The American Journal of Bioethics, 9(11): 4–14, 2009

Copyright
c Taylor & Francis Group, LLC

ISSN: 1526-5161 print / 1536-0075 online
DOI: 10.1080/15265160903197531

Target Article

“Listen to the People”: Public

Deliberation About Social Distancing
Measures in a Pandemic
Nancy M. Baum, University of Michigan School of Public Health
Peter D. Jacobson, University of Michigan School of Public Health
Susan D. Goold, University of Michigan Medical School

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health
orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing
measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures
are prolonged. They shared opposition to closure of religious organizations, citing the need for shared support and worship during times of crises. Group discussions
elicited evidence of community-mindedness (e.g., recognition of an extant duty not to infect others), while some also acknowledged strong self-interest. Participants
conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement
and sustain due to strains on family resources and lack of trust in government.
Keywords: health policy, population, public health

A classic tension exists in public health practice between ef- pandemic preparedness, and those have focused largely on
forts to ensure the health and safety of communities while si- setting priorities for the allocation of scarce resources dur-
multaneously respecting the liberties of individuals within ing a pandemic (US CDC 2007; Keystone Center for Science
those communities (Gostin 2000). Nowhere is this tension and Public Policy 2005). Little has focused on policy deci-
more apparent than in pandemic planning and response. As sions about implementing social distancing measures. The
we have seen in the current response to the H1N1 influenza empirical study reported here moves beyond the concep-
outbreak, public health officials implement a variety of so- tual discussions in the literature. It adds to the limited data
cial distancing measures (e.g., school and business closures, that assesses public responses to the ethical issues raised by
quarantine) in communities to contain contagion. In do- social distancing measures likely to be employed during a
ing so, these measures limit personal freedoms and may pandemic.
create serious ethical challenges for institutions and larger Public involvement in policy decisions can occur in a
communities (Gostin 2006; Schuklenk and Gartland 2006; number of ways. We conducted an exploratory study using
Thompson et al. 2006; Zhang et al. 2006; Kotalik 2005). deliberative procedures to characterize public perceptions
Public engagement in difficult, ethically laden planning about social distancing measures likely to be implemented
decisions may be an important element of transparent pro- during a pandemic. Deliberative procedures involve rep-
cesses, help create public trust in the health care system, resentative groups in informed discussions about issues
improve voluntary compliance with public health orders, that directly affect them (Goold et al. 2007; Abelson et al.,
and ultimately, contribute to just outcomes. Conceptually, 2003a; 2003b). A central tenet of deliberation is that free
the literature on pandemic planning recognizes the need and equal individuals, often with dissimilar perspectives,
to engage the public in the planning process to make eth- join together in discussion with the opportunity to gain
ically tenable decisions (Kass et al. 2008; Keystone Center a deeper understanding of policy issues and the various
for Science and Public Policy. 2005; 2007; Lemon et al. 2007; contexts, understandings and points of view, and possi-
Thomas et al. 2007; DeCoster 2006; Kotalik 2005; University bly reach a consensus on a recommended course of action.
of Toronto Joint Centre for Bioethics 2005). Yet despite this Egalitarian principles form the basis for equal opportuni-
awareness in the literature, there have been few opportu- ties for participation and reduction of existing social power
nities for public participation in policy making related to structures, allowing participants to work together as equals

The authors would like to thank Bruce A. Cadwallender for his insights and expertise in emergency preparedness and response, Rosalind
E. Keith for assistance in coding, and the members of the public in Southeast Michigan who participated in these focus groups.
Address correspondence to Nancy M. Baum, University of Michigan School of Public Health, Health Management and Policy, 109
Observatory, Ann Arbor, MI 48109. E-mail: nmbaum@umich.edu

