An Eastern Principle of Relational Autonomy Shaped Attitudes Toward Mask Mandate During the COVID-19 Pandemic

Abstract

Photo by Pam Menegakis on Unsplash

Abstract

The Coronavirus 2019 (COVID-19) pandemic caught the whole world off guard and overwhelmed the disease control measures of many nations. During the pandemic, many countries resorted to masking mandates as one of the most effective ways to curb the spread of the virus. The execution of this mandate revealed significant regional and cultural differences between the US and East Asia. Chinese people in Hong Kong have voluntarily and favourably adopted it more than Americans. For the Hong Kong Chinese, mask mandate compliance can be seen as a representation of personal autonomy rather than a violation of it. This attitudinal difference in a global outbreak suggests that we must reconsider the principle of autonomy through the eyes of one’s own culture and the factors that are unique to it. Governments and institutions need to acknowledge the importance of this before implementing health policies, as it can adversely affect adherence and acceptance among their citizens. This paper aims to identify the cultural differences in defining autonomy among the Chinese Hong Kong people, along with other factors that may be relatively unique and upheld by them.

Introduction

The COVID-19 pandemic caught the world off-guard and overwhelmed the disease control measures of many nations. Many countries implemented mask mandates, seen as one of the most effective ways to curb virus spread. Execution of these mandates revealed major regional and cultural differences between the US and East Asia.

This paper will explore these differences and consider how the bioethical principle of autonomy can vary based on cultural and historical experience. Chinese people in Hong Kong generally viewed mask mandates more favorably than Americans. For Hong Kong Chinese, mask mandate compliance was a representation of personal autonomy, rather than a violation of it. In the US, where attitudes can be more individualistic, some people considered mask mandates to be an infringement of personal freedom. This paper will first analyze this variation by focusing on the unique historical factors that affected public perception in Hong Kong. It will also examine the cultural tenets and concepts of autonomy of Hong Kong Chinese people that made mask mandates so successful, while contrasting them with cultural concepts in the US that made the same policy much more controversial. Acknowledging these different cultural interpretations of autonomy can help governments and institutions design health policies that are more likely to be accepted by their citizens, leading to more effective public health interventions.

Background

Empirical evidence suggests that timely government responses were critical to curbing COVID-19 spread, but a lack of evidence-based consensus prevailed on many health measures, like mask requirements.[1] Enough scientific evidence is now available proving the efficacy of mask wearing during the pandemic, in conjunction with social distancing practices, in reducing casualties and deaths – when compliance was high.[2] In fact, data suggests mask-wearing became more popular as the scientific evidence about the airborne nature of COVID-19 transmission increased.[3]

Mask mandate implementation triggered varying responses, with data demonstrating attitudinal differences between the West and the East.[4] It is imperative to understand cultural considerations when it comes to mask mandates, both at a personal and community level, to understand this divergence. Unlike people in East Asian regions like Hong Kong and Japan, wearing masks in public was novel and uncommon for most North Americans before the COVID-19 outbreak, and resulted in sustained opposition in some areas. Violation of individual autonomy and paternalism were often cited as reasons people were opposed to mask mandates.[5] This global division is a result of cultural, political, and social differences between individuals and societies, with far more mask mandate opposition seen in the US than in Hong Kong.

Even in places like the US, some individual rights can be legally restricted to a certain degree for compelling societal goals, such as preventing the transmission of COVID-19. Individual or community rejection of wearing masks during the pandemic triggered ethical, health, and safety concerns. An unmasked person is more vulnerable in crowded and poorly ventilated places, as the virus is air-borne. By not taking proper precautions to protect themselves or others, people added to the heavily burdened health care system. Resistance to health guidelines exacerbated political polarization, especially in the West. Mask mandates in some North American countries ignited protests by “anti-maskers” who viewed such restrictions as an infringement on their rights to freedom and democracy,[6] and, more extreme, as a way for the government to exercise control over its people.[7] In extreme cases, masks served as a trigger for xenophobia and violence against Asian-Americans and Asian immigrants.[8] In Hong Kong, mask mandates were not viewed as a violation of personal or public autonomy.

