What is a public health ‘guideline’?

We are now entering year two of COVID-tide, and an effective vaccine to stop the pandemic appears to be soon at hand. It has been a tough year, and probably will continue to be abnormal for a while, if public health and epidemiological experts are to be believed.

The pandemic has forced many people to learn a lot about the world very rapidly. Many of us have had a crash course in epidemiology, immunology, and public health over the last year. One thing we seem to have also learned is how complex and impotent our public health institutions are.

One of the problems in public health is that many public health experts have no real practical authority. They’re academics, and most of their conversations in ordinary circumstances are among themselves. The public health officials do have some authority, but it is often limited to medical providers and the adjacent industries (think CDC, FDA, etc.). In ordinary circumstances few people would think there is anything strange about this constrained mandate. Indeed, there is a vigorous (though small) cottage industry of ferreting out strange make-work regulations from these agencies, thereby indicating that even the limited mandate may be too broad in ordinary times.

The trouble now is that these public health agencies (and even more, academics) can’t really make rules for the general public. They issue "guidelines". Both a rule and a guideline are a kind of norm, and so it is common to see the words used interchangeably, particularly in these quasi-medical contexts. There is, however, an important difference between a guideline and (what I will call) a rule, and I want to think out loud about this difference for a bit.

Put simply, a rule requires enforcement, whereas a guideline is merely advice. If we distinguish these two concepts in this way, it helps illuminate the problems we’re having with all the various pieces of public health and medical advice we’ve gotten over the last year.

Start with a rule. If don’t enforce compliance with a rule, it is hard to see what practical import it has. Enforcing public health rules is really, really hard. Enforcing rules in general is hard, but in this case, we’re trying to deal with many kinds of behaviors performed by many kinds of people in many kinds of situations. It is implausible that a single one-size-fits-all rule could cover every case. And so it is hard to enforce the rule in a non-draconian way.

Consider, for example, the recent news that NY governor Andrew Cuomo was going to levy fines and other penalties for not following the state’s vaccination "guidelines". This action is totally reasonable and incredibly stupid all at once. It is being made by the proper person: only Cuomo, or someone elected official like him, plausibly has the authority to punish in this way. It also gives a powerful extrinsic motivation to comply. However, it is far too powerful, and in this way quite stupid. In a time where vaccines have extremely short shelf-life and are in very limited supply, while also being extremely effective, making people second-guess their use of the vaccine is a bad idea, for it makes it more likely that vaccines will be wasted. Better for it to go in the wrong arm than in no arm at all.

Other public health measures have proven very hard to enforce. Mask-wearing is a notable case. I can’t think of much actual argument in favor of the moral or civil right to go unmasked. (This essay complicates matters somewhat, though I don’t think it makes a case for a right.) Preventing social gatherings has also been difficult, not least because there are many different sorts of them, and some have been "approved" for political or religious reasons.

Any rule that is simple enough to remember will necessarily have some exceptions in the wide variety of relevant contexts. This adds another difficulty to enforcement, because it is not the case that every instance of non-mask-wearing (for example) is wrong, or even against the rules. Trying to suss out every possible case is a fools errand, and a waste of political or moral authority.

Because the rules are hard to enforce, and because they are often issued by people who have no practical authority, they often come in the form of "guidelines." A guideline is basically a kind of structured advice, given in the style and tone of a rule. It is notable in that it is effectively unenforceable by the one making it; if it were enforceable, it would be a rule, and it would require real enforcement.

Some public health "guidelines" are actually rules, particularly when the constrain the action of various other actors. Medical guidelines, for example, are often really rules for medical professionals. Failure to comply can earn one a hefty penalty. Cuomo’s order mentioned earlier is like this. The NY public health officials promulgated "guidelines", but Cuomo’s actions reveal that these are really rules, since there are penalties for non-compliance.

The trouble with true guidelines is that they have only as much authority as advice does. Guidelines about the size of gatherings, for example, depend on groups deciding to follow the norm. Other groups may decide that they care about their fellowship more than the guideline, and it is hard to clearly say what is wrong about this. (To be clear, I think there often is something wrong about flouting the guidelines, for reasons I’ll get to momentarily.)

Advice is a peculiar thing. Agnes Callard offers a helpful distinction between three different things: "instructions", "coaching", and "advice". Asking for advice, in this trichotomy, is "instructions for self-transformation." That is, it is asking for coaching delivered in the form of instructions.

