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Résumé : Photo by Pam Menegakis on Unsplash Abstract The Coronavirus 2019 (COVID-19) pandemic caught the whole world off guard and overwhelmed the disease control measures of many nations. During the pandemic, many countries resorted to masking mandates as one of the most effective ways to curb the spread of the virus. The execution of this mandate revealed significant regional and cultural differences between the US and East Asia. Chinese people in Hong Kong have voluntarily and favourably adopted it more than Americans. For the Hong Kong Chinese, mask mandate compliance can be seen as a representation of personal autonomy rather than a violation of it. This attitudinal difference in a global outbreak suggests that we must reconsider the principle of autonomy through the eyes of one’s own culture and the factors that are unique to it. Governments and institutions need to acknowledge the importance of this before implementing health policies, as it can adversely affect adherence and acceptance among their citizens. This paper aims to identify the cultural differences in defining autonomy among the Chinese Hong Kong people, along with other factors that may be relatively unique and upheld by them. Introduction The COVID-19 pandemic caught the world off-guard and overwhelmed the disease control measures of many nations. Many countries implemented mask mandates, seen as one of the most effective ways to curb virus spread. Execution of these mandates revealed major regional and cultural differences between the US and East Asia. This paper will explore these differences and consider how the bioethical principle of autonomy can vary based on cultural and historical experience. Chinese people in Hong Kong generally viewed mask mandates more favorably than Americans. For Hong Kong Chinese, mask mandate compliance was a representation of personal autonomy, rather than a violation of it. In the US, where attitudes can be more individualistic, some people considered mask mandates to be an infringement of personal freedom. This paper will first analyze this variation by focusing on the unique historical factors that affected public perception in Hong Kong. It will also examine the cultural tenets and concepts of autonomy of Hong Kong Chinese people that made mask mandates so successful, while contrasting them with cultural concepts in the US that made the same policy much more controversial. Acknowledging these different cultural interpretations of autonomy can help governments and institutions design health policies that are more likely to be accepted by their citizens, leading to more effective public health interventions. Background Empirical evidence suggests that timely government responses were critical to curbing COVID-19 spread, but a lack of evidence-based consensus prevailed on many health measures, like mask requirements.[1] Enough scientific evidence is now available proving the efficacy of mask wearing during the pandemic, in conjunction with social distancing practices, in reducing casualties and deaths – when compliance was high.[2] In fact, data suggests mask-wearing became more popular as the scientific evidence about the airborne nature of COVID-19 transmission increased.[3] Mask mandate implementation triggered varying responses, with data demonstrating attitudinal differences between the West and the East.[4] It is imperative to understand cultural considerations when it comes to mask mandates, both at a personal and community level, to understand this divergence. Unlike people in East Asian regions like Hong Kong and Japan, wearing masks in public was novel and uncommon for most North Americans before the COVID-19 outbreak, and resulted in sustained opposition in some areas. Violation of individual autonomy and paternalism were often cited as reasons people were opposed to mask mandates.[5] This global division is a result of cultural, political, and social differences between individuals and societies, with far more mask mandate opposition seen in the US than in Hong Kong. Even in places like the US, some individual rights can be legally restricted to a certain degree for compelling societal goals, such as preventing the transmission of COVID-19. Individual or community rejection of wearing masks during the pandemic triggered ethical, health, and safety concerns. An unmasked person is more vulnerable in crowded and poorly ventilated places, as the virus is air-borne. By not taking proper precautions to protect themselves or others, people added to the heavily burdened health care system. Resistance to health guidelines exacerbated political polarization, especially in the West. Mask mandates in some North American countries ignited protests by “anti-maskers” who viewed such restrictions as an infringement on their rights to freedom and democracy,[6] and, more extreme, as a way for the government to exercise control over its people.