A Delicate Balance

[Comrade Tortoise]

This was written by me as a term paper. Enjoy



Striking the Balance
An Attempt at Balancing the Needs of the Individual with the Needs of Society as a Whole


There are things in this world which dwarf the death toll from every war in human history. They have shaped human history, decided the course of wars, and wiped hundreds of millions of people off the face of the Earth. These things are not weapons of mass destruction, or geological cataclysms. Rather, they are organisms and biologically active particles only a few microns across that exist naturally. Despite the fact that smallpox has killed over three hundred million people in the twentieth century alone and the black plague killed two thirds of the population of continental Europe in the 14th century,( Oldstone, 1998) considerations for infectious disease was been left out of the field of bioethics. (Francis et al, 2005). Modern ethical considerations in medical ethics focus on the autonomy of a patient who’s decisions directly affect only themselves and their immediate friends and family. In the event of an outbreak of infectious disease, such as the near certainty of H5N1 Avian Influenza (or similar pathogen) mutating to transmit person to person, we will be forced to consider what to do when that individual autonomy conflicts with the preservation of the lives of hundreds, thousands, even millions of people. Measures that are traditionally taken in the event of disease outbreaks include: Isolation of infected patients either in their homes or in medical wards, tracing contacts of the infected to find those who may have been exposed, and quarantine of those who have been exposed.. Each of these measures carries with it ethical implications regarding patient autonomy, justice, and privacy (Gostin et al, 2003) I would also point out that different diseases have different ethical implications because the consequences expressed in terms of rate of infection and mortality are different; and for the sake of brevity, I will focus primarily on the ethical implications of H5N1 Avian Influenza.


H5N1 is a type A Influenza virus with symptoms similar to more familiar forms of Influenza. They include fever, cough, sore throat, muscle aches, and eye infections. As well as acute respiratory distress, and viral pneumonia. Currently, over half of those infected die from the disease. Though it is possible that the only reports are from the most severe of cases, so the mortality rate may be overstated (CDC, 2006) It is also transmitted in a similar way, through large virus-laden droplets that are generated when an infected individual sneezes or coughs (CDC, 2006) These settle in the mucous membranes of the upper respiratory tract of people in close physical contact to the infected. Transmittance is also possible through contact with objects which touch the mucous membranes; such as touching a door handle touched or sneezed on by an infected person, then rubbing one’s nose, eyes or mouth (CDC, 2006) Transmission in adults typically is possible one day before onset of symptoms and up to five days after symptoms end. Children can transmit for up to ten days after symptoms end.


To put influenza in a global perspective; the 1917-1918 Spanish flu pandemic killed between twenty and forty million people, and literally decided the First World War in favor of the Allied Powers. It is estimated that a fifth of the world’s population was infected, and that two to three percent of those infected died (Oldstone 1998) This horrific rate of infection was at a time in the world’s history when flight was in it’s infancy, and long distance travel was possible only by ship, which, necessarily, took a long time and tended to be fairly expensive. Few people had automobiles and many people never left their home towns.


So what does this mean for H5N1? Well, in today’s globalized economy, possible modes of transmission are everywhere. International airlines reduce journeys that would have taken days to weeks a hundred years ago, to a few hours, in relatively cramped conditions. One infected person sneezes, and he exposes everyone within a two meter radius to the virus. If he then uses the lavatory, he exposes everyone who uses that same lavatory. Automobiles and our highway system make it possible for an infected individual to traverse the united states in less than two weeks, exposing dozens if not hundreds of people along the way in bathrooms, hotels, and rest stops. Each of those people would also be traveling, and could, once they begin transmitting the virus, infect others. In short, even if H5N1 has the same mortality rate as Spanish Flu, it will infect more people in a shorter amount of time.


The following analysis of the moral status of quarantine and isolation will be undertaken with the knowledge that an infected or exposed person is victim, patient, and disease vector. The principles which form the focus of the field of bioethics, such as autonomy and privacy, need to be modified in infectious disease cases in order to take this knowledge into account (Francis et al, 2005) We need to strike a balance between the libertarian goals of protecting privacy and personal autonomy, and the utilitarian aims of protecting the public good (Selgelid, 2005) I must also talk about the moral status of contact tracing because quarantine and isolation would not exist if it did not take place.


Contact tracing, and of reporting incidences of disease by name, is of crucial importance in the event of an H5N1 outbreak. Authorities need to know who has been exposed so that they can begin the quarantine and isolation process, as well as to understand the spread of the disease and design countermeasures. However, there are ethical concerns in this technique, mainly individual privacy concerns (Gostin et al, 2003) This is an instance where the right to privacy of individuals needs to be weighed against the public good. To use the United States as an example, privacy is enshrined into the US Constitution by implication of the fourth, ninth, and fourteenth amendments. It is one of the things which has allowed it to function. From what citizens say behind closed doors about their elected officials, to who they are sleeping with, being protected from government intrusion in their lives allows their economy and political process to function as they should and have for over two hundred years. The country must be direly threatened before a violation of those principles is permitted. In addition, there are some concerns regarding social stigma attached to infection or exposure.


