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Abstract

This entry provides a standard characterization of coercion and its main alternatives and illustrates its contemporary applications in global bioethics. Coercion is deﬁned as a mode of inﬂuence that operates by threats and force; aims at controlling the recipient’s being, movement, or will; and leaves, at least initially, its recipient disadvantaged. Coercion is seen, in liberal traditions, as morally wrong insofar as it restricts its recipients’ freedom or liberty or violates their autonomy. This can be interpreted in as many ways as there are deﬁnitions of freedom, liberty, and autonomy. In non-liberal traditions, coercion is morally wrong only if its practices or consequences are bad.

When the use of threats and force is discussed in global bioethics, it is important to recognize the complexity of the concept. Coercion does not always occur where it is thought to occur, it does sometimes take place where it is not normally seen to take place, and it is not automatically bad. What is called involuntary treatment may not be truly involuntary, explicit coercion by the state may be quite legitimate, and analyses of intimidation, deception, and exploitation can offer insights that challenge initial beliefs. Ethical considerations must be open to diverse background ideas that lead different people to different conclusions.

Introduction

This entry proceeds, after a historical comment, from theoretical deﬁnitions and general moral considerations to practical applications in global bioethics.

The ﬁrst section observes the roots of the concept in philosophical discussions and political developments and notes how the traditional, state-centered view of coercion is currently challenged by economic and cultural globalization.

The second section offers a conceptual clariﬁcation of the notion of coercion. Following a tentative characterization, concise analyses of the roles of threats, force, freedom, and compromised agency are presented. Considerations of coercion without agency, and the distinction between public and private uses of force and threats, follow. Brief comments on intimidation, deception, and exploitation as arguably coercive modes of inﬂuence complete the conceptual part of the entry.

The third section examines the ethical dimensions of coercion and some of its instances in global bioethics. It opens with an account of the prima facie moral wrongness of coercion based on its curtailing effect on freedom, liberty, and autonomy and, after highlighting two kinds of starting points for normative assessments, continues with two liberal justiﬁcations of threats and force. After four alternative political views on coercion – anarchist, communitarian, conservative, and socialist – are outlined, the section closes with some prime examples of coercive inﬂuence in global bioethics.

Since deﬁnitions of coercion vary in different jurisdictions, the characterizations given here concentrate on conceptual and moral considerations that are customary in international discussions on the topic, not on legal descriptions. It should be noted that the concept of coercion, as it is analyzed here, is a Western notion and that different cultures can have very different approaches to the phenomenon identiﬁed by it. But since global bioethics is, among other things, an attempt to deal with the impact of Western thought on world-wide affairs, the use of the chosen vocabulary and the ensuing imagery serves at least one worthwhile purpose.

Background Of The Notion

Coercion has been studied in European philosophical literature at least since Plato, Aristotle, Epicurus, and the Stoics. Philosophers of Greek and Roman antiquity had differing, and sometimes conﬂicting, views on coercion, but all agreed that considerations of freedom and responsibility are closely linked with the intertwined phenomena of necessity, compulsion, and coercion. The concept gained growing political importance at the end of the medieval period and the beginning of the modern era, as the relationship between states and their citizens came into focus in the writings of Thomas Aquinas (1265–1272), Thomas Hobbes (1652), John Locke (1690), and Immanuel Kant (1797).

One common notion among philosophers has been that a monopoly of coercion should rest with states – that states should stabilize social life by sovereignly controlling the coercive activities of other parties, primarily their own citizens. Although this line of thought is still central, the limitation to the citizens of states, and the power of states to hold on to their historical monopoly, has come under scrutiny with such growing trends as ﬁnance capitalism and globalization. Nationstates may have little or no control over ﬁnancial market mechanisms, and they may have limited authority over supranational corporations and other sovereign states and fractions. Bioethical codes issued by global institutions like the World Health Organization (WHO) can be seen as an attempt to take on the stabilizing role without coercion – to root out coercion practiced by commercial and political agents, through the use of noncoercive interventions.

Conceptual Clarification

Terminological Caveat

The concept of coercion is contested in current debates. The following deﬁnitions and characterizations reﬂect widely accepted notions, but competing ideas are also portrayed for better coverage of the topic in its complexity. Regardless of the chosen deﬁnition, matters can be expressed clearly by using qualifying attributes, for instance, “coercion by threats,” “wrongful coercion,” “coercion by circumstances,” and the like instead of just “coercion.”