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 Social-Distancing Measures

(Elster 1998; Manin et al. 1987). When participants of equal

moral standing disagree about issues, they may be able to Table 1. Participant characteristics (n = 37)
maintain mutual respect for one another in a deliberative
process (Gutmann and Thompson, 2002). Individual views Characteristic Value
may change based on the arguments of others (Miller 2003) Median age† 43 yrs
and individuals with disparate views on an issue may be Women 73%
able to agree on what is fair or what is in the common in- Employed 81%
terest. It is, in part, this capacity for public-mindedness that Parenting young children 51%
makes deliberative processes particularly well suited for Health care workers† 15%
addressing the difficult, value-laden public health issues Race†
raised in pandemic planning for implementing quarantine African American 25%
and other social distancing measures. Caucasian 72%
To some scholars, deliberation does more than con- American Indian 3%
tribute to better decisions; it may be necessary to reach truly Native Hawaiian/Pacific Islander 0%
just decisions. Through deliberation, individuals consent to Latino 0%
certain decisions that affect them, and transparent, explicit Other 3%
reasoning typical of deliberative processes allows this type Education†
of consent (Fleck 1991). The idea that individuals should High school 9%
be able to see, understand and authorize the process that Some college 38%
governs them is a powerful attestation to the principle of Bachelor’s degree 38%
respect for individuals. Deliberation is expected to improve Master’s degree or more 16%
the accountability of decision-makers to the participants or Insured at time of focus group† 84%
to the community at large, and it may help increase the legit- Uninsured within last year† 25%
imacy of a decision and public trust in the decision-making
process (Lenaghan 1999). †
n = 32.
One objective of this study was to evaluate public will- Participants self-identified race and chose all that applied from: African
American, Caucasian, American Indian, Native Hawaiian/Pacific Islander,
ingness to accept and comply with social distancing mea-
Asian, Latino, Other.
sures likely to be imposed during a pandemic as well as
understand diverse points of view on challenging ethical
questions for public health practitioners. Closing public Q1 : Would you support the closing of schools and daycare centers
gatherings and imposing quarantine are expected to have before the pandemic strikes your community? Your state? Why or
protective individual effects (Hsieh, et al. 2005), but they why not? Would you support the closing of worksites? Of religious
aim, ultimately, to protect the larger community from the organization meetings?
effects of infectious disease.
Q2 : Would you support school/work/religious closings for a sustained
period of time (e.g., three weeks)? Why or why not?
METHODS
In the summer of 2008 we convened four focus groups with Q3 : Would you support encouraging those who have been exposed to
37 members of the public from four counties in Southeast the flu but who are not yet sick to stay home from work and school?
Michigan to evaluate their willingness to accept measures Why or why not?
intended to control contagion and reduce morbidity and
Q4 : Would you support quarantine or travel restrictions for those
mortality in an influenza pandemic. Each group included
exposed to the flu? Why or why not?
8 to 10 adults, and lasted approximately 90 minutes. We
recruited participants by distributing flyers directly to day- Q5 : What is your advice to policy makers?
care centers and places of worship, and posting flyers in
public venues including retail stores, coffee shops, libraries These questions were followed by probes to follow-
and community centers. We posted electronic messages on up participants’ comments and arguments. A professional
craigslist (available at: www.craigslist.org) and ran adver- facilitator led the participants in discussion. Discussion
tisements in area newspapers. Groups were selected to in- opened with factual questions about previous experiences
clude some participants who were employed, and some with disasters, asked in a round-robin fashion to engage all
who were parenting young children (school-age, or in pre- participants early in the session. After a short educational
school or daycare) in order to generate rich discussion about session about influenza and pandemics, the facilitator en-
the effects of pandemic response policies on the workplace couraged participants to discuss reactions to social distanc-
and the level of support for school and daycare closure dur- ing measures likely to be put in place during a pandemic
ing a pandemic. (Table 1 lists participant characteristics.) (Q1−5 ). All focus group discussions were recorded and tran-
After thorough review of the literature on social distanc- scribed verbatim.
ing measures likely to be implemented during a pandemic, We conducted qualitative, thematic analysis of the dis-
we developed a discussion protocol, which included the cussion data (Creswell 2006; Krueger 1998; Weber 1990).
following main questions: After multiple readings of the transcripts, two researchers

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(NMB and SDG) developed a codebook by classifying home so you’re affecting a lot more than people getting sick, you’ve
emergent themes into categories of codes. The codebook just affected a huge financial workings to the bulk of the country.
included inclusion and exclusion criteria and relevant ex- That’s a big decision.
amples. We developed the codes interactively following
close reading and comparison of the text, and discussed to- Some feared that economic pressures to go to work would
gether the new themes and sub-themes suggested by the lead to unsafe situations, such as children left home unat-
data. Researchers (NMB and REK) then coded all focus tended, or would further spread disease by unsupervised
group transcripts. After initial coding, the researchers com- teenagers intent on socializing despite school or business
pared coding decisions for two of the four transcripts, and closures. One mother added:
disagreement about coding decisions was discussed until
My high schooler will not stay home. I mean she would not self-stay
agreement was reached. The codebook was modified to re-
home or allow me to tell her to stay home. . . . she’s got work to do,
flect new insights, and we then recoded all four transcripts. stuff to do . . . so that’s from a parent of an older kid. It won’t work
The codebook and transcripts were imported into NVIVO (laughs).
Qualitative Software Version 8, 2008 (QSR International Pty
Ltd.) to facilitate nuanced analyses.
Religious Concerns
RESULTS
Some participants in all four groups shared opposition to
In focus group discussions, participants appeared to un-
mandatory closure of religious organizations during a pan-
derstand many aspects of the potential morbidity and mor-
demic. They cited the importance of religious communities
tality risks associated with an influenza pandemic. Indeed,
for support, for opportunities to worship and pray together
they expressed fear quite openly during their immediate re-
during crises. One remarked:
sponses to the pandemic information. One participant said,
“. . . it takes months to develop the vaccine but it’s in hours that I don’t know, I think people should have the choice if they need to
it’s going to happen, so it doesn’t seem like it matches up very go to church for whatever reason at this time, this kind of thing and
well, so it’s pretty scary.” Even with this understanding, par- they’re going to make the choice I guess to go out. That might be a
ticipants expressed many concerns about the economic and place that they need to go.
other burdens associated with proposed social distancing
measures such as the closing of schools, businesses and re- Participants also shared concerns that religious gatherings
ligious organizations. (Illustrative participant quotes are in may be important venues for information sharing during
italics below and in Table 2.) times when community fear is high. Some wanted religious
institutions to have the freedom to choose whether to re-
Economic Burdens main open during a pandemic. One participant commented,
Immediate economic needs, job security, the need for es- “Seems like those places would make the decision themselves to
sential goods and services, and long-term effects on the close though, rather than having the government tell them they
economy from extended business or school closure or quar- have to close down.” The financial fragility of religious orga-
antine were among concerns addressed in all four group nizations was also a concern, with mandatory closure seen
discussions. For example, several parents, especially in two as a financial hardship for many institutions.
groups held in lower-income communities, viewed stay- In contrast, a small minority of participants argued in
ing home from work to care for children during school or support of the closing of churches, synagogues and mosques
daycare closures as a “luxury” not all families could afford during a pandemic, considering religious gatherings to be
and still “pay the bills”. Similarly some worried that staying optional activities and dangerous environments conducive
home from work, either to care for children or for illness, for transmission. One participant shared the following
could lead to loss of a job: perspective:

