As Toronto seeks to stem the tide of SARS, we have witnessed the extraordinary introduction of forced quarantine. Last week, when two members of a Catholic charismatic group in the Toronto area refused to stay home, court orders were issued to force them to do so. Other limits on people's liberty have also been imposed. Earlier this month, after a Hewlett-Packard employee returned to work while under quarantine (leading to 200 others also being quarantined), the company deactivated all of its employees' security passes. As still other people suspected of having SARS have failed to observe their 10-day isolation, there have been calls for their braceleting to prevent the spread of SARS.
For some, such efforts provide comfort, because they appear to be directed at protecting the health of individuals who might otherwise be infected by those who refuse to voluntarily quarantine themselves. For others, they raise concerns that we are panicking and unduly restricting the civil liberties of those we hold in quarantine or force to wear a monitoring bracelet. I would suggest that it is only through a thorough weighing of all of the relevant variables that we will be able to come to conclusions about what are ethically defensible responses to SARS.
Because liberty is a keystone value in Canadian society, liberty-restricting methods to contain disease should only be contemplated in extraordinary circumstances. But they can be contemplated. Put colloquially, my right to swing my fist ends at the tip of your nose. That is, my liberty can be limited by others (including the state) if, through the exercise of my liberty, I cause or threaten significant harm to others.
To be ethically defensible, the limit on my liberty must be less significant than the harm to be prevented, the limit on my liberty must be reasonably connected to the prevention of the harm (in the case of SARS, it should not be tainted by racist assumptions that anyone of Asian appearance is a carrier). And there must be no other reasonable options to prevent the harm.
(Anthony Jenkins/The Globe and Mail)
Clearly, if I am or might be infected with SARS and I choose to exercise my liberty by going out of quarantine, I may threaten the well-being of others. So the harm of limiting my liberty through holding me in quarantine or braceleting me must be weighed against the harm of my exercising my liberty. Such weighing must take actual risk into account and be grounded in fact (again, not in racist assumptions). And we must have considered such alternatives as public compensation for wages lost during a voluntary quarantine.
We must also consider privacy: Individuals have an interest in preventing personal information — such as whether or not they have SARS — being spread about without their consent. Again, however, privacy is not an absolute right. Where serious harm to others can be prevented or reduced by disclosure of personal information or monitoring, and where there are no effective alternatives, such disclosure can be ethically defensible.
Many of the individuals affected by liberty-restricting methods of containment may not wish to expose others to danger, but may feel that they must break quarantine to earn money to feed and house their families. The question then becomes one of society's obligations: When we ask or force individuals to limit their liberty in order to protect "public health," what then does the public owe these individuals?
Along with liberty, privacy, and the basic necessities of life, we must also consider the harms associated with individuals not observing voluntary quarantines. First and foremost there is the harm to health — of those exposed to SARS directly, and those they expose in turn. All the measures that seem so punitive — forced quarantine, braceleting, disclosure of personal information — may well reduce the risk of transmission and, therefore, protect health.
Another potential harm is to the financial well-being of those whose jobs and livelihoods are adversely affected — hotel workers, for example — as Toronto gains the reputation of being North America's "SARS capital." (The city, which earns about $7.2-billion annually from tourism, has lost tens of millions of dollars from the cancellation of recent conferences due to SARS fears.)
The economic impact of such cancellations will be most profoundly felt by the working poor. Forced quarantine, braceleting, and disclosure of personal information may help restore economic security to these people by helping bring the spread of SARS under control. It may change the increasingly widespread perception of Toronto as an unsafe place to visit.
To balance all these issues and interests in an ethical way, we need more information about risks of transmission and costs of alternative methods of reducing risk, about the potential harms involved as well as the potential benefits. Only then can we ascribe weights to the various values involved, and determine which methods that may restrict the liberties of our fellow citizens are ethically defensible.
To act without such careful consideration is indefensible.
Jocelyn Downie, director of the Health Law Institute at Dalhousie University, is Canada Research Chair in Health Law and Policy and associate professor at Dalhousie's faculties of law and medicine.
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