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The American Journal of Bioethics, 7(2): 1–5, 2007 Copyright c© Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265160701193559

Editorial

Ethics and Public Health Emergencies: Restrictions on Liberty

Matthew K. Wynia, American Medical Association

Responses to public health emergencies can entail difficult decisions about restricting individual liberties to prevent the spread of disease. The quintessential example is

quarantine. While isolating sick patients tends not to provoke much concern, quarantine of healthy people who only might be infected often is controversial. In fact, as

the experience with severe acute respiratory syndrome (SARS) shows, the vast majority of those placed under quarantine typically don’t become ill. Efforts to enforce

involuntary quarantine through military or police powers also can backfire, stoking both panic and disease spread. Yet quarantine is part of a limited arsenal of options

when effective treatment or prophylaxis is not available, and some evidence suggests it can be effective, especially when it is voluntary, home-based and accompanied

by extensive outreach, communication and education efforts. Even assuming that quarantine is medically effective, however, it still must be ethically justified because it

creates harms for many of those affected. Moreover, ethical principles of reciprocity, transparency, non-discrimination and accountability should guide any implementation

of quarantine.

The policy decisions for a President in dealing with an avian flu outbreak are difficult. One example: If we had an outbreak somewhere in the United States, do we not then quarantine that part of the country, and how do you then enforce a quarantine? . . . Obviously, the best way to deal with a pandemic is to isolate it and keep it isolated in the region in which it begins.

—President George W. Bush, October 4, 2005.

There are three broad ethical issues related to handling public health emergencies, which I’ve come to call the 3 R’s: Rationing, Restrictions, and Responsibilities. In a recent in- stallment of this Public Health and Bioethics series, I looked at rationing, using pandemic flu planning and the annual flu vaccine distribution system as lenses through which one can examine rationing decisions during public health emer- gencies (Wynia 2006). In this installment, we’ll look at the issue of restrictions on liberty and again, we’ll focus on one especially acute dilemma: quarantine.

As Wendy Parmet has written, “Quarantine is the most extreme form of action a government takes in the name of public health . . . Although other [restraints on liberty] raise the issue of the state’s power to sacrifice an individual’s rights to protect the public, quarantine poses this question in its starkest form.” (Parmet 1985) So we’ll use quaran- tine as a way to think through the ethical issues involved in restricting individual liberties to promote public health. In reality, though, quarantine would never be used alone and the Centers for Disease Control and Prevention’s (CDC’s) Principles of Community Containment comprise a range of coordinated strategies (Tomianovic 2006). Other impinge- ments on liberty, such as so-called “social distancing” meth-

Address correspondence to Matthew K. Wynia, Director, The Institute for Ethics, American Medical Association, 515 N. State Street, Chicago, IL 60610. E-mail: [email protected] Disclaimer: The views expressed are the author’s own. This article should not be construed as representing policies of the American Medical Association.

ods (declaring “snow days,” or canceling school and other public events), surveillance and contact tracing, and mak- ing infection control measures mandatory (wearing masks, vaccination, hand washing, and so on), can also be critically important in disease control. But ethically, justifications for quarantine will subsume these less restrictive measures as well.

First, some definitions; although the terms “quarantine” and “isolation” often are used interchangeably, they are not the same. Quarantine refers to the separation or restriction of movement of healthy persons who have been exposed, or who might have been exposed, to an infectious disease. Isola- tion is the separation of people who already are ill and who are presumed or known to be infected. Isolation is much less controversial and it has long been used routinely for hospitalized patients with tuberculosis, chickenpox, bacte- rial meningitis and other infections. Not only is the rationale for isolation typically very strong (people with symptoms are often much more contagious), but people in isolation are already experiencing the indignities and suffering re- lated to sickness. Being isolated might be the least of their worries.

By contrast, people in quarantine are healthy and many of them aren’t ever going to become ill. As a result, it is not known with any certainty whether or not they are, or ever will be, contagious. For example Rothstein and his col- leagues report that during the SARS epidemic in Taiwan, “131,132 people were placed under quarantine, but only 12 were found to be potential cases of SARS” (Rothstein et al. 2003, 131). Of these, they say only 2 were eventu- ally confirmed. Another report suggested that 133 of those

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quarantined eventually developed SARS (Edelson 2006). Even so, that means that 1,000 or so uninfected people were placed under quarantine for each person who actually was infected. And SARS cases continued to climb in both Taiwan and China after widespread quarantine was being used in both countries (Edelson 2006).