Right now a lot of people are afraid of losing their jobs so they work . . . you cannot allow people to come together because it will cause
while they’re sick. They’re pushing themselves afraid of losing their more fatalities and then they’ll go to the health care workers. The
jobs if they don’t show up, so I think there would have to be some kind health care workers will be dropping like flies in a true pandemic and
of legal, something legal in place so fear would not put people in the you cannot, you have to disallow any group meetings or you will just
worst way. continue to spread the virus. It’s a very cold thing to say, I realize
that but it’s a very realistic thing to say . . . Do we sacrifice health
Participants readily identified elements of the economy, care workers so that they can have religion?
such as grocery stores, as important societal infrastructure
that must be maintained during other closures. Many feared
that extended closure of schools or businesses would ir- Community-Mindedness
reparably damage an already fragile economy. One partici-
Group discussions elicited evidence of community-
pant said:
mindedness (e.g., recognition of an extant duty not to infect
If you shut down the schools though, you’ve basically shut down the others). Some participants described their own intentions
economy because you’d have to have, then people would have to stay regarding responsible actions, while others commented on

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Table 2. Focus group discussion themes

Economic burdens associated with school and “Right now a lot of people are afraid of losing their jobs so
business closure. Concerns about job security, they work while they’re sick. They’re pushing themselves
long-term effects on the economy and afraid of losing their jobs if they don’t show up, so I think
childcare needs. there would have to be some kind of legal, something legal
in place so fear would not put people in the worst way.”
“. . . if they keep your kids home from school so you can’t
work, people are going to go, ‘I can’t do that, you know, I
have to go to work, I have to have somebody take care of
my kids’ . . . some people might choose to keep their kids
home from school if they had that luxury, but too many
people now don’t.”
“If you shut down the schools though, you’ve basically shut
down the economy because you’d have to have, then
people would have to stay home so you’re affecting a lot
more than people getting sick, you’ve just affected a huge
financial workings to the bulk of the country. That’s a big
decision.” “
“My only concern would be that would be some parents
who can’t get off of work and you’re going to have a lot of
child care issues coming up and that could mean people
you know, maybe losing their jobs if they have to stay
home with their kids. So there has to be some help for the
parents . . . ”
“My high schooler will not stay home. I mean she would
not self-stay home or allow me to tell her to stay home.
. . . she’s got work to do, stuff to do . . . so that’s from a
parent of an older kid. It won’t work (laughs).”
Religious institutions are vital during “I personally feel that that churches, temples, synagogues
emergencies. whatever should remain open. I mean if it’s a pandemic
and there’s marshal law imposed, you know, the populous
is going to be in a panic, in a state of collapse and people
are going to turn to their, in large numbers, turn to their
faith to sustain them which you know, many faiths
although, although almost all faiths that I’m familiar with
support worship outside of the temple, you know, they’re
going to want to be a gathering.”
“I don’t know, I think people should have the choice if they
need to go to church for whatever reason at this time, this
kind of thing and they’re going to make the choice I guess
to go out. That might be a place that they need to go.”
“Seems like those places would make the decision
themselves to close though rather than having the
government tell them they have to close down”
In contrast, religious gatherings should be “. . . you cannot allow people to come together because it
closed. will cause more fatalities and then they’ll go to the health
care workers. The health care workers will be dropping
like flies in a true pandemic and you cannot, you have to
disallow any group meetings or you will just continue to
spread the virus. It’s a very cold thing to say, I realize that
but it’s a very realistic thing to say. . . . Do we sacrifice
health care workers so that they can have religion?”
(Continued on next page)

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Table 2. Focus group discussion themes (Continued)

Evidence of community mindedness in terms of “. . . you know, if you can’t go to church for one week because
containing contagion. everyone’s sick, then you know, call everybody on the phone or
something. Do something different for the good of everybody else,
you may have to suffer a little bit here and there.”
“Well my thing is, I work at Tim Horton’s so I do not want to spread
it to anybody else nor do I want them to come to me and then give it
to my family. . . ”
“I have a family too and I want to protect my own family so my thing
is the best thing for us right now is I want you going nowhere, I
want you right here, locking you up, I don’t know how you’re going
to do it or I don’t know how they’re going to do it? Lock the house,
shut the house down, you know, but I don’t want you to go and
infect and hurt nobody else.”
“I agree there has to be a plan and that plan has to be stuck to, no
matter what but the plan can’t be created based on popularity and
what, you know, what will make the most people happy because
what will make the most people happy is certainly not the common
good.”
“I mean, the financial struggle of the church and employees of the
church would face would obviously be a concern but I would think
that in the interest of the greater good of the community, that would
be one choice where you could say, you know, you could call your
pastor on the phone or if you need some spiritual guidance or
whatever. . . ”
In contrast, some clear statements of self-interest. “You’d have people, you know, mowing over each other to get to the
front of the line. I mean I think, maybe I’m just thinking the worst
of people . . . so I’m going to do what I’m going to do because I’ve
got to take care of myself.”
“We always think of self first and that’s being real about it. I’m not
thinking about if you going to be okay. . . I mean frankly speaking,
you know, that’s being honest and right then and there, we’re not
thinking about let me save the world.”
Desire for public education and opportunities for “Well I’ve been a resident for 7 years and I’ve never seen anything
public input in policy decisions. from the health department about anything in the mail. I’ve never
read anything about, even when the bird scare came. . . . I think
there’s not enough prevention and education . . . where’s the
prevention and education, accountability and responsibility to
educate people?”
“I think it’d also be really important that community education is
emphasized. So many people think, “oh the flu, you know, I’ve lived
through it before” but I think just the way we were talking earlier,
to really understand the severity of it and you know, what can
happen and how easily it can be spread. I think the education
process would be very important.”
“Now they need to be doing documentaries to educate people about
the potential, about what has happened in the past and about what
the plan would be. So that needs to start, you know, early so people
know what the possibilities are and what can be done.”
“Listen to the people. Groups like this are important. The public have
[sic] well meaning opinions that the policy makers may not know.
Listen to the people.”
“Focus groups are important. Listen to the average citizens. If there
are task forces, citizens should be on each task force.”
(Continued on next page)

