Ebola, Ethics & Safety

English: Color-enhanced electron micrograph of...

English: Color-enhanced electron micrograph of Ebola virus particles. Polski: Mikrofotografia elektronowa cząsteczek wirusa Ebola w fałszywych kolorach. (Photo credit: Wikipedia)

Kaci Hickox, a nurse from my home state of Maine, returned to the United States after serving as a health care worker in the Ebola outbreak. Rather than being greeted as a hero, she was confined to an unheated tent with a box for a toilet and no shower. She did not have any symptoms and tested negative for Ebola. After threatening a lawsuit, she was released and allowed to return to Maine. After arriving home, she refused to be quarantined again. She did, however, state that she would be following the CDC protocols. Her situation puts a face on a general moral concern, namely the ethics of balancing rights with safety.

While past outbreaks of Ebola in Africa were met largely with indifference from the West (aside from those who went to render aid, of course), the current outbreak has infected the United States with a severe case of fear. Some folks in the media have fanned the flames of this fear knowing that it will attract viewers. Politicians have also contributed to the fear. Some have worked hard to make Ebola into a political game piece that will allow them to bash their opponents and score points by appeasing fears they have helped create. Because of this fear, most Americans have claimed they support a travel ban in regards to Ebola infected countries and some states have started imposing mandatory quarantines. While it is to be expected that politicians will often pander to the fears of the public, the ethics of the matter should be considered rationally.

While Ebola is scary, the basic “formula” for sorting out the matter is rather simple. It is an approach that I use for all situations in which rights (or liberties) are in conflict with safety. The basic idea is this. The first step is sorting out the level of risk. This includes determining the probability that the harm will occur as well as the severity of the harm (both in quantity and quality). In the case of Ebola, the probability that someone will get it in the United States is extremely low. As the actual experts have pointed out, infection requires direct contact with bodily fluids while a person is infectious. Even then, the infection rate seems relatively low, at least in the United States. In terms of the harm, Ebola can be fatal. However, timely treatment in a well-equipped facility has been shown to be very effective. In terms of the things that are likely to harm or kill an American in the United States, Ebola is near the bottom of the list. As such, a rational assessment of the threat is that it is a small one in the United States.

The second step is determining key facts about the proposals to create safety. One obvious concern is the effectiveness of the proposed method. As an example, the 21-day mandatory quarantine would be effective at containing Ebola. If someone shows no symptoms during that time, then she is almost certainly Ebola free and can be released. If a person shows symptoms, then she can be treated immediately. An alternative, namely tracking and monitoring people rather than locking them up would also be fairly effective—it has worked so far. However, there are the worries that this method could fail—bureaucratic failures might happen or people might refuse to cooperate. A second concern is the cost of the method in terms of both practical costs and other consequences. In the case of the 21-day quarantine, there are the obvious economic and psychological costs to the person being quarantined. After all, most people will not be able to work from quarantine and the person will be isolated from others. There is also the cost of the quarantine itself. In terms of other consequences, it has been argued that imposing this quarantine will discourage volunteers from going to help out and this will be worse for the United States. This is because it is best for the rest of the world if Ebola is stopped in Africa and this will require volunteers from around the world. In the case of the tracking and monitoring approach, there would be a cost—but far less than a mandatory quarantine.

From a practical standpoint, assessing a proposed method of safety is a utilitarian calculation: does the risk warrant the cost of the method? To use some non-Ebola examples, every aircraft could be made as safe as Air-Force One, every car could be made as safe as a NASCAR vehicle, and all guns could be taken away to prevent gun accidents and homicides. However, we have decided that the cost of such safety would be too high and hence we are willing to allow some number of people to die. In the case of Ebola, the calculation is a question of considering the risk presented against the effectiveness and cost of the proposed method. Since I am not a medical expert, I am reluctant to make a definite claim. However, the medical experts do seem to hold that the quarantine approach is not warranted in the case of people who lack symptoms and test negative.

The third concern is the moral concern. Sorting out the moral aspect involves weighing the practical concerns (risk, effectiveness and cost) against the right (or liberty) in question. Some also include the legal aspects of the matter here as well, although law and morality are distinct (except, obviously, for those who are legalists and regard the law as determining morality). Since I am not a lawyer, I will leave the legal aspects to experts in that area and focus on the ethics of the matter.

