All US states provide for isolation, or quarantine by statute. This is a typical example of a state statute that provides authority for public health officers. Legal authority for quarantine, and I would like to emphasize several words in this passage. The authority extends to isolate, and treat persons afflicted with a communicable disease, who are either unable, or unwilling to observe the department's rules and regulations. This is the essence of public health authority. I also want to emphasize the last phrase. It says exposed to a disease. Exposed to a disease communicable to man. That means the quarantine authority need not rely on someone already having the disease. A quarantine order can be issued if someone has merely been exposed to a disease, and we don't know yet whether the person will develop the disease. These are old statutes. Incidentally, we're using legislation that was first developed in the 19th century. But the legal authority for public health officials extends to all manner of communicable disease, including Ebola. It's an authority that's granted to the public health department of the state. It can issue quarantines without the need for judicial approval. If it needs to enforce an order for a non-compliant patient, for example. At that point, the department can petition a court to involve law enforcement, including an arrest warrant, and confinement. In the US, patients have substantial due process protections, because the use of quarantine, or isolation can severely restrict civil liberties. Individuals have rights to due process of law, and generally isolation, or quarantine, must be carried out in the least restrictive setting necessary to maintain public health. On the other hand, societal rights are also significant, namely a right to be protected from individuals who pose public health threats. Courts weigh these in many different contexts, when conflicts between individuals, and government authority occur. But with respect to public health orders, the judicial role here is quite limited. The most widely discussed example to date, however, has been the case of a health worker subject to strict quarantine orders, imposed first by the state of New Jersey. Where the returning health worker was detained at an airport, and then by the state of Maine, where she was ordered into home confinement. The health worker had no symptoms throughout the quarantine, and never developed the disease. The quarantine order in Maine, was a judicial modification of a public health order. A state judge ruled that public health officials had not proved, by clear and convincing evidence, that limiting respondents movements to the degree requested was needed to protect the public. The modification eased the most stringent aspect of the order, home seclusion for three weeks, while retaining monitoring and social distancing aspects of the quarantine order consistent with CDC recommendations. Medical groups argued that automatic quarantines of three week, for persons displaying no symptoms, will discourage health care workers from traveling to Ebola stricken countries. Maine on the other hand, and other states, contend that such restrictions are necessary to protect the public health. States that provide more stringent quarantine measures then recommended by the CDC, include not only New Jersey, and New York, but also Georgia. And I will use Georgia as an example. If a traveler arriving at the Atlanta airport shows symptoms, they are isolated immediately. But if they show now symptoms, quarantine orders depend upon the risk of exposure. What is considered category 1, high risk, and that is travelers with known direct exposure to an Ebola patient, will be subjected to quarantine at a designated facility. The third category, medical personnel actively involved in treating Ebola patients returning to the United States, means that individuals in this category, are issued a 21-day active monitoring order, and will be visually monitored by public health twice per day. Georgia public health authorities will assess the development of symptoms, and adjust restrictions as necessary. Noncompliance with these directives would result in quarantine at a state designated facility. Note once again, state laws are primary here. The federal government acts only at the immediate entry point of a border. I would also like to point out, however, a concept known as private bordering. Institutions, such as Emory Healthcare, have their own policies with respect to employees. Particularly for travel, work restrictions upon return, and for compensation, and leave policies. This is not law in the sense that we are speaking of, but it is an important aspect of a response to Ebola. While quarantine laws have generated much discussion, and media attention in the United States, public health law is a broad term, and applies to many other aspects of treating, and controlling Ebola. I will briefly mention other areas of law relevant to communicable disease. The first of these is safety of health workers. The Federal Occupational Safety and Health Administration sets safety standards to protect hospital workers, and can fine hospitals, and other health care facilities for violation of those standards. Manufacturers of protective suits may also face liability by health workers, if it is proved that the protective gear was manufactured, or designed defectively. A recent lawsuit seeks damages from a manufacturer over claims that its surgical gowns protected against Ebola, when allegedly the gowns had failed industry standards. Health workers who allege inadequate training by their employers may be limited to worker compensation systems, but those claims are of importance in terms of the legal system. Second, we should say a few words about legal standards for contact tracing. Contact tracing is a very important part of public health control measures. Inevitably, tracing contacts of someone who's been exposed to the Ebola virus, compromises privacy rights, by the need to divulge the name of the patient who may have exposed others. Public health officials, and health care providers are required to report the names of persons for a number of specific diseases, including Ebola. Healthcare providers are very familiar with rules governing the confidentiality of health records, and patient identifying information. Health information privacy is governed by the Federal Health Insurance Portability and Accountability Act of 1996, commonly referred to as HIPAA. Regulations under HIPAA are quite detailed. The most relevant exceptions authorize healthcare providers to release information to public health departments as required by state law, and for law enforcement purposes. Private health care providers, and