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Table 2. Focus group discussion themes (Continued)

Illness must be an imminent threat to endure “I would say yes but I would have to see if it’s like, how far it’s gone
hardships associated with closures and travel so far you know what I mean, before you close your schools because
restrictions. of the mess there’s going to be.”
“. . . that right now it’s in some third world country and it may come
here. I don’t think that’s going to be good enough. I think there’s
going to have to be some indication that it is actually in your own
community before you take steps as drastic as shutting down
anything.”
“I’d have to see some evidence that this is really going to affect our
community. Other than that, I don’t, I wouldn’t see keeping them
out for an extended period of time for their own benefit, for the
benefit of the educators and the benefit of the parents.”
“. . . So if it hasn’t hit Michigan yet, I mean who can afford just to
take off their jobs and stop their whole world if it’s not even here
yet. Now after it’s here, that’s another issue, but if it’s not even here
yet, no.”
Distrust in government. “. . . it’s just hard, I just don’t trust the government. They got an
upper hand so even though they can hear us out and say that
they’re going to do something but you know, I just brace for it.”
“. . . I don’t think our government has the intestinal integrity to do
what is right.”
“With the government, we already know, they’re going to know and
they’re not going to let us know until a week or two later, after the
outbreak has already started so you know, they’re going to get theirs
and they’ll be vaccinated. They’re going to make sure their families
are taken care of.”
“. . . I’m skeptical I think because I’ve seen so many things over the
years that it was like, ‘This is the horrible thing that’s going to
happen and the government killing us, terrorists are going to get
the United States and Y2K is going to destroy the computer
industry’ and so I’m a little distrustful or mistrustful of
information all on these sides.”

the design of pandemic response policies and the impor- We always think of self first and that’s being real about it. I’m not
tance of keeping the larger community in mind. One noted: thinking about if you going to be okay . . . I mean frankly speaking,
you know, that’s being honest and right then and there, we’re not
thinking about let me save the world.
I agree there has to be a plan and that plan has to be stuck to, no
matter what but the plan can’t be created based on popularity and Public Input and Education
what, you know, what will make the most people happy because what
will make the most people happy is certainly not the common good. Participants shared a desire for accessible and accurate in-
formation about limiting contagion. Some complained that
they had never received any information about pandemic
Participants discussed the importance of modifying one’s preparedness or knew of any recent educational efforts
own routines “for the good of everyone else” and suggested that within their communities. Participants emphasized the im-
policymakers be “selfless” in designing and implementing portance of both public education and opportunities for
community actions. public input into pandemic response planning. “Make a plan
Participants in three of the four groups expressed diver- and stick to it,” said one participant, and that included, for
gent views from those espousing community-mindedness, her, making sure the public knew the plan. Another person
and acknowledged that strong self-interest often holds sway added, “Focus groups are important. Listen to the average citi-
during public disasters. This contributed to comments both zens. If there are task forces, citizens should be on each task force.”
about the self-interest of others (e.g., those who manufac- Another emphasized the importance of opportunities for
ture antiviral agents taking some “off the top” for their own public input adding, “Listen to the people. Groups like this are
families) and their own intense desires to keep their loved important. The public have [sic] well meaning opinions that the
ones safe. For example, one woman remarked: policy makers may not know. Listen to the people.”

