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Skidding at Speed: The Ethics of Head Protection While Skiing

Spicer, John MA, MBBS*; Hooper, Carwyn R. PhD, MBBS

Clinical Journal of Sport Medicine: November 2015 - Volume 25 - Issue 6 - p 461–463
doi: 10.1097/JSM.0000000000000245
Editorial
Free

*Health Education South London, University of London, London, United Kingdom; and

St George's, University of London, Institute of Medical and Biomedical Education, London, United Kingdom.

Corresponding Author: John Spicer, FRCGP, MA, FHEA, MBBS, Health Education South London, University of London, Stewart House, 32 Russell Square, London WC1B 5DN, United Kingdom (jspicer@southlondon.hee.nhs.uk).

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INTRODUCTION

Recreational alpine skiing is an increasingly popular activity. There are more than 200 million skiers worldwide, and they can choose to ski at more than 2000 ski resorts.1 People who ski in a conservative and safe manner are unlikely to suffer serious injury. However, as the tragic incident involving Michael Schumacher recently demonstrated, skiing can be a very risky activity.2 There is a particular concern in relation to head injuries. These kinds of injuries account for only 9% to 19% of all reported winter sport injuries, but traumatic brain injury is the leading cause of death and serious injury among skiers.3,4 Some legislators have responded to these grim statistics by forcing children to wear helmets while skiing.5–9 A few years ago, the Canadian province of Nova Scotia went 1 step further by passing a law requiring adults to wear helmets on the slopes.10 In this article, we will explore the empirical and ethical rationale for forcing adults to wear ski helmets.

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EMPIRICAL CLAIM

Whether adults (or children) should be forced to wear ski helmets depends, in part, on empirical evidence. In particular, policy makers need to be sure that there is considerable evidence for 4 empirical claims before they seriously consider mandating helmets. These 4 empirical claims are as follows: (1) helmets can reduce head injuries; (2) helmets do not cause significant risk compensation behavior (or have other effects that reduce their net effectiveness); (3) mandates will be effective in increasing the use of helmets; and (4) mandates will be more effective than other, less liberty-restricting policies.

Regarding the first claim, there is growing evidence that helmets can reduce head and neck injuries.11,12 Indeed, a recent meta-analysis concluded that helmets reduced the risk of head injury by as much as 35%. A small number of studies have also suggested that helmets provide significant protective effects against potentially severe head injuries. Perhaps, it would be wrong to say that the evidence for the effectiveness of helmets is unequivocal. However, the data are very compelling.

Evidence for the second claim is more contentious. A number of experts have raised concerns that people wearing helmets may take greater risks (eg, by skiing faster or “jumping”) because of the false sense of security that helmets can engender.13–15 This is particularly problematic because the protective effect of helmets diminishes at higher speeds.16 However, there is reason to believe that wearing helmets will have the opposite effect. This is because helmets remind wearers of the fact that they are engaged in a dangerous activity.17,18 Indeed, one study recently found that helmet wearers reported skiing at slower speeds and challenged themselves less than non-helmet wearers.15

The third and fourth claims are much harder to prove. There is some evidence that ski helmet mandates increase helmet use in children, but there is very little evidence that adult ski helmet legislation achieves the same result. It is also important to note that the prevalence of helmet use in adults (and in children) is increasing even in countries where no mandates exist.19 In Switzerland, for example, helmet use increased from 63% to 75% between 2008 to 2009 and 2009 to 2010, and helmet use in children has reached more than 92% in some ski-regions.20 Indeed, Switzerland and Austria seems to have similar levels of helmet use among child skiers although there is no mandate in the former but there is in (many parts) of the later. This matters because it suggests that less illiberal policies (eg, educational campaigns) may be just as effective as mandates in increasing helmet use.

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Ethical Arguments

If the 4 empirical claims noted above turn out to be well substantiated, it will be tempting to conclude without further ado that legislators should force adults to wear ski helmets.18 However, no amount of empirical evidence can furnish us with sufficient reason to implement a legal policy. Normative arguments are also required.