Hong Kong appeared better prepared for the COVID-19 pandemic than other countries. It applied strategies for controlling virus spread quickly, likely due to personal and institutional memory of the 2003 severe acute respiratory syndrome (SARS) outbreak.[9] As an epicenter of the SARS outbreak, Hong Kong had 1,750 confirmed cases and 286 deaths, including eight healthcare professionals.[10] The explosive spread of the virus had caught the health and hospital authorities unprepared.[11] Implementing reforms inspired by that experience, by the third week of 2020, the Hong Kong Special Administrative Region’s (HKSAR) government activated its anti-epidemic response plans as COVID-19 was first emerging. Residents responded quickly and eagerly, with high rates of voluntary masking, handwashing, social distancing, and the use of thermometers at the entrances of many public spaces.[12] The collective memory of SARS positively impacted their understanding of and response to COVID-19. They prioritized civic responsibility and community well-being in critical public health crises.[13] The high mask compliance controlled community spread.[14] As a result, Hong Kong emerged relatively unscathed despite its dense population, especially in the early days of the pandemic.[15] However, it was not necessarily just their recent historical experience that influenced Hong Kong’s willingness to follow public precautions.

The Concept of Autonomy and How it Differs by Region and Culture

The word autonomy, derived from Greek words autos (‘self’) and nomos (‘rule’, ‘governance’ or ‘law’), originally referred to self-rule or self-governance of independent city-states.[16] Personal autonomy is defined as, at a minimum, self-rule that is free from controlling interference by others and from limitations that prevent meaningful choice, like inadequate understanding. Respect for autonomy is widely accepted as a dominant value in contemporary biomedical ethics. It is considered integral to informed consent,[17] a concept that gained prominence in the movement to end involuntary participation in medical research.[18] Conceptually, it evolved in Western contexts and disregards some non-Western regional and cultural influences.[19] The pandemic led to questions about how autonomy is defined and operationalized, prompting some bioethicists to call for an alternative to this individualistic vision.[20] Traditionally, autonomy enjoys the highest priority in American bioethics,[21] yet some suggest that this was never the intent. Instead, the original goal was to construct a concept of respect for autonomy that is not excessively individualistic, not excessively focused on reason, and not unduly legalistic.[22] By not neglecting emotions or downplaying social practices, this broader definition aligns well with the Hong Kong Chinese view on autonomy.

The Western concept of autonomy focuses on self-determination, prioritizing the subjective value of individual independence. The East Asian or Hong Kong Chinese concept may, by contrast, be perceived as relatively more objective, family-facilitated, and culturally-comprised.[23]

Mask mandates came at a huge personal cost.[24] Apart from the physical discomfort, there was an increased sense of self-social isolation and anxiety when mask mandates were imposed during the pandemic; children could not develop their language and social skills normally with their masks on; people with hearing difficulties could not understand and communicate effectively with others in the absence of facial and visual cues.[25] In many places, their removal came as a great relief and brought back a semblance of normal everyday life. While Hong Kong was one of the last places in the world to remove mask mandates (it did so on March 2, 2023),[26] many people preferred to keep their masks on.[27] This attitude may have a cultural and social basis.[28] The masking rate was high, and the public was confident of its effectiveness.[29] Most people didn’t intend to violate the mandate, were rather eager to wear masks and reluctant to take them off even after 945 days when Hong Kong lifted its mask mandate.[30] Culturally, this could be seen as an alternative way of exercising autonomy.

Relational Autonomy

In recent years, bioethicists have emphasized relational autonomy as a way to incorporate a wider variety of ethical experience.[31] For purposes of this paper, the definition of relational autonomy is the capacity to make decisions as an individual embedded in social relationships.[32]  Humans are always involved in a network of social relations. Their choices are highly influenced by social categories like gender, ethnicity, and culture.[33] The broader conception of autonomy may provide a robust alternative to thinner, individually centered definitions and can encompass responses like those seen in Hong Kong more completely. This approach may also provide a more sustainable ethical grounding for intrusive social interventions in future crises.[34]

In Hong Kong, high mask mandate compliance during the pandemic may be evidence of relational autonomy. It has a network of close physical and social relations, partially due to crowding and limited living space. As of 2022, close to 30 percent of Hong Kong’s over 7 million residents live in public rental housing.[35] As of March 2023, the average living space for renters was 13.8 square meters per person. A large population of poor people live in cage homes, which are subdivided flats with bed-sized areas enclosed in wire mesh.[36] Individual autonomy is hard to exercise without the input or influence of others who share this small, confined space.

