An Evaluation of the Ethical Considerations of Forced Quarantine
Michelle L Magario-May 5, 2011
Abstract
It is ethical, moral and legal, to use physical force to attain quarantine of potentially infectious persons. Using the ethical theory of utilitarianism, and adhering to the principles of beneficence, non-maleficence and justice, quarantine can be an important tool for public health administrators during both emergency and non-emergency situations. When approached with careful scrutiny and prudence, quarantine can assist public health officials and personnel to fulfill their obligation of protecting the public’s safety and welfare.
History
In modern day terms, quarantine refers to the act of segregating asymptomatic individuals who have been exposed to infectious disease (and are potentially contagious) and differs from isolation which refers to the segregation of individuals known to be infectious and therefore capable of transmitting the disease (Gostin & Berkman, 2007). The term quarantine comes from the Italian “quaranta giorni”, and refers to the 40 day waiting period for vessels entering the port of Venice during the 14th century Black Death plague outbreak in Italy (Swendiman & Elsea, 2006). Mandatory or forced quarantine has been practiced by virtually all civilizations since the beginning of recorded history. The practice is mentioned in both Leviticus and Numbers in the Old Testament as well as in the ancient Greek writings of Thucydides and Hippocrates, and is well known to have occurred in medieval Europe in response to The Plague. The first report of quarantine being practiced in America was in the Massachusetts Bay Colony in 1647 and the first American federal quarantine law was passed in 1796 during a yellow fever outbreak (Swendiman & Elsea, 2006). More recently, quarantine was employed internationally in response to the SARS outbreak between 2002 and 2003 that claimed the lives of 774 people in 29 countries (Rothstein, 2004).
While generally considered to be an acceptable recourse to impede the transmission of infectious diseases, the use of quarantines has been applied with poor judgment, ignorance, and under the most deplorable conditions. In 1900, President McKinley ordered the quarantine of all Chinese and Japanese residents of San Francisco’s Chinatown after a bubonic plague victim was discovered, under the assumption that their diet of rice was a contributing factor in contracting the disease (Ries, 2004). While this event occurred long before a thorough understanding of the infectious disease process was known, this scenario has been repeated up until very recently and includes the Cuban government ordering the mandatory quarantine of HIV infected persons as recently as 1994 (Ries, 2004). In order to protect the rights, freedoms and liberties that we, as Americans enjoy, and to balance those entitlements against the need to protect society as a whole, the U.S. Supreme Court has made several rulings regarding the constitutionality of quarantines’ practice. In addition, the U.S. Supreme Court has ruled on who has the authority to impose such restrictions.
Legal Authorization
While the legalities of quarantine are beyond the scope of this paper, it is important to make note of the landmark decisions that allow public health officials to restrict the rights of certain individuals. The question of federal authority was most recently affirmed in the case of the United States v. Shinnick in 1963 which gave the U. S. Federal government the right to quarantine persons arriving into the United States from foreign countries, or those traveling across state lines, who pose a potential health risk to the public (Richards, Burris, McNelis, & Hargan, 2005). The question of state authority was originally addressed in the 10th Amendment to the U.S. Constitution which states that powers not delegated to the federal government are thereby reserved to the states respectively, or to the people. This premise was defined and upheld in Jacobson v. Massachusetts in 1905, the use of force to attain quarantine-affirmed in Gibbons v. Ogden in 1824, and the application of quarantine to an entire geographical area-affirmed in Compagnie Francaise de Navigation a Vapeur v. Louisiana State Board of Health in 1902 (Swendiman & Elsea, 2006). While these landmark decisions give the authority to use quarantine, by force if necessary, to protect the safety and welfare of the community, the question remains—Should we avail ourselves of this authority?
Ethical considerations
The utilitarian model for ethics in public health is based on the principle that “decisions should be judged by the sum consequences, in particular by their effect on the sum total of individual well being” (Roberts & Reich, 2002, p. 1055). Basically, it refers to the processes and procedures that give the greatest good to the greatest numbers. Using this theory, in response to the previous question, the answer would be a resounding yes; it is not only acceptable, but highly recommended that we avail ourselves of the authority to use force to protect society as a whole, even if the consequences to a minority of the population are undesirable. The utilitarian theory is additionally supported by the ethical principles of beneficence, non-maleficence and justice. Each of these principles can be addressed in turn to affirm this belief.
