Illustrative image for C.D.C.’s Latest Mask Guidance: Science, Politics, and Public Health

Bioethics Forum Essay

C.D.C.’s Latest Mask Guidance: Science, Politics, and Public Health

Throughout the coronavirus pandemic, science and politics have been at play in government policy decisions and communication about those decisions.  This statement would seem to be an obvious platitude.  However, misconceptions about the role of science and of politics have obfuscated discourse concerning the U.S. government’s pandemic policy decisions.  The latest example of this obfuscation is the policy guidance issued by the Centers for Disease Control and Prevention on May 13 that people who have been fully vaccinated against the coronavirus virus no longer need to wear face masks indoors, with some exceptions.  This guidance was backed by recent real-world scientific studies that showed a high level of protection from disease and infection for those who have been immunized with one of the three vaccines that have received emergency use authorizations in the U.S.

A prominent mantra in public discourse during the pandemic has been “just follow the science.”  And it would appear that this is precisely what the C.D.C. tried to do with  its most recent face mask guidance.  If “just follow the science” is meant to underscore that public health decisions should be evidence-based in light of rigorous and relevant scientific studies, then it would go without saying.  But this mantra suggests that these policy decisions can be determined by science and science alone.  Public health decisions, however, always involve value judgments, which are not a matter of science, although they can and ought to be informed by scientific evidence.  At stake in the C.D.C.’s decision on face masks for those who are fully vaccinated is a trade-off between protecting the public from the transmission of the virus, with potential consequences for health and health care, and promoting the return of society to pre-pandemic normality.  Science alone cannot guide policymakers in deciding what weight to give these competing considerations.

Because science alone can’t determine public health policy decisions, politics necessarily comes into play.  However, the role of politics is obscured by the contemporary understanding of “politics” as denoting narrow, partisan thinking and action.  For example, in an opinion essay criticizing the C.D.C. for failing to consult with the top levels of the Biden administration before issuing its latest guidance on face masks, Leana Wen wrote that  “there’s a big difference between listening to scientists and ceding policymaking to one scientific organization.” She added that intervening by the Biden administration in this case “wouldn’t be about politics; it would be for the public good.”  

Wen gets it right that the C.D.C.’s decision was not just a matter of science.  But it is off-base to describe consultation with the Administration before issuing such policy guidance as not about politics but about the public good.  For central to politics, in a legitimate broad sense of the term, is making decisions aimed at the public good.  Indeed, any decision by a government agency is inherently a matter of politics in this broad sense.  To be sure, decisions oriented to promoting the public good can be contested with respect to ends and to means.  What counts as the public good and how to promote it in a particular context are matters of disagreement and debate—the very stuff of politics. 

Wen rightly criticizes the C.D.C.’s decision as premature in light of the fact that less than 40% of the U.S. population had been fully vaccinated and that no mechanism is in place to reliably verify whether someone has been fully vaccinated.  The C.D.C. policy seems to be based on the unrealistic assumption that those who are not vaccinated will continue to wear masks indoors in public settings.  Responsible politics ought always to have in view potential negative unintended consequences of policy decisions.  The C.D.C. guidance likely encourages unvaccinated individuals to forego face masks, especially those who have been politically opposed to mask mandates.  Therefore, this policy guidance risks endangering others who have not been vaccinated but are trying to protect themselves from becoming infected.  Regardless of whether the C.D.C. was right on the science about vaccination obviating the need to wear face masks, it arguably was wrong on the politics of its policy decision—a decision that Wen described as “an astounding strategic and tactical mistake.”  In other words, the C.D.C. erred by just following science without giving due attention to politics.

Conceptual clarity about the scope of science and of politics certainly does not suffice to make sound public health decisions; however, it is vital to realistic appraisal of what is at stake in those decisions.

Franklin G. Miller, PhD, is a professor of medical ethics in medicine at Weill Cornell Medical School and a Hastings Center fellow.

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  1. Dr. Miller: you are, of course, correct that “follow the science” is a vapid idea when (as is nearly always the case) the science has to be *interpreted* via value judgments. [I wrote a chapter for a 2018 Hastings Center report about how pervasive, inevitable, and hidden these value judgments are: https://onlinelibrary.wiley.com/doi/full/10.1002/hast.818%5D

    But in the case of the CDC mask advice, they didn’t even “follow the science”! “Recent real-world scientific studies that showed a high level of protection from disease and infection for those who have been immunized” provide a useful answer **to the wrong question.**

    CDC should have considered the evidence for what would — now WILL– happen when unvaccinated people pretending to be otherwise doff their masks, and infect those who haven’t been able to, or can’t, be vaccinated. They should also have considered the remaining doubt that vaccinated people can’t possibly spread Covid to the unprotected, a risk that masks will naturally help reduce.

    One more non-scientific point: as usual over many decades, CDC does what it wants without consulting with OSHA, the agency tasked with protecting 130 million US workers. That’s “policy”– and a rude and thoughtless one.