This stark fact raises the first and by far the most impor- tant dilemma related to quarantine: it entails a substantial breach of individual freedom—and it’s only possible ethi- cal justification is consequential. That is, to have any hope of being ethically acceptable, quarantine must be effective at protecting the public’s health. But does it work? Is quar- antine effective? If not, then any remaining notions about how to ethically justify and implement quarantine become moot.

IS QUARANTINE EFFECTIVE?

Unfortunately, there is no simple answer to this question, since the effectiveness of any particular quarantine ac- tion will depend on social characteristics (such as whether the population accepts quarantine or rebels against it), biologic/disease characteristics (such as transmissibility, duration of infectiousness, the recovery rate, and whether symptoms correlate with contagion), and even individual characteristics (such as whether or not individuals, both in and out of quarantine, adhere to infection control measures like wearing masks or avoiding public gatherings). But the absence of a uniform, clear answer doesn’t mean there aren’t plenty of strong opinions about the general effectiveness of quarantine.

Some have asserted, for example, that the use of quar- antine for SARS was “unnecessarily harmful,” if not com- pletely ineffective (Annas 2006, 13). Quoting Benjamin Franklin, George Annas argues that, “Those who would give up an essential liberty to purchase temporary security de- serve neither liberty nor security” (2006, 5). And, he rightly bemoans the effects of reorganizing public health work into a military or police model (of which quarantine is only a part), which will undermine public trust, promote fear and panic, and therefore, ultimately, backfire as a public health strategy.

To support the claim that quarantine was not worth- while for SARS, he notes several experiences that should give pause to proponents of early and widespread invol- untary quarantine as a strategy for containing disease. For instance, when a rumor spread that all of Beijing might be placed under quarantine, 245,000 migrant workers appar- ently fled the city. In Hong Kong’s Amoy Gardens apartment complex, the site of an early outbreak, officials declared a quarantine, but when they showed up to relocate residents to the quarantine facility there was no one home in more than half of the complex’s 264 apartments (Annas 2006, 14).

These examples show that, even outside of the independence-minded United States, it is hard to enforce an involuntary quarantine. Indeed, in every country that attempted to institute quarantine for SARS, violations oc-

curred (Rothstein et al. 2003). In Singapore, one individual was arrested when his picture showed up on the front page of the paper—a beer in one hand and his quarantine order in the other. As former Senator Sam Nunn said after partic- ipating in the Dark Winter exercise, in which an attempted mass quarantine failed, “there is no force on earth that can make Americans do something that they do not believe is in their own best interests and that of their families” (Annas 2006, 19).

Even more concerning is that Rothstein and his col- leagues note that, “officials in Taiwan now believe that its aggressive use of quarantine contributed to public panic . . . ” (Rothstein et al. 2003, 131). One thing is clear from these ex- amples and others: quarantine done poorly can induce peo- ple to mistrust and avoid the public health system—and if this happens, then quarantine is not merely ineffective, it can actually feed the spread of the disease as frightened people break quarantine, flee and disperse into the population.

On the other hand, some claim that the widespread in- voluntary quarantines in China “proved to be effective” (Rothstein et al. 2003, 131). Indeed, the conventional wisdom from the SARS experience is that it was the use of quaran- tine that ultimately broke the epidemic, since no effective therapy or vaccine was available.

In this regard, it is worth recognizing that even if quar- antine weren’t extremely effective, it wouldn’t take much for it to surpass the effectiveness of some of the other measures taken. As a comparison, consider mass screening programs: Chinese officials screened more than 14 million travelers but found only 12 cases of SARS, and more than 1 mil- lion people had their temperatures taken at Toronto airports without identifying a single case (Edelson 2006). Now that’s ineffective—though only in hindsight, of course. Worse yet, some clusters of cases in China were traced back to trans- mission that probably occurred while people were standing in line together, waiting to have their temperatures checked (Edelson 2006).

In retrospect, the major key to controlling SARS was preventing transmission after symptoms arose and once the patient was hospitalized, since asymptomatic patients seem not to have been very infectious (Svoboda et al. 2004; Wenzel and Edmunds 2003). In other words, strict isolation was crit- ical; quarantine of asymptomatic people probably played a relatively small part in controlling spread of the disease. Even so, that doesn’t mean it was worthless, nor that quar- antine wouldn’t be critical in a future epidemic caused by a different organism.