Tentative Characterization

Coercion is a means to inﬂuence the behavior of agents. In exemplary instances of coercion, the inﬂuence is exerted by other agents, and the agents involved on both sides (subjects and objects) are competent, adequately informed, voluntary, and free. According to narrow deﬁnitions, coercion involves explicit threats, while broader accounts include also coercion by the direct use of force. The threats (and, if conceptually allowed, force) typically restrict or violate the object’s freedom, liberty, or autonomy, although this is not required in all interpretations. Coercion is standardly thought to leave the objects worse off than they would have been without the inﬂuence, whatever course of action or inaction they choose to take; but, again, some interpretations also seem to permit the notion of beneﬁcial coercion. Subjects of coercion are usually seen as less responsible for their actions than uncoerced agents. And since subjects of coercion can also be under the inﬂuence of force or threats, their responsibility can also be lowered. The following analyses will endeavor to clarify the essence and mutual relationships of these partly conﬂicting readings.

Role Of Threats

Coercion, in a narrow sense, can be distinguished from two other methods of inﬂuence. It can be distinguished from the use of force, another freedom-limiting activity; and it can be told apart from rational persuasion and facilitation, practices that do not curtail the recipient’s freedom or at least do not curtail the recipient’s freedom in a bad way. The key to the narrow view is the idea of an explicit verbal threat issued by the subject and received by the object of coercion. The threat is designed to give the objects to understand that unless they comply with the subject’s demands and thereby worsen their own situation or the situation of others, the subject will see to it that they or others will come to some kind of harm. The typical institutional case is law – the state’s way of telling citizens what they must and must not do in order to avoid legal sanctions. An oft-quoted private line is the robber’s classic, “Your money or your life.”

Coercion in this sense does not render its objects incapable of making decisions, although it limits their scope of options. After the law has been issued, or the robber’s line delivered, it is not possible to break the new law and avoid sanctions or to exit the encounter with the mugger both ﬁnancially and physically unscathed. But the choice between breaking the law and being punished or observing the law and remaining unsanctioned, or handing over the money and keeping one’s life or keeping the money and losing one’s life rests, according to the logic of the model, with the coerced agent.

Use Of Force

The direct use of force results in agents, the objects of force, being physically restrained, moved, or otherwise interfered with against their own will. This mode of inﬂuence leaves no room for the agent’s choices – prison walls deﬁne the space in which movement is possible, a push over a cliff top determines the fall, and a punch causes the incapacitating injury without any decision making by the forced agent.

Broad deﬁnitions of coercion include, in addition to threats, the direct use of force. The advantage of this approach is that the two liberty restricting modes of inﬂuence come under the same umbrella heading. Threats, if realistically backed up, mark the reduction of the agent’s future action alternatives at least by one. The use of force reduces the future action alternatives of the object in a similar, if more extensive, way. A prisoner cannot leave the place of conﬁnement, an involuntarily moved individual cannot counteract the moving power, and an object of physical violence cannot return to the original, unharmed state, or do the things that would have been possible in that prior condition.

The conceptual clarity sought by the alternative, narrow deﬁnitions of coercion is to distinguish between modes of inﬂuence that short-circuit agency and decision making and those that work through them. Direct use of force seems to treat agents like things, whereas the use of threats, while changing the premises of decision making, still allows a measure of freedom in its objects. This has some implications when it comes to the ethical assessment of activities, as will be seen further on.

Terminologically, the existence of the two interpretations presents no particular problem. In what follows, “coercion narrowly construed” (and other expressions including the word “narrow” as a qualiﬁer) and “coercion by threats” will be used synonymously; while “coercion broadly construed” (and its derivatives) will refer to the use of both threats and force.

Freedom And Compromised Agency

If coercion is thought to restrict the freedom (or liberty or autonomy) of its objects, it is conceptually important that the agents inﬂuenced are free to begin with. This, at least, is emphasized in liberal readings that draw on the seminal work of John Stuart Mill (1859). Agents can be coerced only if they are competent, adequately informed, voluntary, and free.

