JRSM >
Volume 97, Number 6 >
Pp. 262-265
1 Division of Community Health Sciences, University of Edinburgh
2 Healthcare Commission, London
3 Department of Primary Health Care and General Practice, Imperial College
London, UK
Correspondence to: Professor Aziz Sheikh, Division of Community Health: GP
Section, University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX,
Scotland, UK
E-mail:
aziz.sheikh{at}ed.ac.uk
 | INTRODUCTION |
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 TOP INTRODUCTION ARE CYCLE HELMETS EFFECTIVE?THE ETHICS OF LEGISLATIONCONCLUSIONSREFERENCES |
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| ARE CYCLE HELMETS EFFECTIVE? |
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TOPINTRODUCTIONARE CYCLE HELMETS EFFECTIVE?THE ETHICS OF LEGISLATIONCONCLUSIONSREFERENCES |
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Observational studies, looking at regional and national time trends of head injury, have shed further light on the question, revealing a strong association between increasing helmet use and declining rates of injury.14-17 Randomized controlled trials would undoubtedly allow a clearer picture of the efficacy of cycle helmets, but such studies are impractical on account of the very large numbers that would be required and ethical concerns about randomization to non-helmet use.18 Indeed, clinical equipoise regarding the benefits of helmet wearing would be hard to achieve, given the existing evidence. To find sufficient numbers of cyclists who were in equipoise about the merits of helmets and about the convenience of wearing them, and who were prepared to comply with their assigned helmet wearing or non-wearing behaviour after randomization, would be near impossible.
Recognizing the methodological constraints, we believe that evidence for the effectiveness of cycle helmets is now strong. Indeed, it may not get stronger, and a strategy of ‘wait and see’ no longer seems justified. Therefore, attention has shifted to discussions regarding the ethical merits of cycle helmet legislation. Here we examine the key ethical issues according to the ‘four principles’ framework of Beauchamp and Childress.19,20
| THE ETHICS OF LEGISLATION |
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TOPINTRODUCTIONARE CYCLE HELMETS EFFECTIVE?THE ETHICS OF LEGISLATIONCONCLUSIONSREFERENCES |
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We argue that there are good, but mildly paternalistic, justice-related grounds for making this choice collectively rather than individually.
Evidence from other countries shows that legislative programmes have been effective.15,23 Looking at the substantial burden of cycling-related head injury and the modest achievements of campaigns to promote voluntary use, several countries have concluded that legislation is the most effective way of realizing the benefits of cycle helmets. Bicycle helmet laws currently exist in five provinces of Canada, one-third of US states, and throughout Australia and New Zealand and have recently been introduced in Slovenia for children aged 14 and under. Early results indicate that legislation significantly increases the proportion of cyclists wearing helmets. More importantly, they reveal a reduction in absolute numbers of cycling fatalities and serious head injuries. Critics of legislation, however, point out that the reduction in injuries can be at least partly explained by a decrease in cycling per se.24 The possibility that, in Britain, legislation might reduce cycling from its already low level is real cause for concern, because the health benefits of cycling greatly outweigh the risks from head injury.25 Similar concerns were expressed about a flight from the motorcycle, before motorcycle helmets became compulsory—initially an unpopular law—but the legislation probably had no long-term adverse effects on this mode of transport. The evidence in our possession suggests that, although there might be a transitory reduction in cycle use after legislation for helmet wearing, in the medium term the effect is likely to be negligible. Moreover, if legislation were to reduce rates of serious injury and promote increased public confidence in cycling, the effect might even be to make cycling more popular.
We can also ask whether the legislative intervention is efficient in achieving the aim of protecting cyclists while not adversely affecting patterns of cycle usage. In principle it should be, since it may be cheaper than implementing a health promotion programme aimed at increasing the voluntary use of helmets. There is a pragmatic question that is incalculable at this stage: law requires enforcement, and there is a question over what the appropriate enforcement strategy should be. However, the threat of sanction has an important symbolic value. It is important that the law should be enforced equitably and that it be phased in over time, to ensure that individuals have a fair chance to comply.
Autonomy
One of the strongest arguments against legislation is that this constitutes
an unwarranted infringement of the civil liberties of
cyclists.26-28
Furthermore, it is argued that enforcing cycle helmet use is tantamount to
penalizing the cyclist when, in many cases, it is the motorist who is
responsible for the
accident.29,30
In addition, there is reason to be suspicious of turning a pleasant leisure
activity into a ‘medicalized behaviour’.
Whilst acknowledging that legislation will of necessity restrict autonomy, proponents can point to the precedents of vehicle (including cycle) lights, speed limits, motorcycle helmets, front seat-belts and more recently rear seat-belts, stressing that any infringement of autonomy is minimal. For the law to work, individuals should autonomously choose to obey, and allow that it can be necessary as a mechanism for behavioural change, in circumstances where change is good but hard to achieve. The medicalization argument is not convincing; no one appears to regard seat belts in this way, for example.
