A Philosopher's Blog

Ebola, Safety & Ethics

Posted in Ethics, Medicine/Health, Philosophy by Michael LaBossiere on October 31, 2014
English: Color-enhanced electron micrograph of...

English: Color-enhanced electron micrograph of Ebola virus particles. Polski: Mikrofotografia elektronowa cząsteczek wirusa Ebola w fałszywych kolorach. (Photo credit: Wikipedia)

Kaci Hickox, a nurse from my home state of Maine, returned to the United States after serving as a health care worker in the Ebola outbreak. Rather than being greeted as a hero, she was confined to an unheated tent with a box for a toilet and no shower. She did not have any symptoms and tested negative for Ebola. After threatening a lawsuit, she was released and allowed to return to Maine. After arriving home, she refused to be quarantined again. She did, however, state that she would be following the CDC protocols. Her situation puts a face on a general moral concern, namely the ethics of balancing rights with safety.

While past outbreaks of Ebola in Africa were met largely with indifference from the West (aside from those who went to render aid, of course), the current outbreak has infected the United States with a severe case of fear. Some folks in the media have fanned the flames of this fear knowing that it will attract viewers. Politicians have also contributed to the fear. Some have worked hard to make Ebola into a political game piece that will allow them to bash their opponents and score points by appeasing fears they have helped create. Because of this fear, most Americans have claimed they support a travel ban in regards to Ebola infected countries and some states have started imposing mandatory quarantines. While it is to be expected that politicians will often pander to the fears of the public, the ethics of the matter should be considered rationally.

While Ebola is scary, the basic “formula” for sorting out the matter is rather simple. It is an approach that I use for all situations in which rights (or liberties) are in conflict with safety. The basic idea is this. The first step is sorting out the level of risk. This includes determining the probability that the harm will occur as well as the severity of the harm (both in quantity and quality). In the case of Ebola, the probability that someone will get it in the United States is extremely low. As the actual experts have pointed out, infection requires direct contact with bodily fluids while a person is infectious. Even then, the infection rate seems relatively low, at least in the United States. In terms of the harm, Ebola can be fatal. However, timely treatment in a well-equipped facility has been shown to be very effective. In terms of the things that are likely to harm or kill an American in the United States, Ebola is near the bottom of the list. As such, a rational assessment of the threat is that it is a small one in the United States.

The second step is determining key facts about the proposals to create safety. One obvious concern is the effectiveness of the proposed method. As an example, the 21-day mandatory quarantine would be effective at containing Ebola. If someone shows no symptoms during that time, then she is almost certainly Ebola free and can be released. If a person shows symptoms, then she can be treated immediately. An alternative, namely tracking and monitoring people rather than locking them up would also be fairly effective—it has worked so far. However, there are the worries that this method could fail—bureaucratic failures might happen or people might refuse to cooperate. A second concern is the cost of the method in terms of both practical costs and other consequences. In the case of the 21-day quarantine, there are the obvious economic and psychological costs to the person being quarantined. After all, most people will not be able to work from quarantine and the person will be isolated from others. There is also the cost of the quarantine itself. In terms of other consequences, it has been argued that imposing this quarantine will discourage volunteers from going to help out and this will be worse for the United States. This is because it is best for the rest of the world if Ebola is stopped in Africa and this will require volunteers from around the world. In the case of the tracking and monitoring approach, there would be a cost—but far less than a mandatory quarantine.

From a practical standpoint, assessing a proposed method of safety is a utilitarian calculation: does the risk warrant the cost of the method? To use some non-Ebola examples, every aircraft could be made as safe as Air-Force One, every car could be made as safe as a NASCAR vehicle, and all guns could be taken away to prevent gun accidents and homicides. However, we have decided that the cost of such safety would be too high and hence we are willing to allow some number of people to die. In the case of Ebola, the calculation is a question of considering the risk presented against the effectiveness and cost of the proposed method. Since I am not a medical expert, I am reluctant to make a definite claim. However, the medical experts do seem to hold that the quarantine approach is not warranted in the case of people who lack symptoms and test negative.

The third concern is the moral concern. Sorting out the moral aspect involves weighing the practical concerns (risk, effectiveness and cost) against the right (or liberty) in question. Some also include the legal aspects of the matter here as well, although law and morality are distinct (except, obviously, for those who are legalists and regard the law as determining morality). Since I am not a lawyer, I will leave the legal aspects to experts in that area and focus on the ethics of the matter.

When working through the moral aspect of the matter, the challenge is determining whether or not the practical concerns morally justify restricting or even eliminating rights (or liberties) in the name of safety. This should, obviously enough, be based on consistent principles in regards to balancing safety and rights. Unfortunately, people tend to be wildly inconsistent in this matter. In the case of Ebola, some people have expressed the “better safe than sorry” view and have elected to impose or support mandatory quarantines at the expense of the rights and liberties of those being quarantined. In the case of gun rights, these are often taken as trumping concerns about safety. The same holds true of the “right” or liberty to operate automobiles: tens of thousands of people die each year on the roads, yet any proposal to deny people this right would be rejected. In general, people assess these matters based on feelings, prejudices, biases, ideology and other non-rational factors—this explains the lack of consistency. So, people are wiling to impose on basic rights for little or no gain to safety, while also being content to refuse even modest infringements in matters that result in great harm. However, there are also legitimate grounds for differences: people can, after due consideration, assess the weight of rights against safety very differently.

