Individualism: The Basis of Public Health or Its Nemesis?
The Individual in Modern Medical Ethics
Public health ethics, together with basic human rights law, are based around the primacy of freedom of choice, otherwise considered the necessity of informed consent. While prominent arguments have been raised against bodily autonomy in the past few years, there are very good reasons why power in medicine was held to be with the individual patient rather than the practitioner.
Firstly, when people are given power over others, they commonly misuse it. This was apparent under European fascism and the eugenics approaches common in the United States and elsewhere in the first half of the 20th century. Secondly, psychological experiments have routinely shown that ordinary people can turn into abusers where a “mob mentality” develops. Third, if all people are considered of equal worth, then it is untenable for one person to have control over the bodies of others and decide on the acceptability of their beliefs and values
Many cultures have been based on inequality, such as caste systems and those condoning slavery. Justifications for colonialism were based on this premise, as have been involuntary sterilization campaigns in many countries. Therefore, we should not view such approaches as far in the past or theoretical – the world has continued to see ethnically-based violence and wars, and division based on characteristics such as race, religion, or skin color. The public health professions have historically been active implementers of such movements. We should expect that such sentiment still exists today.
The opposite of authoritarian or fascist ideologies is individualism, which is a mainstay in the history of political thought, where the sanctity of human beings as being “ends in themselves” requires a profound metaphysical commitment to human dignity, autonomy, freedom, and moral worth. Without valuing individualism, informed choice is meaningless. Under post-World War Two medical ethics, an individual has the right to decide their own treatment, in their own context.
Exceptions occur in three areas. First, where a person has a severe mental illness or other major incapacity that impairs their decision-making. As above, any decision then made by others can only take their interests into account. Secondly, where a person is intending to commit a crime, such as deliberately injuring another. Thirdly, as the Siracusa protocol states, where certain rights may be limited to deal with a serious threat to a population’s health (Siracusa Principles, Article 25).
These exceptions obviously raise room for abuse. In the recent Covid pandemic, the Journal of the American Medical Association (JAMA) ran an article that would have fitted well with pre-WWII European fascism or North American eugenics. It suggested that doctors who held “false beliefs on the Covid-19 response (e.g. suggesting poor efficacy of masks and safety of vaccination) were exhibiting neurological illness and therefore should be managed as people unable to make informed choices. The Soviet Union put dissidents in psychiatric institutions in the same manner.
Messaging that “We are all in this together,” “No one is safe until everyone is safe,” and similar rhetoric play on this theme. While the idea of serving a greater good, or doing what is best for the majority, is a widely-held and understandable concept, during the Covid response it allowed major media networks to demonize children for putting adults at risk.
This raises the tension between a proclaimed public good (a person decides others should be restricted to benefit the population) versus individual choice (the right to make one’s own judgment on how one acts), even when (as in most things in life) others are involved. In Western nations since WWII, the emphasis was clearly on individual choice. In Communist and other authoritarian regimes, the emphasis was on a proclaimed collective good. These are fundamentally different drivers for how society should act in a health crisis.
Recent wording related to the World Health Organization’s pandemic prevention, preparedness, and response (PPPR) agenda suggests a specific drive to downplay individual rights (bodily autonomy or “individualism”). We provide here a series of examples across several new international documents on pandemic preparedness, which correspond to new wording added to the draft Pandemic Agreement intended for a vote at the 78th World Health Assembly in May 2025. The examples seem related, suggesting an intentional introduction of this theme.
We question here whether a sea change is underway in international public health ethics, and whether medical ethics developed to counter the approaches of European fascism and colonialism are deliberately being eroded to promote a new centrist authoritarian agenda.
The Global Pandemic Monitoring Board (GPMB) 2024 Annual Report
The Global Pandemic Monitoring Board (GPMB) produced its annual report in late 2024, advocating strongly for the core areas of WHO PPPR proposals. The GPMB is co-convened by WHO and the World Bank but ostensibly independent, as with other similar panels. Its annual report, promoted specifically by the WHO at the World Health Summit in October 2024, listed major drivers of pandemic risk and recommended actions to address them. For the first time we are aware in a WHO-linked report, ‘Individualism’ is specifically identified as a major driver of pandemic risk.
The inclusion of individualism as a major driver of pandemic risk is backed by just one citation. This is a study by Huang et al. published in the Nature journal Humanities and Social Science Communications in 2022. We discuss this paper in detail below.