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Imminent Threat which may range from excessive fear of contagion to beliefs
All groups discussed the need to have compelling reasons that “it’s just the ‘flu” and that the government’s reaction
to endure the inconvenience or hardships such measures is overblown. Information campaigns exhort the public to
would bring. In light of the expected economic burdens stay home if they are ill, avoid contact with others who ap-
associated with social distancing measures, participants ex- pear ill, avoid crowded venues, avoid unnecessary travel (in
pressed a need to know that threat of a disease was im- this case usually to Mexico), and maintain a ‘safe distance’
minent and severe before agreeing to comply with policies from everyone. At least one state added the threat of fines to
that would likely be onerous and disruptive. One partici- pressure people to stay home with illness (Hochberg 2009).
pant said, “Well it would be total chaos if we start shutting down The variation in community responses is likely to be
things before we know hard core facts.” Another commented: due, in part, to the lack of clear evidence on the effective-
ness and optimal use of social distancing measures. The
. . . that right now it’s in some third world country and it may come field of public health highly values scientific evidence of
here. I don’t think that’s going to be good enough. I think there’s going effectiveness of policies and practices. Unfortunately, social
to have to be some indication that it is actually in your own commu- distancing measures have generally lacked strong empiri-
nity before you take steps as drastic as shutting down anything. cal validation of effectiveness (Bartlett 2008; Aledort et al.
2007; World Health Organization [WHO] Writing Group
Distrust in Government 2006). Experts advocate school and other closures based
on the best available evidence, as well as past experiences
Despite desires for public input and public education, par- with other infectious diseases, but in the face of uncertainty
ticipants in all of our focus groups, which were held in about contagion and virulence of a novel infectious agent,
well-off, low-income and middle class communities and in- judgments about timing and duration of closures will vary.
cluded participants from underrepresented minorities, ar- Valuable historical research recently conducted by Markel
ticulated distrust of government. They suggested that politi- and colleagues sheds some important light on the question
cians would do the politically expedient thing rather than of effectiveness. They found that during the 1918–1919 pan-
what is right in a crisis and that public officials may not demic, those cities with early and sustained social distanc-
always convey accurate information to the public. Partic- ing interventions had lower peak and overall death rates.
ipants expressed skepticism that politically difficult deci- Such interventions were intended not just to reduce attack
sions would trump desires for re-election, and that politi- rates and mortality, but also to slow transmission, which
cians would, like others, be looking out for themselves by today might also provide society time to prepare vaccines,
seeking special treatment, as indicated in this comment: disperse antiviral medication, and bolster response plans
With the government, we already know, they’re going to know and
in communities not yet infected (Markel et al. 2007). Yet it
they’re not going to let us know until a week or two later, after the is precisely the extended time period of social distancing
outbreak has already started so you know, they’re going to get theirs measures that worried so many of our participants. They
and they’ll be vaccinated. They’re going to make sure their families discussed their concerns in the context of their everyday
are taken care of. lives—concerns about job stability, financial fragility and
their abilities to truly keep children and teens in safe, iso-
They emphasized the importance of involving non- lated environments. These financial concerns are consistent
politicians in plan development and enforcement of re- with findings from a national survey conducted by Blendon
sponse plans without undue influence from interest groups. and colleagues in 2006, which informed the United States
In contrast, one participant spoke positively of a gov- Department of Health and Human Services (US DHHS),
ernmental role in controlling an expected surge in demand Centers for Disease Control and Prevention (CDC) (2007)
for scarce resources (in this case, antiviral medications). recommendations for community nonpharmaceutical inter-
ventions.
DISCUSSION These economic concerns are justified, not only because
Our current experience with the H1N1 influenza A virus so many in Michigan and other places in the country are
brings to light some of the complexity of dealing with an un- experiencing high unemployment rates and are in frail fi-
predictable contagious disease, and puts to the test the emer- nancial condition, but also because currently there is no
gency preparedness, including preparing for pandemics, program to provide income support to individuals who
that has figured prominently in public health departments are out of work for an extended period of time as a re-
since September 2001. With limited information, for instance sult of a pandemic. Some pandemic response plans in other
about mortality rates, and varying legal authority in com- countries, such as Australia, include provisions for income
munities to implement social distancing measures, public assistance to individuals who suffer as a result of lost in-
health responses to this virus varied (Hodge 2009). Numer- come due to a pandemic (Commonwealth of Australia
ous communities closed schools and other public venues. 2009). Workers with young children lack guarantees of job
Differing responses on the part of public administrators, security if schools and daycare centers close, compelling
and a spectrum of news reports about the threat (or lack them to stay home to supervise their children. The Fam-
thereof) from H1N1tend to be mirrored in public reactions, ily Medical Leave Act may offer job security if a family

