The Public Health Ethics of Contagion

The recent film Contagion illustrates the challenges a society may experience when facing a rapidly spreading and highly lethal virus. Director Steven Soderbergh carefully constructed the film to reflect a realistic public health and medical response to a severe pandemic. Many of the technical public health aspects of the film are believably depicted; the disease transmission pathways demonstrated in the film are plausible, for example, and the core issues discussed by public health officials also are both credible and accurate. Included in the latter are relevant comments about the epidemiological investigation and such basic infection control measures as social distancing and the frequent washing of hands.

The public panic and social disruption represented also are certainly possible, particularly about the problems likely when dealing with such a lethal and fast moving pandemic. However, there is one implausible scene in which vaccine allocation is depicted more or less as a lottery system. Although that scene may add to the film’s dramatic impact, it does not do justice to the painstaking processes actually used to prioritize and allocate the limited medical countermeasures likely to be available, particularly during the early stages of a public health emergency.

When making these types of decisions in a real-life situation, there are several essential ethical principles that must be considered. These values fall into two broad ethical “value” categories: (a) substantive; and (b) procedural. Substantive values are those that drive the actions taken and/or positions promoted – including, but not limited to, such basic principles as trust and fairness. Procedural values encompass the standards used – accountability and transparency, primarily – in making important decisions. When procedural values are properly used, they promote substantive values. For example, when the public sees that leaders are establishing accountability and maintaining transparency, it becomes much easier to trust other actions taken by those same leaders.

In Contagion, though, the lottery system mentioned earlier, although intended to provide the limited supply of vaccine to the public as it becomes available, was not entirely plausible. A random date was selected, and those born on that day were offered the vaccine. The randomness of the system – one chance in 365 of being selected – was an obvious effort to at least seem to establish fairness. However, there are and should be other ethical values to take into consideration in such a scenario. Prominent among those values are public protection and reciprocity. In addition, the isolation and quarantine measures depicted in the film raise some “interesting” – some would say disturbing – questions about individual liberty.

Vaccination Prioritization: The “Public Protection” Value

The ethical principle known as “public protection” suggests that particular emphasis should almost always be placed on accomplishing the greatest good for the largest number of people in a given community. That guideline, however, does not always translate directly into what seems to be best for each and every individual, if only because at least some people at risk will, out of necessity, be prioritized higher or lower than others based on the overall risks and benefits at stake for the community’s overall population.

In the United States, the primary group of experts who guide vaccination decisions are the 15 members of the Advisory Committee on Immunization Practices (ACIP), who are appointed by the Secretary of the U.S. Department of Health and Human Services to specifically provide such guidance on vaccine-preventable diseases. Those 15 people are selected primarily because of their expertise in disciplines related to immunizations. Applying factual processes to the Contagion scenario would almost certainly result in a very different vaccine prioritization method than what is depicted in the film.

During a pandemic, the impact of the disease on all segments of the population is first carefully, and comprehensively, evaluated and the population groups considered to be at increased risk of severe outcomes are then determined. ACIP carefully reviews all of the information available and then makes the recommendations used to guide state and local vaccination program policies. Probably the best recent example of how the system works is how the ACIP members determined who should be in the “Vaccine Priority Groups” for the H1N1 Influenza Vaccination. Long-standing members of the Seasonal Influenza Vaccine Priority Groups are people over 50 years old. However, that group was not included among the H1N1 Influenza Vaccine Priority Groups because the information available at the time suggested they were at a lower risk of infection than the members of certain other groups such as young children and pregnant women.

Healthcare Worker Protection: The “Reciprocity” Value

In Contagion, Lawrence Fishburne plays a CDC (Centers for Disease Control and Prevention) physician named Dr. Ellis Cheever. As a healthcare worker and public health official, he was provided, quite properly, his own high-priority vaccination. He then chose to pass his vaccine on to the child of a friend. But that scene raised at least two important questions in the minds of a number of moviegoers: (a) Should a healthcare worker have special consideration and receive his or her vaccination before others do? (b) Is it more important for a physician to be vaccinated than a child?

