Public Health and Ethical Consideration on the Quarantine of
Diamond Princess

CBEL Report Volume 3, Issue 2

Regular Article

Public Health and Ethical Considerations on the Quarantine of
Diamond Princess
Reina Motegi (The University of Tokyo)
Junko Kiriya (The University of Tokyo)
Masamine Jimba (The University of Tokyo)

Abstract:
Japan experienced a sharp increase of coronavirus disease 2019 (COVID-19) patients with the case of the cruise
ship Diamond Princess docked at Yokohama. The Japanese government decided to take the massive quarantine
measure to prevent the spread of the coronavirus in the country. However, the quarantine measure must be justified
with an ethical point of view since it imposed the threat to human rights. We used an analytic tool for public healthethics to discuss the case with ethical considerations, focusing on burdens of people on board and ways to minimize
them. Although the quarantine on the ship was proved to be effective in controlling the virus, it is important to further
discuss and seek the intervention that is evidence based, fairly implemented and socially acceptable.

Keywords:
public health ethics, ethics framework, COVID-19, quarantine, Diamond Princess

1. Introduction

1-2. Overview of Diamond Princess Cruise Ship Case

1-1. Background

The first case Japan faced this disease was a

The outbreak of novel coronavirus infectious

luxurious travel ship, called Diamond Princess thatdisease (COVID-19) caused by SARS-CoV-2 started incame back to Yokohama port with a number of

Wuhan, China, in December 2019 (Wu, Leung andpassengers infected with SARS-CoV-2. The cruise ship

Leung 2020), and it has spread all over the world. As ofembarked on a trip from Yokohama city, Japan on

September 1st, 2020, the total 25892040 people haveJanuary 20th, 2020 and had a total of 3711 people

been infected worldwide and 860322 of whom died ofonboard, 2661 of whom were passengers and 1045 were

the disease. Japan has confirmed the total 68392 cases

crews, from 57 countries. During the journey, awith more than 1200 death cases (Johns Hopkins

passenger, who got off in Hong Kong on January 25th,

Coronavirus Resource Center 2020).

had respiratory symptoms on the ship, and was tested
positive for COVID-19 on February 1st. The

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CBEL Report Volume 3, Issue 2

Reina Motegi, Junko Kiriya & Masamine Jimba

information was notified to Japan next day and an

which power can be right fully exercised over any

anchorage quarantine measure was initiated. All

member of a civilized community, against his will, is topassengers and crew members then underwent theprevent harm to others” (Mill 1977: 223). Thus, in theinitial health evaluation, the infection tests and theircontext of quarantine, the authority must clarify theclose contacts records were collected from February 3rd

situation that people who may have the virus are likely

to 5th and they found 10 positive cases (The Ministry of

to harm the uninfected individuals. It is also important

Health, Labour and Welfare 2020). After a course of

to note that they must justify the liberty violation of

inspections, the government adopted a mandatory

people in quarantine. However, to date, little is known

quarantine measure on the ship from February 5th toabout the extent to which the Japanese government

19th. On February 7th, thermometers were distributed

exercised COVID-19 quarantine on the ship with ethicalto all passengers and crews to self-monitor their bodyconsiderations.

temperature twice a day. The Fever Call Center (FCC)This article paid attention to quarantine on thewas also established on the cruise ship dedicated to calls

cruise ship from the ethical perspective becausefrom anyone who had suspicious symptoms. Finally,

quarantine imposes a heavy burden on individuals inafter 14 days of quarantine, people who had met theterms of their freedom, thus it requires the ethicalcriteria of disembarkation left the cruise ship.

considerations to justify beyond mere medical

It is important to distinct the technical differences

effectiveness (Wynia 2007).

between the public measure of quarantine and isolation.
Quarantine is defined as “separation and restriction of

1-3. Objective

the movement of people who were exposed to aGiven the significance of addressing the publiccontagious disease to see if they become sick.” On thehealth ethics in quarantine on the ship, it is important toother hand, isolation is defined as “separation of sickexamine how the quarantine measure should be

people with a contagious disease from people who are

ethically justified in the public health emergency.

