Cambridge Books Online

http://ebooks.cambridge.org/

Public Health Ethics

Key Concepts and Issues in Policy and Practice

Edited by Angus Dawson

Book DOI: http://dx.doi.org/10.1017/CBO9780511862670

Online ISBN: 9780511862670

Hardback ISBN: 9780521868976

Paperback ISBN: 9780521689366

Chapter

6 - Infectious disease control pp. 100-117

Chapter DOI: http://dx.doi.org/10.1017/CBO9780511862670.007

Cambridge University Press

 Section 2 Issues

Infectious disease control

Chapter

6 Marcel Verweij

Introduction
Infectious diseases have been one of the major factors affecting public health in the past,
and will probably remain so in the future. There was a time that physicians thought that, at
some point in the future, the perils of infectious diseases would have been overcome. In the
middle part of the twentieth century, progress was made in controlling diseases such as
smallpox, measles, typhoid and plague. Better diet and hygiene, improved living conditions
and vaccinations all helped to strengthen people’s immunity against several diseases.
Patients who got ill could be treated effectively with antibiotics. Morbidity and mortality
due to several infectious diseases decreased significantly. However, this success story has
had its limits: advances in medicine and public health have mainly benefited the developed
world, whereas infectious diseases in the developing world have remained high; new viruses
such as HIV and SARS have created new problems in both high- and low-income contexts;
extreme multi-drug resistant forms of tuberculosis are spreading, especially among people
living with HIV and AIDS; and, lastly, at the beginning of the twenty-first century, many
countries and the World Health Organization started preparations for an influenza pan-
demic that could in the future be reminiscent of the 1918 Spanish Flu.
Medical treatment of patients with clinical symptoms is only one and probably not the
most important way to control infectious diseases. The spread of disease can be reduced
most effectively by controlling infection, for example by improving hygiene, by social
distancing or quarantine, by raising immunity, etc. Many of these interventions require
collaborative ‘public’ action (Verweij and Dawson, 2007). If human contact is a source for
infection, then preventive measures must aim at reducing or even prohibiting such contacts.
However, such measures can have negative if not detrimental consequences for some.
Measures of control may involve excluding some individuals or groups from public life.
This chapter discusses various examples of measures to protect public health against
infectious diseases. The focus will be on contagious disease that spreads from human to
human, because controlling measures against such diseases can have a deep impact on
personal life and well-being. Moreover, such controlling measures are often compulsory
and set constraints on the liberties of individuals or groups. The largest part of the ethical
discussion in this chapter will focus on the justifications for such compulsory interventions.
Protection against animal diseases (including avian influenza), food-borne diseases (for
example, salmonella) and non-contagious diseases (for example, tetanus) also raise moral
questions but these will not be discussed.

Public Health Ethics, ed. Angus Dawson. Published by Cambridge University Press. # Cambridge
University Press 2011.
100

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 101

Historic examples
The phrase ‘social distancing’ as a measure to prevent infection is a relatively new term,
but it has been practised throughout history; as long as it has been known that certain
diseases are contagious. People have always tried to protect themselves and others by
setting patients with particular diseases ‘apart’, and excluding them from the rest of
society. People with suspected symptoms of a disease could be treated as outcasts or
outlaws, or sent to a closed institution, such as a leprosarium. History provides numerous
examples that illustrate how such measures could be harmful and unjust to the victims of
disease. Saul Brody describes how in the Middle Ages, leprosy patients – or at least
persons who were thought to have this disease – were cast out of society. The first step
would be to detect suspected lepers. They were then presented to special committees of
‘experts’ with the job of making a diagnosis. This physical examination might be carried
out by doctors and surgeons, or often certain laypersons, such as gate porters, policemen,
priests, monks or even other lepers (Brody, 1974: 63–4).
There must have been a considerable risk that diseases were misclassified: any skin disease
or abnormality could be seen as a form of leprosy. If a person was judged to be a leper, the
victim was told that he would be separated from the healthy population. The law could be
very hostile to lepers, and for many, the leprosarium might even be a relatively save haven:
In brief, the law could place a person outside of society by depriving him of his rights to marry or
to stay married, and to own and transmit property. It could simply and effectively deprive the leper
of the right to have a home, and that being so, it could compel him to depend upon the very
society which, out of loathing and fear, wrote those laws. Under such circumstances, the best the
leper could do would be to turn from the world and enter the closed society of the leprosarium.
There, at least, he would have a bed and food. The prison could also be a refuge.
(Brody, 1974: 86)

This may sound like ending the social life of a person, and actually it was meant to be so: the
diagnosis of leprosy could be a reason for authorities to officially declare that the victim was
now judged socially dead. The church played an important role, providing symbols and
rituals that were similar to those of a funeral. A mass was held for the leper, who at some
places was required to stand in a grave in a cemetery. The officiating priest would throw
some earth from the grave over the victim’s head, explaining that this symbolized the death
of the leper to the world. As harsh as this may sound, the fear of leprosy sometimes led
some to enact even more drastic measures. For example, Henry II of England, as well as
Philip V of France,
. . . chose to replace the religious service with a simple civil ceremony. It consisted of strapping
the leper to a post and setting him afire. [Edward I of England] adhered a trifle more closely to
the letter of the ecumenical decree. Lepers, during his reign, were permitted the comforts of a
Christian funeral. They were led down to the cemetery and buried alive.
(Roueché, 1953: 117)

Leprosy is a devastating and mutilating disease, which explains the phobia-like responses to
lepers throughout history. However, despite this fear, leprosy was not a disease that
disrupted cities or the whole of society like some epidemics of other infectious diseases.
For example, the various pandemics of bubonic plague could easily destroy city life in a
short time, as the panic accompanying such disasters must have been immense. The Great
Plague of 1665 killed almost one-third of the inhabitants of London who did not flee

