Making the public protect public health: the ethics of promoting collective action in emergencies.

Effective public health responses to many infectious diseases require sustained collective action. Communicable disease control in populations can only be achieved by high levels of public compliance with health directives. However, governing authorities have limited options if public compliance is insufficient and collective action is failing. Mechanisms to promote public compliance occur on a spectrum from providing public health advice, offering incentives so people cooperate more, to enacting coercive public health orders and mandates. Because the burdens and benefits of these interventions have patterned distributions across society and raise questions of fairness and legitimacy, they have ethical dimensions. Against the background of government responses to COVID-19, we draw on Amatai Etzioni's compliance mechanisms to analyse the ethics and politics of using state power to drive collective action during public health emergencies. We show how different compliance mechanisms have been applied simultaneously and strategically and that the political and ethical impacts of their interaction warrant particular attention. When considering the adoption of compliance strategies, at the level of individuals and groups, it is important to recognise that intervention uptake will vary based on the threat faced, the characteristics of the population and communities, and local capacity to implement strategies. The use of compliance mechanisms during COVID-19 is also instructive. Significant preparatory work to enculture more restrictive social norms and high levels of public compliance must be undertaken immediately if efforts to sustain collective action against pressing global health problems such as global heating and antimicrobial resistance are to be successful.