In addition to being a reflection of physical space, relational autonomy can also align with deeper historical and cultural norms. In Chinese society, the concept of family is often tightly bound by traditional and cultural values. In the Chinese language, ‘autonomy’ (zi-zhu, 自主) also means self-determination of units of people, such as a family and community, rather than individuals. Under this conception of autonomy, family members of a patient are involved in making healthcare decisions together with the patient. This version of autonomy is more family-centric than individual-based; consideration of the group may supersede individual consideration.

Conceptions of autonomy are further linked to communitarian values held by many Chinese people, including those in Hong Kong. Individual autonomy in Chinese culture is strongly influenced by a culture of filial considerations. Communitarianism is the interlinking idea that human identities are largely shaped by different kinds of constitutive communities or social relations and that this conception of human nature should inform our moral and political judgments as well as policies and institutions.[37] Pure individualism is not considered ideal for forming moral judgments and making daily decisions. Humans are not meant to live alone; they need a sense of belonging, acceptance, and identity in their community. Interdependence motivates and nurtures an individual to care for others out of moral obligation. Communitarianism and relational autonomy reflect a more nuanced understanding of how human identities are shaped by constitutive communities and impact moral and political judgments as well as policies and institutions.[38]

Relational autonomy could be a result of such undesirable social and environmental conditions. It is a relatively dynamic attribute that considers relationship complexities reflecting a more precise reality.[39] On a positive note, a family sharing a small living space can live happily if there is enough support and love. This echoes the concept that relational autonomy does not necessarily reject the notion of self but reflects how an individual with support from family and friends can make decisions and enjoy autonomy while considering others. Willingness to comply with mask mandates during the pandemic aligns with these general cultural differences between the Chinese and the Americans.[40]

Adherence to Mask Mandate is an Act of Both Personal and Relational Autonomy

It is common for sick people in Hong Kong to wear masks in public places during cold and flu seasons to protect themselves and minimize spread.[41] The original intention of Asians wearing masks was not to protect themselves but to protect others first.[42] The high mask compliance in Hong Kong is not only due to its past experiences, but also a sense of collective responsibility and civic duty to reduce disease transmission. It is an active expression of autonomy–both personal and relational–which is perceived differently in some parts of the West. Mask mandates allow individuals to do what they want to do, like protecting themselves and others in a health crisis in a densely populated city like Hong Kong.

Hong Kong Chinese people are inclined to include others in their considerations and actions due to cultural and philosophical influences. Exercising their autonomy, including relational autonomy, by choosing to adhere to mask mandates during the pandemic is closely linked to the communitarian values that are heavily influenced by Confucianism.

A Comparison with the US

The willingness to wear masks during the COVID-19 pandemic was not restricted to Chinese people or East Asians in general. Many Westerners also embraced face masks during the outbreak, but the sharp difference between the rates of compliance and the protests against mask mandates was notable between the East and the West.[43] Those with preexisting conditions who felt fragile and vulnerable to infections, or wanted to protect the people who did, donned masks regardless of location. Cancer patients in the US felt unprotected from COVID-19 when there was no mask mandate.[44] Some were harassed and insulted by “anti-maskers” when they wore masks for their protection. In certain cases, patients were anxious when their health care providers didn’t wear masks. To others, mask mandates were perceived as restrictions infringing on their freedom.[45] Traditionally, individual rights and freedom are highly esteemed in the US.[46] Anti-mask rallies across North America further divided the public on mask use.[47] This resistance, due to its individualistic nature,[48] was especially apparent during the initial spread of the virus. However, not all reasons for refusing to wear a mask were explicitly political. The top three reasons for opposing public mask wearing in the US were physical discomfort and negative effects, lack of effectiveness, and being unnecessary or inappropriate for certain people or under certain circumstances. Apart from individual freedom, there were medical and social reasons for not complying with mask mandates during the pandemic.