Beneficence is the ethical principle that dictates that actions benefit others and in the case of quarantine, applies to society as a whole. This is a cornerstone belief in the application of quarantine. The interests and welfare of the community must outweigh those of the individual. This belief comes at a cost and likewise, its acceptance must be earned in order to be acceptable to the people. In a democratic society, such the United States, it is the people who dictate, through the political process, what will and will not be acceptable to the majority. With regards to quarantine, defended by the principle of beneficence, governmental decisions that restrict or encumber individual freedoms must be made through transparency and trust (Beyrer, 2003). Likewise, decisions must not cause unnecessary harm to those they are imposed upon. This is the foundation of the principle of non-maleficence.
The principle of non-maleficence dictates that decisions must do no harm, or at a minimum cause the least harm possible and in the case of quarantine, applies to those being quarantined. It prescribes that the benefits of an action outweigh the burdens associated with that action. In the case of quarantine, the benefits to society (protection from infectious disease) must be greater than the burdens placed upon those in quarantine. Harms to those placed in quarantine can be numerous and multifaceted. The medical and psychological needs of the quarantined must be thoroughly addressed. In addition, many researchers have supported the notion of financial reciprocity for those burdened by quarantine (Rothstein, 2004). The practice of financial reciprocity in exchange for quarantine was implemented by the Canadian government during the recent SARS outbreak in an effort to ease the burdens of those in quarantine (Ries, 2004). It was, however, acknowledged that the same may not be feasible in the U.S. as it would be seen as a burden to taxpayers and employers (Rothstein, 2004). Some would see this additional burden as unjust.
The balance between beneficence and non-maleficence can be an ethical dilemma for policy makers. The challenge for public health officials is to achieve a balance between preserving individual liberties while at the same time defending the health and safety of the community. This challenge can be minimized, to a certain extent, by employing practices that are fair and just. The third ethical principle that supports the use of quarantine is justice. The principle of justice dictates that decisions are fair and equitable to those involved. Decisions must not be applied in a manner that is discriminatory or biased. In the context of quarantine, it means that decisions for the application of quarantine be made using a fair process, include a publicly available rationale for those decisions, a mechanism for dispute resolution, and a regulatory body to enforce decisions (Baum, Golllust, & Jacobson, 2007). In addition, officials need to exhibit transparency regarding the goals to be accomplished, and whether the benefits and burdens of the decisions are expected to be distributed equally throughout the community. Where inequality exists, there must be a rationale and justification for that disparity (Baum, et al., 2007). Mistrust will occur if deception or secrecy is suspected and will have a profoundly negative impact on the quarantine process. Likewise, conflicts of interest, serving for profit or catering to special interests will not be tolerated by the public and the notion of public health will lose all credibility (Etkind, Arias, Bagley, & Nelson, 2008).
In accordance with the principle of justice, the U. S. justice system’s foundation of substantive due process can be applied to the quarantine scenario and is likely to be accepted by citizens as it is a prized and recognized institution. Mark Hitchcock (2007) has offered four criteria to ensure that substantive due process applies to quarantine situations. They include:
A demonstrated public health necessity
An effective intervention with a demonstrable means-end connection
Proportionality-the intervention is neither too narrowly or broadly tailored
It is the least restrictive in terms of infringing on individual rights while accomplishing its purpose and does not inflict unnecessary harm (Hitchcock, 2007, p. 15)
Through applying these protocols to quarantine situations, it is suggested that society will respond favorably, or at least not hostilely, to those measures.
Conclusion
The institution of forced or mandatory quarantine to halt the spread and transmission of infectious diseases is ethical and justifiable. The ethical principles supporting this notion include beneficence, non-maleficence and justice and agree with the utilitarian model of ethical theories. Through utilization of systematic and prudent protocols the challenges of the quarantine process can be mitigated. The obligation of public health officials is to protect and preserve the safety, welfare and health of the communities they serve. While the use of quarantine should be reserved for serious and drastic situations where the consequences of the disease outweigh all other considerations, it is important to have a clear set of protocols and standards in place before the need for application arises. It is not an option to be used indiscriminately or without caution, but it must remain an option.
References
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