When working through the moral aspect of the matter, the challenge is determining whether or not the practical concerns morally justify restricting or even eliminating rights (or liberties) in the name of safety. This should, obviously enough, be based on consistent principles in regards to balancing safety and rights. Unfortunately, people tend to be wildly inconsistent in this matter. In the case of Ebola, some people have expressed the “better safe than sorry” view and have elected to impose or support mandatory quarantines at the expense of the rights and liberties of those being quarantined. In the case of gun rights, these are often taken as trumping concerns about safety. The same holds true of the “right” or liberty to operate automobiles: tens of thousands of people die each year on the roads, yet any proposal to deny people this right would be rejected. In general, people assess these matters based on feelings, prejudices, biases, ideology and other non-rational factors—this explains the lack of consistency. So, people are wiling to impose on basic rights for little or no gain to safety, while also being content to refuse even modest infringements in matters that result in great harm. However, there are also legitimate grounds for differences: people can, after due consideration, assess the weight of rights against safety very differently.

Turning back to Ebola, the main moral question is whether or not the safety gained by imposing the quarantine (or travel ban) would justify denying people their rights. In the case of someone who is infectious, the answer would seem to be “yes.” After all, the harm done to the person (being quarantined) is greatly exceeded by the harm that would be inflicted on others by his putting them at risk of infection. In the case of people who are showing no symptoms, who test negative and who are relatively low risk (no known specific exposure to infection), then a mandatory quarantine would not be justified. Naturally, some would argue that “it is better to be safe than sorry” and hence the mandatory quarantine should be imposed. However, if it was justified in the case of Ebola, it would also be justified in other cases in which imposing on rights has even a slight chance of preventing harm. This would seem to justify taking away private vehicles and guns: these kill more people than Ebola. It might also justify imposing mandatory diets and exercise on people to protect them from harm. After all, poor health habits are major causes of health issues and premature deaths. To be consistent, if imposing a mandatory quarantine is warranted on the grounds that rights can be set aside even when the risk is incredibly slight, then this same principle must be applied across the board. This seems rather unreasonable and hence the mandatory quarantine of people who are not infectious is also unreasonable and not morally acceptable.

 

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11 Comments.

  1. Mr LaBossiere is logical, as usual. Ebola is not in the air, and infection requires contact with infectious material.
    That contagion is unlikely unless one has exhibited symptoms. In that case separating the victim from those around him is justified.

    .mek

  2. It is an interesting article.

    I think it was Steven Levitt who made a comparison between travel by automobiles and aeroplanes. He analyzed the claim that a fear of flying is irrational consequent to the fact that the incidence of car crashes far exceeds that of plane crashes. He broke the concept down to person-time: we are exposed to cars more frequently, and the time spent traveling by cars exceeds the time spent in aeroplanes. When one adjusts for person-time, the risk of death by crash/malfunction change dramatically. I read the essay a while ago, so I can’t quote the statistics, but the logic seems sound to me.

    I guess that also explains the fear regarding ebola: the fact that a limited exposure can cause death generates more fear than exposure to firearms (in the US) or automobiles. Based on this, I think your point on the apparent dissonance between the precautionary principle’s selective application ( as it relates to ebola quarantine and guns) may be a false equivalence.

  3. From the lens of Public Health Ethics, James Childress wrote a very good article on what he called the “justificatory principles” for overriding one’s autonomy in favor of a greater good, and I think that these apply here: the action needs to be effective, necessary and proportional, and conducted in a transparent and justifiable manner. Another requirement is that it represents the least-possible infringement of personal liberty.

    Keeping the last point in mind, I think that the government/ public health body has a moral duty to ensure that the conditions in the quarantined areas be liveable and (to a reasonable extent) pleasant. Assuming that this is done, do you think that would make this would make the infringement of personal liberties more acceptable?

  4. Hyder Khan,

    Limited exposure to firearms can also cause death. But, you do raise a good point. If we work out deaths per contact with firearms and compare it to deaths per contact with people who have Ebola, then the fear of Ebola might be rational on a death-per-contact basis. This would, of course, be complicated by the likelihood of contact as well as how we define firearm contact (being shot or just being near one).

  5. Hyder Khan,

    The treatment of the quarantined person would be relevant in the moral assessment of the treatment. However, unjustly locking someone in a nice “prison” would still be a violation of liberty.

  6. Mike LaBossiere

    I agree with your point- quarantines could be viewed as a gross violations of civil liberties. Considering the retributive nature of the prison system, there is a clear mismatch in principles between quarantine and incarceration.

