Ethics and Infectious Disease

Sometimes it was necessary to limit the freedom of movement of infected people to control the spread of infection, writes Professor Colin Thompson

Conventional analyses

Infectious disease presents a tension between maintaining the traditional bounds of confidentiality as to a patient’s diagnosis and, in the interests of containing the spread of an infection, of disclosing that information to those who might be affected and to public officials with responsibility to limit the risk. In addition, sometimes it was necessary to limit the freedom of movement of infected people to control the spread of infection.

In support of these responses, John Stuart Mill’s so-called harm principle was a familiar and apparently adequate ethical basis on which to subjugate individual rights and freedoms to the health of the community.  Mill famously argued that "the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others." 

Justice was seen to be served by applying the same protective measures to a whole population, regardless of their relative social and economic situations.

Further, the need for more elaborate ethical debate was largely circumvented by the wide spread existence of public health legislation that authorised the abridgement of those individual rights and freedoms. 

Historical factors

These limited responses to the ethical challenges of infectious disease may have been the result of the focus of bioethics on the rapid advance in biological science and medical technology.  The unprecedented power that medicine and health care now claimed raised questions about what limits should be applied to its use and what the ethical basis of those should be.  Secondly, a biological, rather than a sociological, conception of the causation of illness was sufficient to inform this focus.  Lastly, bioethics emerged during the late 1960’s, when confident predictions were being made that medical science had all but overcome infectious disease. 

The recent revision

The advent of HIV-AIDS, the outbreaks of avian flu and SARS have revived the need for a more thorough ethical response while the resilience of tuberculosis and malaria have renewed focus on some fundamental sociological factors associated with infectious disease.

Mills’ harm principle justified imposing a limit on autonomy because doing so was necessary to control that risk.  However, as HIV/AIDS showed, some risks are controllable without extensive limits on autonomy.

Further, the principle justifies limiting the voluntary actions that are an exercise of autonomy. Can this principle be used to justify limiting someone’s involuntary actions when they can threaten public safety by simply breathing in a public place: are they exercising their autonomy?

If there are measures that can address the risk – such as mandatory facemasks in public places – would this ethically justified both by the harm principle and the justice of treating everyone in the same way?

Victims and vectors

One reason to treat everyone in the same way is that, for some infectious diseases, people are both actual or potential victims and vectors.  As potential victims, they can be infected by someone else, but there are steps that they can take – or be required to take - to reduce that risk.  The risk that is thereby reduced is both to prevent their becoming a victim and to becoming a vector and a threat to others.  As vector, the patient may be unaware of the contagion, so that, in causing further infection, they may not be “acting” at all. 

Consent to treatment

The conventional approach to information for consent requires the disclosure of treatment options, risks, likely outcomes – all for the patient.   Traditionally, that information is premised on a biological model of disease causation. In treatment for infectious disease, this information now needs to take into account others who will be at risk of infection because of the patient’s choices. With some such diseases, such as HIV/AIDS, those at risk can be identified with some certainty.  But with many other infectious diseases, this is not the case. Because these infectious diseases ignore blood, marital and community ties and are likely to pass among perfect strangers, they confront patients and treating health professionals with questions about the existence and extent of obligations owed to people with whom there is no relationship.

Justice

Traditional ideas about information and consent are embedded in a biomedical model of disease causation.  Infectious disease demands a sociological model that, in turn, brings the recognition of the relationship between relative socio-economic disadvantage and risk of infection. 

Infectious disease is frequently a matter of injustice of the increased risk that accompanies social deprivation.  Accordingly, this recognition supports a far more thorough approach to the justice of response to infectious disease.  The challenge is that, in the name of justice, a better response is likely to demand action to address issues that contribute to the higher risk of infection: sanitation, food security and adequate housing.

With new outbreaks and better knowledge of familiar ones, ethics  - and bioethics – has in recent years begun to offer a more sustained analysis of the justifications for different responses to infectious disease.