Turning back to Ebola, the main moral question is whether or not the safety gained by imposing the quarantine (or travel ban) would justify denying people their rights. In the case of someone who is infectious, the answer would seem to be “yes.” After all, the harm done to the person (being quarantined) is greatly exceeded by the harm that would be inflicted on others by his putting them at risk of infection. In the case of people who are showing no symptoms, who test negative and who are relatively low risk (no known specific exposure to infection), then a mandatory quarantine would not be justified. Naturally, some would argue that “it is better to be safe than sorry” and hence the mandatory quarantine should be imposed. However, if it was justified in the case of Ebola, it would also be justified in other cases in which imposing on rights has even a slight chance of preventing harm. This would seem to justify taking away private vehicles and guns: these kill more people than Ebola. It might also justify imposing mandatory diets and exercise on people to protect them from harm. After all, poor health habits are major causes of health issues and premature deaths. To be consistent, if imposing a mandatory quarantine is warranted on the grounds that rights can be set aside even when the risk is incredibly slight, then this same principle must be applied across the board. This seems rather unreasonable and hence the mandatory quarantine of people who are not infectious is also unreasonable and not morally acceptable.

 

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  1. ajmacdonaldjr said, on October 31, 2014 at 5:09 pm

    The needs of the many outweigh the needs of the few… in some cases… such as infectious disease pandemics. Her bitching about rights and freedoms during what is being presented by the media as a virtual pandemic, is inexcusable. She should be following orders, especially so since she’s a nurse, and especially so in order to alleviate public fears the disease could spread. I suspect she is being told to do what she is doing, because she’s not acting like a healthcare professional. She can’t be that stupid.

    • Michael LaBossiere said, on November 3, 2014 at 1:12 pm

      She is following the guidelines that are based on what is known about Ebola from the past outbreaks. It could be argued that her liberty should be infringed for the good of the many, but that line of reasoning would also warrant taking away cars, guns and swimming pools. After all, a person driving a car has a chance of killing people-much higher, in fact, of the nurse infecting anyone.

      • ajmacdonaldjr said, on November 4, 2014 at 3:32 am

        Hey, I’m all for taking away cars from people… so you’re preaching to the choir there😉 She know everyone’s rights go out the window during an epidemic, or a pandemic. Although this isn’t either of those, the media/government has stoked the fear to such a level that it may as well be. Were she a good, honest, healthcare worker, she would be the first one to submit to the quarantine… if for no other reason than to quell the fears of the public. But no… she’s on the front page of USA Today outside riding her bike, and every comment about her is negative, because people are afraid. This is nothing but a first class, A #1 PSYOPS.

        • Michael LaBossiere said, on November 4, 2014 at 5:16 pm

          We don’t have a pandemic here. Nor will we. She has tested negative for Ebola and has no symptoms, so there are no legitimate grounds for locking her up at home.

          I would probably voluntarily quarantine myself (assuming I would not be fired) for 21 days, but I also drive extremely carefully (no texting, no phone calls, both eyes on the road at all times), handle guns with great caution and so on.

  2. TJB said, on November 1, 2014 at 10:23 am

    Mike, any comments based on this article? About 10% of Ebola victims are contagious without having a fever.

    Dr. Nick Zwinkels, a Dutch physician, last month closed a hospital he had been running with a colleague in central Sierra Leone after five nursing aides contracted Ebola — possibly from unprotected contact with three patients who were not promptly diagnosed with the virus.

    Four of the nursing aides died, as did all three of the patients belatedly found to have Ebola.

    Interviewed by email, Zwinkels said that hospital staff members took the temperature of one of the doomed patients four times a day for three consecutive days, and the patient never showed a fever. The readings were taken by a digital thermometer placed in the armpit, he said.

    Based on what his staff observed, Zwinkels wrote, “it seems that only measuring the temperature as a form of triage is insufficient.”

    He added: “It seems that Ebola can present without fever especially in the first phase.”

    http://www.latimes.com/nation/la-na-1012-ebola-fever-20141012-story.html#page=1

    • Michael LaBossiere said, on November 3, 2014 at 1:23 pm

      Assuming the data is accurate, 85-93% of people with Ebola have a fever, which does make the temperature test a reliable (though imperfect) measure. If it turns out that people can transmit Ebola without having a fever, while showing no symptoms and while testing negative, then there would be a need to re-assess the guidelines regarding the nurse in specific and health care workers in particular. But, the “formula” I use would still apply, namely that of assessing the risk and determining if it warrants imposing on liberty. To use an analogy, when I drove to work this morning, I showed no signs that I might have a stroke and lose control of my truck, possibly killing people. I am healthy and have no warning signs…but it could happen. Yet, it would seem unwarranted to forbid me to drive because there is a nonzero chance that this could happen.

      The temperature test at the airports will only catch a person who isn infected and has a fever, but a person could have Ebola but be in the incubation period. But, as we do with all risks when we are not ruled by fear, we need to consider the risks and the cost of security. After all, we accept the preventable deaths of tens of thousands of people which makes the panic of Ebola seem odd. We should be consistent in our threat assessments and responses, rather than reacting in proportion to the media and pundit generated fear.

  3. ajmacdonaldjr said, on November 2, 2014 at 7:38 pm

    Proof! It IS a Set-Up! Kaci Hickox is a CDC “Epidemic Intelligence Service Officer” http://wp.me/p1MaoJ-323 via @wordpressdotcom


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