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
102 Section 2: Issues

(Moote and Moote, 2004). Whole families passed away. People would become ill and die on
the same day. Inevitably, such panic could lead to drastic measures. Houses of patients
could be sealed until the victims either recovered or died. Guards were posted at the door to
see that no one got out. The guard had to be bribed to allow any food to pass to the inmates.
If patients were not isolated at home but sent to a plague house, they did not only face the
dangers of the plague itself, as unconscious patients were easily confused for those who were
deceased and taken to the cemetery. Although some authorities advised against burying
corpses for 24 hours after death, the fear of infection stimulated caregivers to bury victims
as soon as possible (Noordegraaf and Valk, 1988: 104). If a patient recovered from the
disease, he or she could still be considered dangerous. Like other suspected persons, they
were often required to walk with a white stick, thus motivating others to avoid them
(Noordegraaf and Valk, 1988: 103).
In order to prevent spread of the plague in 1347, the city of Venice and other cities
proclaimed quarantine measures for ships coming from infected areas. Such ships and their
crew were isolated initially for 30, later for 40 days (quaranti giorni). People who did not
develop symptoms of the disease were released after this period and allowed to enter the city
(Biraben, 1976: 173–5). The quarantine rules thus went beyond isolating patients from
healthy persons: all persons on a ship coming from a suspect area were sent to quarantine.
In theory, these measures could protect cities against incoming disease, but they involved
clear risks for those held in quarantine: if someone among them became ill, all ran the risk
of being infected. Some may have tried to escape from quarantine, but they would then face
other risks: violations of the quarantine orders could be punished with the death penalty.
Another classic example of isolation and restriction of liberties is the story of ‘Typhoid
Mary’ (Porter, 1997: 424–5; Wald, 1997). Between 1900 and 1907 Mary Mallon was a cook
in New York. Twenty-two people for whom she cooked or cared for developed typhoid
fever. Mallon remained healthy, but she was suspected and later identified to be a carrier of
the disease. Understandably, she could not grasp that she had caused all the cases of disease,
not having been ill herself. Mary Mallon was isolated against her will in a hospital on North
Brother Island in 1907. In 1910 the public health authorities released her, on condition that
she would refrain from taking up her job as a cook. Unfortunately, in 1915 she did return to
cooking, accepting a job in the Sloane Hospital for Women. Twenty-five people developed
typhoid fever and two of them died. Again Mallon was identified as the vector, and this time
she was sent into quarantine for life. She died in 1938, after having been quarantined for
26 years of her life.
Mary Mallon’s case is especially interesting from an ethical perspective, because she was
not only restricted in her liberties (apparently for good reasons) but also held personally
responsible for the spread of disease. Public health officials possibly contributed to this
accusation, naming her ‘Typhoid Mary’ in their medical publications. Later newspaper
articles showed cartoons of Mallon adding small skulls in a frying pan (The New York
American, 20 June 1909). For the public it might have been difficult not to see her as an evil
cook who poisoned her employers and clients.

Measures of infectious disease control

The life of Mary Mallon illustrates how public health authorities can have the power
to restrict people’s individual liberties. Effective infectious disease control may require
a large number of coordinated measures, from surveillance to notification, restricting

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 103

traffic to mandatory isolation or even compulsory medical treatment. Let me review

various measures briefly, with an eye on the values and rights that are at stake. As
will become clear, the impact of such public health interventions on individual well
being and freedom can be immense. After this brief inventory of various measures and
their implications, I will discuss the moral justification of restrictions to freedom
in more detail.

Surveillance, screening and notification

Most preventive measures will only be effective if enacted in a timely manner. A good
surveillance mechanism is therefore indispensable. This involves acquiring data about
infectious diseases – including personal information about individual human beings. In
most, if not all countries, physicians and medical laboratories are legally required to
notify public health authorities if they find cases of specific infectious diseases. For
several diseases an anonymous report may be sufficient, but for many others it will be
necessary to mention the diagnosis together with the patient’s name and address. This is
in contrast to the general requirement to maintain confidentiality, central to Hippocratic
as well as modern medicine.
However, such notification procedures for identified and diagnosed cases will not be
sufficient as a means of surveillance within a population context. Surveillance and control
of infection may be more effective if healthy people are tested on a large scale. For
example, in the Netherlands and many other countries, pregnant women are tested for
HIV and Hepatitis B on a routine basis. Similar practices exist for other diseases,
including tuberculosis. In some contexts people may have the right to ‘opt out’ if they
do not want to be tested, but in other contexts or countries it may be practically difficult
or even legally impossible to refuse a test. Hence such interventions result in restrictions
to the rights to autonomy and bodily integrity, and moral rules that govern normal
medical practice, such as voluntary informed consent, on the grounds of protecting the
public health. Other ethical issues arise if these tests and their results can have negative
effects on the well-being of the persons involved. For example, a positive HIV-test might
make it difficult for someone to acquire health care insurance or life insurance; it could
lead to stigmatization or even social rejection. These disadvantages may sometimes
outweigh possible benefits of the test result, such as timely access to antiviral treatment.
Routine test policies especially raise ethical issues in low-income contexts, where there
may be insufficient access to health care. In such a case, test subjects may be informed that
they have a disease, but left without the treatment they need. This may for example
happen in countries in which HIV is endemic: routine testing for HIV exists, but
antiretroviral treatment may not be available for those who test positive (Rennie and
Behets, 2006). If there are many reasons for individuals to forego testing, then routine
tests in a health care setting may also have drawbacks from a public health perspective.
People who feel ill may decide to abstain from seeking medical care or postpone their visit
to a clinic. This is not only undesirable for the person herself: if the person is pregnant, or
if she suffers from an infectious disease, then it might be harmful to others if she does not
seek medical care in time.
Screening procedures can also be applied at airports, seaports or other places open to
international traffic. During the SARS outbreak in 2003, countries required inbound and
outbound airport passengers to have their bodily temperature taken, with the aim of

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
104 Section 2: Issues

detecting those infected and so stop further spread of the disease. One of the problems
for any screening programme is that tests and procedures can be imprecise. Test results
can therefore be unreliable as an indication of disease. Where there is a case of an
alarming outbreak of a highly infectious disease, screening of travellers should not ‘miss’
cases. However, if tests are made very sensitive – hence minimizing the risk that cases
are missed (false-negatives) – this will inevitably lead to large numbers of false-positive
test results. Consequently, many passengers will need to undergo further examination
and tests before they can be allowed to continue on their journey.