I think a lot of guidelines are trying to do almost exactly this. And this is why they fail. When public health experts issue guidelines, they are appealing to epistemic authority rather than practical authority.

The transformation that people are seeking in public health guidelines is increased knowledge of what to do in a novel public health emergency. Few of us have any personal understanding of all of the complex features of a global pandemic. We need to know what to do for our own safety and well-being, and we look to experts to give us insight. But the experts can’t give us a graduate-level education ("coaching") in epidemiology or any other technical field. (And often they are unable to even explain their own field to non-experts—a real weakness of many kinds of expertise.) They’re forced to give fairly generic and vague bits of practical wisdom. Fundamentally, they’re trying to supply an education in the form of practical instructions. They need us to think differently about various activities, but they lack the time and opportunity to teach us how to understand. So they give instructions—practical maxims that looks more like rules.

It turns out that a lot of people seem to be genuinely looking for just this sort of thing. They want to know what they can do, and generally are willing to follow the instructions, even without external enforcement. Yet because the instructions are generic and impersonal, individuals can gain knowledge without complying. There is some evidence that this is how a lot of people are operating.

(A topic for a different post: some people already have the relevant knowledge, and often it’s far deeper and broader than the guidelines can provide. E.g., people who live in E. Asian countries and have past experience with pandemics. It isn’t unreasonable to listen to them for advice rather than or in addition to "science.")

Yet when people use guidelines to increase their knowledge, but then supplement that information with their knowledge of their own particular circumstances, sometimes they choose to not obey the guidelines—the instructions—even as they benefit from them. Thus the guidelines "fail" to change behavior, which is what they are intended to do. How then is it ever possible to promote compliance with the public health norms without turning them into rules with official enforcement?

There is a large class of norms that aren’t enforced (or enforceable) by the state, and yet substantially constrain our actions. We might call these "manners". Having bad manners won’t get you fined or put in jail, but it will have consequences, most notably your exclusion from certain types of society.

Manners are famously opaque to those outside the society that uses them. They seem pointless or excessively fussy, and often the social opprobrium directed at mannerless behavior seems to far exceed the immediate practical consequences of the faux pas.

Something similar seems to be true of many current public health guidelines. There seems to be little public health need to wear a mask while jogging, for example. Yet at least in some places, appearing outdoors without a mask for any reason is treated as a serious error. To those who care, this treatment is enough to promote compliance (and, crucially, to perpetuate the norm by "enforcing" it against others). To those who don’t care, there is little one can say. If someone doesn’t want to be part of the mannered society, it is hard to justify complying with any of its norms. In this way, manners resemble instructions. Instructions are useful only if you want what they aim at. Some people just don’t care whether others (usually described as "elites" or "liberals") approve of them, and so the informal social enforcement mechanisms just don’t engage.

Further, as I hinted, mannered behavior gets perpetuated by being enforced by the participants, rather than by some central authority. We’ve seen this too. Ordinary citizens berate one another for not following certain guidelines, as if the guidelines empower the man-on-the-street to enforce the norms. If you asked these self-appointed police whether they believe they have any legal authority, they would say of course not (most of the time). But they clearly think they have some right to demand compliance with the norms. This makes a lot more sense if the norms are like manners, where there is no central enforcing authority and each participant is at least somewhat empowered to police the standards of right behavior.

Finally, there are reasons to comply with manners, even if you think they’re stupid. Often manners are the way that a society demonstrates respect for its members. There may be many different possible systems of norms that indicate respect or care for one’s neighbors, but within a given context the individual usually doesn’t have a choice about which system to follow. Following public health guidelines often takes this form. It may be true that in a particular situation a mask is unnecessary (e.g., while jogging), but wearing it demonstrates that one is willing to limit one’s own freedom out of care for others, and that is a useful message on its own. Similarly, forgoing group gatherings to limit the rapid spread of infectious disease may demonstrate respect for the health care workers that are physically, mentally, and morally exhausted, even if you know that no one in your group actually has the disease.

In sum, I think there are good reasons to comply with public health guidelines, but I also think there are some real limits on how much we can say to those who don’t want to. Fundamentally, most of the norms coming from the public health and other science-tinged domains are just advice. It’s probably mostly good advice, but it’s also not irrational or immoral to ignore it. The same is not true for rules that public officials have issued. If you think you are obligated to obey the government, then you should obey their public health mandates. But public officials should be clear too. For those norms that are really important, public officials who have the relevant authority need to use that authority and actually enforce the norms. Though, as I suspect many have realized, doing so may cost them their job. So be it.