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Old and New Ways of Coping with COVID-19: Ethics Matters (Part I)

By Leslie Francis and Margaret Pabst Battin

This post is part I of a two-part series on pandemic control strategies in response to COVID-19.

Your life and the lives of many others may depend now on isolation, quarantine, cordon sanitaire, shelter in place, or physical distancing.

These terms have entered the public consciousness rapidly. Though general awareness has increased, the important practical and ethical differences between these practices require further explanation.

Isolation is the separation of someone who has been identified as ill so that she cannot spread the disease to others. Today’s hospitals accomplish isolation by prohibiting visitors and using negative pressure rooms so airborne contaminants do not spread through ventilation systems. Caregivers wear protective equipment to keep from becoming contaminated themselves.

Isolation can be very lonely for patients, as many patients and their relatives learned to their sorrow when patients became ill in the Life Care Center in Kirkland, Washington. People in isolation may die frightened and alone, without contact with their loved ones.

Strict adherence to isolation protocols is necessary, however, to prevent disease spread.

Quarantine is the separation of 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 puts at greater risk those who remain on board for a lengthy period of time, exposed to infected shipmates. That’s what’s happened aboard cruise ships like the Diamond Princess.

Quarantine, strictly enforced, is effective in preventing the spread of disease from those in quarantine to those outside. However, it will have no impact on disease that is already 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 those outside the group.

The cordon sanitaire, French for sanitary cordon, draws a ring around an affected geographical area to stop the broader spread of disease.

This is what China did with Wuhan: people weren’t allowed to go out, and people weren’t allowed to come in.

This strategy doesn’t prevent the spread of illness within the affected area. It is only effective if it’s strictly enforced: if one person escapes with illness, the strategy will fail. The strategy will also fail if the illness is 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. These may be the more privileged, however, as they have the ability to travel and a place to go—like wealthy New Yorkers fleeing to Florida (and now met by quarantine restrictions).

Cordon sanitaire may also prevent essential supplies from entering the roped-off area or loved ones from coming to visit family members.

Physical distancing—commonly called social distancing—requires staying away from people. Six feet is the suggested safe distance for COVID-19, enough, it is thought, to protect one from droplets from another person’s cough.

Compared to the previous few techniques, physical distancing places relatively fewer demands on those who practice it, but it is also the least effective in preventing pandemic spread — people may be put at risk by those who insist on getting close or do so carelessly. And distancing does little to protect from fomites, viral deposits that remain on surfaces that an infected person has touched.

Physical distancing also can have problematic consequences. Social and emotional isolation can be psychologically difficult and closing places of social congregation may seriously interrupt people’s normal patterns of life and wreak economic havoc.

Sheltering in place is a euphemism for staying at home. It keeps people from congregating and spreading disease. It is of limited efficacy if illness is already widespread; people who need to go out to get treatment or essential goods may spread illness as they go. Essential workers will remain at risk doing their jobs.

As we are seeing across the globe, sheltering in place has particularly harsh consequences for education, childcare, and employment in service industries that cannot be transferred online.

Sheltering in place is often assumed to be the only strategy we have for “flattening the curve” 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, especially on a global scale. Some costs to people are easier to make up than others; 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, tragically, lives that are lost.

Contact tracing, often used in attempts to control the spread of HIV/AIDS and other sexually transmitted diseases, can involve substantial violations of personal privacy. Contact tracing is difficult enough to pursue when the form of contact is an intimate personal relationship; it is nearly impossible to conduct exhaustively in a vast pandemic. South Korea seems to have managed this; but it is far too late for this in much of the US, Europe, India, and the rest of the world.

These strategies—isolation, quarantine, cordon sanitaire, physical distancing, sheltering in place, and contact tracing—have all been used in ancient, medieval, and early modern historical times, when there were no tests, no vaccines, and no effective treatment available. Part II of this series will explain how prompt and widespread testing efforts might help avoid unnecessary use of these ethically troubling strategies.

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