public health officials may communicate with each other about specific patients, and indeed public health workers by necessity, divulge the name of a patient when tracing context. Another aspect of law that relates to communicable disease, is concerned with the right of an individual to consent to medical treatment or screening. What if a person who is suspected of having a contagious disease, such as Ebola, refuses to be tested or treated? In the United States, competent adults generally have the right to refuse medical treatment. Although a patient suffering from a disease, such as Ebola, is unlikely to refuse treatment, one can imagine instances in which a patient might refuse to be tested or screened. A positive test means that the person is then labelled, and potentially ostracized in public, and social relations. That person is also subject to significant restrictions on liberty, even if a cure, or treatment is not available. If there is no cure or treatment, then the primary purpose of testing, is to segregate sick persons from well persons, in order to contain the disease. Healthcare workers can be required to submit to testing for the protection of patients. HIV testing practices, for example, are regulated by state laws. The controversy over HIV testing, in cases of occupational exposure, is reflected in inconsistencies, and variations in state laws, and policies. Involuntary testing, or screening has the potential to infringe upon US Constitutional freedoms. Such as an unreasonable search under the Fourth Amendment, an invasion of privacy,or discrimination, under the Fourteenth Amendment. 'Danger to public health has always been regarded as a sufficient ground for the exercise of police power in restraint of a person's liberty. The only limits on the exercise of this power are, that the regulation must have some reasonable relation to the public health. Nonetheless, in a public health emergency, involuntary testing would likely be justified on the ground that the individual poses an unwarranted danger to the general public. Courts tend to defer to medical professionals on these issues. Health officials likely could, for example, require screening or testing for anyone wishing to leave a quarantined area. Not everyone, potentially exposed to the disease, will inform healthcare workers for fear that he or she will be quarantined, stigmatized or lose employment. Remedies for civil rights violations by public health officials are also limited by the doctrine known as sovereign immunity. And this means, as a general rule, police officers, and public health officials can not be sued personally for actions taken in a good-faith belief of public necessity, including the enforcement of a quarantine order. Next, I would like to briefly address the question, is there a duty to treat an Ebola patient? For hospitals, the answer is yes. Hospital emergency rooms may not turn away any patient until the patient's condition is assessed, and stabilized. The Emergency Medical Treatment and Labor Ac,t known as EMTALA, is a federal law that requires anyone coming to an emergency department to be stabilized, and treated, regardless of their insurance status, or ability to pay. Hospitals may not transfer, or discharge patients needing emergency treatment, except with the informed consent, which is itself a legal doctrine, or stabilization of the patient, or when their condition requires transfer to a hospital better equipped to administer the treatment. Emory University Hospital, for example, has its own guidelines, and procedures for treatment of contagious disease. As well as, especially created isolation unit with rigorous protocols. Staff members who do not comply with these rules could be fired, or sanctioned. Suppliers can be monitored by the hospital, and other safety measures imposed, that are specific to the institution. Outside of the requirements of EMTALA, as a general rule, medical professionals can refuse to treat patients in many circumstances. Because medicine is highly regulated, however, physicians do not have unlimited discretion to refuse to accept a person as a new patient. Physician's cannot refuse to accept a person for ethnic, racial, or religious reasons. Nor can they discriminate based on the person's sex, unless the sex of the patient is relevant to the physician's specialty. Outside of these protected areas, physicians have latitude in refusing to accept persons as patients. This means that patients usually could not win a lawsuit against the medical professional for refusing to treat him or her. But refusing to treat a patient could result in termination of employment, depending upon the policies of the employer. More importantly, refusal to treat, raises ethical, and professional concerns, as well as, the possibility of sanctions by a state medical board. Finally, I want to discuss the concept of a public health emergency. A public health emergency can be declared by the governor of a state. No state in the United States has declared the Ebola virus to be a public health emergency. But in the event of the declaration of a public health emergency in some other contingency, such as a wide spread flu. By statute, the state's public health powers are significantly expanded. Following the declaration of a public health emergency, the governor has broad powers, among those including the following. To perform, and exercise any functions deemed necessary to promote, and secure the safety, and protection of the civilian population. Commandeer, or utilize any private property, if the governor finds this necessary to cope with the emergency, or disaster. And compel a health care facility, to provide services, or the use of its facility, if such services, or use are reasonable, and necessary for emergency response. And finally, the governor can direct, and compel the evacuation of all, or part of the population, from any area within the state, if he, or she deems this action necessary for the preservation of life. In this session, we have considered an overview of some of the major issues of public health law in the United States. We've focused on quarantine, and isolation authority, which again, is primarily in state government with state public health officials in the lead. We focused on this for several reasons. First of all, it illustrates the unique brand of federalism within the United States. In which, the states, and not the federal government have primary control over public health issues. Quarantine, and isolation has also been a matter of public dispute, and media attention. These measures are deemed essential by public health officials, and it is their careful application. That requires great professionalism, and ethical responsibility.