    However, if one also recognizes the role of the prison system in sequestering potentially dangerous individuals from harming other members of the community, we find some logical consistency with the justifications upon which we “incarcerate” healthy individuals (quarantine). My comment regarding ensuring decent conditions in quarantine camps was an attempt to remove the retributive effect seen with the prison system.

  7. Mike LaBossiere

    Other than automobile accidents and guns, poor dietary habits would cause an individual harm, as opposed to the community at large. Therefore, I will focus on the former (for now, at least- if you are willing, we can explore the latter as well).

    In the case of guns and cars, there is already a policy of limiting availability and usage. One doesn’t have unfettered access to cars the way one does to food owing to the fact that the former is more of a public concern than the latter. There are circumstances where one may have a drivers license revoked. Furthermore, it is commonly (and, in my opinion, correctly) argued that the legal limit of alcohol consumption before being declared an unsafe driver may not impair most individuals. Therefore, the government recognizes that the potential for impairment is more important than actual impairment.

    I am not from the U.S, so I do not view gun ownership as an ideological issue, and do not believe that citizens (especially in cities) have the right to bear arms. However, even in the U.S, there are limitations on the sale and ownership of weapons. Furthermore, certain types of weapons
    are viewed and accepted as being military tools, and the sale of them is illegal. (Disclaimer- the fact that I am not from the US may mean that my facts are not valid, so please correct me if I am mistaken).

    Although these laws do not doesn’t constitute “taking (cars/guns) away”, it is a limitation. Similarly, one’s civil rights are not “taken away” when one is forced into quarantine, they are just temporarily limited. Also, as stated in the case of cars, the potential of being contagious may be more important than actually being contagious.

    Therefore, I would argue that the principles of quarantine are consistent with most health-related laws.

  8. I am sorry for spamming the comments section of this post, but I have one final observation I recognize the fact that this argument could be viewed as a red herring, but I hope to show that it is not.

    Most of your arguments could also be considered valid in the context of vaccinations- especially when school admissions may be limited consequent to being unable to prove one’s vaccination status. To travel out of my part of the world, one needs to produce a document showing that one has been vaccinated recently against polio (independent of having been immunized against it over a year ago). One could argue that mandatory vaccination programmes are also a violation of civil liberties.

    The reason I do not believe it is a red herring is because of the concept of herd immunity. If enough people in the community are vaccinated, the benefits/ risk reduction in a single individual are minimal at best. This is why the US allows certain individuals to refuse on grounds of religion- the fact that the majority are immunized means that their immunization status is irrelevant.

    This would mean that the individual being vaccinated is not solely in the interest of his/her health, but in the interest of “maintaining the herd”, and ensuring that they do not pose a risk to others. This is also corroborated by the travel restrictions I mentioned- the social demographic engaging in international travel in my country are unlikely to get polio, even if they are never immunized. This is because they are almost never exposed (better hygiene in the areas they live is very important, and better overall health). Therefore, the reason is to bolster the numbers in the “herd” and to confer these benefits to unimmunized people.

    Limiting one’s ability to join certain educational institutions, to travel and, in the case of health workers and the flu vaccine, to limit their employment opportunities consequent to being unvaccinated could be seen as a violation of civil liberties.

    However, morbidity and mortality rates consequent to low vaccination rates are very well documented. Furthermore, if vaccination rates are low, even individuals who have been vaccinated may be at risk (if their general health is poor).

    Back to my original point- when it comes to public health, there is a history of prioritizing harm reduction over civil rights. This would, in my opinion, mean that there is across-the-board consistency in public health-related issues.

  9. Hyder Khan,

    I would agree that a quarantine of a person can be justified. Going with a gun analogy, just as a person who has established that he is a danger to others can be denied the right to keep and bear arms, a person who has been shown to be infectious with a dangerous disease can justly be quarantined. But, if the person does not present a danger, then such a denial of liberty would be unwarranted. Unfounded fear would not suffice.

  10. In the US, the sale of automatic (military) weapons is not illegal-a person just needs the proper background check and enough money to pay for the stamp (and gun).

  11. Hyder Khan,

    The point about vaccines is apt. People are compelled to get vaccines in the United States (although exceptions are allowed). As you note, the justification of the imposition is based on the general good. I’m fine with this, since most vaccines meet the conditions I specify. That is, the imposition on the individual is outweighed by the harms of not vaccinating (both to the individual and the general population).

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