The ethics of defeating COVID-19

Isolation, quarantine, cordon sanitaire, shelter in place, physical distancing.  These were unfamiliar words just a few weeks ago. Now, your life and the lives of many others may depend on them.

Isolation is the separation of someone who has been identified as ill so that she cannot spread the disease to others. Isolation requires careful management to keep the infection inside the area in which the patient is kept. Today’s hospitals accomplish isolation by prohibiting visitors, using protective equipment, and creating negative pressure rooms to prevent airborne spread.

Isolation can be very lonely, as many patients and families learned to their sorrow when patients became ill in the Life Care Center in Kirkland, Washington. People in isolation may die alone, without contact with their loved ones, frightened, and unable to be comforted by the familiar. Caregivers dressed in protective garb will appear alien. Yet strict adherence to protocols is needed to prevent spread.

Quarantine separates people believed to have been exposed to a contagious disease. The term stems from the practice in Venice during the plague years: ships were made to stay offshore for forty days before landing to ensure that they did not carry pestilence. While quarantine may be effective in preventing the spread of illness from ship to shore, it augments risks to those who remain on board, exposed to infected shipmates.

People who have been exposed to COVID-19 and self-quarantine at home don’t put the public at risk but may increase risks to their roommates or family members who will also be in quarantine. Quarantine, strictly enforced, prevents disease spread of from those in quarantine to those outside.  However, it will have no impact on disease that has already become established in a community, unless ill community members can be identified and isolated and all of their contacts put in quarantine. And group quarantine presents significant issues of justice: the still-well are put at greater risk to save the rest of us.

The cordon sanitaire draws a ring around a geographical area, as China did with Wuhan: People weren’t allowed to go out or come in. This strategy doesn’t prevent illness spread within the affected area. It is only effective if it’s strictly enforced:  if one ill person escapes, the strategy will fail. The strategy also assumes the illness is not already outside the cordon’s boundaries.

A cordon sanitaire prevents people from leaving who might otherwise have been able to protect themselves by getting away. To be sure, these people are likely to be among the more privileged, with the ability to travel and a place to go. Cordon sanitaire may prevent essential supplies from entering the roped-off area, a particular burden to the less well off.  It will prevent loved ones from coming to visit family members. Stopping transit bringing disease has great costs that may not be fairly distributed.

Physical distancing requires staying away from people—supposedly six feet away for COVID-19. Distancing is less effective than other strategies in preventing pandemic spread. People may be put at risk if other insist on getting close or do so carelessly. And distancing does little to protect from fomites, virus deposits that remain on surfaces such as stair railings, doorknobs, cereal boxes at the grocery store, or gasoline pumps.

Distancing also is hard. Social and emotional isolation can be psychologically difficult for some people. Closing normal places of social congregation, from restaurants and bars to mosques and churches, may seriously patterns of life and wreak economic havoc.

Contact tracing, much used to control the spread of sexually transmitted diseases, can violate personal privacy. Contact tracing is difficult enough for intimate personal relationships; it is nearly impossible to conduct exhaustively in a vast pandemic. If we can identify discrete cases and then trace contacts, we could use far more fine-tuned methods for effective control.  South Korea may have managed this, but it is too little too late elsewhere.

Sheltering in place is a euphemism for staying at home. Its effects are limited if illness is already widespread. Essential workers will remain at risk doing their jobs; other workers will lose their jobs. Parents may be stressed with additional childcare and child-education responsibilities if they are also trying to work from home, while kids themselves are cut off from physical contact with their friends.

Sheltering in place has harsh consequences for education, childcare, and employment in industries that cannot go online. Sheltering in place is often assumed to be the only strategy we have so that hospitals are not overwhelmed by a surge of very sick patients, but the practical and ethical costs of sheltering in place can be immense. We can pay people to stay home with effective sick leave, but we can’t re-create jobs that are ended, businesses that go bankrupt, or lives that are lost.

All of these strategies have been used in ancient, medieval, and early modern historical times, when there were no tests, no vaccines, and no effective treatment available. We can avoid unnecessary reliance on these methods, however, if only we are willing and able to test in time.

Extensive testing is already being put into effect in limited but promising ways.  The northern Italian village of Vò tested all 3,000 inhabitants, using quarantine for those who tested positive. This made it possible to stop the spread of the coronavirus in under 14 days.  The strategy required a complete cordon sanitaire of this mountain town and was successful because when it was implemented only 3% of the population had disease. Seattle, Washington, is conducting a SCAN study of a population sample to trace the spread of COVID-19. Testing is constantly improving, too, with results now available in a matter of minutes or hours.

New testing methods may allow us to avoid many of the inequities and injustices of the traditional methods of pandemic control, if we can get them deployed sufficiently quickly and effectively. We wouldn’t need to isolate people unless it was clear that they actually have the virus.   A contemporary cordon sanitaire could be permeable, allowing people who test negative to come and go through the barrier. Quarantine that confines people who are not ill with those who are, thus incubating further spread, would be obsolete; only true positives, whether on a cruise ship or in a nursing home, would need to undergo quarantine. And sheltering in place?  It wouldn’t be necessary either, unless, as in the current COVID-19 pandemic, the disease had already moved far beyond our capacity to contain it.

At the moment, many parts of the world without adequate testing or treatment are forced to rely primarily on strategies from earlier eras or use those strategies in conjunction with whatever testing capacities are available. Once an outbreak has become widespread, effective case identification and contact tracing become increasingly difficult. Lack of adequate public health resources complicates these difficulties. As we develop more adequate testing, we may be able to move away from primary reliance on forms of pandemic control that cause significant harm or use those earlier forms more judiciously in conjunction with testing.  If we’re going to continue to use them—quarantine, isolation, cordon sanitaire, contact tracing, and massive lockdown measures including confinement to home—we need to be alert to the ethical challenges they raise.

Ethics look different with infectious disease as the central paradigm: All of us are potential victims and vectors to one another. COVID-19 has reminded us of the power of this paradigm: we must assess how we deal with this pandemic, and for the next one, in light of our shared vulnerabilities.

Featured Image Credit: by athree23 via Pixabay