not sick” (Centers for Disease Control and Prevention

Therefore, this article aimed to analyze the response of2017). On the ship, those who were tested positive were

the Japanese government to Diamond Princess Cruisetransferred to hospitals for insolation and care, and theShip case from an ethical perspective.

rest were kept on board for quarantine.
The basic ethical principle for public health is1-4. Analysis Tool

‘Harm Principle,’ and it helps us to address to what

We analyzed the case of Diamond Princess using

extent it is possible to restrict the freedom of individuals

an analytic tool for public health ethics created by Kassto achieve public health goals. The original libertarian,(2001). She suggests a 6-step framework that guides

John Stuart Mill said in his book, “On Liberty”, that the

public health experts or policy makers to choose aharm principle is the notion that “the only purpose forcourse of action that is ethically sound. She has applied2

Public Health and Ethical Consideration on the Quarantine of
Diamond Princess

CBEL Report Volume 3, Issue 2

this framework to the case of avian influenza and2. Ethical Evaluation Based on the Framework

discussed

2-1. Public health goal of the quarantine

theethicalissuesofitspandemic

preparedness program (Kass 2015). This framework

In the context of quarantine, the purpose is to limit

helps them to realize the moral issues surrounding

the spread of the disease by separating those who may

public health work and consider how to respond to them.

carry the virus from uninfected people (Ries 2006).

The first step of the framework is goal

However, the Japanese government did not clearly

identification. Public health work should aim at

explain the purpose of the quarantine measure on the

reducing morbidity or mortality of diseases. Second,cruise ship. According to the Quarantine Act (1951) inpublic health professionals ought to examine if

Japan, quarantine should be done to prevent the inflow

interventions are sufficiently supported by data orof epidemics into Japan. The article 1 of the Quarantine

evidence to reach goals, because the most of public

Act (1951) states that “the purpose of this Act is tohealth programs are based on certain assumptions thatprevent infectious disease-causing pathogens that are

they will achieve their stated goals at the end. Then, thenot native to Japan from entering the country via marine

third step is to identify what kind of burdens or harms

vessels or aircrafts as well as to ensure that necessary

could occur through the public health works. She

measures are taken to prevent other infectious diseases

presents three categories of burdens: risks to privacy

involving vessels

and

self-

quarantine measure ought to aim protecting health ofdetermination and risks to justice. Fourth, it is important

Japanese citizens and minimize the spread of the disease

to consider whether the burdens of interventions can be

as much as possible.

confidentiality,

risks

to

libertyandminimized without reducing its efficacy greatly. The

One

of

the

or

aircrafts.” Ultimately,

possiblereasons

behindthethepenultimate step of the framework is the fair distribution

government’s decision is that they had already predictedof benefits and burdens, which corresponds to the ethic

the spread of the virus within the ship. NIID (2020a)

principle of distribution justice. This asks us to treat

said that SARS-CoV-2 had been already spread in thepeople in a way that does not leave and discriminate

cruise ship before it arrived at Yokohama port on

specific group of people. Finally, it is ethically required

February 3rd, 2020 based on their epidemiologicalto compare whether the expected benefits outbalance

analysis data. One recent study also revealed that thethe burden of people.

COVID-19 outbreak has already expanded to most of

The information of Diamond Princess Cruise Ship

the decks before the arrival and quarantine (Tsuboi, etfor the analysis was collected from the official reports

al. 2020). It may have happened possibly viaof the Ministry of Health, Labour and Welfare and therecreational activities and communal spaces which were

National Institute of Infectious Diseases (NIID).

available to all passengers before quarantine (Rich2020).