What ethical reasons could provide the link between the empirical evidence and a legal mandate? We do not offer an exhaustive list of ethical rationales here. Instead, we will focus on ethical arguments based on 3 kinds of duties: the duty to oneself, the duty to loved ones, and the duty to society.

The duty to oneself provides the weakest reason to impose a mandate. We do not deny that the putative duty to self has a powerful philosophical pedigree. The great 18th century German philosopher, Kant,21 waxed most eloquently on the notion that people had duties to themselves. In particular, he argued that we must preserve in ourselves the capacity to act in accordance with the moral law. However, few contemporary ethicists believe that we can be bound by duties to ourselves. Moreover, Kant himself did not think that the state should enforce duties to oneself. This is partly because such a policy would be paternalistic and would deprive people of the opportunity to behave autonomously.

The second ground seems prima facie more plausible. Few people would deny that adults have strong duties of care towards dependents, and that they also have some duties towards loved ones who are not dependent upon them. Most would also agree that these duties require people to reduce the risks they take with their own health to protect loved ones from “collateral damage.” However, as with the duty to oneself, using the power of the state to enforce these kinds of duties in relation is draconian. We concede that the state can force people to care for their children. However, no jurisdiction prohibits parents from smoking, drinking, and taking other (much more significant) health risks in the name of protecting dependents. This is because such legislative actions would entail too great an invasion of individual liberty to be ethically acceptable.

The third argument relies on the claim that skiers who are seriously injured because of their failure to wear a helmet will harm society by imposing substantial burdens on the community at large. In particular, resources will need to be spent rescuing these skiers and then providing them with short, medium, and (in some cases) long-term care. Resources will also be temporarily (or permanently) lost because a seriously injured skier will struggle to be an economically productive member of society.

There is little doubt that every citizen has a duty to reduce the risks they pose to society. However, the mere existence of social harms does not provide sufficient ethical justification for prohibiting the activity that generates the harm. This is because there is sometimes great personal and social value in the activities that generate harms, and there is also great personal and social value in allowing people to act in an autonomous, although risky, ways. Thus, although it is a legitimate function of state to protect the population from harms generated by individuals, there has to be a balance between liberty rights on the one hand and the enforcement of the duty to avoid causing harm on the other hand.

The question, then, is whether there is a sufficient reason to enforce a mandate on this kind of ground in the case of ski helmets. Elsewhere, we have argued against mandates that would require adult cyclists to wear helmets.22 However, cycling and skiing are different in an ethically salient sense. Cycling, for many, is a “necessary” part of modern day life. This is especially true in cities where cycling is often the quickest and the cheapest way of commuting to work. Skiing, meanwhile, for all its joys, is not essential in the same way, and it is replaceable by other strenuous activities of similar levels of enjoyment. For professional skiers and people who commute to work on skis, this distinction does not hold; but for the recreational skiers, the difference is as undeniable as it is normatively relevant. For this reason, we believe that there are much stronger ethical grounds for imposing adult ski helmet mandates than there are for imposing adult cycle helmet mandates.

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CONCLUSIONS

The justification for a legal change in relation to ski helmet legislation rests on normative arguments and empirical evidence. In this article, we have outlined the empirical claims that need to be substantiated to legitimize a ski helmet mandate for adults and we have also discussed some of the normative arguments that could underpin such a mandate. In particular, we have noted that the duty to society offers a powerful rationale for forcing adults to ski with helmets. However, we cannot support imposing such a policy at this time because there is insufficient empirical evidence to convince us that doing so would be both fair and proportionate. In particular, there is insufficient evidence that a ski helmet mandate would be more effective than other, less illiberal, policies. Thus, although we consider it wise for everyone to wear a helmet while skiing (as one of the authors of this article decided to do 3 years ago), we also believe that adults should be allowed to make up their own minds about whether to wear a helmet when taking to the pistes this winter.

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