Thus, the GPMB, endorsed by the WHO, has raised individualism (presumably bodily autonomy or individual sovereignty) as a driver of harm to the global population, apparently in direct contravention of prior international norms such as the Universal Declaration of Human Rights, the Geneva Convention and associated rights-based protocols, and the Nuremberg Codes, to name a few. This raises concerns not only from an ethical and political perspective but also through the lack of evidence provided to even back the contention, as we show below in regard to the Huang study.
The Elders
The Elders, a group with members overlapping the GPMB and long advocating for the WHO’s pandemic agenda, published a position paper on PPPR on 30th January 2025. While it reflects talking points of similar earlier reports (e.g. the Independent Panel report of 2021) and is similarly relaxed regarding the provision of evidence to back its claims of existential threat, it also raises the theme of individualism. This seems unlikely to be coincidental, particularly as authors overlap with the GPMB.
While not actually providing the citation, its claims of the threat of individualism to Covid outcomes look to be from Huang et al. (2022), the same source as the GPMB: “A 2021 study found that the more individualistic a country, the higher its COVID-19 transmission and death toll, and the less likely its people were to adhere to prevention measures.” As noted below, this is a major mischaracterization of the findings, though not the conclusions, of Huang and co-authors, The populations with a communal history, while having better Covid-19 outcomes, also had lower vaccine uptake.
The Elders then make the seemingly contradictory but fascinating statement in the context of pandemics; “Authoritarian leaders can exploit the culture of individualism to further divide people in the interest of consolidating their power. The imperative for authoritarian leaders [was] to project strength and thereby behave complacently during COVID-19.” This implies that authoritarianism promotes individual autonomy, whereas closures and mandates were a sign of non-authoritarian governance.
Given its central evidentiary role within both reports, it is necessary to unpack Huang et al.’s study to better understand its claims, robustness, and the epidemic authority it should be awarded.
HUANG et al. 2022; Manufacturing Evidence to Support a Narrative?
A group of four Chinese academics published a research paper in Humanities and Social Science Communications in 2022. Individualism and the fight against COVID-19 became the sole source cited as evidence that individualism is a major driver of pandemic risk in the GPMB report promoted by the WHO, and subsequently that of The Elders. Huang and co-authors conclude:
“Evidence collectively suggests that a greater reluctance among people in more individualistic cultures to heed virus fighting policies impose a negative public health externality in a pandemic.”
By individualism, they mean:
“Individualism captures the extent to which people in a society are mentally and habitually empowered to make their own choices (Hofstede 1980).”
Funded by academic institutions in China, the study compared countries in their Covid-19 outcomes against measures of individualism. This measure included the number of winners of the Nobel Prizes for literature and peace that they had produced; considered by the authors as a marker of a national tendency for individuality.
As they state:
“Using the number of Nobel-Prize (sic) winners to instrument individualism, we show that countries scoring high on individualism generally have a more severe COVID-19 situation.”
From these conceptual foundations, the study then compared West and East German provinces from 2020 to 2021, considering that they had “inherited [individualism-collectivism traits] from their divergent political trajectories prior to the German reunification in 1990. While the eastern provinces had higher Covid-19 mortality rates in 2021, the study noted that the average age was higher and after various adjustments concluded that the eastern provinces suffered relatively lower Covid harm in both years.
Of particular interest regarding the German arm of the study, the researchers noted that the eastern provinces also had lower Covid vaccination rates associated with their overall improved outcomes. Yet, rather than concluding (as they did with past collectivist history) that this was a driver for lower mortality, they stated that “vaccine scepticism” was being “deliberately instrumentalized by right-wing groups.”
The authors also seem to ignore the possibility that lower Covid vaccination rates in East Germany (and in Central and Eastern Europe in general) may themselves be an effect of a lower trust in institutions inherited from the Communist era. As a result, they imply that a lack of individualism reduced severe Covid, but too much individualism reduced vaccination rates (which were supposed to reduce severe Covid). The internal contradictions here may have escaped the Nature reviewers and the GPMB.
