Who Decides?

The Covid-19 moment has been fraught in countless ways, but perhaps most so when concerned with arguments about the trade-offs between strict measures to control viral contagion, and the economic consequences of those trade-offs. At the heart of these arguments has been one—often unspoken—question: who gets to decide what is right for societies? Who decides how to evaluate the trade-offs?

Perhaps this question is illuminated by analogy.

Increases in speed limits across the country have been associated with 37,000 deaths during the past 25 years. In 1993, 41 states had a maximum speed limit of 65 mph; the other nine states had a speed limit of 55 mph. Today, by contrast, 41 states have maximum speed limits of 70 mph or higher; six have 80 mph speed limits. The change has happened slowly as advocacy groups have argued for higher speed limits to reflect reality—many drivers exceed the speed limit anyway.

The trade-offs appear to be clear. A 5 mph increase in maximum speed limit is associated with an 8% increase in interstate fatalities; it also saves a bit more than six minutes on a 100-mile trip when driving at 70 mph vs. 65 mph.

Is the increased risk of death worth the thrill of driving faster and saving time on travel?

We know that reducing speed limits to something that is still quite fast—65 mph—will save lives. The highway speed limit in Canada, for example, is 100 km/hour (about 62 mph); the motor vehicle fatality rate per capita in Canada is also about half what it is in the U.S.

Prevention is at the core of public health. We know what we should do, because we know that lowering speed limits saves lives.

But we have long accepted, as a society, that public health does not get to decide what speed limits should be. That decision ultimately rests with elected officials, or regulatory agencies appointed by those officials. Why? Elected office holders are the only body within society that is directly accountable to the populations affected by the rules they set. It is on them to balance the trade-offs, to listen to the input from public health, but also to the input from enthusiasts for higher speeds who value their freedom to go faster.

Such political decisions are open to particular manipulation by special interest groups. For example, in this case, motor vehicle manufacturers may have sales and profits to gain from cars going fast, even as they suffer few direct downside consequences. But our democratic system is designed to give voice to competing ideas and values, within a pluralist world. And if public officials miscalculate the acceptability of a particular trade-off they can be removed from office, accountable for their actions.

The voice of public health clearly should be central in decision-making around policies affecting the wellbeing of populations. But even in a pandemic, our role is not to dictate policy; rather, we should be the best possible advocates for the approach that values life and health above all else. Fundamentally we have a critical—but still singular—perspective, and it is on society to decide how it wants to structure itself, through the offices of our elected representatives.


Michael Stein & Sandro Galea

As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.