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CBEL Report Volume 3, Issue 2

2-2. Effectiveness of the quarantine on achieving its
goal

Reina Motegi, Junko Kiriya & Masamine Jimba

2-3. Known or potential burden of the quarantine
For the quarantine measure, the costs for liberty

Kass (2001: 1778) argues that “as a rule of thumb,and self-governance are the most obvious threat tothe greater the burdens posed by a program the stronger

people during quarantine since it imposes a paternalistic

the evidence must be to demonstrate that the program

compliance (Kass 2001). Their autonomy was

will achieve its goals.” Selgelid (2009) also mentions

threatened during on the board quarantine. Moreover,that authorities should explain public health measuresthey were also exposed to physical and psychologicalwith the higher level of evidence when the basic therisks.

human right is at stake. Here arises another question:

First of all, there was a possibility of getting

what kind of and how much of evidence is enough toinfected by SARS-CoV-2 despite the government’s

justify the quarantine measure?

attempt to control the disease. Although those who had

While researchers emphasize the importance of the

been infected were sent to hospitals, there was still astrong scientific evidence, the effectiveness ofchance people remained would get infected. NIID

quarantine has not been proved yet. Moreover, the case(2020b) reported that the specimen of SARS-CoV-2 onof Diamond Princess occurred in the early phase of thethe ship was found mostly from the floor and pillows

global COVID-19 pandemic when the available

from passenger cabins. This evidence suggests that the

information in controlling the virus spread as well as thepassengers and crews were exposed to the high-risk

characteristics of the virus was extremely scarce.

environment. In addition, those who had underlying

Although quarantine was implemented in the past

medical conditions were facing the greater danger. Their

pandemics such as AIDS and SARS (Hoffman 2004;

medical supplies such as medications of diabetes or highGostin, et al. 2003), the outbreak on the cruise ship was

blood pressure were running out during quarantine anda unique environment and there was no case of suchsome of them could not receive them for a certain period

quarantine caused by the emerging infectious diseaseof time (The Asashi Shimbun 2020b).

(Tsuboi et al. 2020).

Another burden people under quarantine faced wasWith this situation in mind, the effectiveness ofthat quarantine placed a tremendous psychologicalquarantine depends heavily on outbreak stage and thestrain on the individuals. People on the ship was undertransmission characteristic (Gostin et al. 2020). Eventhe stress of restricted movement and had to bear thethough the high level of evidence is ideal, if the society

fear of SARS-CoV-2. According to the report from thefaces a greater risk, public health officials may have toDisaster Psychiatric Assistance Team (2020), over 100

use lower level of evidence before imposing coercive

people were exposed to the severe stress condition andmeasures, such as quarantine (Selgelid 2009).

they needed to receive psychological care immediately.
The crew members were under the double stressbecause they had a sense of responsibility as a crew and4

Public Health and Ethical Consideration on the Quarantine of
Diamond Princess

anxiety of the infection risk (The Japan Times 2020).

CBEL Report Volume 3, Issue 2

One possible option would be to quarantine on the

In addition to physical and psychological threatsland. However, it is important to remind that Yokohama,being on the ship, medical workers who have engaged

where the cruise ship arrived at, is the second populated

in Diamond Princess response faced on-the-the-job

city in Japan. The other possibility was to order homeharassment (The Japanese Association for Disasterquarantine to those who did not present the symptoms.

Medicine

healthQuarantine at home is a preferred method to control theexamination and inspections of the individuals on

outbreak because it is voluntary participation andaboard, prescription of necessary medications andrequires less liberty restriction (Certon and Landwirth

medical transport of those who were tested positive2005). However, in the case of Wuhan, China during(Anan et al. 2020). Although their works were essential

COVID-19 outbreak, the high transmission to family

to the quarantine management, the Japanese Association

members was reported after the home quarantine started

for Disaster Medicine (2020) reported that some

(Xu, et al. 2020). Therefore, the home might not work

medical workers who were dispatched to the cruise shipas the segregation facility in terms of protecting people

were being discriminated. They said at least one of

who have not been infected the virus.

2020).