The authors’ explanation of why collectivism is superior to individualism speaks volumes about the concentration on mass compliance within the centralized policies of the Covid-19 response. To quote it in full:
“The author of The Communist Manifesto, Karl Marx, in his early writing, criticizes the notion of natural rights found in the “Declaration of the Rights of Man” (1791) from the French Revolution as reflecting only the egoistic part of human nature, without acknowledging the community-oriented part of human nature. As a political system, a communist regime can cause a shift towards more collectivistic cultural values from the top down, such as through value inculcation by workplace organizations, by political education and through the control of media by the authorities (Wallace, 1997)”.
It is concerning from a human rights perspective that this paper by Huang et al., promoting a communist-inspired response to health emergencies, constitutes the only evidence the GPMB thought necessary to back their assertion that individualism is a health threat. Having promoted the GPMB findings, the WHO Secretariat has now added a curious line to the draft Pandemic Agreement, seemingly seeking to codify this concern in future pandemic policy.
The Draft Pandemic Agreement
The draft Pandemic Agreement through which the WHO and certain Member States hope to address increased funding demands and governance of PPPR continues to be negotiated in Geneva. After three years, it is still subject to dispute between countries regarding the areas of ownership of genomic samples, sharing of profits from vaccines and other medical countermeasures, and control over intellectual property. The intent is to put a draft to a vote at the May 2025 World Health Assembly. Whilst a recently released draft concentrated on the remaining points of dispute, it also added an entirely new paragraph on a seemingly unrelated topic, continuing the theme of individualism being a public health threat.
In addition to the agreed text in Article 1 of the draft Pandemic Agreement, “Recognizing that States bear the primary responsibility for the health and well-being of their peoples,” the International Negotiating Body’s latest proposal for the draft Agreement of 15 November 2025 included a subsequent paragraph, stipulating the responsibilities of individuals in the event of a pandemic:
“[1bis. Recognizing that individuals, having duties to other individuals and to the community to which they belong, and that the relevant stakeholders, are under responsibility to strive for the observance of the objective of the present Agreement,]”
The square brackets indicate that “there were divergent views” with respect to the proposed text. The lack of consensus among WHO Member States speaks to their understandable reluctance to open a can of worms by recognizing a subsidiary individual responsibility for health and well-being, and perhaps doubt that the place for such an assertion should be a legally binding international agreement. The lack of clarity inevitably raises thorny questions around what these individual duties encompass; whether they are envisioned as legally binding or to act as a reminder of our moral and ethical duties towards others, and how they are to be discharged and enforced against citizens (if legally binding) when stipulated by an international agency.
Pre-Covid-19 WHO recommendations on pandemic influenza promoting a whole-of-society approach to pandemic preparedness detail the “essential roles” of individuals and families during a pandemic. While recognizing the state as “the natural leader for overall [PPPR] coordination and communication,” the WHO views national PPPR as a ‘whole-of-society responsibility.’ Accordingly, the WHO considers that individuals have the following responsibilities to address the spread of infectious diseases: “the adoption of individual and household measures such as covering coughs and sneezes, hand washing, and the voluntary isolation of persons with respiratory illness may prevent additional infections.”
This guidance document also highlights the importance of households and families in ensuring access to “reliable information” (i.e. from the WHO, local and national governments) on par with access to food, water, and medicine. With regards to individual responsibilities towards one’s community for those who have recovered from the virus, the WHO suggests considering options to volunteer with community organizations to assist others.
However, the scope of this personal responsibility has arguably expanded since the Covid-19 pandemic. A 2024 paper by Davies and Savulescu explores this, suggesting that “in the absence of extreme levels of coercion” individuals have a “responsibility for following reasonable and well-communicated guidance” to prevent the spread of the disease. This suggestion is broadly in keeping with pre-existing WHO guidelines but underlines the problem of determining what is “reasonable guidance.” The disparity in individuals’ access to “reliable information” and their ability to discern reasonable from unreasonable advice, applied to their own context, are critical to making an informed choice.
The authors further stipulate that this personal responsibility entails complying with a range of medical countermeasures and non-pharmaceutical interventions (NPIs), including mask and vaccine mandates, social distancing, self-isolation, and sharing information with public health officials. This raises the problem that many benchmarks changed during Covid-19 without a clear evidence base.
And some changes, such as masking, explicitly go against the Cochrane Collaboration meta-analysis of efficacy as well as several other supporting published studies. In this case, the appeal is to institutional opinion (e.g. WHO) rather than evidence, making assessment of ‘reasonable’ guidance highly problematic.