Measures after cases have been found: contact-tracing

and further testing
If a case of a contagious disease has been confirmed there may be reason to trace people
who have been in contact with the index-patient. The necessity and urgency of contact-
tracing, as well as the way to do it, will differ for various diseases. A disease like
tuberculosis spreads easily in the right conditions. Contact-tracing may involve mobil-
izing whole communities to test family members, neighbours, colleagues or classmates;
or, alternatively, warning the public that everyone who has been at a specific place at a
specific time (for example, a shopping centre or cinema) should report to the health
authorities and have themselves tested. One problem with such a strategy is that it may
raise panic and fear. In some cases however, the commotion and concerns, or even fear,
that are part of panic, may be justified. More important moral issues occur if such panic
arises where the name of the index-patient is known to the public. If they are in fear of
infection, people may easily confuse natural causes and transmission with culpability
and responsibility, thereby stigmatizing and possibly harming the initial victim of the
disease. Contact-tracing and screening programmes should therefore protect privacy
where possible.
Somewhat different problems of privacy and confidentiality arise if public health
professionals try to trace and notify contacts of people with a sexually transmitted
disease. The natural way to do this is to ask the index-patient to contact his or her sex
partners, as it will be difficult for public health nurses to trace contacts without the
index-patient’s cooperation. However, for most people, sex is a private matter, and if a
patient does not want to cooperate, or contact the partners him/herself, further
attempts to trace contacts will be futile. In some cases however, a physician or public
health professional may have good reason to consider traceable individuals to be at risk.
One typical example is where a physician is treating a person with syphilis and knows
that the patient’s spouse is not aware of the diagnosis. On the one hand, the physician
could protect the spouse by warning them about the patient’s condition, but, on the
other hand, the physician has an obligation of confidentiality towards their patient.
Some would argue that a patient who deceives their spouse and refuses to warn them
about the risk they run, forfeits all rights to confidentiality. However, for public health
physicians working on sexually transmitted diseases, the importance of confidentiality
goes beyond the right of the individual patient. For infectious disease control to be
effective, the public should be able to trust public health authorities to keep their
personal health information confidential. This holds especially for prevention and
treatment of sexually transmitted diseases. STD clinics will be most effective if patients
can trust that their private details and stories are held confidential. If confidentiality is

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 105

not respected in public health, many patients with infectious diseases may postpone or
even forego visiting a STD clinic. Confidentiality has its limits, but partner notification
without consent, as a measure of infectious disease control, may only be justified in
exceptional cases.1

Public health measures: reducing contacts, quarantine and isolation

An important part of infectious disease control is to prevent further spread of disease
during an outbreak. This is especially true for respiratory infections like influenza, where
coughing, sneezing or talking are important means of transmission, as it makes sense to
limit the number of contacts between healthy people, and to avoid large group meetings or
other risk situations. In an outbreak, public health authorities may decide to cancel fairs,
football matches, to close schools, crèches, companies or shops. Again this will be a clear –
but sometimes necessary – restriction of liberties for many people, but moreover, these
measures will have significant impact on their daily life, as well as on their financial
resources or their property. For example, the closing of factories, offices and shops and
cancelling of mass-events will involve financial burdens for companies and citizens.
Employees may run the risk of losing their job if their place of work is closed for a long
time. Such burdens will be faced particularly severely by vulnerable groups who are social-
economically worse-off, for example employees with temporary jobs or no contracts at all.
If certain groups of people run risks and bear significant extra costs due to public health
measures, the question arises whether they would have a justified claim to receiving
compensation for their losses. Government-based compensation schemes can be considered
as an expression of solidarity: if there is a public health threat then all citizens should be
willing to share in the costs of protective measures – after all, if such measures are effective
then everyone will benefit.
Compensation schemes are also an important issue for containment of animal diseases
such as avian influenza. Livestock have, throughout time, played an important role in the
spread and transmission of many human infectious diseases. Nowadays, outbreaks in
livestock are often countered by mass culling of all animals that have either been exposed
to the disease or even all animals within a particular distance of confirmed cases. Compen-
sation schemes may not only be a matter of justice and solidarity; they can also serve a
pragmatic role in maintaining surveillance. Few farmers may be willing to report disease in
their livestock early on in an outbreak, if they face having their animals culled without
compensation. Compensation schemes may thus support surveillance programmes, which
are essential to any timely and effective response to an outbreak of infectious diseases.
From an ethical point of view, the most appalling public health measures are quarantine
and isolation of persons. Both concepts are used for the same sort of measures, but it makes
sense to distinguish them in a way that is morally relevant. Gostin defines isolation as the
physical separation and confinement of an individual or group of individuals who are
known to be infected with a contagious disease from non-isolated individuals, to prevent or

1
Such a breach of confidentiality may be justified more often in the practice of individual health care.
One such case would be where a health care provider, for example, a family physician, is caring for a
patient who has a sexually transmitted disease and who refuses to tell their spouse, and where the
physician also has a caring relationship with the spouse. The patient’s refusal would make it
impossible for the physician to sustain a fiduciary relationship with their other client.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
106 Section 2: Issues

limit the transmission of the disease to non-isolated individuals (Gostin, 2000: 210).
Quarantine also involves separation, but this applies to healthy individuals or groups who
may have been exposed to a contagious or possibly contagious disease. Both isolation and
quarantine measures can be applied to large groups. As was illustrated in the historical
examples given above, extreme forms of isolation or quarantine may be similar to putting
individuals in jail, excluding them from public life completely – possibly for the rest of their
lives. Even if the means of separations are less severe, the impact on personal life may be
overwhelming, as it combines most of the adverse events that arise in all other public health
measures. Isolation and quarantine effectively make it impossible for individuals to con-
tinue their lives as planned, to fulfil their jobs and responsibilities, to earn their living, to see
and care for their loved ones. The separation of persons also has an important symbolic
dimension. Individuals or groups are labelled as dangerous, which could undermine their
sense of being part of a community. Being separated from the community, there is a risk
that isolated and quarantined groups will not have sufficient access to such basic needs as
food or health care. In short, all quarantined and isolated individuals are deprived of at least
some essential sources for well-being. Moreover, quarantine measures may mean that all
suspected persons are held together: this includes persons who are in fact exposed to the
disease and may get ill in the short term, as well as those who are only believed to be
exposed but are in fact not infected. The non-infected persons may be detained with people
who may infect them. In this way, quarantine procedures, while intended to reduce the risks
of contagion within the larger population, may actually increase the risk for (at least part of)
the quarantined population.
It is clear that isolation and quarantine procedures can have extremely adverse implica-
tions for individuals and that procedures should be applied with due care. In the last few
decades, much work has been done to develop procedures and regulations in such a way
that risks for quarantined persons are minimized, and that they at least have rights to due
process that protect citizens from arbitrary detention. However, even if these measures are
applied with due care, they remain morally problematic and require a strong moral
justification. Before turning to this issue, let me briefly discuss a last category of measures
of infectious disease control.

