• Ethics

In the mid 21st century, humans finally established a small community on Mars. The Martian colony grew slowly over its first 50 years. There were substantial technical challenges to living in the artificial biospheres. Early colonists had to accept significant restrictions because of the harshness of the environment, and the limited shared physical space.

However, by 2116, the community was starting to relax its initial strictures. There was a growing community of young, native Martians. Technology was more robust. Some of the initial strict rules were being reconsidered and debated in the Martian parliament. One question, tabled for late 2116, was whether it should be permissible to grow tobacco. Smoking had not been an option for the initial colonists. Only non-smokers were allowed to travel because of the dangers of fire during the long journey from Earth and in the first generation of domes. But now the atmospheric regulators were stable enough to cope with combustion of plant matter, while the community had sophisticated mechanisms to prevent dangerous fires.

Should Martians be allowed to smoke?

Several of the papers in this issue address the questions that our hypothetical Martian community would face. One way of casting the debate over tobacco policy sees it in terms of a trade-off between wellbeing and autonomy. Those in favour of banning cigarettes empasise the significant improvements in people's health and wellbeing from not smoking (see feature article by Kalle Grill and Kristin Voigt page 293). Those opposed to such a ban, draw on traditional liberal principles to reject any hard paternalistic restriction to individual freedom on the basis of concern for the good of the individual (see response by Jessica Flanigan page 305).

Grill and Voigt take a nuanced view. They point out the very substantial reductions in wellbeing associated with smoking, while acknowledging that there are some individuals (for example those who smoke very infrequently purely for pleasure, or who are of advanced age and unlikely to experience harm from continued smoking) whose wellbeing may be enhanced by smoking. They highlight that the harms of smoking fall disproportionately on those who are already disadvantaged—generating an equality-based reason to seek a ban on cigarettes (though, against this, Shein argues that restrictions on smoking might also disproportionately affect those who are disadvantaged (see page 285)). Some authors who have advocated a ban on cigarettes seek to undermine the autonomy-based argument. They claim that decisions to smoke are often non-voluntary because people are unaware of the risks, start smoking before they are old enough to consent, or because they are addicted. Decisions may also be irrational because they are based on cognitive bias, or fail to secure the goals that the individual would choose. Grill and Voigt accept that smoking choices may more rational and voluntary than often assumed, and that even irrational choices warrant respect. However, they argue that the costs of a cigarette ban (in terms of reduced freedom) are reduced because relatively few smokers benefit overall from smoking, many smokers would prefer not to smoke, and a proportion would appear to endorse a smoking ban.

However, as highlighted by Sarah Conly (see page 302), it is hard to know how to weigh up the liberty versus wellbeing arguments. While Grill and Voigt (and Conly) are persuaded that the arguments favour a ban—others will place more weight on freedom. Conly claims that we need an in-principle argument to arbitrate between these.

One interesting element towards the end of Grill and Voigt's paper is the suggestion that future people have a weaker autonomy-based reason to oppose a smoking ban. If we imagine our community of Martians, there might be some who would like to have the freedom to smoke (whether or not they actually choose to do so). However, Grill and Voigt suggest that in a society that lacked the social norms supporting and reinforcing smoking, and without any members having been exposed to the temptation to smoke—there would be very little lost by not having the freedom to smoke. In contrast, the very large numbers of future people whose lives would be shortened if they commenced smoking, and who would suffer serious health-related harms—provide a strong reason not to allow smoking on Mars. Framed in this way, it looks like the Martian tobacco debate might be one-sided, and short-lived.

One question that Grill and Voigt do not address is what form the tobacco ban should take, and what penalties would be imposed if it were breached. Would there be a fine imposed on colonists who were found to be smoking illicitly, or would they imprisoned? Or would penalties be focused more on those who grow or sell tobacco in the colony? Some ways of implementing a tobacco ban might have more profound (and potentially more worrisome) impacts on individual liberty and autonomy (see commentary by Halliday page 286). Grill and Voigt also set aside questions about the effectiveness of a ban, and its impact on a black market. Given the failure of past attempts to prohibit tobacco (and other substances), Flanigan argues that we should use less coercive alternatives to encourage people not to smoke (see page 305).

One less-restrictive alternative to a complete ban on cigarettes is explored by Daniel Halliday—perhaps our Martian colony should only allow smoking for people who have purchased a license? By requiring a relatively large up-front payment, there would be a strong financial disincentive to starting to smoke. One of the potential reasons why people start smoking is that the costs (financial and physical) are temporally delayed, which can lead to people ignoring or discounting them. A smoking license might be particularly effective at discouraging adolescent smokers; this would be attractive because adolescents appear to be most vulnerable to peer pressure and advertising.

Halliday's argument builds on existing support for the use of sales tax to discourage smoking. If we think it is acceptable for the state to impose taxes, we must accept that some restrictions on individual liberty are acceptable. If it is acceptable to impose taxes for the sole purpose of discouraging unhealthy behaviour—that implies that at least soft paternalism is justified. We could simply shift some or all of the sales tax on current cigarette sales, and impose it up-front in exchange for a license.

But there are challenges for the smoking license solution. Shein argues that such licenses would be discriminatory—since they would fall most heavily on those least able to afford them. Simon Chapman, who has long advocated for the use of smoking licenses, argues that Halliday's model of the license is unrealistic (see page 288). Chapman's own preferred version is that they should complement, rather than replace sales tax, that they should impose maximum consumption limits of 2 packets per day, and that they should build in financial compensation (or incentives) for those who give up their license.

One possible extension of the idea of a smoking license would be their application to other forms of nicotine delivery. Yvette van der Eijk analyses the ethical arguments around 21st century electronic nicotine delivery systems (ENDS) (see page 273). There has been considerable debate recently. Some see such systems as a valuable form of harm reduction since they potentially have less health effects than cigarettes, and may help some smokers to quit. Others are concerned that they risk increasing harm (because they lead to or perpetuate nicotine addiction, and may have some harms of their own). Van der Eijk draws on liberal principles to suggest that ENDS should not be available to non-smokers (because they offer no benefit and only potential harm) or to children (because they are not fully autonomous). She argues that nicotine-containing devices should only be available with a prescription for existing smokers.

Using thought experiments, like that of the Martian colony, can be helpful in allowing us to step back and gain a new perspective on problems. We can sometimes imagine that the current approach to a problem is the only option, or that it would be impossible to adopt another approach. Imagining what policy we would adopt if starting afresh can help to avoid status quo bias. It is not at all clear that our hypothetical Martian colony would simply adopt a free market approach to providing cigarettes or other forms of nicotine-delivery. That should motivate us to think hard about other ways of moving forward.

However, medical ethics is not merely about developing theoretical solutions in ideal situations. It must also address the non-ideal social structures in which we find ourselves, and the challenges and limitations of policies and politics. The perspectives in this issue provide a diverse and valuable contribution to debates about paternalism—here on Earth.