Face-off: the ethics of compulsory mask policies

Face masks are everywhere you look these days. Donald Trump wearing one for the first time; Rishi Sunak not – only to sport the “wrong kind” a few days later. A spate of articles about how you can wear a mask without fogging up your glasses. Sell-out tartan masks, bedazzled face masks, and, confusingly, from one Brazilian beauty salon, a mask made of delicate, holey tulle.

In June, following months of debate, the World Health Organization (WHO) advised governments to encourage the wearing of face masks in public spaces where social distancing is difficult. More and more countries have now enacted compulsory face mask policies, including, in various circumstances, the four nations of UK.

The issue has prompted endless debate, and become indelibly political and increasingly polarised. This post cannot address all of those complexities. Rather, it speaks to the two most commonly heard refrains in opposition to face masks – “there’s not enough evidence to support it” and “it’s an infringement on my rights” – before finishing with a plea for solidarity.

Evolving evidence

Before we can enact any measures we need to understand both the disease itself, and the efficacy of any proposed intervention. Our understanding of the SARS-CoV-2 virus – its epidemiology, transmission, immunology, and treatment – was non-existent at the beginning of the year and, even as it has expanded at a quantum pace, there is still much that we don’t know.

In recent months there has been number of developments which have spurred the move towards masks. Crucially, for the WHO to change its guidance, this was the knowledge that asymptomatic and pre-symptomatic transmission is possible, and maybe even common; and that airborne and aerosol transmission “cannot be ruled out”.

As for the efficacy of masks in response to this new knowledge, the evidence is less clear. Although there is still no scientific consensus on the benefits of face masks, there are a number of studies which suggest some marginal benefits from mask wearing and more compelling empirical evidence from everyday scenarios, including anecdotally. In the context of a global pandemic, which has fundamentally altered the lives of everyone in some form, even marginal gains are significant.

In an ideal world, evidence would be based on robust controlled trials and peer-reviewed research – but there is little about the past few months that has been ideal for anybody. Uncertainty about the evidence is not a sufficient justification for not taking action: in the face of a serious or irreversible threat to health, scientific uncertainty must be resolved in favour of prevention. Although the evidence on masks seems to be taking the flack now, it’s important to remember that many of the measures implemented at the start of the pandemic – school closures, city-wide lockdowns – were similarly taken on the basis of little to no scientific evidence of their effectiveness.

In the absence of clear evidence that an intervention will be effective in achieving a desired aim, interventions should be accompanied by a robust evidence-gathering programme, and be able to be clearly justified, with reference to fairness, the costs and benefits of action, and proportionality – which takes us to the second argument against masks.

An infringement of liberty rights?

In any public health measures, the more intrusive the intervention, the greater the justification required – an approach we set out in what we called “the intervention ladder” in our 2007 public health report.

The wearing of a piece of fabric pales in comparison to the intrusion of the measures introduced at the start of the pandemic which closed down workplaces, confined people to home, separated loved ones – it would be very difficult to argue otherwise. For many, the intrusion is less about the wearing of a mask and more about the mandatory nature of doing so.

Many of the measures taken in response to the pandemic have exposed the tension inherent in the very nature of public health which serves the needs of the population of a whole: how far can the rights of the individual take precedence over the rights and interests of others, individually or as a group – “the greater good”. In a liberal democracy we respect individual’s liberty by allowing them to make decisions for themselves, even if we don’t always agree with those choices, or think them to be rational. Mandatory policies eliminate that individual choice, and so shift the emphasis away from the interests of the individual, and towards providing benefit to a group – of which, it should be remembered, that individual is a part.

In the context of a global pandemic which, at time of writing, has seen over 15 million cases and over 639,000 deaths globally, the nuisance or inconvenience that being required to wear a mask might cause to individuals is vastly outweighed by the potential net benefit.

The harms of the pandemic have come not just from the virus itself, but the measures taken to prevent its spread: the isolation of lockdown, the loss of employment, the impact on education. Wearing a mask will not just help reduce the spread of the disease, but also reduce the risks of having to enact more onerous policies such as the reintroduction of strict lockdown measures. It is a very small price to pay in return for a “new normal” where can resume some semblance of everyday life.

The distribution of burdens

It should not be forgotten that interventions do not fall on everyone equally – and that includes the wearing of face masks. Masks represent a significant barrier for deaf people who rely on lipreading – addressed in part by the creation of masks with a transparent panel in them).

Masks are not free from racial politics either, whether that’s because they’re seen as a signifier of East Asian identity in a pandemic that has already been racialised, or will only exacerbate the suspicion and profiling faced by young Black men. Muslim women have contended with the politics of face coverings for many years – for countries where religious face coverings have been outlawed, the introduction of mandatory protective masks pulls at the thread of those laws.

Masks can expose privilege in other ways, too. Although face masks have been mooted as an inexpensive way to prevent the spread of the virus, that all depends on your interpretation of cost. At a time where millions of Britons (and indeed, many more worldwide) are on the precipice of poverty as a result of loss of earnings from COVID-19 that cost cannot be ignored. (Indeed, this week, the French government sent out 40 million masks to seven million people living in poverty).

A final plea: solidarity and what we owe to each other

Liberty is important, yes, but it’s one value among many that should feature in our response to the crisis. Overarching all of this is one final value: solidarity, the willingness to bear burdens in order to help others in the face of a shared circumstance.

As we noted in our briefing note at the outset of the pandemic, for many people, contracting COVID-19 is likely only to involve a mild illness. For others, however, they will experience serious illness and some will (and have) died as a result. This places an ethical responsibility on everybody to take measures to reduce the spread – hand washing, social distancing, and yes, the wearing of masks.

Mask wearing should be seen more as an act of altruism rather than self-preservation: I’m wearing a mask to protect you, and you wear one to protect me. It is a physical reminder of what we owe to each other as fellow, equal human beings and what unites us against a common threat.