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7.2.3 Enforcing Quarantine Orders

Ross E.G. Upshur, MD, MSc, MA, CCFP, FRCPC

Learning Objectives

  1. To appreciate the basis, in ethics and law, of restrictive measures for communicable disease control
  2. To appreciate the role of the physician in a communicable disease disaster

Case

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.

Questions

  1. What are the legal obligations of the attending physician in the context of infectious diseases of public health importance?
  2. What are the ethical obligations of physicians in the control of a communicable disease of public health significance?
  3. What restrictive measures could be contemplated for Mrs. X, and how would they be justified?

Discussion

Q1. What are the legal obligations of the attending physician in the context of infectious diseases of public health importance?

Physicians play a critical role in the identification and management of communicable diseases. In all provinces, physicians are obligated by law to report a list of communicable diseases (which varies from province to province) and are encouraged to report to public health authorities any communicable disease of public health concern. For example, in Ontario, the Health Protection and Promotion Act specifies that "physicians and hospital administrators make a report when, in the course of providing professional services, they have formed the opinion that an individual

  • has or may have a reportable disease and is not a patient or out-patient of a hospital;
  • is or may be infected with an agent of a communicable disease;
  • is under the care and treatment of the physician for a communicable disease, but refuses treatment, or neglects to continue treatment in a manner and to a degree that is satisfactory to the physician." (quoted from policy on mandatory reporting of the College of Physicians and Surgeons of Ontario)1

These reports must be made to the Medical Officer of Health or the responsible public health authority in the jurisdiction. Physicians should be aware of the mandatory reporting requirements in their jurisdiction and be aware of the medical officer or public health authority to whom they are obligated to report. Public health has the legitimate authority and the trained personnel to undertake investigations of communicable disease outbreaks, including the contact tracing of those persons at risk for disease because of exposure to the case. In times of communicable disease emergencies, such as the severe acute respiratory syndrome (SARS) outbreak or an influenza pandemic, physicians are trusted and valuable responders to aid in the control of communicable diseases.

Q2. What are the ethical obligations of physicians in the control of a communicable disease of public health significance?

There are numerous roles that physicians can play. In addition to meeting their legal obligations to report communicable diseases to the local public health authorities, physicians can perform several key clinical interventions. Lo and Katz have outlined physicians' ethical obligations in a public health emergency and have made recommendations for how physicians can best support patients who are required to be isolated or quarantined.2 Among these recommendations, physicians should consider the following:

  1. Address the Patient's Needs and Concerns. The fiduciary duties of physicians are not trumped by a public health emergency requiring the use of restrictive means. The physician-patient relationship is an excellent vehicle for facilitating understanding of what is expected of patients for the control of the disease and why, as well as for providing emotional support and reassurance. It is likely that, when a treating physician explains the necessity of the intervention, it will more likely be accepted.
  2. Protect the Public Health. In times of public health need, individual rights and certain aspects of the physician-patient relationship may be subordinated to public good, particularly concerning privacy and confidentiality of health information.
  3. Set Limits Clearly. The physician must be clear in ensuring that the patient is aware of the limits to autonomy that may be in place and that these are legally sanctioned.
  4. Establish Common Ground With Patients.
  5. Act in the Best Interests of the Patient to the Extent Ethically Appropriate.
  6. Advocate on Behalf of Patients. A physician can assist in ensuring that the patient is not unfairly detained and that their rights are protected. This may entail coordination with legal representatives.
  7. Mitigate the Adverse Consequences of Public Health Restrictions. A physician can assist in ensuring that the burdens imposed by restrictive measures do not adversely affect employment or cause undue psychological stress.

The World Medical Association has made the following recommendations (among others) to physicians, urging them to recognize the importance of medical involvement to public health emergencies:3

  • Prepare educational materials for patients and staff, including recommendations for proper infection control. An educated patient/public that recognizes the necessity for stringent measures such as quarantine and isolation will make a physician's job easier should s/he have to utilize such procedures when a pandemic occurs.
  • Develop a clinic plan to decrease potential for contact, including isolation areas for infected patients, use of close-fitting surgical masks, designating separate blocks of time for non-influenza-related patient care, and postponing non-essential medical visits.
Q3. What restrictive measures could be contemplated for Mrs. X, and how would they be justified?

Two types of restrictive measures are frequently used in communicable disease control, and the distinction between them is important to observe. Quarantine refers to the compulsory physical separation, including restriction of movement, of populations or groups of healthy people who have been potentially exposed to a contagious disease, or to efforts to segregate these persons within specified geographic areas. These individuals do not manifest any signs and symptoms of disease, but they are at risk due to exposure to a case. Isolation, on the other hand, refers to the separation and confinement of individuals with signs, symptoms or laboratory evidence of infection to prevent them from transmitting disease to others.4

Restrictive measures are non-medical measures used in the control of communicable diseases. Many infectious diseases are spread from person to person, and in these circumstances the use of restrictive measures may be appropriate. This is because the separation of the infected or exposed people from the uninfected people stops the chain of disease transmission. In the case of Mrs. X, it is important to isolate her and to institute appropriate infection control and treatment measures. Contacting public health will ensure that proper contact tracing is carried out. It may be required that exposed contacts be quarantined for a specified duration. Physicians can play an essential role in explaining the necessity and importance of such measures.

Conclusion

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.

References

  1. 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
  2. Lo B, Katz MH. Clinical decision making during public health emergencies: ethical considerations. Annals of Internal Medicine 2005; 143(7): 493�8.
  3. 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/
  4. 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.
  5. 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

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