“If I increase my risk, a lot of people say, well can’t people just be allowed to take their own risk? The problem with a pandemic, or an epidemic infection like this is, if I as an individual increase my risk I increase the risk to everyone around me, and then everyone who is a contact to theirs. And sooner or later, the chain will meet people who are vulnerable or elderly or have a long-term problem from Covid. So you cannot, in an epidemic, just take your own risk. Unfortunately, you’re taking a risk on behalf of everybody else”

(Chris Whitty, UK Chief Medical advisor, BBC News Special, Coronavirus Daily Update: 84. Coronavirus Update 21/09/2020)

Respect for autonomy is one of the key moral principles of biomedical ethics. This entry offers some observations on how the conditions of the COVID-19 pandemic may have a bearing on how this important principle is characterised.

The traditional account of autonomy asserts the existence of an idealised unitary and independent self. One capable of rational action, choice, and the maximising of individual preferences. In contrast the relational account of autonomy asserts the existence of a practical self. One that is oriented towards people’s (inter-) dependence and vulnerability. Such an account also entails an interest in the socially constituted nature of an individual’s practical identity, and how this identity is shaped by and in relation to existing structures and other people. While both the traditional and relational accounts acknowledge conditions on the exercise and development of a person’s autonomy, the traditional account tends to emphasise freedom conditions, while the relational account tends to emphasise opportunity conditions (Mackenzie, 2014). On a relational conception, our identities are made up of three interrelated dimensions: self-determination, self-governance and self-authorisation. A brief outline of these dimensions and the implications for our behaviours and for public health during a pandemic is provided here.

Self-determination consists in the “freedom and opportunity to make and enact choices of practical import to one’s life, that is, choices about what to value, who to be, and what to do” (Mackenzie, 2014: 17). On a relational conception, self-determination entails a concern not only with the freedom to make and enact choices, but also a concern with the structural conditions creating the opportunities for people to make and exercise such choices. In the pandemic context, this might mean the provision of functioning digital contact tracing systems enabling citizens to make and enact choices to protect themselves and others.

Self-governance consists in “having the skills and capacities necessary to make choices and enact decisions that express or cohere with one’s reflectively constituted diachronic practical identity” (Mackenzie, 2014: 17). In contrast to the external structural conditions on autonomy and self-determination, self-governance is an internal condition on autonomy. In a pandemic context, this might mean giving attention to our abilities to use digital contact tracing technologies and our awareness and understanding of the benefits to our own and the public’s health.

Self-authorization involves “regarding oneself as having the normative authority to be self-determining and self-governing. In other words, it involves regarding oneself as authorized to exercise practical control over one’s life, to determine one’s own reasons for action, and to define one’s values and identity-shaping practical commitments” (Mckenzie, 2014: 18). In a pandemic context it is worth reflecting on whether the ‘normative authority’ for exercising practical control over one’s life derives less from freedom conditions and more from opportunity conditions and the development of our relevant capacities for self-governance.

In a pandemic the relational conception of autonomy and an enabling of its constituent dimensions is a persuasive guide to our reasons and actions.

Mackenzie, C. (2014). “Three dimensions of autonomy: A relational analysis”. In: Veltman, A. and Piper. M. (eds.) Autonomy, Oppression, and Gender. Oxford: Oxford University Press, pp.15-41.

The scale and spread of the global pandemic have surprised everyone. With the governments of countries across all continents becoming involved except Antarctica. Not since WWII has there been an event that has brought the instruments of state institutions and the behaviour of the public into such close proximity with each other. 

While the COVID-19 pandemic is clearly a global issue that crosses national boundaries and jurisdictions, particular states have adopted different approaches and measures within their own populations in order to contain the spread of the virus. Approaches and measures that have also been taken within the context of specific cultural norms. A case in point has been the tendency to take a scientific evidence-based approach within the UK in order to persuade the public of the rightness of the measures for governing the situation, versus a more hierarchical approach adopted by the governments of many other countries.  Whichever approach is adopted, the ethical principles underpinning these measures—and thereby their acceptability to the public— remains an interesting area of debate.

In his book “Privacy and Freedom” (Westin, 1970), Alan Westin defined privacy as the “claim of individuals, groups, or institutions to determine for themselves when, how, and to what extent information about them is communicated to others” (p.7). Now known as the ‘informational definition of privacy’ it is a definition intended to be read against a background of limits on the state and limits on any unwarranted intrusion by the state into the private life of individuals. It is also a definition that has since been extended to situations when individuals may also choose to determine for themselves when to place limits on the access of others to the individual self. 