For example, a recent study used mathematical models to demonstrate that even a very “leaky” quarantine could have dramatic effects on the spread and duration of a pan- demic flu epidemic (Wu et al. 2006). Even if only half the people in quarantine complied, infection rates would still be cut almost in half. This makes sense if you consider how the flu typically spreads—even very mildly symptomatic people can be contagious. So averting a single new infection early on can have huge ripple effects on subsequent infec- tions. In addition, merely delaying infections can “smooth

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out” or widen the epidemic curve, giving responders more time to prepare and perhaps alleviating the strain on the health care system (Doney 2006).

Given this, it would be very helpful for policy makers to know the likely characteristics of the specific disease in question when contemplating quarantine. Since influenza is typically easy to transmit even before the infected per- son has severe symptoms—and given US travel patterns—it seems very unlikely that cordoning off of a region could pre- vent the virus from getting out. By the time symptoms are being detected among the first wave of patients, spread will already have occurred. As epidemiologic models suggest, however, home-based quarantine, or “sheltering in place,” might still dramatically slow the subsequent spread of the disease, which makes the careful use of quarantine a worth- while strategy. But policy makers should not assume that a regional quarantine would be the best approach—and it should be known that military enforcement of such an ef- fort could easily backfire by creating public fear, mistrust and even panic, provoking attempts to escape quarantine and run.

Finally, quarantine often is used when no treatments or vaccines are available—so its effectiveness is sometimes measured against a relatively short yardstick . . . essentially doing nothing. But that’s the wrong way to look at it, since quarantine should not be used alone. It would be especially helpful to assess the utility of various types of quarantine (such as at home versus in a quarantine facility), and to compare quarantine against and in combination with other detection and containment strategies (use of “snow days,” screening programs, strict isolation of ill patients, and so on). Such comparisons would give policy makers better data, and would lessen over-reliance on the precautionary prin- ciple to justify early and harsh application of quarantine. I have argued for the value of the precautionary principle be- fore (Wynia 2005), but it can also be used to justify virtually any restriction on liberty if the potential harm from failure to contain the disease is bad enough.

PUBLIC SUPPORT

Despite the uncertainty surrounding its effectiveness, the American public generally supports the use of quarantine. In a recent survey, 94% of Americans said they would com- ply with a 7–10 day voluntary quarantine if they were ex- posed to a pandemic flu (Blendon et al. 2006a). This supports Paul Edelson’s comment that,

it is a canard sometimes used to justify authoritarian actions that the public responds to emergencies by losing control and panicking; indeed it is the consensus of social scientists that people in emergency situations tend to be more cooperative and more generous toward others then they may normally be (Edelson 2006, 29–30).

In short, the vast majority of Americans say that in a crisis they would be willing to sacrifice their own liberty for the good of their community.

What the public worries about, as should we, is that quarantine will be done poorly. Will those placed under quarantine be well cared for? Will they be recognized as making a sacrifice that is helping to protect the rest of the community, and for which they should receive respect, ap- preciation and support—or will they suffer stigma, eco- nomic losses and discrimination? Will they receive food de- livery, salary replacement and job security? Will they receive rapid medical care if they become ill, or prophylaxis if it be- comes available? And if they are placed under quarantine outside the home, will someone care for their children, their pets, or their parents? In a recent 4-nation survey about out- of-home quarantine, many people were concerned about overcrowding, cross-infection, and the inability to commu- nicate with their families (Blendon et al. 2006b). Sadly, al- most 25% of Americans say they could not afford to miss work for a week, and nearly 1 in 5 said their employer would probably require them to work while ill, even if they might infect others (Blendon et al. 2006a).

Researchers note that quarantine also places a tremen- dous psychological strain on the individual and the com- munity. In one study, symptoms of post-traumatic stress disorder and depression were seen in nearly one-third of those quarantined (Hawryluck et al. 2004). Others warn that quarantine can be used in a discriminatory way (Reis 2006). History shows this is possible (Parmet 1985). A court ruled in 1900, for example, that public health officials had acted with an “evil eye and an unequal hand” in placing an entire community of Chinese immigrants under quarantine in re- sponse to a plague scare (Gostin, Bayer and Fairchild 2003). While no discriminatory patterns were seen in those quar- antined during the SARS outbreak in Canada (Reis 2006), caution nevertheless is warranted. Meanwhile, merely being placed under quarantine can lead to stigma. And strict med- ical confidentiality is almost impossible to maintain, since the reason for the quarantine is likely to be well-known.