They

performed

daily

workers had been called an “infection source” or “germs”

Consequently, in order to minimize burdens ofby their colleagues, and other workers could not go onto

quarantine, it is important to maximize the quality of life

the property of hospitals where they work. On top of(QOL) of the passengers and crew members to assure

them, some of their children were being asked to staytheir rights of reasonable lives. To maximize the QOL,home

the officials must protect passengers and crew members

from

their

kindergartens(The

Japanese

Association for Disaster Medicine 2020).

and ensure that they stay healthy including food, water,
place to rest, good medical care, sanitary facilities and2-4. Minimization of burdens

good hygiene (Nakazawa, et al. 2020).

Kass (2001: 1780) said “if two options exist to

As for the burden of medical workers, it isaddress a public health problem, we are required,important to consider the level of risk that they have to

ethically, to choose the approach that poses fewer risks

take by going into the cruise ship to save lives of others.

to other moral claims, such as liberty, privacy,

This poses the fundamental question in regard to theiropportunity, and justice, assuming benefits are notduties to treat. Even though health care professionals

significantly reduced.” Therefore, in addition to themight have a strong moral obligation to serve and accept

effort of minimizing burdens, the Japanese government

the extraordinary situations like pandemics (Kotalik

is required to consider a measure that is the most2005), it is by no means the society can disrespect the

ethically acceptable. Were there other options in thequality of their lives for the sake of saving the rest ofcase of Diamond Princess case?

citizens (Pahlman, Tohmo and Gylling 2010). The

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CBEL Report Volume 3, Issue 2

Reina Motegi, Junko Kiriya & Masamine Jimba

society should specify the threshold of duty because

resource. The priority of the screening was based on age

risk-taking commitment of health care professionals

and comorbidities because more than 30% ofshould not be taken for granted (Selgelid and Chenpassengers were over 70 years old. Passengers aged2008). If the society requires medical workers to serve

over 80 years prioritize first, followed by those in their

their duties, it is the government that has responsibility

seventies and so on (National Institute of Infectious

to support their works so that they can fully engage in

Diseases 2020a). NIID explained that the elderly andtheir roles without any disadvantages.

people with complications were prioritize because they
were more vulnerable to SARS-CoV-2 and the2-5. Fair implementation of the quarantine

transmission of the virus would cause severe healthThis part of framework corresponds to the notion

conditions.

of ‘Distributive Justice’, which requires the fair

According to “The Difference Principle” proposed

distribution of burdens and benefits in societies (Rawls

by John Rawls in his book, “A Theory of Justice”, those1999). Kass (2001: 1781) said neither public health

who were advantaged least should receive the greatest

burdens

providedadvantage (Rawls 1999: 53). In the case of Diamonddisproportionately, and the unfair distribution has to be

Princess, people who had to stay in the cabins withjustified with the scientific data.

negative result of inspections and crew members who

andbenefitsshouldbe

NIID (2020a) admitted that they could not isolate

were obliged to continue working can be regarded as the

everyone to private cabins, and most people stayed inleast-advantaged in terms of burdens during the

double rooms during quarantine on the cruise ship.

quarantine. Therefore, in order to justify the inequality

Given that the specimens of SARS-CoV-2 were highlyof their rights and liberties, it is also important to further

found in passenger’s cabins (National Institute of

the argument that aims to equally maximize the position

Infectious Diseases 2020b), people who had to use theirof the least advantaged.

shared rooms were at higher risk of infection. Thisshows that the government could not distribute the2-6. Balance between the benefits and burdens of theresources equally, and some people had to sacrificequarantine

more than others. However, at the same time, it was

In a general sense, quarantine must be the last

impossible to provide a single room to every single

resort in response to the public health emergency

people practically considering the number of cabins the

because it requires legal, ethical and logisticalcruise ship owned.

challenges (Gostin, et al. 2020). It is essential to

As for the screening evaluation, the government
could not initially perform COVID-19 testing to all

consider whether benefits of the individuals outweightheir burdens.