Mandatory medical treatment

Surveillance, routine testing and quarantine procedures may only have limited effects if
infected patients are not treated against their disease. Medical treatment of infectious
diseases is not only beneficial (if not necessary) for the patient himself, it will also be
essential to prevent further infections of others. Hence, the availability of, and compliance
with, antibiotic or antiviral treatment is not only an issue of individual health care but of
public health. One of the most frequent contexts for compulsory treatment is tuberculosis
control. Antibiotic treatment for tuberculosis may take up to 6 months in ‘normal’ cases,
and 24 months in cases of multi-drug resistant forms of tuberculosis. Completion of
therapy is not only necessary to result in a cure, and to take away the risk of infection,
but also to prevent the development of drug resistant forms of tuberculosis. However, many
patients may decide to stop treatment as soon as they feel better. Adherence to therapy may
be particularly difficult for persons who belong to marginalized groups such as the
homeless or drug abusers. Hence, various strategies have been developed to promote
adherence to therapy. Apart from voluntary schemes, there are also compulsory options.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 107

A common approach to ensure adherence to treatment is directly observed therapy (DOT):

patients are monitored to ensure they take their drugs, at least for a certain period. DOT as
such may not be compulsory, although it does impose restrictions upon a patient’s freedom.
Yet if this approach is not successful, for example, because a patient does not come to the
physician to receive treatment, public health officials may consider compulsory detention
for the duration of the treatment (Lerner, 1999). The combination of detention with
compulsory treatment is a step further than ‘just’ isolation of patients, as it involves a
violation of bodily integrity and the right to refuse treatment – rights that are central in
modern health care practices in Western societies. However, the right to refuse treatment
and the rules of informed consent may be primarily relevant for medical decisions about
patient care, where the benefits and harms of treatment and non-treatment primarily
concern the patient herself. If patients with infectious diseases neglect the treatment they
need, this could have harmful implications for others, and that may be reason to overrule
the requirements of informed consent.
Just as in the case of isolation and quarantine, it is reasonable to install requirements of
due process, in order to protect patients from unnecessary restriction upon their freedom.
Diseases like tuberculosis are often most prevalent among the marginalized in society, and
detention (sometimes even in gaol) may reflect social prejudice rather than just public
health concerns. Public health officials should not simply assume that patients who belong
to certain risk groups (for example, intravenous drug abusers) can only be treated if they are
detained.

Well-being and freedom

All these measures for infectious disease control involve a tension between the importance
of protecting public health, and the liberty and interests of individual people (patients,
infected persons, possibly infected persons) whose freedom may be curtailed in the name of
public health. Let me review in more detail the main values at stake, well-being and
freedom, before discussing possible ways to justify compulsory measures.
First of all, most interventions, especially when compulsory, curtail the freedom to
move, to travel, to meet persons one wants to meet, etc. Although such liberties are of
intrinsic value themselves, restrictions will especially be problematic where they deprive
people of certain important sources of well-being. For example, restrictions upon travel-
ling may effectively make it impossible for people to go to work, to earn their living, or to
sustain their business. The financial burdens of such forms of control on individuals and
companies may be immense. The losses due to public health constraints, however, go far
beyond economical and financial burdens. Quarantine measures and travel restrictions
may prevent people from seeing their loved ones, or caring for their children, parents or
friends. Many people who are less independent may face significant risks to their health if
caregivers cannot come and help them. The possibly infected people held in quarantine
with others may run a significantly higher risk of becoming a victim of the disease because
they are held together with others who are in fact infectious. Moreover, if certain groups
of people are ‘set aside’ because they are considered to be a (potential) risk to the rest of
the community, this may have an enormous impact on how they are viewed by that
community. From a moral point of view these groups are innocent; from a medical point
of view they may be a source of infection – hence potentially dangerous. In the process
of stigmatization that goes with outbreaks of contagious diseases, medical and moral

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
108 Section 2: Issues

judgments may get easily confused. As a result, diagnosed patients or suspected persons
may be systematically avoided and have their interests neglected. In short, while public
health measures, from screening to quarantine, are aimed at protecting the health and
welfare of the public, such measures inevitably will have negative if not detrimental effects
on the well-being of certain sub-groups.
Second, even apart from the impact on human well-being, the constraints on liberty and
individual rights are morally controversial as such. Measures of infectious disease control
may force people to behave in specific ways, hence curtailing their freedom of choice and
movement. Surveillance and notification policies may be considered a violation of rights to
privacy and confidentiality; and compulsory vaccinations and treatment violate moral
rights to bodily integrity. A central idea behind these values is that individual persons are
capable of reasoning, making choices and determining the course of their lives – and that
these capacities are grounds for respecting persons and the choices they make. In a liberal
society where individual rights are considered of utmost importance, the possibilities to
curtail or overrule those rights should therefore be limited. One should treat persons with
respect: that is, treat them as ends in themselves, and not merely as means to or obstructing
factors for the realization of other ends – however worthwhile aims such as the protection
of health might be. They are autonomous beings, that is, beings with practical reason, who
can and do set their own ends. Rules of informed consent – as common as they are in
individual health care – are often seen as especially important in protecting autonomy. The
ideal route for infectious diseases control is therefore to inform persons about necessary
precautions (to have themselves screened, to isolate themselves, to accept treatment, etc.)
and to trust that they will act accordingly. However, the circumstances of infectious diseases
control, and especially outbreak management, are far from ideal. Infectious diseases may
raise panic, and people may distrust government institutions, and therefore refuse to
cooperate. Moreover, while measures of infectious disease control are aiming at protecting
the health of the many, they will often impose risks on individual persons. Hence, for these
individuals it could be most rational to refuse to cooperate, and to avoid tests, quarantine or
vaccination. In such circumstances, compulsory measures may be inevitable to prevent
spread of disease. Which moral grounds could provide justification for such infringements
on individual rights and freedom?