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member has a serious health condition, but there will be already feel threatened, could prove to be a significant hur-
a great many healthy children who will need supervision dle in pandemic planning and response.
and whose parents would not meet the Act’s criteria (US The second ethical challenge highlighted by our find-
DHHS www.pandemicflu.gov). The economic concerns we ings concerns the need to ensure that the benefits and
heard from our participants should serve as a caution to burdens associated with proposed policy actions are dis-
policy makers about public willingness to comply with sus- tributed fairly. Policy makers will need to ensure that
tained social distancing measures. Policy makers must ad- vulnerable populations or other sub-populations do not
dress such concerns to effectively implement and sustain shoulder unfair burdens or receive fewer benefits during
social distancing measures during a pandemic. a pandemic due to the implementation of social distanc-
Participants’ perceptions of what constitutes an immi- ing measures. The financial struggles that many will face
nent infectious disease threat may be tied to their concerns as a result of mandatory school or business closure dur-
about job security as well. Many suggested that disease ing a pandemic, for instance, will be most pronounced for
must be present in their own communities before they low-income workers and the least well-off in society. These
would accept or support business, school or religious clo- groups will have fewer financial resources to sustain them
sures. While this requirement for close proximity seems fi- during business or school closures, and may be at higher
nancially prudent, it may ultimately put communities at risk of job loss if they lack vacation or sick leave benefits.
greater risk of infection and compromise their abilities to They may also be less able to negotiate systems to obtain
minimize the negative impacts of the disease, including on information about an outbreak, or scarce resources such as
the economy. Indeed this tension was recognized by partici- antiviral medications.
pants. One participant with an infant in daycare commented A number of frameworks have been developed to as-
that she would likely keep her child home from daycare sist policy makers and practitioners to consider the ethical
even if their particular setting was not officially closed due implications of public health actions and to help determine
to a pandemic, to further reduce her child’s risk of infection. when individual restrictions and other policy actions are
At least one participant in each of the groups shared inten- justified. (Baum et al. 2007; Gostin and Powers 2006; Bayer
tions to voluntarily keep their school-age children home in and Fairchild 2004; Nieburg et al. 2003; Childress et al. 2002;
the event of a pandemic, even if their children’s’ schools Callahan and Jennings 2002; Kass 2001.) Common among
were not officially closed. Further empirical assessment of most of them are considerations of: 1) whether the proposed
public reaction to the 2009 H1N1 outbreak will be important restriction on the individual is expected to be effective in
to further gauge expected public responses. achieving its intended goals; 2) whether failing to imple-
The findings from this study reveal at least two broad ment the policy would cause greater harms; 3) whether there
ethical challenges with which policy makers must contend are less restrictive options that could achieve the goals; and
to ensure that public health responses to a pandemic are 4) whether the benefits and burdens associated with the
just. The first is the tension between protecting personal au- policy are equitably shared among community members.
tonomy and promoting community well being. There is a Since the empirical evidence of the effectiveness of social
long history in public health policy and practice of restrict- distancing measures is limited, and there are potentially
ing individual rights when needed to reduce health risks to large and predictable economic and other burdens associ-
a community, such as vaccination requirements for school ated with these measures which are likely to be unequally
entry and limitations on smoking in public places. Out of distributed, policy makers may have a special obligation
respect for individual freedoms, however, these restrictions to consider both how to mitigate inequities and provide
are not employed lightly. For example, mandatory closure opportunities for public education and input in the policy
of private entities during a pandemic may even require a making process. Deliberative processes can offer individ-
declaration of an emergency before public health officials uals opportunities for engagement in complex issues such
have the authority to execute them. as these. When individuals learn about an issue and better
The free exercise of religion has special status in our understand the ways the particular issue may affect them
society, as set out in the First Amendment of the US in their daily lives, they can, in turn, help policy makers un-
Constitution, so it is not surprising that many participants derstand diverse points of view about, and likely responses,
in our focus groups had strong reactions to the possibility to a proposed policy. In the case of social distancing mea-
of mandatory closure of religious institutions. Closing of sures, deliberation may be an effective process to gain public
religious institutions in response to a pandemic may thus insights and to gauge the extent of the burdens the inter-
prove to be particularly challenging for health officials. Par- ventions are likely to produce.
ticipants in our groups emphasized the importance of reli- Those deliberating may or may not come to consensus
gious gatherings during times of crisis, suggesting that con- on an issue (e.g., whether schools should be closed before an
tingency plans to provide alternative avenues for spiritual influenza pandemic reaches a particular geographic bound-
guidance and support must be considered. Given the skep- ary), but the process of deliberation may itself be useful. In
ticism and distrust of government many of our participants deliberation, affected individuals may behave as citizens, and
expressed, restrictions on religious observance, which could work toward a goal that is perhaps larger than themselves
offend or anger citizens during a time of crisis in which they (personal communication, Abelson 2009, Ann Arbor, MI).

November, Volume 9, Number 11, 2009 ajob 11

The American Journal of Bioethics

Those holding dissenting views are encouraged to share should also heed participants’ requests for education and
them and, importantly, to share the reasoning behind those opportunities for public input in planning processes. If
views. This may challenge existing perspectives, encour- individuals feel disconnected, poorly informed, or without
age some to change their minds or it may simply create a voice in designing policies that have a direct impact on
some common ground on which to base a group decision. their lives, further distrust in government could ensue.
Gutmann and Thompson (2002) suggest that there may be The current H1N1 outbreak provides opportunities for
times when individuals do not get what they want or need comparing communities with and without meaningful
in a deliberative process, but that if the process is perceived public input in planning processes.
as fair, those individuals participating in the deliberation This study suggests numerous implications for policy
can accept the collective decision as legitimate. Even if a makers. Based on our findings, even in the face of a pan-
deliberative group does not come to consensus, their dis- demic, social distancing measures may be challenging to
course may inform policy makers’ decisions. That is, the implement and sustain due to strains on family resources
deliberations themselves may offer clarity and a significant and these challenges will be exacerbated by lack of trust
depth of understanding. It is important to recognize, how- in government. Policy makers must consider incorporating
ever, that even if consensus is reached, even high quality mechanisms for financial support into response plans, par-
democratic deliberations do not guarantee that any partic- ticularly for the poorest sectors of society, if social distancing
ular outcome will be right or just. In some cases, the public measures are likely to be sustained. Public education and
may “get it wrong” and may put forth recommendations or input in policy processes could provide communities with
make requests that are not in the community’s best interest, realistic expectations and help ensure compliance with re-
are inconsistent with expert knowledge, or are in conflict sponse measures—our participants were clear in their desire
with another important societal principle or with the rights for timely and accurate information. It will be particularly
of a certain group (personal communication, J. Chamberlin important for public health officials to work in conjunction
2009 Ann Arbor, MI; Dworkin 1984). In general, deliberative with religious and other community leaders to execute so-
processes are not intended to directly set social policy, but cial distancing plans effectively, without creating animosity
rather to inform the larger policy process. that may erode compliance. Given that many participants
Our participants showed a clear capacity for delibera- shared public-spirited attitudes, emphasizing the commu-
tion. As members of the public, most with no health care nity benefit of individual sacrifice may also be a successful
background, they were able to discuss a complex and chal- strategy. Policy makers must assess the public response to
lenging public health issue, to listen to others’ opinions and the current H1 N1 influenza outbreak, in particular the bur-
to share opposing viewpoints. They identified issues and dens associated with the relatively brief measures that were
articulated concerns about the economic and other burdens implemented in various communities, and identify ways to
associated with social distancing measures that academics support those who need it most. Current planning efforts
and policy makers in the US and around the world are be- should include public dialogue and clear leadership from
ginning to recognize as important in pandemic planning public officials to engender trust and legitimacy in poten-
and response. Deliberative procedures can be employed in tially contentious pandemic response plans.
many parts of the world, yet because an important princi- This exploratory study is limited in scope. Our results
ple of deliberation is that free and equal individuals join are based on participants from four different communities
together in discussion, this process may only be feasible in in one particular geographic region in Michigan. Still, given
democratic societies. To ensure that a variety of viewpoints the scant literature on public views of social distancing dur-
are included, policy makers purposefully bring together in- ing pandemics, our findings may provide public health
dividuals from various sectors of society, which may be a leaders, struggling with the tensions between individual
tall task in societies where social divisions are pronounced. freedoms and public well-being and cognizant of the risk
While much of the discourse we describe highlights that a pandemic could worsen existing societal inequities,
challenges in pandemic response, participants also exhib- some insight into how members of the public see those ten-
ited evidence of community-mindedness on which to build. sions. Additional empirical work is urgently needed to gain
Most groups emphasized the need to maintain essential a clearer understanding of public views and willingness to
services, paralleling similar priorities identified in a pilot abide by pandemic response plans.