  2. I agree with Dr. Miller’s observation that public health decisions involve value judgments, and have previously made the point elsewhere (Paola F. The impossible and the undesirable, JPAE 2020;31(3):111). However, I respectfully disagree with his assertion that “the C.D.C. erred by . . . [not] giving due attention to politics.” The CDC recommendation (available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html) read in part that fully vaccinated people can “Resume activities without wearing masks or physically distancing, except where required by federal, state, local, tribal, or territorial laws, rules and regulations, including local business and workplace guidance.” That “except” is a big qualification and, I would argue, gives political actors–federal, state, local, and private–more than their due. Furthermore, Dr. Miller’s conclusion that Leana Wen was correct about the prematurity of the CDC’s pronouncement is also based in part on a value judgment. Dr. Miller and Leana Wen seem to be of the opinion that the harm that will follow from allowing the vaccinated to forego wearing masks (there is a risk that some unvaccinated individuals will pretend to be vaccinated and forego masks, possibly increasing the number of COVID cases) exceeds the harm that would follow from compelling the vaccinated to continue to wear masks for some indeterminate time (something that would certainly undermine liberty interests, both in the concrete and in the abstract, and risk disincentivizing vaccination). Of course, some of our disagreement over the CDC’s pronouncement might reflect differences of opinion about facts and probabilities; but no doubt, some of our disagreement reflects differences in our ranking of harms–differences about value. And value disagreements are OK in the political sphere; but it seems to me that there are more politic ways of telling someone with who you disagree that they erred.

    1. I would agree with Dr. Paola with a caveat. In this era of post-truth politics and even post-truth science, my trust that the CDC’s recommendations are made based on objective facts is nominal. Might the need for continued distancing by wearing masks be in the best interest of the public health based on objective data it would be too “messy” to share? We have seen evidence of this cherry-picking of information that is made public since the pandemic was declared (e.g. recently the ‘died of’ versus ‘died with’ controversy). It is difficult to have an honest disagreement about facts and probabilities when truth is in the eyes of the beholders.

      1. I was focused on the role of value in public health decisions, but I agree with Dr. Anderson that another source of disagreement about the CDC’s recommendations is trust or lack thereof. To the extent that one mistrusts the CDC, one is less likely to accept it’s representation of the “facts” and the conclusions it draws based on those facts.

  3. Dr. Paola: (1) the CDC *cannot* supersede federal, state, and local laws, so their “except” is lovely but not more than pro forma– they failed to coordinate with OSHA and other agencies who have different/greater expertise; (2) we shouldn’t need to incentivize vaccination by providing “rewards”– we are not toddlers (well…). The reward of vaccination is the protection it provides for self and others, even if it doesn’t immediately provide “relief from the tyranny” of mask-wearing.

    Finally, “liberty interests” must balance the inconvenience (and delusionality) of anti-maskers against the liberty of the immunocomprised and not-yet-vaccinated to NOT be exposed to needless harm, wouldn’t you agree?

    1. Dr. Finkel writes, “’liberty interests’ must balance the inconvenience (and delusionality) of anti-maskers against the liberty of the immunocomprised [sic] and not-yet-vaccinated to NOT be exposed to needless harm, wouldn’t you agree?” I’m not sure I would characterize one’s interest in not being unreasonably exposed to harm as a “liberty” interest, but I have no objection to characterizing it as such as long as the interest (liberty or otherwise) only gets weighed once; in any event, it goes without saying (although I believe I did say it) that the competing interests need to be weighed in formulating public policy.

      Referring to the harm suffered by “anti-maskers” compelled to wear one as “inconvenience” and to their position as the product of a delusion trivializes a position that I suspect is held by a sizable fraction of the U.S. population, many of whom believe that there are interests at stake here arguably greater than being COVID-free.

      1. Thanks for the reply, and sorry for the misspelling (which I saw immediately and could not fix). I don’t think I denied that you want to weigh competing interests; I just objected to your only referring to one side of the ledger as involving “liberty interests.”

        Yes, I have scorn for those who can’t wait to doff their masks, because I do consider masking a mere inconvenience, and because I’ve heard from dozens of them (I moderate a large Facebook page near Princeton NJ) and they revel in their selfishness and obliviousness to those around them. Many are convinced that mask mandates are a “deep state tyranny” that only “sheeple” obey.

        So yes, I trivialize their position, because I believe it is trivial. You obviously disagree.

  4. Thank you for this thoughtful analysis of the complex interaction between science and politics in the mask debate. In addition, we should note the is a fundamental disagreement at the level of worldview, where beliefs determine our understanding of human personhood. Are we a random collection of particles in an existential universe? If so, each is their own arbiter of truth, morality and ethics. But if there is order and purpose in the universe, each person is accountable and responsible for their choices. Certain consequences follow from choosing vaccination, or not.
    At this point, science fails us, because it only provides incomplete information. but it does give us probabilities and confidence intervals. Each person must choose their option. In this case, there seem to be three: (1) I will be vaccinated, (2) I will never be vaccinated, and (3) I will wait for more evidence. We focus vaccination arguments on this third group.
    This allows for respectful disagreement that is lacking in politics. Scientists and philosophers should be able to avoid ad hominem accusations and stick to substance. Most unvaccinated people I meet are in the third group. Dr. Finkel and I each have data from non-overlapping small convenience subject to self-selection bias. My unvaccinated acquaintances usually offer sound, but misinformed, reasoning. They should be persuaded if we can lead them to better quality data. It’s the same risk/benefit tradeoff analysis as for any new drug.
    I believe that each individual is responsible for their choice. If I choose to be vaccinated, I run the minuscule risk of a severe adverse event. If not, I accrue the risk of COVID infection. The vaccinated person can unmask in situations where the risk (never zero) is acceptable, without being responsible for the risk a voluntarily unvaccinated person assumes. Decisions have consequences! This leaves the few patients with vaccine contraindications and those that can’t mount a robust immune response, due to a medical condition or immunosuppressive drugs. This is a small enough group that, if > 85% of the rest are vaccinated, they should be reasonably safe. National polls suggest that with persuasive data that should be achievable.

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