An everyday understanding of the phenomenon appears to challenge this. Very young children and cognitively disabled individuals may not be competent decision makers, but it is feasible to say that they are coerced when their behavior is inﬂuenced by the use of threats and force. A person approaching an unsafe bridge may not know about its condition and, hence, is not an adequately informed decision maker, but it is still feasible to say that the person is coerced if forcibly prevented from entering the bridge. Emotionally agitated people may not be voluntary decision makers, but threatening them to change their behavior can be called coercion. And people who are already under a serious and credible threat may not be free decision makers, but causing them to do things against their wishes by further threats or force can still be dubbed coercion. This is a perfectly legitimate, colloquial way of conceptualizing the matter, but it is not the only one in theoretical literature.

A more common view within the liberal tradition states that agents cannot be coerced if their agency is compromised to begin with. This applies particularly to situations that allow the broader liberty of individuals to be promoted by more conﬁned restrictions. Mill thought that helping children or “backward societies” to achieve liberty cannot be considered coercive, because the objects of control are incompetent, or in his words, in their “nonage.” (His idea of “backward societies” in their “nonage” would obviously be a matter of dispute in contemporary global ethics.) He also thought that the person approaching the unsafe bridge and stopped is not coerced – there is, according to Mill, no “real infringement of his liberty; for liberty consists in doing what one desires, and he does not desire to fall into the river.” Similar considerations can be extended to individuals whose agency is compromised in other ways. Coercion does not occur when benevolent agents promote the future freedom of other agents by threats and force, if the objects of the interventions are emotionally agitated or under the undue inﬂuence of external factors to the degree that they are incapable of voluntary or free decision making.

The conﬂict between these two interpretations can be treated, for the purposes of ethical analyses, as predominantly verbal. Both parties agree that the use of threats and force can sometimes be legitimate. (Note that Mill and the other liberals conﬁne the discussion to instances of justiﬁable paternalism – to cases in which the freedom and liberty of individuals is limited for their own alleged good. This category is often in use when coercive agencies endeavor to justify their activities, also in the context of global bioethics.) A conceptually neutral solution here is to say that the use of threats and force can, despite their freedom-curtailing nature, be considered justiﬁable in speciﬁed circumstances. The label attached to this kind of activity – coercion or not coercion – is not crucial.

The Possibility Of Coercion Without Agency

The agent inﬂuenced can, according to the selected psychological and social theory, be an individual, a group of individuals, or a collective entity. Since agents, by deﬁnition, make choices, they are (at least if the conditions of competence, adequate information, voluntariness, and freedom are met) open to the possibility of coercion in the narrow sense. Within broader interpretations, use of force can coerce agents regardless of their ability to make decisions.

The party exerting inﬂuence is also most naturally construed as an agent – an individual, a group, or a collective – though there are exceptions. Compelling and threatening situations and circumstances are sometimes produced, entirely or in part, by environmental factors (for instance, natural disasters) and sometimes brought about, arguably, by emergent social mechanisms (“market forces” or “inexorable economic laws”) rather than the choices of particular, identiﬁable agents. Since agents are the only ones who can be morally responsible for coercion, ethical scrutiny is likely to concentrate on their involvement. Its extent, and the alleged existence and inﬂuence of factors outside human control, are focal topics in the normative assessment of real-life practices.

There are conceptual limits to calling nonhuman inﬂuences coercive. The laws of nature deﬁne the parameters of what we can and cannot do, but it would be unhelpful to consider them coercive in the same sense as we do human actions. The regularities observed in physics, chemistry, biology, psychology, and sociology set, insofar as they are real and well documented, a threshold below which it is safer to talk about natural necessity or natural forces than to evoke the idea of coercion. Human beings may be forced by their physiology to eat, but it would not be terminologically useful to say that, due to our coercive physique, we must make a daily difﬁcult choice between eating and fasting, surviving and dying. (An anorectic might disagree, though, which goes to show that every possible conceptual solution has its potential advocates.)