members on board due to the capacity limitation. Thus,

In contrast, when the decision has to made in athey had to prioritize some passengers to allocate thesituation like COVID-19 where little is known about its

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Public Health and Ethical Consideration on the Quarantine of
Diamond Princess

CBEL Report Volume 3, Issue 2

risks, authorities might not have enough time togovernment to maintain, recognizing that somecompare and test the all available options. In fact, theinfringements of liberty and other burdens are

Japanese government had initially limited eligibility for

unavoidable” (Kass 2001: 1781). It opens the discussion

the inspections to those who had the symptoms before

on what benefits a society should gain through a public

the quarantine (The Asahi Shimbun 2020a), but they

health and why it cannot be obtained by other methods.

switched

toperformthesystematic

screeninginspections after the several confirmed cases on the ship.
This suggests that it was difficult for them to evaluate
the possible impact of the outbreak on the ship.

3. Discussion
This article examined the ethical issue on
quarantine in Diamond Princess Cruise Ship by using

There are several researches that have examined

the public health ethic framework. The argument

the efficacy of quarantine aboard (Zhang et al. 2020;highlighted that although the human rights of people

Mizumoto and Chowell 2020; Nishimura 2020; Tsuboi

during quarantine were at stake to some extent, theet al. 2020). Although their results are not precisely

response of Japanese government included the ethicalcorresponding, the overall results suggest that theconsiderations to maximize the benefits of thenumber of confirmed COVID-19 cases on the ship wereindividuals on board with the effort of isolation of

gradually decreased after the initiation of quarantine.

infected people in the early stage, prioritizing those who

Nishimura (2020) said that the movement restriction led

were the most at risk and providing the minimum

to reducing the case of secondary transmissions on

quality of living conditions to passengers. To make theboard. Tsuboi et al. (2020) discussed that the set ofgovernment led intervention better, it is important tocountermeasures such as the early isolation of infected

proceed the highly burdensome measure like quarantine

people, thermometer distribution, the establishment ofon the cruise ship with its transparency and

FCC and the systematic testing may have contributed toaccountability. Moreover, the ethical justification for thethe reduction of transmission.

burdens and benefits of interventions should be

Lastly, Nakazawa et al. (2020) point out that theprioritize including the principle they base on.

importance of ‘Procedural Justice’ in the government’s

This study has limitations. The whole argument

decision of quarantine aboard the ship. Although therelies on one framework. This might have narrowed theepidemiological effectiveness of an intervention wasperspective of the evaluation process. In addition, therevealed retrospectively, the ethical consideration

available data for the analysis was limited, and we could

during quarantine is also significant to make a betternot conduct interviews with those who were involved indecision. The Procedural Justice is a concept that

this case.

“requires a society to engage in a democratic process to

Despite the limitations above, this article may

determine which public health functions it wants its

present some insights to the public health work. To our

7

CBEL Report Volume 3, Issue 2

Reina Motegi, Junko Kiriya & Masamine Jimba

knowledge, this is the first article that specificallyfrom

focuses on the quarantine on Diamond Princess Cruise

May 2020]<https://medicine.yale.edu/yjbm/>[24

Ship from an ethical point of view. The authors believe

Disaster Psychiatric Assistance Team (2020) A Reportthat this article provides some insights on quarantine

on DPAT Activities on the Cruise Ship induring pandemics and similar situations where the

Response to the New Coronavirus [online]

society has to balance the benefits and burdens ofavailablequarantine. Nevertheless, the further ethical discussion<https://www.nisseikyo.or.jp/images/news/gyo

is warranted to seek the practical measure to maximize

usei/coronavirus/200304-04.pdf>

the benefits for those who involved the case and2020]

overcome unprecedented challenge of quarantine.

from

[29

May

Gostin, L. O., Bayer, R., and Fairchild, A. L. (2003)‘Ethical and Legal Challenges Posed by Severe

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DOI:

https://doi.org/10.1016/j.ijid.2020.02.033

Received 10 September 2020
Final version accepted 28 October 202011