7.2.3 Enforcing Quarantine Orders
Ross E.G. Upshur, MD, MSc, MA, CCFP, FRCPC
- To appreciate the basis, in ethics and law, of restrictive measures for communicable disease control
- To appreciate the role of the physician in a communicable disease disaster
During a community outbreak of an unknown respiratory illness, Mrs. X, an otherwise healthy 46-year-old woman, presents to a primary care office with a 10-day history of cough, fever and malaise. Physical examination and radiographic and laboratory investigations confirm a right lower lobe pneumonia. Mrs. X. has recently returned from a trip in an area affected by a similar outbreak. The World Health Organization has issued an advisory, and national and local public health authorities have issued alerts indicating the need to bring cases to their attention.
Mrs. X lives at home with her husband and three children, and she reports being unwell on her flight home and while attending work (open office with 20 co-workers). She attended a walk-in clinic two days ago, where she was told she had a viral illness, was prescribed fluids, acetaminophen and rest, and was advised to follow up if she did not improve.
- What are the legal obligations of the attending physician in the context of infectious diseases of public health importance?
- What are the ethical obligations of physicians in the control of a communicable disease of public health significance?
- What restrictive measures could be contemplated for Mrs. X, and how would they be justified?
Public health emergencies requiring the use of restrictive measures are comparatively rare. However, as recent experience with SARS and concerns with resistant strains of tuberculosis and possible bioterrorism indicate, it is possible that physicians will be in a position to play a role in an infectious disease emergency. In such situations, the usual exclusive concern for the welfare of individual patients is altered, and the physician's role and obligations to the public good assume greater weight.
Infectious disease outbreaks of community significance are often accompanied by a great deal of uncertainty, particularly in situations involving novel pathogens. Restrictive measures may be used by public health, often with legal sanction, in circumstances of controversy and in the absence of unequivocal evidence of their effectiveness. This is often justified by appeal to the precautionary principle. The recent SARS Commission, headed by Justice Campbell, recommended the following:5
That the precautionary principle, which states that action to reduce risk need not await scientific certainty, be expressly adopted as a guiding principle throughout Ontario's health, public health and worker safety systems by way of policy statement, by explicit reference in all relevant operational standards and directions, and by way of inclusion, through preamble, statement of principle, or otherwise, in the Occupational Health and Safety Act, the Health Protection and Promotion Act, and all relevant health statutes and regulations.
In addition to the precautionary principle, the justification of the use of restrictive means requires evidence of potential harm to the community and the use of the least restrictive means to control the problem. The necessity for such measures must be publicly communicated along with a clear statement of what is required of individuals who are detained, and the consequences of failing to comply with public health orders. Patients have a legal right to appeal and to have legal counsel. There is an additional obligation on behalf of society to apply such measures fairly and in a non-discriminatory manner and to support individuals psychologically and ensure that their basic needs are provided for.
A physician is a valuable human resource to both patients and the public in such circumstances. Physicians should, as Lo and Katz argue,2 use their clinical skills and experience to control the problem, recognize and articulate to patients their changed role, and cooperate with public health officials for the common good.
- College of Physicians and Surgeons of Ontario. Mandatory reporting, Policy #3-05 [reviewed and updated September 2005]. Duties: 9. Communicable and reportable disease. College of Physicians and Surgeons of Ontario; 2006. Available from: http://www.cpso.on.ca/policies/mandatory.htm#Disease
- Lo B, Katz MH. Clinical decision making during public health emergencies: ethical considerations. Annals of Internal Medicine 2005; 143(7): 493�8.
- World Medical Association. World Medical Association statement on avian and pandemic influenza. Pilanesberg, South Africa: World Medical Association; 2006. Available from: https://www.wma.net/policies-post/wma-statement-on-avian-and-pandemic-influenza/
- Barbera J, Macintyre A, Gostin L, Inglesby T, O�Toole T, et al. Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences. JAMA: Journal of the American Medical Association 2001; 286(21): 2711�7.
- The SARS Commission. Spring of Fear. Final report. Toronto: Government of Ontario; 2006. pp-29-30 http://www.archives.gov.on.ca/en/e_records/sars/report/v1-pdf/Volume1.pdf
- Gostin L. Public health strategies for pandemic influenza. JAMA: Journal of the American Medical Association 2006; 295: 1700�4. Physicians on the front line: quarantine as a public health strategy.Available from: http://jamanetwork.com/journals/jama/article-abstract/202648
- Reis NM. Public health law and ethics: lessons from SARS and quarantine. Health Law Review 2004; 13(1): 3–6. Upshur REG. The ethics of quarantine. Virtual Mentor [online journal] 2003; 5(11). Available from: http://www.hli.ualberta.ca/HealthLawJournals/~/media/hli/Publications/HLR/13-1-Ries.pdf