Two Types Of Coercion In The Global Context

Insofar as nation-states and their coalitions have the monopoly of legitimate coercion, they are the only agencies that can afford the explicit use of threats and force. Laws and international treaties can, often justiﬁably, issue directives deﬁning the types of action and inaction they expect from citizens, nations, and other agents; and the kinds of sanctions that those not complying with the rules can expect to face. National and international authorities can also, and again often justiﬁably, use direct force to shape the environment in which their subjects – and others – will, as a consequence, be compelled to operate. If the intent of the latter type of activities is benign, the terms “facilitation” or “enablement” can be used. It should be noted, however, that by foreclosing action alternatives, these activities are freedom restricting in a technical sense and thereby, if freedom is to be protected, also in need of justiﬁcation.

Private actors – citizens, companies, nongovernmental organizations, and business corporations – are not usually allowed to use explicit coercive power within this model. (Commercial security agencies are an exception, but the power they use can perhaps be explained away as an extension of the state’s authority.) As a corollary of the governmental monopoly, private agents practicing explicit coercion will ideally be caught and punished. This is practically important, yet theoretically uninteresting. Private agents do, however, also engage in more complicated practices that involve, on the surface, only harmless offers but can in a more detailed analysis be seen as coercive. They can issue implicit threats, manipulate information about their doings, or take advantage of already existing circumstances that are experienced as compulsive or threatening. The corresponding modes of action, namely, intimidation, deception, and exploitation, are central to the study of coercion in global bioethics.

Private agents can also, like their public counterparts, instigate or participate in facilitation and enablement programs that limit the action alternatives of their recipients. These provide another interesting topic for studies in global bioethics.

Arguably Coercive Activities

The cases of intimidation, deception, and exploitation represent variations of the themes introduced by the use of threats and force.

Intimidation can be seen as a form of psychological compulsion – “compulsion” here meaning something between force and threats. The agent exerting the inﬂuence creates an environment in which other agents feel that they must comply with the intimidating power’s explicit or implicit demands lest they come to harm. Note that in this case, no threat is explicated – it is only assumed by the parties. Legal systems have their ways of deﬁning intimidation, its wrongfulness, and its effects on the intimidated agent’s responsibility. In ethical analyses, at least within the liberal model, it is essential to consider the extent to which the object’s options are limited and to which this limitation can be attributed to the subject’s choices.

Deception and related practices inﬂuence action by compromising the adequacy of the subject’s informedness in decision making. Since lying is usually frowned upon, the deceiver is automatically facing an ethical challenge in these cases. Sometimes, however, this kind of inﬂuence is defended in healthcare provision and scientiﬁc research, often in terms of the best interest of the subjects. And sometimes it is argued that there is a sharp distinction between deliberate lies and less than rigorous efforts to inform one’s negotiation partners. In the liberal framework of coercion, it is ethically important to ﬁnd out how ﬁrmly the object’s freedom is curtailed and how deliberately and malignly the subject has contributed to this.

Exploitation takes place when agents endeavor to beneﬁt from coercive situations and circumstances that other agents are in. Exploiters have not always produced the situations or circumstances themselves, nor can they necessarily alleviate them. If they have not, or cannot, they can defend their activities by referring to the prevailing conditions as a natural baseline against which their own actions are set. A harmless offer, as far as the subject’s moral responsibility is concerned, does not turn into an unethical threat just because the subject is incentivized by the environment to accept it, even if it does beneﬁt the object. In global bioethics, exploitation has been alleged, for instance, in pharmaceutical trials involving study subjects in less afﬂuent countries.

Ethical Dimensions

What Is Wrong With Coercion? A Liberal View

In liberal theories, the use of threats and force against competent, adequately informed, voluntary, and free agents is always prima facie wrong – it is wrong unless proven otherwise by weightier considerations. The wrongness stems from the freedom-curtailing effect that is a necessary part of these activities. Threats and force do not take place unless their objects are deprived of at least one action alternative that they would otherwise have had.

A common misconception hampers efforts to discuss coercion in this framework. Many people assume that inﬂuence over others is wrong in the liberal sense only if it renders its objects totally unfree – unable to make decisions at all. That is not the point of this normative view. Objects of force cannot make the choices they are prevented from making by force and threats, but they can make many others. Prisoners cannot exit their places of conﬁnement without special permission, but they can in civilized penitentiaries decide what to do with their time – read, write, exercise, watch television, pray, or sing hymns. Objects of threats are only deprived of one option – the option to disregard the threat and go unsanctioned – but that is, in the liberal framework, a sufﬁcient reason for considering the threat initially immoral and in need of further justiﬁcation.