Regarding the nature of these responsibilities, Davies and Savilescu argue for a moral responsibility but don’t consider that this enables governments to “legally enforce vaccination.” Further, they recognize that financially vulnerable individuals may not be able to afford to self-isolate and miss work, suggesting that there are exceptions to the rule. One might add that others may also recognize that longer-term societal harms such as the increased poverty and interruption to education caused by the Covid response can make compliance with such short-term recommendations inappropriate.
There is also a “knowledge condition” on responsibility, as individuals may have reasonable grounds to refuse an intervention due to uncertainty, exposure to misinformation, and well-founded mistrust in institutions, including assessment of evidence of costs and benefits within their own context.
It is hard to imagine how consensus can be reached on such complex and ambiguous matters in the context of the Pandemic Agreement negotiations, let alone have them codified into law. These examples provide only a small insight into the array of questions that the inclusion of a paragraph on individual responsibility in the Pandemic Agreement will raise. Such ambiguity opens the prospect for abuse and justification of extraordinary measures that undermine individual rights and freedoms.
Perhaps the most important concern is whether the Pandemic Agreement could become a license for coercive vaccine mandates, other medical countermeasures, and non-pharmaceutical interventions, or whether it would remain in the realm of moral and ethical responsibilities born by individuals. The latter could be misappropriated to justify some degree of coercion and curtailment of individual rights and freedoms. This mirrors a longstanding debate in political theory, where moral justifications “to force one to be free” to enhance a form of collective “positive freedom” can come with significant cost to an individual’s “negative liberty.”
In practice, getting a correct balance often boils down to mechanisms to restrain power, in which human rights and the individualism they seek to protect play a historic role. However, the former scenario of giving license to coercive measures has a far more destructive potential to legitimate extreme coercion and individual liability for failures to comply with dictates that an individual or person in power decides are one’s ‘duties’ towards others. Ultimately, neither is desirable for the preservation of some degree of individual agency in matters concerning one’s health.
The Logic of Restricting the Many to Benefit the Few
Despite the concentration of mortality in the elderly and those with significant comorbidities, the SARS-CoV-2 virus was met with society-wide restrictive and coercive measures on a scale not previously employed. This Covid-19 response underwrote a massive shift in wealth globally from the many to the few. Healthcare and digital corporations, and individuals invested in them, gained unprecedented increases in wealth through the restrictions on what many had come to accept as immutable human rights – one’s choice as to how one deals with a threat to one’s health.
Whilst there has long been tension between individual sovereignty (bodily autonomy) and the need to act in ways that limit risk to others, the emphasis in Western nations had clearly been on the side of the individual for the 75 years prior to the Covid-19 outbreak. The success of the Covid-19 response in enriching a few, and in promoting the vast pandemic industry based on ever-expanding surveillance and vaccine-related responses, provides a strong driver to many in positions of influence to continue down this road.
The apparent attack on the concept of individualism, characterized on flimsy evidence as being a major driver of pandemic risk, is consistent with this authoritarian drive in public health. Self-interest is a strong driver of policy, and the public health community has an unfortunate history of facilitating and abetting those who would abrogate the rights of others for personal gain. This is an extremely concerning trend, more so when it is provided with a veneer of legitimacy by panels of eminent individuals. Its incorporation now into the latest draft of the WHO’s Pandemic Agreement appears to signal an interest in downgrading the concept of individual rights at the level of international law.
The WHO constitution defines health as physical, mental, and social well-being. It is hard to see how mental and social well-being are best served by forcing individuals to forgo their autonomy and be forced to follow the dictates of others. History tells us that power will be abused, but understanding human capital also tells us that those who lack autonomy tend to have shorter lives. It is telling that the only study quoted in the recommendations detailed here considers the achievement of Nobel Prizes in literature and peace to be signs of a negative social tendency. Others would consider such achievements a sign of human flourishing and advancement.
The attempt now to codify the concept that individualism is a threat to health into international law, through the draft Pandemic Agreement, should alarm us all. The somewhat ludicrous level of evidence provided to support it says much of the risk this approach poses, and the harm we can expect. Modern public health ethics have been based on support for populations through the upholding of individual human rights. Moreover, empirically, there is no crisis demanding an urgent rethink and the abandonment of individual liberties. Those advocating this change should reflect on the definition of health, and why we have designated the individual as the primary unit of moral concern and thus as the chief arbiter of healthcare.
