The ethics of quarantine: Treading carefully

It has been many years since the idea of quarantine has been such a hot topic. Still, with society's increasing concern about the dangers of emerging and re-emerging infections -- whether it be a smallpox attack by terrorists, SARS or, more recently, the threat of avian influenza -- this public health intervention is taking on greater prominence in the public discourse.

White House statements regarding pandemic preparedness now frequently touch on quarantine procedures. And the Centers for Disease Control and Prevention is in the midst of overhauling its quarantine regulations for the first time in at least 25 years. The proposed changes include provisions that would establish a clear appeals process for people subjected to quarantine and explicit authority to offer vaccinations and medical treatment to them.

Clearly, physicians, too, have an important stake in the overall dialogue. That's why a report issued by the American Medical Association's Council on Ethical and Judicial Affairs and approved by the AMA House of Delegates at its Interim Meeting in November is so timely.

Quarantine, according to the CDC, is the separation and restriction of movement or activities of people who are not ill but who are believed to have been exposed to infection. In an effort to prevent transmission of disease, people are usually limited to their homes but also might be quarantined in community-based facilities or, on a wider basis, by closing borders or erecting geographic barriers.

With this in mind, it is easy to see why the approach can become entangled in serious issues of civil liberty, patients' rights and the doctor-patient relationship.

The CEJA report advances important ethical guidelines to help physicians adequately balance these concerns. After all, this potential conflict between personal freedom and public health is at the crux of the challenges that quarantine presents. Moreover, there is very limited modern experience with this intervention, making attention to how it can function in this day and age an imperative.

CEJA offers doctors a framework for what to do when and if such constraints are implemented. Bottom line: Physicians must do everything possible to protect the rights and privacy of patients without compromising public well-being. In other words, physicians need to enforce quarantine, but they should strive to see that it is well-implemented and that those affected are well cared for.

In this situation, physicians should seek to ensure that the least restrictive quarantine measures are used to minimize the negative impact on the community while still providing, to the extent possible, for individual needs. The quarantine should result from valid science and not simply target socioeconomic, racial or ethnic groups. Physicians also should advocate for the highest possible level of confidentiality of personal health information in the context of public health reporting.

In addition, physicians are responsible for encouraging patients to follow quarantine measures by educating them about the potential harm they pose to themselves and to others. If the patient doesn't comply, physicians should support mandatory action.

Meanwhile, physicians also should be vigilant in meeting mandatory illness reporting requirements, minimizing the risk of transmitting infectious diseases to patients, staying well so they remain able to provide care to others and seeking treatment if they think they might be ill. Frontline doctors have an increased ethical obligation to avail themselves of protective and preventive steps and to adhere to mandated public health interventions.

In the end, all of these concepts share a common theme -- that physicians should support quarantine and isolation measures that adequately protect the population's health while minimizing infringements upon individual rights of liberty and self-determination. With that said, physicians should take advantage of the guidance CEJA has provided to understand the controversial issues involved in quarantine -- before there is a crisis.