It should be recalled that respect for autonomy is only one of the principles of medical and social ethics although there is a presumption in its favour in most societies. Our argument here is that, in the light of the evidence, most people would rationally choose to wear a helmet, and we would all allow that there are good social grounds for encouraging cycle helmet wearing. But equally, we know that doing what is in our own interest can be hard without external encouragement. We recommend legislation as a collectively autonomous choice in favour of one kind of external encouragement. Naturally, one condition for this argument to work is that it is applied in a democratic society.
Justice
We can divide justice into two parts—procedural and
substantive.31 From
a procedural point of view, three questions are important. First, the law
should be consistent: if a principle is applied in one area, then it should be
applied in all equivalent areas in an equivalent way. Secondly, we must
require that the legislation is enacted in a fair way—that it is enacted
after full public consultation, and after full debate and discussion in
Parliament. In this manner, the legislation arises out of collective choice,
rather than simply being imposed by experts. Thirdly, the legislation must be
applied fairly—that is to say, without arbitrary administration, and
penalizing ‘offenders’ in accordance with the merits of the case.
Thus, it would be unjust to penalize a non-compliant cyclist in a road
accident more harshly than the motorist, where the fault for the accident lay
with the motorist. And it would clearly be unjust to use not wearing a cycle
helmet as a pretext for harassment of ethnic minorities (e.g. turban-wearing
sikhs) or others by the police.
Substantively, we must consider whether the overall collective benefits, and the local benefits to other road users, outweigh the strong claims of individual autonomy. Principally the benefit is a social one—reduced costs to the health service or to one's fellow purchasers of insurance. It is arguable that individuals have some sort of duty to their fellows of taking responsibility for their own health, and that sometimes this duty is an enforceable one. Interestingly, in more ‘libertarian’ societies, such as the US and Australia, compulsory cycle helmet wearing is often a ‘State’ rather than a federal law, in the interests of requiring individuals to be responsible for their health, since many of the severely injured will eventually need to use the State health safety net.
One argument made widely in cycling circles is that cycle helmet legislation distracts us from more effective means of protecting cyclists, such as separating them from motorized traffic. We sympathize with this view and do not believe bicycle helmets fully resolve the issue of cyclists' safety. However, this does not detract from the proven value of cycle helmets in both the short and the long term. Hence we do not agree that our proposal is unfair to cyclists.
| CONCLUSIONS |
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TOPINTRODUCTIONARE CYCLE HELMETS EFFECTIVE?THE ETHICS OF LEGISLATIONCONCLUSIONSREFERENCES |
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The particular difficulty for our case concerns the relationship between autonomy and beneficence. We accept that our argument is mildly paternalistic, in that we are arguing that the interests of personal safety and public welfare safety outweigh the slight harm of infringing individual autonomy. However, as noted in the section on the principle of autonomy, a rational person ought to be able to accept the welfare and safety arguments and autonomously agree to obey the law that we propose.33,34 Moreover, a law that could not command such rational respect would be a bad law. The tyranny of imposing it could not be justified (that would fail the test of the principle of justice, even if it could be narrowly justified on welfare grounds). Unless respect for autonomy really does amount to letting people do whatever they wish unless they harm another, some constraint such as the rationality test (a detailed discussion of which falls beyond the scope of this paper) is needed. Hence, on a plausible understanding of the scope of ‘respect for autonomy’, we hold that there is no major tension between the requirements of the ‘four principles’ in this case.
In summary, we have concluded that there is a strong case for making the wearing of cycle helmets legally compulsory. The argument is weakly paternalistic, in that it gives higher priority to social costs and individual risks than to individual autonomy. We argue that this prioritization is consistent with other injury-prevention legislation. We see three options for the future:
We would favour the last of these options. However, the children-only case has some merit—notably that the autonomy considerations are weaker. We have a general obligation to promote the welfare of children, and there is evidence that adults' behaviour is modified because adults wish to support their children's use of helmets. Against this, the sanctions (e.g. fines) would fall against the adult, so that the effect would be similar to the general legislation option, with the added disbenefit that attempts to identify and penalize the ‘responsible’ adult could cause much resentment and dispute. We also conjecture that by applying the law to children but not adults we would encourage a ‘rite of passage’ effect (much as happens with cigarette smoking), whereby older children abandoned helmets to signify their maturity. This perverse effect would subvert an explicit, if secondary, policy aim of making helmets compulsory for children, which is to encourage adults to adopt helmets in order to set an example without compromise to adults' legal liberty and moral autonomy.
| Acknowledgments |
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| REFERENCES |
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TOPINTRODUCTIONARE CYCLE HELMETS EFFECTIVE?THE ETHICS OF LEGISLATIONCONCLUSIONSREFERENCES |
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A. Swanson, A. Cook, R. Ashcroft, and A. Sheikh Authors' reply J R Soc Med, August 1, 2004; 97(8): 410 - 411. [Full Text] [PDF]
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