The risks however, of not using contact tracing and name reporting, in my view, outweigh these concerns. Unless names are reported to health and law enforcement officials in the event of an outbreak; not only will scientists and government officials be unable to adequately study the pattern of infection, but they will be unable to trace the contacts of infected patients effectively. This would have the effect of essentially leaving the exposed or infected free and able to continue spreading or potentially spreading the disease. This could endanger the lives of everyone they come in contact with, who would in turn endanger the lives of everyone they came into contact with. It is then imperative for the direct safety of everyone within a population that authorities be able to tell who is infected, and who has been exposed in order that measures may be taken to curb further transmission. Now, this does not give license to health and governmental officials to use the information at their whim. The overall privacy and economic interests of the population need to be protected. Partially for reasons of respecting their dignity, but also for economic reasons. The economic backlash of an infectious disease outbreak will be severe enough as it is. People will die, subjecting families to income loss and funeral costs. Industry will suffer from the loss of workers due to death and quarantine. In addition to this, post-outbreak insurance companies will probably increase their premiums, thus harming people already devastated by the disease. Such behavior is not only unjust, but also causes harm to society in general, and thus needs to be prevented with stringent privacy controls, such as not allowing the names of infected and exposed individuals to be used for any purpose but contact tracing and surveillance. And infection must be prevented, by legislation, from being used to increase medical insurance premiums or deny medical insurance. One could argue that an insurance company should have the ability to increase premiums or deny insurance to someone who contracted H5N1, however that would only further victimize those already devastated by a horrible illness. Thus, health officials should never release specific information to any private organization unless that data has been anonymized. In addition, the information should be permitted for pure research purposes only. This would avoid increases in insurance premiums by area, and would prevent the attachment of social stigma to large proportions of the population. If the HIV outbreak in the 1980s and the blockades set up in 1916 to prevent the passage of people who may have polio told us anything, it is that people are not reasonable when it comes to disease. Politicians will scheme and use the illness to their political advantage. People will panic and do unspeakable things to their fellow man. The disease will be blamed not on the virus, but by whatever paranoia or prejudice is popular among the common man at the time; or on whatever group of people is susceptible. (Oldstone, 1998) Plainly, such behavior does not come close to our ideas about justice and fairness; and needs to be prevented without harming the ability to fight disease.

The end result of contact tracing is finding individuals who are infected or exposed to the disease, in this hypothetical case H5N1 Avian Influenza Isolation is the separation for the duration of communicability infected individuals in such a way as to reduce the possibility of transmission of infection (Gostin et al, 2006) Commonly this is done in hospital wards set up for the purpose, so that the infected can receive treatment. This is easiest in the early stages of the outbreak, naturally. If the infection spreads faster than authorities can keep up with it, then isolation would probably have to be done in the home. Quarantine is the isolation of exposed persons during the incubation period so as to reduce the possibility of transmission. They can happen at the individual or population level, in contrast to isolation which functions at the individual level.


The ethical problems are similar between the two however, and thus they can be addressed jointly. Both of them concern patient autonomy and freedom of movement, as well as economic problems. Some literature supports the idea that patient autonomy can be preserved by making the procedures voluntary ( DiGiovanni et al, 2004) The question remains though, what happens when someone says no? Getting people to consider the ramifications of their actions is one thing. But what happens when someone does not care? Is it their choice to endanger others? Certainly, this varies from disease to disease. We wouldn’t for example, force quarantine on someone suffering from the common cold. What happens when the stakes are high? I would take the position that, at least in the case of an H5N1 outbreak with the same mortality rate of the 1918 Spanish flu pandemic, that the “needs of many, simply outweigh the needs of the few, or the oneâ€

[Mayabird]

Good paper. It's true, that infectious diseases are often left out of these bioethics discussions. They focus more on, let's say, human reproductive cloning (which I doubt will be common even if it was allowed and the telomere issues are fixed) than the possibility of pandemics.

Another bioethical issue concerns the spread of Ebola. As it is transmitted by fluids, isolating an infected patient and quickly cremating the body will stop the spread; it is doubtful that the current form would be able to cause an epidemic in any developed countries.

However, in the African countries where it is endemic, a common funerary practice is for family members and locals to touch the body of the deceased before burial, supposedly to prove that witchcraft was not involved in the person's death. This brings people in contact with the fluids of the person who died, and causes the rapid spread. People who refuse to touch the body for fear of infection are likely to be killed as a witch who supposedly magically caused their deaths. During the Marburg fever (a disease in the same family as Ebola) outbreak in Angola not long ago, doctors were attacked because they isolated patients and then quickly disposed of the bodies to prevent the spread of disease. The locals thought the doctors had caused the disease by magic, or were stealing their family members, and they were not being allowed to have their normal funerals. People who say "let local customs rule" or "let the individuals decide" would have condemned thousands more to nasty deaths.

[frigidmagi]

Usually it is best to allow local customs and the individual decide, but people often forget that costoms have to change with their enviroment and that sometimes the individual's rights are not the most importent thing to consider.