study of public engagement about allocation of scarce
resources during a pandemic (Keystone Center for Science
and Public Policy 2005) and consistent with the recommen-
REFERENCES
dations of some scholars (Kass et al. 2008). Communities
ask citizens to comply with voluntary social distancing Abelson, J., J. Eyles, C. McLeod, P. Collins, C. McMulland, and P.
provisions (e.g., home quarantine) to avoid enforcement Forest. 2003a. Does deliberation make a difference? Results from a
measures. Our participants’ concern for the health of the citizens’ panel study of health goals priority setting. Health Policy
entire community suggests that individuals could and 66: 95–106.
would comply with policies that are challenging personally, Abelson, J., P. Forest, J. Eyles, P. Smith, E. Martin, and F. Gau-
if the community benefits are clear to them. Policymakers vin. 2003b. Deliberations about deliberative methods: Issues in the

12 ajob November, Volume 9, Number 11, 2009

 Social-Distancing Measures

design and evaluation of public participation processes. Social Sci- C. Clancy, and L. Churchill. New York, NY: Oxford University
ence and Medicine 57: 239–251. Press.
Aledort, J., N. Lurie, J. Wasserman, and S. Bozzette. 2008. Non- Hochberg, H. N. C. April 29, 2009. Enforces isolation law in
pharmaceutical public health interventions for pandemic influenza: suspected flu cases. National Performance Review (NPR) Morning
An evaluation of the evidence base. Bio Medical Chromatography Edition. Available at: http://www.npr.org/templates/story/story.
(BMC) Public Health 7: 208–216. php?storyId=103596942&ft=1&f=103521633 (accessed May 4,
Bartlett, J., and L. Borio. 2008. The current status of planning for 2009).
pandemic influenza and implications for health care planning in Hodge, J. 2009. The legal landscape for school closures in response
the United States. Healthcare Epidemiology 46: 919–925. to pandemic influenza or other public health threats. Biosecurity
Baum, N., S. Gollust, S. Goold, and P. Jacobson. 2007. Looking and Bioterrorism: Biodefense Strategy, Practice, and Science. 7(1): 45–
ahead: Addressing ethical challenges in public health practice. Jour- 50.
nal of Law, Medicine, and Ethics. 35(4): 657–667. Hsieh, Y., C. King, C. Chen, M. Ho, J. Lee, F. Liu, et al. 2005. Quaran-
Bayer, R., and A. Fairchild. 2004. The genesis of public health ethics. tine for severe acute respiratory syndrome (SARS), Taiwan. Emerg-
Bioethics 18(6): 473–492. ing Infectious Disease 11(2): 278–282.
Blendon, R., L. Koonin, J. Benson, M. Cetron, W. Pollard, E. Mitchell, Kass, N. 2001. An ethics framework for public health. American
et al. 2006. Public response to community mitigation measures for Journal of Public Health 91(11): 1776–1782.
pandemic influenza. Emerging Infectious Diseases. 14(5): 778–786. Kass, N. E., J. Otto, O’Brien, D., and M. Minson, 2008. Ethics and se-
Callahan, D., and B. Jennings. 2002. Ethics and public health: Forg- vere pandemic influenza: Maintaining essential functions through
ing a strong relationship. American Journal of Public Health 92(2): a fair and considered response. Biosecurity and Bioterrorism: Biode-
169–176. fences Strategy, Practice, and Science 6(3): 227–236.
Childress, J., R. Faden, R. Gaare, L. Gostin, J. Kahn, R. Bonnie, Keystone Center for Science and Public Policy. 2005. Final re-
et al. 2002. Public health ethics: Mapping the terrain. Journal of Law, port: Citizen voices on pandemic flu choices. Available at:
Medicine, and Ethics 30: 170–178. http://www.keystone.org/spp/health-pandemic.html (accessed
July 10, 2008).
Commonwealth of Australia. 2009. National Action Plan for Human
Influenza Pandemic. Available at: http://www.dpmc.gov.au/ publi- Keystone Center for Science and Public Policy. 2007. Fi-
cations/pandemic/docs/NAP.pdf (accessed May 23, 2009). nal Report: The Public Engagement Project on Community Con-
trol Measures for Pandemic Influenza. Available at: http://www.
Creswell, J. 2006. Qualitative Inquiry and Research Design: Choosing
keystone.org/spp/health-pandemic.html (accessed July 10, 2007).
Among Five Approaches. Thousand Oaks, CA: Sage Publications.
DeCoster, B. 2006. Currents in contemporary ethics: Avian in- Kotalik, J. 2005. Preparing for an influenza pandemic: Ethical issues.
Bioethics 19(4): 422–431.
fluenza and the failure of public rationing discussions. Journal of
Law, Medicine, and Ethics 34(3): 620–623. Krueger, R. 1998. Analyzing & Reporting Focus Group Results.
Dworkin, R. 1984. Rights as trumps. In Theories of Rights, ed. J. Thousand Oaks, CA: Sage Publications.
Waldron. Oxford, UK: Oxford University Press, 153–167. Lemon, S., M. Hamburg, S. Fredrick, E. Choffnes, and A. Mack.
2007. Ethical and legal considerations in mitigating pandemic dis-
Elster, J., ed. 1998. Deliberative Democracy. Cambridge, MA:
ease: Workshop summary. National Academy of Sciences. Available
Cambridge University Press.
at: http://www.edu/catalog/11917.html (accessed September 9,
Fleck, L. 1991. Just health care rationing: A democratic decision-
2007).
making approach. University of Pennsylvania Law Review 140: 1597–
Lenaghan, J. 1999. Involving the public in rationing decisions.
1636.
Health Policy 49: 45–61.
Goold, S., L. Damschroder, and N. Baum. 2007. Deliberative proce-
Manin, B. 1987. On legitimacy and political deliberation. In Political
dures in bioethics. In Empirical Methods for Bioethics: A Primer, eds.
Theory, trans. E. Stein, and J. Mansbridge, 15(3): 338–368.
L. Jacoby, and L. Siminoff. Cambridge, UK: Emerald Group, 11:
183–201. Markel, H., H. Lipman, J. Navarro, A. Sloan, J. Michalsen, A.
Stern, et al. 2007. Nonpharmaceutical interventions implemented
Gostin, L. 2000. Public Health Law: Power, Duty, Restraint. Berkeley,
by United States cities during the 1918–1919 influenza pan-
CA: University of California Press.
demic. Journal of the American Medical Association. 298(6): 644–
Gostin, L. 2006. Medical countermeasures for pandemic influenza: 654.
Ethics and the law. Journal of American Medical Association 295(5):
Miller, D. 2003. Deliberative democracy and social choice. In Debat-
554–556.
ing Deliberative Democracy, eds. J. Fishkin, and P. Laslett. Malden,
Gostin, L., and M. Powers. 2006. What does social justice require MA: Blackwell Publishing
for the public’s health? Public health ethics and policy imperatives.
Nieburg, P., R. Bernheim, and R. Bonnie. 2003. Ethics and
Health Affairs 25(4): 1053–1060.
the practice of public health. In Law in Public Health Prac-
Gutmann, A., and D. Thompson. 2002 Just deliberation about tice, eds. R. Goodman et al. New York, NY: Oxford University
health care. In Ethical Dimensions of Health Policy, eds. M. Danis, Press.

