Community Zero: A Relational Account of the Ethics of Sanitary Cordon
By: George Botros
Tags: Covid 19, Italy, Coronavirus, China

China Daily / Reuters

The recently enforced “sanitary cordons,” vis-à-vis the novel coronavirus strain, surrounding some Italian and Chinese regions have brought the ethics of disease containment to the fore. Sanitary cordons are physical or effective barriers intended to enforce “community quarantines” (Cetron, Martin, & Julius Landwirth, 2) to insulate a community from infection or, more commonly, contain an infection within a community. In either case, I consider the “cordoned community” to be whichever group is unable to traverse the cordon on suspicion of infection. Insofar as living among an uninfected population is non-rival and non-excludable, a relative absence of communicable diseases may be thought of as a “public good,” the cost for which is disproportionately accrued by cordoned communities. In particular, they may face stigmatization by association with a disease; they may experience poorer conditions than their counterparts with freedom of movement; they may incur the brunt of the frustrations and economic costs of controlling disease spread; and healthy members of diseased cordoned communities may be placed at a greater risk of disease contraction. Historically, sanitary cordons have unduly targeted marginalized communities (Tognotti, 254) and have been employed to suppress the spread of subversive ideas and expand state power (Tognotti, 254). In light of these possible pitfalls, the ethics of community quarantines must be understood through a relational lens and by reference to four key relational principles.

In contemporary bioethics, community quarantines are often justified on the grounds that they prevent harm to the surrounding populace and protect precious healthcare resources to better serve the cordoned community. These justifications, such as those advanced by bioethicist Ross Upschur and philosopher John Stuart Mills, are often steeped in the liberal ethical tradition and couched in the jargon of personal liberty, autonomy, and externalities. Historically, though, liberalism has been more hostile to state-issued quarantines. In the years following the French Revolution, quarantines of communities infected with smallpox sparked numerous popular uprisings in England, France, Italy, and other European states on the grounds that they betrayed enlightenment ideals (Tognotti, 256). Contemporary liberal justifications seem, therefore, an uneasy and paradoxical compromise between foundational liberal principles and the public health.

On the other hand, “relational” approaches to public health ethics understands individuals, not as wholly autonomous agents, but as constructed by and inextricably linked to their communities (Baylis, 202). These approaches offer powerful insights into the communal aspects of quarantine and into communal vulnerability to domination, humiliation and stigmatization by privileged public health decisionmakers. The relational account of the ethics of community quarantines begins with an understanding of individuals as members of communities.

Most fundamentally, cordoned individuals are residents of the same geographic region, but this trait may intersect with other socially and epidemiologically salient characteristics such as class, age, ethnicity, disability, population density, and homelessness. History is rife with examples of quarantines being used explicitly to further disadvantage marginalized communities. Dark-Age sanitary cordons often explicitly prevented Jews, minorities, and lepers from entering (Tognotti, 254) and 19th-century Neapolitan health officials disproportionately restricted the movements of prostitutes and the homeless (Tognotti, 256) to name a couple.

Contemporary liberal theory opposes discriminatory interventions because they denigrate the individual by emphasizing his or her group. This framing is reductive for an ethics of community quarantines because, even in the absence of explicitly unequal quarantine interventions, quarantines may implicitly inflict harm on a particular group. For example, elderly people or those living with disabilities may require medication that is harder to receive within the confines of a community quarantine. Relational theory readily identifies this as an example of a marginalized community experiencing a disadvantage where a dogmatically individualistic mindset may view these as parallel, but discrete cases of individual misfortune.

Relational theory also emphasizes the group membership of those erecting sanitary cordons. Historically, this authority has been afforded to dominant groups, even in cases where the dominant group was not a majority in the location. For example, sanitary cordons throughout Panama were erected by the U.S. in the late 19th and early 20th centuries on pretenses of mitigating harm to Panamanians from syphilis and gonorrhea. Rather than reducing harm, cordoning efforts served more to protect U.S. soldiers from disease, to justify tighter control of Panama, to protect mainland Americans who worried diseases could spread from Panama to the States (as it already had from India to Britain), to reinforce conceptions of Panamanian women as unclean and promiscuous, and to justify the incarceration of suspected Panamanian sex workers (Ahuja, 20). Such examples underscore the dynamics of domination and submission that exist between those erecting a cordon and those excluded by it. Although these policies were justified at the time by reference to a Millian ethical imperative to reduce harm, contemporary liberal scholars would of course cringe in shocked opposition at its implementation. Within the context of a relational ethical framework, however, such an implementation seems increasingly predictable.

I outline four principles, informed by a relational ethic, which prima facie justify the establishment of sanitary cordon: the unharm principle, representativity, reciprocity, and the least restrictive means principle. These principles are meant as relational counterpoints to Upshur’s influential four principles justifying quarantine: the harm principle, transparency, reciprocity, and the least-restrictive means principle.

The unharm principle dictates that sanitary cordons should not reinforce systemic disadvantage and domination however feasible. In particular, this principle implies that domestic stakeholders, rather than outside authorities, should regulate their own quarantines so as to prevent an occupier/occupied dynamic. Representativity mandates particular influence be afforded to the communities most vulnerable to an infectious disease outbreak and to the consequences of a quarantine. Proactive efforts must be undertaken to place representatives of communities disadvantaged socially or vulnerable epidemiologically in positions to understand the nature of the outbreak and decide matters related to the sanitary cordons. This principle is meant to ensure that quarantines are scientifically warranted and to ensure accommodations for quarantined people are responsive to the special vulnerabilities of cordoned sub-communities.

Traditional bioethicist Ross Upshur conceptualizes reciprocity as the obligation to assist cordoned persons in dealing with their confinement through measures such as providing them with “adequate food and shelter” and workplace accommodations. In this framing, public health officials are empowered to pay back quarantined communities “at cost” by ensuring their most basic necessities are met while they are quarantined. A broader, relational definition of reciprocity must insist further that reciprocity be understood within the broader discourse of the population’s obligations to the community prior to an outbreak. To be specific, the right of a city to quarantine its homeless community should go hand in hand with the city’s obligation to tend to the everyday medical concerns of the homeless community, such as substance use, mental health, and malnutrition. Moreover, reciprocity cannot be narrowly understood in terms of so-called “distributive justice,” a conception of justice which places emphasis on individuals’ burdens and benefits. Reciprocity must further encompass a fair dispensation of social benefits such as respect and opportunities within the conceptual framework of “social justice” (Baylis, 202). Similarly, traditional conceptions of the least-restrictive means principle must be reinterpreted through a relational lens and within the broader context of pre-outbreak public health. Insofar as disease outbreaks may be prevented in impoverished communities by access to routine public health measures, such as improved sanitation or anti-smoking efforts, the least-restrictive means principle should be hardest to satisfy among these underserved populations.

Relational frameworks provide unique insights, beyond those of traditional liberal frameworks, into the ethics of sanitary cordons. In particular, they provide a framework for understanding who is empowered to enforce quarantines on whom, ask how conceptions of obligations to the public in an outbreak confers rights in the absence of one, and provide insights into the effects of quarantines on communities (as distinct from individuals). In evaluating the ethics of a particular quarantine, four key principles, rooted in relational theory, must be considered: the unharm principle, representativity, reciprocity, and the least restrictive means principle.