ACIP typically includes healthcare workers as a Vaccine Priority Group – for several reasons. To begin with, healthcare workers and EMS (emergency medical services) workers in general, are at increased risk of infection during pandemics; in addition, they also pose an infection risk to vulnerable patients under their care. An increase in healthcare worker absenteeism during a pandemic also diminishes healthcare system capacity during a time of particularly high demand. The primary ethical principle applicable in such situations is called “reciprocity” – which in practice means that, for those who bear a disproportionate share of the risk while they are serving others, it is reasonable and right to reciprocate and “pay them back,” in a sense, for the added risk they carry by offering them additional protection. Such reciprocity extends beyond vaccination, of course, to any measure that reduces their risk – including the allocation of personal protective equipment and provision of family support.

Isolation and Quarantine: The “Individual Liberty” Value

It is important to distinguish between isolation and quarantine. Although both are intended to reduce the spread of disease, they are fundamentally different policies. Isolation is separating sick individuals from those who are well. Quarantine is separating those who are well, or at least seem to be, but may have been exposed, from those who are well and have not been exposed. Both processes, isolation and quarantine, are portrayed in Contagion. However, isolation is a relatively common process and is used regularly in healthcare today; quarantine, though, is less frequently used and is far more controversial.

The legal and political authority for quarantine in the United States is rooted in the Commerce Clause of the Constitution, which states, among other things, that Congress has the power to make “all laws which shall be necessary and proper” to regulate commerce with foreign nations. That statement has been and is interpreted to include the assurance of “public health” as it relates to persons arriving at U.S. ports of entry (land, sea, or air). The CDC is the agency responsible for maintaining the nation’s quarantine capacity and has in fact established twenty quarantine stations across the country. However, if an infected individual passes through customs without displaying symptoms, or if an illness originates within the United States itself, there are several other relatively broad public health laws in place that provide the authority needed by local and state public health officials to institute the restrictive measures that might well be needed.

In Contagion, the character Beth Emhoff (played by Gwyneth Paltrow) returns from Hong Kong to the United States through Chicago. She has already unknowingly been infected, but is not yet symptomatic. In reality, if she had been symptomatic she might have been retained at the quarantine station for observation.

After arriving home in Minneapolis she collapses and is rushed to the hospital with a mysterious illness. The depiction of the isolation and quarantine activities that follow is legally plausible – but in practice it raises a myriad of social, political, and philosophical issues. The quarantine measures portrayed in the movie challenge the most fundamental precept of democratic nations: the ethical principle of individual liberty. Although there are public health precedents that strike what seems to be a common-sense balance between public health and individual liberties – e.g., laws demanding that active tuberculosis patients receive treatment, and that public water supplies be fluoridated – the practicality of imposing a truly large-scale quarantine is questionable.

The actual international epidemic that most closely resembles the Contagion scenario is the 2003 severe acute respiratory syndrome (SARS) outbreak. The lessons learned from the quarantine efforts associated with SARS underscore the difficulties caused by and acceptability of restrictive measures imposed to assure public health. Public resistance increases dramatically as the scope of quarantine measures expands. History has shown that, when citizens hear that a widespread quarantine is coming, a common reaction is to flee the area to maintain personal autonomy. But that response, of course, can quickly and directly result in further spread of the disease. The complete quarantine of a major geographic area, another possible “solution,” also would create unmanageable logistical challenges that would leave government officials responsible for the care and feeding of an almost totally immobilized population.

There is a difficult balance rarely accomplished by film makers. Documentaries may effectively, and accurately, present the technical details of health and medical issues – but those impersonal presentations seldom ignite the imagination or stir the emotions. On the other hand, films that stimulate the imagination are often so implausible that almost nothing useful can be gleaned.

Fortunately for the nation’s moviegoers, Contagion strikes a reasonable balance. Although some aspects of the film are implausible and/or impractical, the film does a reasonably good job outlining and illustrating many of the key public health issues associated with biosecurity. In addition, by doing so, it provides the excellent context needed for an ethical real-life dialogue that must be continued.