November, Volume 9, Number 11, 2009 ajob 13

The American Journal of Bioethics

Schuklenk, U., and K. Gartland. 2006. Confronting an influenza US DHHS CDC. 2007. Vaccination Prioritization for Pandemic In-
pandemic: Ethical and scientific issues. Biochemical Society Transac- fluenza. Available at: http://www.webdialogues.net/cs/panflu-
tions 34(6): 1151–1154. engage-home/view/di/104?x-t=home.view (accessed 05/04/
Thomas, J., A. Dasgupta, and A. Martinot. 2007. Ethics in a pan- 2009).
demic: A survey of the state pandemic influenza plans. American University of Toronto Joint Centre for Bioethics Pandemic Influenza
Journal of Public Health 97(S1): S26–S31. Working Group. 2005. Stand on Guard for Thee: Ethical Consider-
ations in Preparedness Planning for Pandemic Influenza. Toronto,
Thompson, A., K. Faith, J. Gibson, and R. Upshur. 2006. Pandemic
CAN: University of Toronto Joint Centre for Bioethics. Available
influenza preparedness: An ethical framework to guide decision-
at: http://www.jointcentreforbioethics.ca/people/documents/
making. Bio Medical Review (BMR) Medical Ethics 7(12). Available at:
upshur stand guard.pdf#search-“standonguardforthee” (accessed
http://www.biomedcentral.com/1472–6939/7/12 (accessed April
September 13, 2009).
28, 2007).
Weber, R. P. 1990. Basic Content Analysis. Beverly Hills, CA: Sage
United States Department of Health and Human Services
Publications.
(US DHHS), Centers for Disease Control and Prevention
(CDC). 2007. Interim Pre-Pandemic Planning Guidance: Commu- World Health Organization (WHO) Writing Group. 2006. Non-
nity Strategy for Pandemic Influenza Mitigation in the United pharmaceutical interventions for pandemic influenza, international
States—Early, Targeted, Layered Use of Nonpharmaceutical Inter- measures. Emerging Infectious Diseases 12: 81–94.
ventions. US DHHS, CDC. Available at: http://pandemicflu. Zhang, X., M. Meltzer, and P. Wortley. 2006. FluSurge—a tool to
gov/professional/community/mitigation.html (accessed August estimate demand for hospital services during the next pandemic
21, 2007). influenza. Medical Decision Making 26: 617–623.

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