The harm principle

Even ethical theories that see individual rights and especially liberty rights as the strongest
possible moral claims – as trumps vis-à-vis other moral considerations such as the common
good – will necessarily acknowledge limits to those rights. If people use their freedom to
harm others or otherwise impose their will on another person, then the freedom of the
aggressor is undermining the freedom of others. Any liberal framework that endorses
freedom or autonomy as an important value will therefore accept that someone’s freedom
must be curtailed if this is necessary to protect the freedom of other persons. Ideally every
individual enjoys maximum freedom that is still consistent with the equal liberties of her
fellow citizens. According to John Stuart Mill (1859: 22) the only purpose for which
someone’s freedom can be constrained is to protect other individuals. One should not
compel persons to act in specific ways for their own good, but it is justified to limit their
freedom in order to prevent evil to third parties. This idea is normally referred to as the
harm principle:

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 109

HP1: It is justified to restrict the liberty of person A in order to prevent A from causing harm
to person B.2

Moreover, according to Mill, this is the only justification of liberty-limiting actions and
policies. Even the strongest libertarian will agree with liberty-limiting interventions that
protect against harm, and HP1 is therefore relatively uncontroversial. Moreover, the
application of the principle to protection against the harms of infection may seem rather
straightforward. The principle and its application however do raise important questions.
First, the concept of ‘causing harm’ is not as clear as one might hope – certainly not in
relation to the harmful nature of contagion. Second, the harm principle as understood in
HP1 can be given a very strong justification as it is in a sense a necessary condition to
freedom as such, but this is a rather narrow interpretation of Mill’s harm principle.
Although HP1 may apply to certain measures of infectious diseases control, many forms
of infection (hence policies to prevent infection) fall outside the scope of HP1. Many
authors in fact endorse a broader interpretation of the harm principle, but such an
expanded principle HP2 (see below) may require other sources of justification.

‘Causing harm’
A paradigmatic case of harm, where the harm principle would obviously apply, is one where
someone deliberately intends to infect another with a dangerous disease. A recent example
is the Groningen case in the Netherlands. In 2007, three people in Groningen were arrested
because they had injected others with HIV-infected blood. The culprits – all HIV seroposi-
tive themselves – contacted their victims through internet chat boxes, and invited them to
homosexual sex parties at home. During these meetings they first intoxicated their victims,
and then administered intravenous injections with HIV-infected blood. They also injected
blood in each other’s veins, ‘just for the kick’ as they confessed after their arrest.
Although persons with HIV can be treated relatively well (at least in high income
countries), the infection does severely undermine their health. Adequate medical treatment
involves a complex regimen of drugs that negatively affect their quality of life. A deliberate
and malevolent act to infect someone else with HIV is a clear case of harm. State interven-
tions to prevent such harms and to punish evildoers are justified on the basis of the harm
principle.
The Groningen case may be a paradigmatic case of inflicting harm, but it is not a
paradigm case of infectious disease control. Public health measures to control contagious
diseases do not focus on active malevolent behaviour, but on more common means of
infection. For example, even though persons may be aware that they are a carrier of a virus
or other infectious agent, they may simply forget to take precautions, or otherwise act
negligently and spread disease. The story of ‘Typhoid Mary’ Mallon is a case in point. At
some point she was told she carried a disease that could be easily transmitted if she worked
in a kitchen, but she decided to take up her job after all, hence infecting more persons. As
discussed before, public health measures that demand people isolate themselves, or refrain
from certain activities, or otherwise take precautions, may be detrimental to their own well-
being, and this may well motivate them to be non-compliant or negligent. The reason why
such measures as compulsory isolation are used is because such behaviour, even though

2
It is not necessary for the principle that B is a specific person. It could be a non-assignable member of
the public.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
110 Section 2: Issues

normally not malevolent, can be dangerous to others. If there is a clear risk that infected
persons will harm others, even though the harm is caused by negligent rather than
malevolent behaviour, then the harm principle may justify compulsory measures.
So far we have focused on cases where people have negligently or malevolently imposed
risk on others. Again, these cases cover only part of all current possibilities for compulsory
measures. Infectious diseases may spread where no one is yet aware of the infection.
A disease could have an incubation period where an asymptomatic person is already
infectious. Or persons may have certain symptoms, but not realize that they are infectious.
Many policies – including compulsory measures – aim to prevent spread of disease in such
contexts: mandatory screening at borders, routine HIV-tests for pregnant persons in risk
groups, prohibition of mass events, closing of schools, etc. Can the concept of harm and the
scope of the harm principle be stretched much further, and justify such measures as well? It
is often assumed in public health law and ethics that the principle can be as broad as this
(Gostin, 2003). Yet this depends partly on how the principle and its core concept, harm, are
understood.
Is it correct to assume that Sally, who does not know she is a hepatitis B carrier, and who
has unprotected sex with Richard, is causing harm to Richard? Is Henry causing harm to his
colleagues if he goes to work, unaware that he is a vector for a new and dangerous influenza
virus? Paul got very ill and was admitted to a hospital, and now it appears that he has SARS
and that he infected two nurses who cared for him. Did Paul harm the nurses?
Maybe Sally is causing harm if we assume that she and Richard should have taken
precautions against sexually transmitted diseases anyway. If that is true, this may reveal that
‘harming others’ and even ‘causing harm’ are normative concepts, that only apply when
certain moral norms are transgressed.3 Joel Feinberg (1984: 36) indeed defines harm as a
wrongful setback to the interests of another person, where ‘wrongful’ refers to transgression
of a moral norm (Feinberg,4: 36). Certainly Henry can not be considered as harming his
colleagues, if harm would involve the transgression of a moral norm: he just goes to work
and is perfectly justified in doing so. Paul did not ‘do’ anything, and even though actually
his admittance to the hospital did appear to be a threat, there is no sense in which Paul
could have been responsible for it. This seems to imply that, if we emphasize the moral
nature of causing harm, HP1 only justifies compulsory measures towards persons who are
in some sense responsible for the harm that they produce.5 Compulsory policies towards
persons who are unaware that they pose a threat to the health of others might not be
justified on this interpretation of the harm principle.

3
The example may provoke the reaction that Richard can not be said to have been harmed if he
agreed to having unprotected sex (volenti non fit injuria), but this only affirms the claim that harm is
a moral concept.
4
However, Feinberg is specifically focusing on the role of the harm principle in the context of criminal
law, and this may be a reason for thinking that the relevance of his concept of harm in the
context of infectious disease control is limited.
5
Note that this is not just a result of the definition of harm as such, but also in our understanding of
someone causing harm. Did Henry cause harm to his colleagues, or was the harm caused by the
virus? Statements of causal responsibility may seem purely empirical, but when they concern actions
or omissions of persons, they will inevitably involve evaluative statements that presuppose some
background of norms (Yoder, 2002).

