Nurse Kaci Hickox leaves her home on a rural road in Fort Kent, Maine.
"I never had Ebola. I never had symptoms of Ebola. No one should be victimized by being placed in a quarantine if they do not have any symptoms of Ebola, because asymptomatic people are not a health risk," wrote Kaci Hickox in a recent article for the Guardian.
Hickox made international headlines last month when, returning from nursing Ebola Virus Disease (EVD) patients in Sierra Leone, she was put into an isolation tent in New Jersey. She subsequently resisted a quarantine order, insisting on taking a bicycle ride with her boyfriend despite the limitations the state of Maine tried to impose.
One of the hallmarks of American culture is our freedom to choose. From bicycle rides to breakfast cereals to our personal physician, we are a nation of choosey choosers.
As a consequence, quarantine is an ethically challenging idea for us because quarantine of those exposed to contagious disease and isolation of the sick curtail individual freedom in the interest of the common good. Quarantine and isolation ask us to limit our choices to protect the health of others. We are to balance community good—in this case, health and well-being—with individual rights, particularly autonomy and the right to choose; the goal is to protect the community with minimal restriction on the action and movement of individuals.
How should we strike this balance? We can start with the primary duty of health care workers and of all of us: to do no harm, which includes not putting ourselves or others at risk of avoidable harm. Even if we cannot help, we must not make matters worse. Simply said, but not so simply done. We must define harm, determine risk, and identify who may be harmed and how severely.
Risk analysis relies on answering two questions—(1) how likely are we to be harmed? and, (2) how great will the harm be? Most often these track in opposite directions. The more severe the harm—in this case, horrific illness and perhaps death—the less risk tolerant we are. And, risk tolerance varies from person to person, just ask a financial planner or a skydiving instructor.
Spurred by Hickox return from her time volunteering with Doctors Without Borders, governors with apparently a near zero risk tolerance mandated the quarantine of health care workers returning from Sierra Leone, Liberia, and Guinea. However good their intention to protect their citizens from disease, the governors' knee-jerk response was likely driven by fear and uninformed by good science. Unless people exhibit symptoms of EVD, they are not contagious even if infected, and there is no justified reason to severely restrict their movements. To do so when harm is so unlikely is to treat these workers unfairly.
Fairness asks us to treat people the same unless they differ in ethically relevant ways. We might think about the mandatory quarantine of health care workers and others in terms of fairness by asking if there are ethically relevant differences among those who are:
- Potentially exposed to EVD
- Exposed to EVD but asymptomatic
- Symptomatic but unconfirmed
- Confirmed to have EVD
Given that asymptomatic individuals, even if harboring the virus, are not contagious, it seems reasonable to treat them differently than those who are symptomatic and undergoing confirmatory testing or those who have been diagnosed with EVD. Isolate and treat those with confirmed EVD; quarantine, watch, and test those with symptoms, notably fever; watch and test those exposed but asymptomatic.
So far, I've talked about health risk. But the spread of EVD presents other risks as well, including public hysteria. Although it is unfair to mandate quarantine across the board for people traveling from Sierra, Leone, Liberia, Guinea, and Mali, this does not mean that individuals can shirk their responsibility to minimize the real risk of community panic, which is arguably more contagious than the Ebola virus. During the 21-day watch and test period when we don't know what we don't know, responsible behavior of those exposed may include taking a bike ride but not heading to the bowling alley or embarking on a cruise around the world.
Of course, this is everyone's obligation when symptomatic with any infectious disease, including a cold, the seasonal flu, or a stomach virus. I am guessing that some of the most vocal critics of Kaci Hickox have themselves gotten on a plane while coughing and sneezing. So far, Liberian Thomas Eric Duncan and Dr. Martin Salia from Sierra Leone have died in the United States from EVD contracted in Africa. But, each year, the seasonal flu claims the lives of over 23,000 Americans here at home. As we confront the very difficult ethical problems associated with EVD, including temporary loss of some individual freedom, it would be a good idea to examine our own risk-taking behavior and to factor in concern for the spread of both routine and rare infectious disease and the public's health as well as our own.
Margaret R. McLean is the associate director and director of bioethics at the Markkula Center for Applied Ethics at Santa Clara University.
December 2014