[7] In extreme cases, masks served as a trigger for xenophobia and violence against Asian-Americans and Asian immigrants.[8] In Hong Kong, mask mandates were not viewed as a violation of personal or public autonomy. Hong Kong appeared better prepared for the COVID-19 pandemic than other countries. It applied strategies for controlling virus spread quickly, likely due to personal and institutional memory of the 2003 severe acute respiratory syndrome (SARS) outbreak.[9] As an epicenter of the SARS outbreak, Hong Kong had 1,750 confirmed cases and 286 deaths, including eight healthcare professionals.[10] The explosive spread of the virus had caught the health and hospital authorities unprepared.[11] Implementing reforms inspired by that experience, by the third week of 2020, the Hong Kong Special Administrative Region’s (HKSAR) government activated its anti-epidemic response plans as COVID-19 was first emerging. Residents responded quickly and eagerly, with high rates of voluntary masking, handwashing, social distancing, and the use of thermometers at the entrances of many public spaces.[12] The collective memory of SARS positively impacted their understanding of and response to COVID-19. They prioritized civic responsibility and community well-being in critical public health crises.[13] The high mask compliance controlled community spread.[14] As a result, Hong Kong emerged relatively unscathed despite its dense population, especially in the early days of the pandemic.[15] However, it was not necessarily just their recent historical experience that influenced Hong Kong’s willingness to follow public precautions. The Concept of Autonomy and How it Differs by Region and Culture The word autonomy, derived from Greek words autos (‘self’) and nomos (‘rule’, ‘governance’ or ‘law’), originally referred to self-rule or self-governance of independent city-states.[16] Personal autonomy is defined as, at a minimum, self-rule that is free from controlling interference by others and from limitations that prevent meaningful choice, like inadequate understanding. Respect for autonomy is widely accepted as a dominant value in contemporary biomedical ethics. It is considered integral to informed consent,[17] a concept that gained prominence in the movement to end involuntary participation in medical research.[18] Conceptually, it evolved in Western contexts and disregards some non-Western regional and cultural influences.[19] The pandemic led to questions about how autonomy is defined and operationalized, prompting some bioethicists to call for an alternative to this individualistic vision.[20] Traditionally, autonomy enjoys the highest priority in American bioethics,[21] yet some suggest that this was never the intent. Instead, the original goal was to construct a concept of respect for autonomy that is not excessively individualistic, not excessively focused on reason, and not unduly legalistic.[22] By not neglecting emotions or downplaying social practices, this broader definition aligns well with the Hong Kong Chinese view on autonomy. The Western concept of autonomy focuses on self-determination, prioritizing the subjective value of individual independence. The East Asian or Hong Kong Chinese concept may, by contrast, be perceived as relatively more objective, family-facilitated, and culturally-comprised.[23] Mask mandates came at a huge personal cost.[24] Apart from the physical discomfort, there was an increased sense of self-social isolation and anxiety when mask mandates were imposed during the pandemic; children could not develop their language and social skills normally with their masks on; people with hearing difficulties could not understand and communicate effectively with others in the absence of facial and visual cues.[25] In many places, their removal came as a great relief and brought back a semblance of normal everyday life. While Hong Kong was one of the last places in the world to remove mask mandates (it did so on March 2, 2023),[26] many people preferred to keep their masks on.[27] This attitude may have a cultural and social basis.[28] The masking rate was high, and the public was confident of its effectiveness.[29] Most people didn’t intend to violate the mandate, were rather eager to wear masks and reluctant to take them off even after 945 days when Hong Kong lifted its mask mandate.[30] Culturally, this could be seen as an alternative way of exercising autonomy. Relational Autonomy In recent years, bioethicists have emphasized relational autonomy as a way to incorporate a wider variety of ethical experience.[31] For purposes of this paper, the definition of relational autonomy is the capacity to make decisions as an individual embedded in social relationships.[32] Humans are always involved in a network of social relations. Their choices are highly influenced by social categories like gender, ethnicity, and culture.[33] The broader conception of autonomy may provide a robust alternative to thinner, individually centered definitions and can encompass responses like