ETHICAL JUSTIFICATIONS FOR QUARANTINE

Given these risks, and since quarantine imposes sizeable costs on individuals and communities in terms of both lib- erty and economic impacts, quarantine requires some eth- ical justification beyond mere medical effectiveness. And quarantine should always be implemented with certain eth- ical considerations in mind.

The basic ethical justification for quarantine—beyond the consequentialist argument—stems from our moral obli- gation not to harm others. Even libertarians, strict defend- ers of individual rights, typically find justification for at least some limited uses of quarantine on the basis of the so-called, “harm principle.” As articulated by the original libertarian, John Stuart Mill in On Liberty, the harm principle is the no- tion that “the only purpose for which power can be right- fully exercised over any member of a civilised community, against his will, is to prevent harm to others” (Mill 1859). Under this basic principle, if quarantine prevents exposed people from infecting others, it can be just. Of course, this leaves a great deal open to interpretation; starting with the

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fact that many people in quarantine will be exposed but not infected, which means they actually pose no danger to oth- ers. So how should one decide whether to infringe liberty to prevent a mere risk of harm to others?

In addition, a series of widely discussed ethical princi- ples should be borne in mind when implementing quar- antine. These were succinctly captured in the “Siracusa Principles,” which demand that coercive public health mea- sures be “legitimate, legal, necessary, non-discriminatory and represent the least restrictive means appropriate to the reasonable achievement of public health goals” (United Na- tions 1984). In particular, note that using the “least restric- tive means,” suggests that any limitations on civil liberties should be proportionate and no more restrictive than is re- ally necessary. In other words, don’t use involuntary quar- antine or surveillance devices such as bracelets if voluntary measures will work; don’t restrict someone to one room if an entire house is available; don’t preclude visitors if personal protective equipment is effective; and don’t cut someone off from their work if they can do it from inside quarantine. The idea is to preserve freedom and opportunity as far as possi- ble, while still preventing significant risk of harm to others.

Finally, a number of experts have stressed the princi- ples of reciprocity, transparency, non-discrimination, and accountability, or the right to a due process to challenge one’s quarantine (Council on Ethical and Judicial Affairs 2006; Gostin, Bayer and Fairchild 2003; Upshur 2003). Reci- procity, transparency and non-discrimination were noted already, but the last right, the right to due process, deserves a final mention.

The logistics of individualized, formal due process hear- ings in the setting of a mass quarantine could pose a signifi- cant challenge. But more importantly, the right to challenge one’s quarantine is related to the legal notion of habeas corpus (Welborn 2005), which has been under attack of late in re- sponse to threats against the public (Dorf 2006). As a result, during an epidemic it might well be up to public health pro- fessionals, doctors and others to ensure that individual lib- erties are not sacrificed in vain, misguided and perhaps even counter-productive efforts to protect the public’s health.

While panic among the public is rare during public health crises, the same cannot be said with any certainty of political leaders. The urge to be perceived as respond- ing aggressively to a major problem might cause some to suggest the use of police or militarily enforced quarantines of broad populations, cities or regions, even though this would almost certainly fail to curtail most epidemics—and could make the situation much worse. Transparent commu- nications, viewing the public as a partner, and attending to the ethical and practical issues that most concern the public are the best—and perhaps only—way to ensure Americans’ compliance with quarantine in our pluralistic democracy.

REFERENCES

Annas, G. J. 2006. The statue of security: Human rights and post- 9/11 epidemics. In Ethics and Epidemics, ed. J. Balint, S. Philpott, R. Baker, and M. Strosberg, 3–28. Amsterdam, Neth.: Elsevier Press.

Blendon, R. J., J. M. Benson, K. J. Weldon, and M. J. Herrmann. 2006a. Pandemic influenza and the public: Survey findings. Presented to the Institute of Medicine, October 26, 2006. Available online at http://www.hsph.harvard.edu/press/releases/press10262006. html. Accessed on November 1, 2006.

Blendon, R. J., C. M. DesRoches, M. S. Cetron, J. M. Benson, T. Meinhardt, and W. Pollard. 2006b. Attitudes toward the use of quar- antine in a public health emergency in four countries. Health Affairs 25: W15–W25.