What Justifies Coercion? Two Liberal Views

Coercion, especially coercion by legitimate state ofﬁcials, has been traditionally justiﬁed on two grounds. One alternative is to say that the coercive arrangement is beneﬁcial to all parties concerned. The other is to redeﬁne freedom, liberty, and autonomy so that they are not limited when acknowledged authorities use threats and force in a considered manner.

Consequentialist liberals argue that while state coercion is prima facie wrong, it is justiﬁed overall, because it secures, to use a utilitarian expression, the greatest happiness of the greatest number of people. Happiness can in the formula be replaced by welfare, well-being, preference satisfaction, desire fulﬁllment, maximization of economic prosperity, or promotion of capabilities, but the core idea remains the same. Citizens must endure restrictions on their freedom as long as these restrictions serve their greater good as a political collective.

Deontological liberals favor a different approach. They contend that freedom should not be deﬁned simply as the non-availability of options. The value of freedom, liberty, and autonomy is in that they are linked with the self-governance and self-realization of individuals as members of their communities and societies. Self-governance is perfectly compatible with reasonable restrictions, when these restrictions are only foreclosing goals that a moral person would not, and should not, be pursuing in any case. And self-realization is not threatened by the non-availability of options that have nothing to do with our growth as human beings. Governments do not curtail the freedom, liberty, or autonomy of their citizens by making it known that those who violate the person or property of another will be punished.

The consequentialist justiﬁcation is consistent with the technical deﬁnition of coercion as the elimination of action alternatives by force or threats. The deontological justiﬁcation can also assume the technical deﬁnition of coercion, or force, as in Jean-Jacques Rousseau’s (1762) famous dictum that in civilized societies people must be “forced to be free.” This, however, may be mere paradoxical use of language. It is also possible to redeﬁne wrongful coercion in deontological models and postulate that it is not a mere curtailer of (possibly trivial) action alternatives but a more sinister mode of inﬂuence that contradicts our freedom or liberty in a deeper sense or violates our essential personal or moral autonomy.

Natural And Moral Baselines: Offers And Threats

When restrictions of freedom, or infringements of liberty or violations of autonomy, are assessed, the ﬁrst step is to identify the relevant states of affairs before and after the alleged act of coercion. One point of comparison is obviously the situation after the threat has been issued or force applied. But what about the other point of comparison? Some suggest that this is provided by the way things actually were before the threat. Others argue that a better foundation is provided by the way things should have been. These constructs can be called the natural baseline and the moral baseline.

The choice of the baseline is thought to mark the difference between certain modes of inﬂuence that can be deﬁned, from a formal viewpoint, either as (inoffensive) offers or (prima facie wrongful) threats. International pharmaceutical trials in countries that have less than functioning healthcare systems provide a good real-life example. Drug companies may offer experimental medication (and, in control groups, placebo) free of charge for populations that would otherwise have no medication for the ailment under investigation. If a natural baseline is accepted as the point of comparison, this is a genuine offer that involves no restrictions of freedom, hence no further justiﬁcation. But it can also be argued that a moral baseline should be used. As a matter of human rights, the population ought to have the option of established treatments available to them.

This turns the seeming offer into a threat in dis guise, or an offer in coercive circumstances, or potential exploitation – regardless of the name, all methods of inﬂuence that are in need of separate moral legitimation.

Situations like these are seldom straightforward, and fuller ethical analyses are needed. Matters cannot be solved simply by postulating a baseline that suits the purposes of one or the other of the parties involved.

What Is Wrong With Coercion? Alternative Views

The liberal reading is the most solid, and the most detailed, conceptual basis for examining cases of alleged coercion. It is not, however, the only one. Its alternatives include anarchistic, communitarian, conservative, and socialist approaches, among others. The wrongness of coercion is seen in a different light in each one of them.