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 111

Expanding the scope of the harm principle

However, the harm principle could also be interpreted in a less restricted way. In
discussions of the harm principle it is unclear how broad its scope exactly is. Does the
principle only justify compulsion or punishment of person A who is him/herself causing
harm to person B? Mill suggests that the principle may also cover cases where A’s
omission to act (for example, to rescue) would result in harms for B. In other words,
A’s actions need not be the source of the harm. If we accept this, in fact we have adopted
an alternative principle:

HP2: It is justified to restrict the liberty of person A in order to prevent harm to others.
(Brink, 2007)

This principle neither requires causal responsibility nor moral responsibility of A for the
harms that are to be prevented. Hence, on this principle also compulsory measures can be
justified towards persons who are unaware that they pose a risk: for example, compulsory
screening of travellers at airports or mandatory HIV tests for pregnant women. A policy by
which all incoming travellers are screened for specific contagious diseases will lower the risk
that outbreaks will occur within a country. Measures that temporarily prohibit the
gathering of large groups of people will inhibit the spread of infection across a population.
This principle could even support compulsory policies towards persons who are known to
be not infected at all, for example vaccination policies of specific groups in order to prepare
for a bioterrorist attack.
As attractive as this interpretation of the harm principle may seem for effective
infectious disease control, it does raise a problem – at least for many libertarians.
If it is irrelevant what or who caused the harm that is to be prevented, almost any
compulsory policy that may promote or protect the health of others could be justified.
For example, the state could openly force some persons into quarantine in order to
convince the public that there is a serious threat to public health and that ‘the state
means business’, thereby stimulating the public to comply all the better (Wilkinson,
2007). Parents could be required to have their children vaccinated against seasonal
influenza, because that may reduce mortality among the elderly (Reichert et al., 2001).
Citizens could be required to pay for vaccination and treatment of persons who cannot
afford such forms of health care, etc. This is not to suggest that such policies would
necessarily be wrong. However, these policies, and the revised version of the harm
principle, may have little to do with the initial attractiveness of the harm principle
in a liberal framework. The harm principle is often presented as a justification for
compulsion and punishment that even the notorious libertarian could accept. This is
because the principle (at least HP1) is still consistent with allowing every person a
maximum liberty.
The revised version of the harm principle, HP2, however also justifies constraints on
freedom of citizens if, for example, that would protect the health of persons who are
relatively frail anyway. This would raise a discussion about whether such interventions
‘really’ aim to prevent harm to those persons, or ‘just’ confer benefits to them (Brink, 2007).
Libertarians would complain that the revised version of the harm principle is not just aimed
at the protection of liberty, but it is already trading off liberty against health and well-being.
Such a trade-off however may well be acceptable – if not essential – in many other
normative theories. Let us briefly focus on two such theories.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
112 Section 2: Issues

Consequentialist and egalitarian approaches to preventing harm

Contrary to what libertarians assume, it makes sense to hold liberty to be one value
among others, and to reject the idea that freedom from intervention should always be
given priority over other values, such as welfare or equality. Public health measures aim
to protect people from diseases that are detrimental to their health and thereby under-
mine their opportunities to live a reasonably good life. Consequentialists will argue
that it may be justified to constrain people’s freedom if this would promote the general
good. Infectious diseases may be detrimental to many different sources of well-being;
consequently, effective prevention may promote well-being in various ways. Adequate
protection against contagious diseases first of all promotes the good by preventing
illness, suffering and premature death. Moreover, public health measures, such as
surveillance, screening, testing and vaccination, and adequate structures to respond to
disease outbreaks will also protect and facilitate people’s societal life: to meet others, to
go work, to receive education and to care for the elderly or the weak. If such measures
require compulsion, this will be justified if the consequences are optimal. From a
consequentialist perspective, the causal routes of the harms are rather irrelevant, and
there are good reasons to prefer HP2 over HP1. Moreover, consequentialists may also
acknowledge that compulsion can help to avoid a collective action problem. Suppose
there is an actual threat of a smallpox outbreak, and it will be possible to contain the
outbreak only if sufficient individuals will be vaccinated. The vaccine however is not
completely safe. In such a case, individuals may forego vaccination and hope that they
will benefit from the vaccination of other persons. However, if many people share this
attitude, the public will not be protected at all, and hence all will be worse off. In order
to avoid such problems, the state could compel the relevant groups to accept vaccin-
ation, for the sake of protection of all.
Liberal egalitarians, like consequentialists, may also support HP2; though partly for
different reasons. They see equality and fairness, next to autonomy, as fundamental values.
Measures aimed at the prevention of infection can be considered as measures to reduce the
risks of infection (hence the risk that harm will occur) within a population. Egalitarians will
be concerned with a fair distribution of risks to health, but also with a fair distribution of
the burdens of preventive measures. Health inequalities that are unjust, for example because
they are caused by inequitable income distributions, need to be reduced. Infectious diseases
may hit the rich as severely as the poor, but often there are clear correlations between social
deprivation and increased prevalence of infectious diseases. Well-off groups will also have
more possibilities to protect themselves against disease: they have better access to relevant
information; they can afford special vaccinations, safe drinking water and hygienic living
conditions; they may avoid places where infectious diseases are more common, decide to
leave the city (or even their job) in case of an outbreak, and can afford therapeutic care
when they get ill, etc. If it is left up to individual citizens to protect themselves, then
arguably many people in socio-economically worse-off groups will be left unprotected.
Egalitarians therefore support government interventions to protect the health of the public
which go beyond the narrow version of the harm principle. Such interventions will at least
aim at universal access to basic health care, paid from public resources, which includes basic
preventive care and public health services (Daniels, 2001). Compulsory measures to reduce
the risks of infectious diseases may also benefit the worse-off groups, and ensure that the
burdens of protection are distributed equitably.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 113

Although consequentialists and egalitarians may both support the expanded version of
the harm principle (HP2), there will also be differences. HP2 fits within a general liberal
framework which the consequentialist may not accept. HP2 still focuses on harm to others
and therefore does not cover paternalistic interventions that restrict someone’s freedom in
order to prevent harm to him or herself. For the consequentialist, all harms, including self-
imposed risks, could be a reason for intervention. Moreover, consequentialists may argue
that in the context of infection it will often be difficult to distinguish acts that are purely
self-regarding. Most contagious diseases do not stick to persons who accepted the risk of
being infected; they will spread from them to others as well.
Liberal egalitarians might respond that at least in some contexts, individuals have the
possibility and responsibility to protect themselves against infection. Sexually transmit-
ted diseases are a good example. Compulsory measures to prevent infection might be
justified where individuals cannot be reasonably expected to protect themselves. If
individuals can easily choose to have protected sex, public health authorities should be
reluctant to intervene and compel them to take precautions. For that matter, compulsory
measures would require interventions in people’s private spheres – interventions which,
if not impossible, would at least be highly impractical. Such pragmatic considerations
will also be relevant to the consequentialist. Moreover, many consequentialists may aim
at promoting well-being and freedom, and for them HP2 will be a reasonable trade-off
between both values.