Council on Ethical and Judicial Affairs. 2006. The use of quarantine and isolation as public health interventions. CEJA Opinion 1-A-06. Chicago, IL: American Medical Association.

Doney, M. 2006. Nonpharmaceutical public health interventions: Strategies and implementation in the setting of pandemic influenza [presentation]. Available online at http://www.bt.cdc.gov/coca/ ppt/COCA NPPHI borders communities Pan Flu.ppt. Accessed on November 3, 2006.

Dorf, M. C. 2006. Why the Military Commissions Act is no com- promise. Available online at http://writ.news.findlaw.com/dorf/ 20061011.html. Accessed on November 3, 2006.

Edelson, P. J. 2006. Quarantine and civil liberties. In Ethics and Epi- demics, ed. J. Balint, S. Philpott, R. Baker, and M. Strosberg, 29–42. Amsterdam, Neth.: Elsevier Press.

Gostin, L. O., R. Bayer, and A. L. Fairchild. 2003. Ethical and legal challenges posed by Severe Acute Respiratory Syndrome. Journal of the American Medical Association 290: 3229–3237.

Hawryluck, L., W. L. Gold, S. Robinson, S. Pogorski, S. Galea, and R. Styra. 2004. SARS control and psychological effects of quarantine, Toronto, Canada. Emerging Infectious Diseases 10: 1206–1212.

Mill, J. S. 1859. On Liberty. Available online at http://www. utilitarianism.com/ol/one.html. Accessed on November 3, 2006.

Parmet, W. E. 1985. AIDS and quarantine: The revival of an archaic doctrine. Hofstra Law Review 14: 53–90.

Reis, N. 2006. The 2003 SARS outbreak in Canada: Legal and ethical lessons about the use of quarantine. In Ethics and Epidemics, ed. J. Balint, S. Philpott, R. Baker, and M. Strosberg, 43–67. Amsterdam, Neth.: Elsevier Press.

Rothstein, M. A., M. G. Alcalde, N. R. Elster, M. A. Majumder, L. I. Palmer, T. H. Stone, and R. E. Hoffman. 2003. Quarantine and isolation: Lessons learned from SARS. Louisville, KY: Institute for Bioethics, Health Policy and Law. Available online at http://www. louisville.edu/medschool/ibhpl/images/pdf/SARS%20REPORT. pdf. Accessed on October 31, 2006.

Svoboda, T., B. Henry, L. Shulman, E. Kennedy, E. Rea, W. Ng, T. Wallington, B. Yaffe, E. Gournis, E. Vicencio, S. Basrur, and R. H. Glazier. 2004. Public health measures to control the spread of the Se- vere Acute Respiratory Syndrome during the outbreak in Toronto. New England Journal of Medicine 350: 2352–2361.

Tomianovic, D. 2006. Quarantine: February 2006 CDC COCA con- ference call. Available online at http://www.bt.cdc.gov/coca/ ppt/quarantine 020706.ppt. Accessed on October 31, 2006.

United Nations Economic and Social Council, U.N. Sub- Commission on Prevention of Discrimination and Protection of Minorities, Siracusa. 1984. Principles on the limitation and

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derogation of provisions in the International Covenant on Civil and Political Rights, Annex, UN Doc E/CN.4/1984/4. Available on- line at http://hei.unige.ch/∼clapham/hrdoc/docs/siracusa.html. Accessed on November 3, 2006.

Upshur, R. 2003. The ethics of quarantine. The Virtual Mentor 5(11): n.p. Available online at http://www.ama-assn.org/ama/ pub/category/print/11535.html. Accessed on October 31, 2006.

Welborn, A. A. 2005. Congressional Research Service report for Congress. Federal and State Isolation and Quarantine Authority. Updated January 18, 2005. Washington, DC: The Library of Congress.

Wenzel, R. P., and M. B. Edmond. 2003. Listening to SARS: Lessons for infection control. Annals of Internal Medicine 139: 592–593.

Wu, J. T., S. Riley, C. Fraser, and G. M. Leung. 2006. Reducing the im- pact of the next influenza pandemic using household-based public health interventions. PLoS Medicine 3(9): e361.

Wynia, M.K. 2005. Public health principlism: The precaution- ary principle and beyond. American Journal of Bioethics 5(3): 3–4.

Wynia, M.K. 2006. Ethics and public health emergencies: Rationing. American Journal of Bioethics 6(6): 4–7.

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