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Individual Freedom or Public Health: What is the Priority?

April 10, 2012

In May 2007 a man in the United States boarded on a series of commercial flights to spend his honeymoon in Europe (full story here). By the time he landed in Rome he had made it on the top of the wanted list of health officials around the world: the man had been found to have multi-drug resistant tuberculosis. TB is highly infective and this particular form is resistant to a series of medicine which makes its treatment difficult, cumbersome and expensive.

So if he had TB, which is spread through air droplets, why was he allowed to fly? The hospital who detected the case stated the man had be warned not to leave the country, however no legal orders was issued to prevent the man from flying abroad. The man responded that health officials had advised him not to travel but they did not prohibit him to do so and encourage to take any precautionary measure. Wherever the truth lies, this case epitomizes one the key ethical dilemma in the health community: to what extent can the freedom of an individual be restricted when his/her behavior might endanger the health of the wider population?

Health authorities in the US did not issue a legal order to stay in the country because at the time before his departure the infection had not been confirmed by laboratory tests: hence, on the basis of the country legislation, there was no ground to limit his freedom to fly. When he arrived in Montreal and was put in isolation, some experts talked of an over-reaction  of the health authorities. As this case shows, at present the position the international health community is decisively tilted in favor of individual rights when it comes to chose between individual freedom and public health.

Nowhere is this debate more heated than in the HIV/AIDS arena. Given the discrimination attached to being HIV positive, the fight to recognize the human rights of those infected can be considered one of the main achievement of the gay communities in the West, which were the first to suffer from HIV related stigma. As a consequence of this fight, the HIV discourse is today premised upon the gentle persuasion of individuals rather than their constriction, which has been for long an essential characteristic of any public health intervention. There are some cases, however, where the attempt to preserve the individual freedom at any cost can actually do a lot of harm to the health of the generic population.

Imagine this scenario: a government wants to know more about the sexual behavior of young people in the country. Put this against the background of a low HIV prevalence  among the general population and of an increasing number of young people who is abandoning the traditional, very conservative sexual behaviors of their parents to engage in high risk practices likely to get them infected. On this basis, the ministry of health wants to know at what age they have sex, with whom, how, how many times: questions which allows to know your epidemic but at the same time concerns the very private life of the individual. Imagine now that with this purpose in mind the MoH design a questionnaire to be administered to young people in schools. When it comes to administer the questionnaire, school directors and parents rise against the questionnaire which contains the word sex, a taboo in the society. As a result the word sexual intercourse is substitute with intimate relationship and the use of injecting drugs with the consumption of energy drinks. The intended recipients are not persuaded and therefore their consent is lacking: as a result the survey is watered down to buy the approval of the individuals  and is purged of its most sensitive questions. Unfortunately, these very sensitive questions are the only ones which can allow an understanding of whether young people are at risk of getting infected or not.

Where to draw the line between individual rights and freedom and public health is the responsibility of the specific society or government. Foreign technical experts have very little say in it. However, when the balance is tipped disproportionally in favor of individual rights one must bear in mind that there is a cost to be paid: the absence of information which could benefit public health. It would be naïve and dangerous to think that defense at any cost of the individuals’ freedom to disclose or not disclose personal information comes without any tradeoff.

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