Conditions for justified compulsion in public health

Let me briefly summarize the argument so far. The narrow version of the harm principle
(HP1) may offer justification for compulsory interventions that prevent people from
deliberately or negligently infecting others, for example, infected persons who resist iso-
lation or treatment. This justification is relatively uncontroversial as it can be based upon
the value of freedom itself. For purposes of effective infectious disease control however, the
scope of HP1 is rather limited. Quarantining healthy persons in order to reduce the risk of
contagion, or mandatory screening at borders, or compulsory tests for pregnant women, all
involve situations where it is less clear whether the persons compelled are indeed causing
harm to others – or even imposing risk on others. Such measures may fall within the scope
of the expanded version of the harm principle (HP2), because here the causal routes of harm
and the moral connotations of our understanding of causing harm are irrelevant. The
expanded principle can be coherent with several normative theories, notably consequential-
ism and egalitarianism. However, the scope of the principle may easily become too broad:
the principle could support sacrificing innocent bystanders, if that would help in some way
to reduce even minor risks within a population. Therefore, a solid justification for compul-
sory measures in terms of the prevention of harm should take into account several further
constraints. Just the fact that a certain compulsory intervention may prevent harm is not
enough to consider the intervention morally right.

Magnitude of harm
A first issue that will be relevant in any justification of compulsory measures is that the
harm or risk to be averted should be significant and realistic. Chicken pox and the
common cold are contagious, but, apart from special circumstances, do not create clear
risks to individuals or the population. Symptoms of chicken pox may be very annoying

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
114 Section 2: Issues

for patients but it is questionable whether one should consider these as harms at all. Many
other contagious diseases however have irreversible effects on the well-being of patients,
or are otherwise mutilating or lethal. Therapeutic possibilities are limited which further
decreases the prognosis for infected patients, as in the case of extremely resistant forms of
tuberculosis. The magnitude of the harms that can be prevented does not only depend on
how severe a disease is for a patient, but also on the mode and speed of transmission.
Infections that lead to severe disease but that also spread rapidly within a population pose
a serious threat to the public health at large. Such a disease, if not averted, will affect many
individuals, and the ravages will not only be visible in each patient, but also on a
population level.

Effectiveness and evidence

A necessary condition for any compulsory public health measure to be justified is that it
should be effective in preventing infection and reducing the risks of disease. This condition
may seem rather obvious: the rationale for controlling measures is indeed to control
and prevent disease, and interventions that do not work make no sense. However, it is
often difficult to evaluate and assess the effects of public health strategies. Evidence is often
historical or anecdotal, supported by common sense. Randomized trials of policies like
surveillance, isolation, or border control are rare if not impossible. Moreover, evaluation of
effectiveness should not just focus on theoretical effects in ideal circumstances, but also on
the feasibility of measures in times of crisis. Especially where measures are compulsory,
people may try to find ways to avoid them. If persons who are tested positive for disease are
isolated from their families, they may decide not to see a doctor if they have symptoms.
Finally, judgments of effectiveness of planned interventions against future diseases, such as
pandemic influenza, are complicated by many uncertainties about the characteristics of the
virus and its effects (infection rate, transmissibility, mortality, risk groups, etc.).
These problems make clear that assessment of effectiveness is often not a simple matter
of appealing to scientific evidence; it requires judgment on the basis of incomplete evidence.

Proportionality and the least restrictive alternative

A further requirement for controlling measures is that their impact on the liberties and
well-being of individuals should be in the right proportion to the magnitude of harm that
can be prevented. Major threats to public health – for example, a bioterrorist attack with
smallpox – may require interventions like compulsory isolation and vaccination, yet such
measures may be effective but not reasonable in order to contain an outbreak of less
severe diseases, like rubella or measles.
Reasonable approaches to protect public health will also endorse the principle of the
least restrictive alternative: measures may sometimes justifiably impose constraints on civil
liberties, but such constraints should not be greater than strictly necessary. Mandatory HIV
tests for all persons who visit a hospital may not be justified if routine (opting-out) tests are
known to be equally effective. Detention and forced treatment of tuberculosis is wrong if
directly observed treatment without detention is also possible and effective. In many cases
however, it is less clear what the least restrictive alternative would be. Especially where there
is much uncertainty about the risks of harm or about the effectiveness of various options,
any intervention could be considered to be the least restrictive means necessary. One
interpretation of the principle is that compulsory interventions should only be imposed

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 115

where less restrictive measures have been tried, and have failed (Annas, 2002). This may be
applicable to treatment of tuberculosis patients, where detention of a patient could be an
option after more voluntary approaches to enhance compliance to therapy have been tried
and failed. However, in emergency situations and public health crises there may be few
possibilities to try voluntary approaches first. ‘The least restrictive alternative’ therefore
makes sense as a general principle that urges public health authorities to compare options
and reflect on which measures are really necessary, but it is not a criterion that can be
simply applied.