Varying Recommendations Among Countries and Trust in Experts

Not all debates about mandates are as clear as an analysis of autonomy. Trust in health experts, medical organizations, and health authorities is an important factor that correlates with citizens’ compliance during pandemics.[49] Doctors and scientists were often among the most trusted professions.[50]

Post-pandemic, many studies have reported a lower trust in doctors and scientists.[51] Contrasting views on face masks, especially during the beginning of the COVID-19 pandemic, contributed to this decrease in trust.[52] In the US, the CDC did not recommend mask-wearing and even said masks would not be effective, contrary to the approaches of Asian countries. It later reversed course, saying mask mandates would be effective, recommending mask use in April 2020 for individuals with respiratory symptoms who had close contact with family members.[53] By contrast, early on, some Chinese government officials and public health experts called for universal use of face masks in public spaces. Inconsistent official guidelines and expert opinions confused the public and health care professionals, and hindered risk communications during the pandemic, complicating the acceptance of mask mandates beyond underlying ethical precepts.[54]

Counterarguments

Despite its usefulness during the COVID-19 pandemic, masking is not free of side effects. The most obvious downside is its physical discomfort, causing difficulty breathing, facial irritation, headache, etc.[55] Mask mandates had many social and developmental costs, especially for young children. As noted above, mask mandates came at a huge personal cost.[56] Apart from the physical discomfort, there were increased senses of self-social isolation and anxiety; children could not develop their language and social skills; people with hearing difficulties could not understand and communicate effectively.[57] Even if relational autonomy applied, the influence of and benefit to the greater community calls for a balanced analysis and evidence-based policies. Consideration of the uncertainty during the early pandemic and the noted problems associated with long-term mask wearing may justify some degree of opposition to masking.

Arguably, relational autonomy is already implicitly part of the practice of autonomy in the US. A person’s values are shaped by their family upbringing, education, experience, and their surrounding communities. An individual is free to consult anyone when making healthcare decisions and evaluating public health recommendations. A recent survey showed that about 43 percent of Americans believed that it is extremely important to wear a mask in crowded settings when feeling sick.[58] In the same survey, 74 percent of people agreed that it is also extremely important to avoid contact with vulnerable people when feeling sick. These findings show that many Americans are also considerate about the well-being of other people as a group or community while at the same time exercising their own autonomy to protect themselves by wearing masks.  

These findings show it is wrong to assume that everyone in the US was an anti-masker. Anti-masking may be rooted in the deep political divides of the US population. Democrats and Republicans are seldom aligned and their views towards the mask mandates also vary widely. Republicans had significantly more negative attitudes toward masks and lower intentions to wear them.[59] These competing factors show that it is important to treat values like autonomy with nuance and consider the range of opinions and political tensions within a population as well as between.

Conclusion

Key differences existed between American and Hong Kong Chinese people’s attitudes toward mask-wearing during the pandemic. Hong Kong Chinese people were accustomed to wearing masks in crowded spaces, when they were unwell, or while taking care of the young or the elderly at home, even after the mask mandate ended. It was considered an act of personal autonomy, yet it also explicitly reflects relational autonomy. Countries with more developed traditions of relational autonomy stemming from communitarian or family-oriented traditions had higher compliance with mask mandates. Their people gave up a certain extent of “freedom” to ensure a higher level of safety for themselves, their family, and society amid the pandemic. In some parts of the US, people prioritized individual freedom and self-comfort. The US and other Western world leaders, including medical professionals, undermined their own credibility and thus public trust in them due to unclear guidelines and policies at the beginning of the pandemic, making it hard for citizens to abide by mask mandates at a later stage. Asian people, in general, displayed a higher level of trust in their public health authorities, creating mutually reinforcing tendencies that made the public more willing to embrace mask mandates.

In conclusion, traditional values and principles upheld by the Hong Kong Chinese people influence how autonomy is perceived and exercised. The concept of autonomy evolves with historical experience and can be impacted by a sequence of events, cultural factors, social norms, and education. Using mask mandates as an example, relational autonomy accommodates a more inclusive definition of self-decision than traditional autonomy, as the former acknowledges and values the influence of relationships between people and their communities when making individual choices. Taking these relationships into account when designing policies, especially in times of crisis, can be critical to a successful response.

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