collectively decide it’s for the greater good. Herein lies another slippery concept, because the greater good is simply an extrapolation of personal belief system to the entire society. An exploration of the world’s different cultural and religious belief systems would illuminate this concept of greater good as being ideological in nature – there are all manner of overlaps and contradictions between them.
Ultimately, I want no part in a society run by scientific experts, who are just as flawed and hypnotised by their own biases as most of us. And I believe the tendency to label people not wanting to wear a mask to feel “in control” is just a projection that betrays the desire of the scientific, medical and political elite to control the population for their own good. I understand the concept of personal sacrifice for the community, but these people making demands and mandates are not my community, so simply put they have no say.