Isolation and quarantine throw harsh light on the complex tensions in public health, between the rights and duties of individuals and concepts of the public interest, says Julian Sheather
Quarantine. Feared and misunderstood in equal measure, its origins lie in 14th century Dubrovnik. The Black Death was ravaging Europe—eventually killing an estimated 30 per cent of its population. Medicine was powerless, scientific knowledge primitive, and fear itself epidemic. In the face of such an existential threat, the only hope was containment—the casting of a cordon sanitaire. Ships and people were held for forty days—quaranta giorna—before entering the city, kept at anchor or on outlying islands to see if they developed the tell-tale symptoms.
Scroll forward nearly seven hundred years to China and the outbreak of a novel coronavirus. The epicentre—Wuhan—is in lockdown, as are neighbouring cities: fifty million people confined. Media stories filtering through suggest conditions are, at best, uneasy. Human instincts do not evolve as fast as medicine. The fear-stalked streets are ghostly. The New York Times reports house-to-house searches, the sick rounded up and herded into makeshift quarantine hospitals. There is talk in the media of Wuhan being sacrificed “for the greater good.”
Quarantine and isolation fall at the restrictive end of social distancing—methods to limit and delay the spread of a pathogen through reducing person-to-person contact. Isolation separates those who have a contagious disease from people who are not sick. Quarantine separates those exposed to a contagious disease to see if they become sick.
Both throw harsh light on the complex tensions in public health between the rights and duties of individuals and concepts of the public interest, most obviously between private freedoms and the public interest in confining the outbreak of a lethal disease. If I may be carrying such a disease, I might have to forego my right to leave my house at will. The rights of others to be spared infection supervene. The UK government has declared the virus a “serious and imminent threat” to public health—allegedly to enable powers to confine an infected individual threatening to abscond from voluntary isolation. The full coercive powers of the state come in to play.
At the forefront of justification for quarantine lie questions of proportionality. There must be clear scientific evidence of person-to-person spread; the disease must be of a nature that requires quarantine, and there must be a reasonable belief that quarantine will be effective—the restrictions must be proportionate to the harms. There is no doubt that the virus is dangerous. Although still too early tell, even if we take a low “guestimate” of mortality at 1%, that is an enormous potential death toll should it turn pandemic. If rates of infection can be slowed by quarantine so that vaccines and effective anti-virals can be developed, huge number of lives could be saved. It looks as if quarantine is justifiable.
But where restrictions are justified, another critical principle comes in to play: reciprocity. Where individual rights are limited, the state accrues additional duties. These include ensuring that any burdens imposed are as limited as possible. Basic amenities such as food, water and medical care must be met. Compensation for lost income should be given. Priority access to novel treatments should be considered. Experience from Ebola suggests that without these guarantees, people will be imaginative in dodging restrictions.
But the reports of fear, anger, and confusion coming out of Wuhan emphasise another element of reciprocity: the requirement to keep people informed. Safe methods of communication need to be established. Regular updates based on the latest scientific information need to be provided. Information about the likely length of quarantine needs to be given—and updated.
Where liberty rights are justifiably curtailed, where individual freedoms are restricted for the public good, other rights and interests require greater vigilance. Along with basic survival needs, the quarantined and isolated have rights to information. These rights are deeply rooted in obligations to show respect for citizens. As Wuhan makes clear, even in cultures accustomed to highly centralised and directive state power, where knowledge is imperfect, and questions of proportionality are in doubt, reciprocity needs to do greater moral work. There can be no justification for keeping the confined in the dark.
Julian Sheather is ethics manager, BMA. The views he expresses in his opinion pieces are entirely his own.
Competing interests: None declared.