Infectious disease control and public trust

Infectious disease control involves a range of measures that are necessary for the protection
of public health, but which may interfere with the interests and rights of individual persons.
Moreover, for most policies to be effective it is important that members of the public
cooperate, even if that might not be in their best interests. But why would individuals
voluntarily cooperate if they run the risk that their privacy is violated (case reporting;
contact tracing), that they may not be allowed to enter or leave a country (airport
screening); or that they will lose their job because they cannot go to work (isolation)?
One answer could be that they have moral obligations to take precautions against infection
and act in the interest of public health (Verweij, 2005). Yet even if citizens acknowledge that
they have such a duty, they may not be motivated to act according to public health
regulations if they do not fully trust that such regulations actually are for the common
good, that policies are applied fairly and that adverse effects on well being are minimized.
Hence, it is essential for effective infectious disease control that the public will trust public
health authorities and have confidence in the interventions that those authorities impose.
If there is a lack of trust in public health authorities, even compulsory policies will be futile.
Conversely, if public health professionals and authorities can and do publicly justify
regulations that are deemed necessary – especially those regulations that are compulsory
in nature – they provide reasons for the public to trust such interventions.
Compulsory interventions should also be applied in a fair and non-discriminatory way;
procedural due process for persons who are separated is then important. Public trust may
be further strengthened if adverse effects of controlling public health measures are coun-
tervailed where possible (stigmatization, social isolation, health risks, economic losses, etc.),
and if persons can expect reasonable compensation for economic losses they have as a result
of such interventions.6 Unfortunately, the possibilities for due process and full compen-
sation schemes may be limited in large-scale public health emergencies, such as a bioter-
rorist attack or influenza pandemic. Emergency situations where many people are
quarantined may not allow time for personal hearings and legal representation for each
individual. And if a large part of the population faces economic losses due to public health
measures, it may be impossible to compensate everyone. One might hope that citizens will
accept the limitations of due process and compensation in a large-scale crisis if they have
confidence in the public health measures.

6
In fact, trust cannot be easily created or promoted. Meijboom et al. (2006: 432–4) argue that,
ultimately, only trustworthiness strengthens trust. Yet if public health authorities publicly justify the
measures they take, and if they are accountable for the implications for citizens (including fair
compensation schemes, etc.), they do become more trustworthy.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
116 Section 2: Issues

Compulsory screening for dangerous infectious diseases, contact tracing, case reporting,
isolation and quarantine, vaccination or treatment – all these measures can deeply interfere
with people’s well-being and freedom, and they require a strong moral justification. There
should be sufficient evidence that a coercive measure is necessary to prevent significant
harm to others. Paradoxically, the more this measure and its justification is endorsed by the
public, the less force and compulsion may be required to protect public health.

Acknowledgement
I have had some very illuminating discussions with Franck Meijboom, Angus Dawson and
Frans Brom that have helped me in developing the argument in this chapter.

References influenza: ethics and the law. Journal of

Agricultural and Environmental Ethics, 19(5):
Annas, G. J. (2002) Bioterrorism, public health, 427–42.
and civil liberties. New England Journal of
Medicine, 346(17): 1337–42. Mill, J. S. (1859) On Liberty. London: John
Parker and Son.
Biraben, J. (1976) Les hommes et la peste en
France et dans les pays Européens et Moote, A. L. and Moote, D. C. (2004) The Great
méditerranées. Tome II: Les hommes face à la Plague: The Story of London’s Most Deadly
peste. Paris: Mouton. Year. Baltimore, MD: The Johns Hopkins
University Press.
Brink, D. (2007) Mill’s moral and political
philosophy. In The Stanford Encyclopedia of Noordegraaf, L. and Valk, G. (1988) De Gave
Philosophy. Available at: http://plato. Gods. De pest in Holland vanaf de late
stanford.edu/entries/mill-moral-political/ middeleeuwen. Bergen: Octavo.
(accessed: 8/12/08). Porter, R. (1997) The Greatest Benefit to
Brody, S. N. (1974) The Disease of the Soul: Mankind. A Medical History of Humanity
Leprosy in Medieval Literature. Ithaca, NY: from Antiquity to Present. London: Harper
Cornell University Press. Collins.
Daniels, N. (2001) Justice, health, and health care. Reichert, T. A., Sugaya, N., Fedson, D. S.,
American Journal of Bioethics, 1(2): 2–16. Glezen, W. P., Simonsen, L. and Tashiro, M.
(2001) The Japanese experience with
Feinberg, J. (1984) Harm to Others. The Moral vaccinating schoolchildren against influenza.
Limits of the Criminal Law, Part I. New York: New England Journal of Medicine, 344, 12:
Oxford University Press. 889–96.
Gostin, L. O. (2000) Public Health Law. Power, Rennie, S. and Behets, F. (2006) Desperately
Duty, Restraint. Berkeley, CA: University of seeking targets: the ethics of routine HIV
California Press. testing in low-income countries. Bulletin
Gostin, L. O. (2003) When terrorism threatens of the World Health Organization,
health: how far are limitations on personal 84(1): 52–7.
and economic liberties justified? Florida Law Rothstein, M. A. and Talbott, M. K. (2007)
Review, 55: 1105. Encouraging compliance with quarantine: a
Gostin, L.O. (2006) Public health strategies for proposal to provide job security and income
pandemic influenza: ethics and the law. replacement. American Journal of Public
Journal of American Medical Association, Health, 97(Suppl 1): S49–56.
295: 1700–4. Roueché, B. (1953) Eleven Blue Men and Other
Lerner, B. H. (1999) Catching patients: Narratives of Medical Detection. Boston, MA:
tuberculosis and detention in the 1990s. Little, Brown and Company.
Chest, 115: 236–41. Verma, G., Upshur, R., Rea, E. and Benatar, S. R.
Meijboom, F. L. B., Visak, T. and Brom, F. W. A. (2004) Critical reflections on evidence, ethics
(2006) Public health strategies for pandemic and effectiveness in the management of

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016
 Chapter 6: Infectious disease control 117

tuberculosis: public health and global Wald, P. (1997) Cultures and carriers. ‘Typhoid
perspectives. BMC Medical Ethics, 5: 2. Mary’ and the science of social control.
Verweij, M. F. (2005) Obligatory precautions Social Text, 15: 181–214.
against infection, Bioethics 19(4): 323–35. Wilkinson, T. M. (2007) Contagious disease
Verweij, M. F. and Dawson, A. (2007) The and self-defence. Res Publica, 13(4):
meaning of ‘public’ in ‘public health’. In 339–59.
Ethics, Prevention, and Public Health, ed. Yoder, S. D. (2002) Individual responsibility for
A. Dawson and M. F. Verweij. Oxford: health: decision, not discovery. Hastings
Oxford University Press. Center Report, 32(2): 22–31.

Downloaded from Cambridge Books Online by IP 130.194.20.173 on Wed Jul 27 12:39:55 BST 2016.
http://dx.doi.org/10.1017/CBO9780511862670.007
Cambridge Books Online © Cambridge University Press, 2016