Anarchists abhor hierarchies, authority, and power. They argue that if these ills were abandoned, people would learn to live together peacefully, guided by reason. For anarchists, coercion, state coercion in particular, is always wrong, because it impedes the moral, political, and material progress that would ensue from the recognition of freedom. Anarchism as such is seldom discussed in global bioethics. But its distant afﬁliate, libertarianism or anarcho-capitalism (Nozick 1974), is arguably the leading economic doctrine of globalization and plays an important role in political debates. The view is a justiﬁcation of a free market, unhindered by states that take on welfare functions and international regulation. Anything that stands in the way of open transactions between consenting parties can be seen as wrongful coercion.

Communitarians reject the individualistic emphasis of liberal and libertarian models. They contend that people should be seen primarily as members of groups and communities, with organic ties with other people – families, ethnicities, gender factions, professions, and so on. These ties, or special role-dependent relations, deﬁne what is right and wrong in human interactions and when it is right or wrong to use physical or verbal force. Many communitarians believe, though, that conﬂicts can in most cases be solved by negotiations based on a thorough understanding of real-life situations (Gilligan 1982). Abstract considerations of formal freedom or bureaucratic calculations of well-being only serve to obstruct the true view on social life. The aptness of inﬂuence by threats and force is a contextual and situational matter.

Conservatives typically believe that there is a correct moral order that takes precedence over deliberations of freedom, liberty, and autonomy in the liberal sense. This moral state of affairs can be encapsulated by ideas like respect for human dignity and promotion of the public good (Kass 2002). Individuals can have spheres of privacy that should be protected, but these are not necessarily aligned with the allegedly neutral avoidance of restricting action alternatives. Conservative ideals come in many forms, ranging from religious doctrines and traditional cultural views to the defense of political status quos and nationally shared values. In these models, coercion (if it can be called that) is warranted when the moral order is defended and unwarranted if the aim is to challenge it and to instigate misplaced and untimely changes.

Socialists, at least those of them who hold Marxist views, argue that the liberal insistence on individual freedom diverts attention from the foundation of social life, which is economic and political (Marx 1867). Real changes take place in the economic infrastructure, and the changes eventually alter the ideological superstructure – ethics and political thinking. The transformation is slow, however, and this is why prevailing philosophies in transitional times are still anchored in earlier economic models. Most notably, liberal thinking in the late and post-industrial era is a hangover from emerging capitalism, and discussions on coercion, among other things, in liberal terms are futile and counter-productive. Coercion can be perfectly legitimate if it promotes social change that ends exploitation and alienation, the inevitable by-products of capitalism.

When the justiﬁcation of force and threats is debated in global bioethics, many themes favored by these approaches, as well as a number of postmodern ideas (Foucault 1976), are intertwined with liberal analyses. For greater conceptual clarity, it is essential to identify these threads and to examine them in their own right where appropriate.

Involuntary Treatment

Moving on to medical matters, an apparently clear case of coercion by force in healthcare is the involuntary treatment of individuals who are seen to have mental disorders and who are judged to be a risk to themselves or others. Indications for this procedure vary from schizophrenia, psychosis, delusions, and dementia to bipolar disorder, alcoholism, and drug addiction.

A liberal justiﬁcation of involuntary treatments can be based on two considerations. One is the best interest of the patients themselves. If they cannot take care of themselves because of their condition, or if they have a tendency to harm themselves, they are thought to be better off in the custody of medical professionals. The other consideration is that their freedom is not necessarily restricted (or their liberty infringed or their autonomy violated) by committing them to treatment against their own immediate wishes. Most of the medical conditions discussed here arguably render individuals unfree to begin with – incapable of making fully voluntary decisions. This would mean that their agency is encumbered so that in a technical sense they cannot be coerced.

Most ideologies, anarchism being a possible exception, can either embrace or at least tolerate the idea of detaining individuals who present a clear and imminent threat to others. For liberals, this is made acceptable by the reduced or missing voluntariness of the agents – otherwise, preemptive practices like this would constitute wrongful intrusions into people’s lives. In other ideologies, the role of individual freedom is not as crucial, and this makes them more amenable to the incarceration of individuals and groups who are believed to pose threats to other people, prevailing values, or current social orders.

