Recent measles outbreaks, including those in New York, on passenger ships and at two California universities, have prompted public health officials to take the unusual step of putting hundreds of people who may have been exposed to the deadly disease under quarantine.
This raises a number of ethical questions, including when it is appropriate to use such a restrictive public health intervention and what to do when patients fail to adhere voluntarily. The AMA Code of Medical Ethics has specific guidance for physicians to follow.
According to the Centers for Disease Control and Prevention (CDC), in roughly the first six months of 2019, some 1,100 individual cases of measles were confirmed—a three-fold increase from all of 2018 and the greatest number of cases reported since 1992. The disease was declared eradicated from the U.S. in 2000.
“Measles is one of the most contagious diseases in the world,” and “is so contagious that if one person has it, up to 90% of the people close to that person who are not immune will also become infected,” the CDC’s website says. The virus can live for up to two hours in the airspace where an infected person coughed or sneezed, the agency adds, and people who are infected “can spread measles to others from four days before through four days after the rash appears.”
In opinion 8.4, “Ethical Use of Quarantine & Isolation,” the Code explains:
Although physicians’ primary ethical obligation is to their individual patients, they also have a long-recognized public health responsibility. In the context of infectious disease, this may include the use of quarantine and isolation to reduce the transmission of disease and protect the health of the public.
In such situations, physicians have a further responsibility to protect their own health to ensure that they remain able to provide care. These responsibilities potentially conflict with patients’ rights of self-determination and with physicians’ duty to advocate for the best interests of individual patients and to provide care in emergencies.
With respect to the use of quarantine and isolation as public health interventions in situations of epidemic disease, individual physicians should:
- Participate in implementing scientifically and ethically sound quarantine and isolation measures in keeping with the duty to provide care in epidemics.
- Educate patients and the public about the nature of the public health threat, potential harm to others and benefits of quarantine and isolation.
- Encourage patients to adhere voluntarily to quarantine and isolation.
- Support mandatory quarantine and isolation when a patient fails to adhere voluntarily.
- Inform patients about and comply with mandatory public health reporting requirements.
- Take appropriate protective and preventive measures to minimize transmission of infectious disease from physician to patient, including accepting immunization for vaccine-preventable disease, in keeping with ethics guidance.
- Seek medical evaluation and treatment if they suspect themselves to be infected, including adhering to mandated public health measures.
The medical profession, in collaboration with public health colleagues and civil authorities, has an ethical responsibility to:
- Ensure that quarantine measures are ethically and scientifically sound by using the least restrictive means available to control disease in the community while protecting individual rights, without bias against any class or category of patients.
- Advocate for the highest possible level of confidentiality when personal health information is transmitted in the context of public health reporting.
- Advocate for access to public health services to ensure timely detection of risks and implementation of public health interventions, including quarantine and isolation.
- Advocate for protective and preventive measures for physicians and others caring for patients with communicable disease.
- Develop educational materials and programs about quarantine and isolation as public health interventions for patients and the public.
Chapter 8 of the Code, “Physicians and the Health of the Community,” features guidance on additional public health subjects, including routine universal immunization of physicians, expedited partner therapy and physicians’ responsibilities in disaster response and preparedness.
The Code of Medical Ethics is updated periodically to address the changing conditions of medicine. The new edition, adopted in June 2016, is the culmination of an eight-year project to comprehensively review, update and reorganize guidance to ensure that the Code remains timely and easy to use for physicians in teaching and in practice.