Many of us are familiar with the story of Mary Mallon, better known as "Typhoid Mary." She was a New York resident who around 1907 was forcibly quarantined twice by the city's health department, including for the final two decades of her life. An asymptomatic typhoid fever carrier, she infected numerous people via her job as a cook. Yet she refused to seek other employment or to accept the fact that she had a contagious illness, spurring the need for her quarantine to protect the public.
Over a century later, Washington state recently arrested and jailed a woman with tuberculosis (TB) who had avoided treatment for well over a year. This has raised the question ― when and how can someone be quarantined or forced to undergo medical treatment against their will?
The Tacoma Case
The situation in Washington state involved a Tacoma woman (identified in court documents only as VN) with an active case of TB. The Tacoma–Pierce County health department had been monitoring her since 2022, attempting unsuccessfully to convince her to enter isolation and receive treatment.
In January 2022, the health department brought a court case in which it sought court-ordered quarantine or isolation for VN. The first of such orders was granted on January 19, 2022. VN ignored it and didn't change her behavior.
The health department went back to court, month after month, through all of 2022. The court order was renewed, but VN did not respond. By February 2023, a little over a year later, the health department had been to 15 court hearings, and VN had ignored them all. In desperation, the health department asked the judge to issue a civil arrest warrant to detain VN and order isolation.
The judge agreed and ordered an arrest warrant. A court monitor was assigned to be in touch with the family but was unable to contact them.
By April 2023, law enforcement had become involved. An officer assigned to surveil VN found that she left her home and went on a public city bus to a local casino. The judge issued an order of contempt of court and for involuntary detention.
On June 1, 2023, after 17 court orders, VN was finally located and detained. Law enforcement transported VN to the Pierce County jail, where she was housed "in a room specially equipped for isolation, testing and treatment to reduce the risk of transmission in the jail," according to a statement by Nigel Turner, division director for communicable disease control for the health department.
The judge ordered that she remain in the negative pressure room in the jail for 45 days until she tested negative for TB. On June 15, 2023, the judge extended the detention to July 30, 2023.
How Often Does Society Jail a Contagious Person?
Having to jail someone with a contagious disease is uncommon, and in our freedom-loving society, it is frowned upon, but in rare instances, it's necessary. According to the Tacoma–Pierce County health department, this was only the third time in 20 years that the health department had to seek a court order to detain a contagious patient who refused treatment for TB.
There's a long history of detaining noncompliant patients with TB for the good of the public. New York was the first municipality to do so. It opened a detention facility in 1903. Critics have pointed out that those who are detained are more likely to be homeless and of lower socioeconomic status.
In the 1990s, the courts became more sensitive to the rights to due process of these patients and advised the use of the least restrictive alternatives for patient compliance. These included the suggestion of isolating patients in locked hospital wards rather than jails.
But detaining and isolating someone in order that they not be a threat to the public and forcing them to undergo treatment are very different things.
Courts (and governments) are willing to order quarantines and isolation to protect the public when necessary ― COVID-19 is a good example of this. However, they are usually unwilling to order involuntary treatment. In the United States, mentally competent patients have a general right to refuse medical treatment. As an example, Jehovah's Witnesses believe that blood transfusions are forbidden, and the courts have consistently held that competent adults may refuse a blood transfusion even if it would be lifesaving. (An exception involves cases in which refusal would result in a child's being orphaned.)
In this case, the health department said that they see about 20 active TB cases per year, and almost all patients are willing to be treated. "When we face challenges with a person who does not want to take medication or isolate, we connect with family members, friends, and people in their community to help," noted the Tacoma–Pierce County health department in a statement.
"We work to remove any barriers that may be in the way of them getting the treatment they need. When these options don't work, the Health Department has an obligation to the community and the legal authority to seek a court order to persuade patients to comply," it stated. "In each case like this, we are constantly balancing risk to the public and the civil liberties of the patient. We are always hopeful a patient will choose to comply voluntarily. Seeking to enforce a court order through a civil arrest warrant is always our last resort."
Self-Determination vs Public Health
The balancing act between respecting a person's self-autonomy and protecting the public at large is a complicated one. Our country is premised on freedom and self-determination, and courts would rather not deprive someone of their liberty ― even the liberty to die without treatment, such as those who refuse blood transfusions.
But one's own liberty does not outweigh the safety of the general public. You may be willing to risk your life, but legally, you are not allowed to risk the lives of others. One of the few things that will motivate a court to issue an order as they did in this case is the danger to public health.
The Tacoma Case ―Update
It's unclear why VN originally chose not to be treated. There may have been language or other barriers (she had a translator at her last two hearings). She did agree to undergo treatment after being quarantined.
On June 23, 2023, after VN had been held in jail for 3 weeks, another hearing was held, and the judge issued an order releasing her under certain conditions. She must remain isolated at home under court supervision, and the health department will continue to provide testing and treatment. Will she comply? The judge must believe so. You can follow this case here.
The takeaway is that although personal freedom and the decision whether to be treated for a disease are important rights, protecting the public is more important. Or, in the famous words of Star Trek's Spock, "the needs of the many outweigh the needs of the few." And while someone may be forcibly quarantined to protect the public, being forcibly treated is extremely uncommon.
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Cite this: Woman Jailed for Refusing TB Treatment or Isolation - Medscape - Jun 27, 2023.