The case this week of a Taiwanese national attending an American university in Europe who—on returning to Taiwan—has been placed in home quarantine for 14 days, renews interest in the social conditions that may tip the ethical scales in favour of one party or another. In this case between the informational privacy of individual citizens on the one hand and a justification for government surveillance for public health purposes on the other (https://www.bbc.co.uk/news/technology-52017993). The specifics of the case are any returning citizen will be requested to supply contact details along with information on recent movements, will be placed in home quarantine for 14 days, and as additional enforcement actions, will also be subject to satellite tracking of their phone, and a fine of up to one million TWD (about £25,000) should they break the conditions of the quarantine.  

While these measures benefit the health and welfare of the population and can be seen to be a fair distribution of burdens in order to prevent further harm, specific individuals may still feel the pinch of such precautionary measures and the lack of informed consent. Westin’s continuing argument is pertinent. On discussing the value of privacy, he makes the following assertion: “the individual’s desire for privacy is never absolute, since participation in society is an equally powerful desire. Thus each individual is continually engaged in a  personal adjustment process in which he balances the desire for privacy with the desire for disclosure and communication of himself to others, in light of the environmental conditions and social norms set by the society in which he lives” (Westin, 1970, p. 7).  Guided by the prevailing conditions and social norms attached to public health, it can be argued that government-citizen relations are undergoing a process of adjustment. Privacy is not an absolute but a relationship.

In the sixth book of the Republic, a Socratic dialogue on just government, the Ancient Greek philosopher Plato likens the Athenian city-state to a ship [1].  On the ship are the ship’s owner and its sailors, while the position of captain is vacant. The question underpinning the dialogue is this: who should be captain? Who should be in charge of steering the ship, and on what basis?

Should it be the shipowner? “The shipowner is bigger and stronger than everyone else on board, but he’s hard of hearing, a bit short-sighted, and his knowledge of seafaring is equally deficient”. It would appear not. While the shipowner is characterised as possessing the superior physical strength, the insensitivity of his senses and the inadequacy of his knowledge constrain him from taking up the role.

Should it be the sailors? “The sailors are quarreling with one another about steering the ship, each of them thinking that he should be the captain, even though he’s never learned the art of navigation, cannot point to anyone who taught it to him, or to a time when he learned it. Indeed, they claim that it isn’t teachable and are ready to cut to pieces anyone who says that it is”. Due to their interminable quarrelling, the sailors believe the person who ought to be captain is the one who possesses the superior rhetorical skills, the person who can persuade the shipowner that he is the right person for the job, “they call the person who is clever at persuading or forcing the shipowner to let them rule a “navigator,” a “captain,” and “one who knows ships,” and dismiss anyone else as useless”. Socrates begs to take a different view, “they don’t understand that a true captain must pay attention to the seasons of the year, the sky, the stars, the winds, and all that pertains to his craft, if he’s really to be the ruler of a ship. And they don’t believe there is any craft that would enable him to determine how he should steer the ship, whether the others want him to or not, or any possibility of mastering this alleged craft or of practicing it at the same time as the craft of navigation”.

For Socrates, a true captain, the person best qualified to steer the ship of state, is the person who has mastered the craft of navigation–by understanding not only how to steer the ship, but also by paying attention to the prevailing conditions or environment within which steering the ship occurs. It is this combination of steering skill, plus attention to environmental conditions that determines, along with the requisite feedback let us say, who ought to steer the ship. While Socrates is not optimistic about the attitude the ship’s occupants will take towards a true captain, or indeed the usefulness of a philosopher to the majority of people, the point being made in the exchange is that the captain is the person who has not only mastered the craft of navigation but is also guided by a form of truth that exists beyond the vested interests being debated.  Irrespective of our agreement or disagreement with Plato’s position, the simile raises the following questions ‘Who ought to steer’? Along with the normative question of why they ought to steer and therefore be accepted as the steersman by the others on board ship.

With some poetic license let us say that on board ship, stored on a disc in the captain’s quarters, is a precious cargo of patient data–a key resource for the effective delivery of a city’s patient care. However, not only is the patient data a resource of value to the city and to its citizens, it is also a resource of value to healthcare researchers, and to commercial companies. The captain, the destination of the ship, and with whom the ship’s cargo will be shared has not yet been confirmed. Against the recent background of recent initiatives like Care.data, Project Nightingale, and Alexa Healthcare Skills, who ought the guardians and steersmen of our patient data be? And why?

          

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[1] The simile has become known as the Ship of State. All citations are from Cooper, J.M. (1997) (ed.) Plato: Complete Works. Cambridge: Hackett Publishing Company. The key passage is contained in Republic VI, 487e7– 489a6, p.1111-1112.