The latter logic has been, and still is, used in many countries to justify the imprisonment of homosexuals, who are, for whatever reason, seen as a danger. The connection of this practice to medicine, and to global bioethics, is that WHO’s International Classiﬁcation of Disorders ICD-9 (1977) – consulted routinely in medical decision making – listed homosexuality as a mental illness. The entry was removed from the subsequent edition of the classiﬁcation, ICD-10 (1990), but due to delays in its implementation, the earlier version is still widely operative.

Funding Of Public Healthcare

The most extensive source of coercion related to healthcare and medical research is public funding. States and local governments collect taxes to ensure the present and future functioning of their healthcare systems, and citizens do not have a choice in the matter. If they refuse to pay their taxes, they will face legal sanctions. This is a textbook example of coercion by threats.

Only libertarians, however, are truly concerned about the situation. For them, the state should only have a minimal role, protecting its citizens from perils to life, liberty, and property. Consequentialist liberals can ﬁnd a justiﬁcation for tax laws in the greater good of the population. Deontological liberals can ﬁnd the legitimation needed in the promotion of equality. The responses of other political philosophies vary according to their background assumptions, but unless they have libertarian leanings, they are likely to accept at least some degree of public involvement in the promotion of the public’s health. At this point, considerations of liberty give way to reﬂections on justice.

International Pharmaceutical Trials And Community Consent

International pharmaceutical trials and their possibly coercive inﬂuence on individuals in less afﬂuent countries can be debated, as noted above, in terms of setting baselines. The discussion then automatically turns to theories of justice and the proper standard of care that should be available to all, despite their social status or place of residence. Unless these matters are taken fully into account in ethical analyses, it is possible that neutral-looking setups are in fact taking advantage of people’s vulnerabilities.

Another matter that guides these reﬂections is the role of freedom. Liberal studies tend to concentrate on individuals and postulate that informed consent should be obtained separately from each person participating in the experiments. A traditional, and communitarian, approach can see matters differently and state that community consent justiﬁes the practice. The action alternatives of individuals may be restricted by the circumstances, but if political or medical authorities see participation as the best alternative, this should sufﬁce to make the decision legitimate.

The communitarian logic, in its turn, may facilitate subtle forms of coercion or near coercion in international research. Investigators may, for instance, guarantee the participation of community members in clinical trials by bribing the community’s leaders. Whether or not the practice itself is deemed to be coercive in the general group-focused framework, the encounter of the local with the global may acquire freedom-restricting dimensions.

The situation is further complicated by the fact that, in practice, many ethical and political frameworks may be in operation simultaneously. Essentially non-liberal systems can legally recognize elements of a liberal egalitarian or conservative model (human rights can arguably be promoted in both); politically rest on contextual totalitarianism, say, the absolute power of the king; yet socially lean toward communitarian thinking. In global bioethics, it is necessary to be aware of such multiple and overlapping normative requirements regulating people’s lives.

Recreational Substance Use

Worldwide restrictions on recreational substance use are not only a clear example of coercion in need of justiﬁcation but also a hotbed of intimidation and deception, by more parties than one.

Legal coercion by threats and force is, of course, part and parcel of policies and campaigns that are aimed at eradicating smoking and drug use and at moderating alcohol consumption. If you smoke in the wrong place, use forbidden drugs, or your alcohol use becomes a problem, you will be punished by law or committed to treatment. Intimidation enters the picture when public authorities, tired with the inefﬁciency of rational persuasion, introduce shocking images in cigarette boxes and wine bottles to frighten smokers and drinkers into quitting. And deception has been detected at least in tobacco industry’s assurances, against established medical opinion, that their products have no adverse health effects.

Restrictions of recreational substance use are standardly justiﬁed by appeals to addiction and public health. Addiction renders the users’ decisions unfree, so they cannot be truly coerced. And public health is such an important goal that it easily legitimizes minor infringements of liberty. This would be fair enough, only that addiction as a mechanism and public health as a value are not particularly well understood in bioethics. There is a danger that ideologically laden readings of them are employed, honestly believing that they are conceptually better grounded than they in fact are.

Conclusion

Coercion in global bioethics is a complex matter. Analyses of it can be initiated by the consideration of the agency of the object and the restrictions of action alternatives that it produces. Since this approach is essentially liberal, other political views and their takes on the matter should also be included. These exercises will always bring out important moral dimensions of the situations studied, even if categorical conclusions may not be reached.

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