Jonathan Woolley
Rutgers University
All in all, cruise ships are safe and healthy places. Thousands of people travel on them every year, and – apart from sunburn – most of those people are just as healthy when they get off the boat as they were when they got on. True, many of these people do suffer severe shock when their bar bill is added up at the end of the voyage – or when they see the final cost of their purchases from the onboard store – but the shock is usually financial, not medical, and they recover shortly afterwards (even if their checking account does not). However, disease outbreaks occasionally do occur on cruise ships. When they do, such outbreaks can provide eye-catching headlines for newspapers and other news media outlets. Eager reporters produce stories describing how hundreds – or perhaps thousands – of people are on board an infected ship. In reality, the vast majority of people never become sick during most of these outbreaks, but that is no matter. The idea of a holiday ship being a floating germ, like something out of a horror movie, is too gripping a tale for the media to resist.
This reporting raises the issue of whether the infected passengers’ names should be disclosed to the public. On the one hand, the infectees have a right to their privacy, just as anyone else does who happens to fall sick. On the other hand, victims’ names or identifying information are routinely disclosed to the public – in news reports of a major house fire, for instance. Consequently, there is a potential ethical quandary for anyone who knows this information about the infected passenger(s). The public’s right to know the specifics of the case must be balanced against the infectee(s) right to privacy (should the infected person so desire it). This issue is further compounded by the possibility that many people (such as other passengers) quickly may learn the name of those infected and then share that information with others. These people may not feel themselves to be bound by any specific code of conduct, or they may not realize the possible extent to which their knowledge may spread once they have started sharing it.
This issue of a rapidly-spreading disease outbreak in a confined space creating a public desire to learn more about the victims is not limited to the maritime transportation industry. Disease has the potential to appear in any situation involving a concentrated group of people. Infections, such as those caused by norovirus, can spread in any location when people congregate and all come into contact with a common object (or with each other). Such a situation provides an easy medium for a disease to spread, particularly one caused by a virus or a bacterium. Under the right circumstances, hotels, conference facilities, passenger aircraft, and gatherings in people’s homes can all serve as a possible transmission site.
Nonetheless, cruise ships infected by norovirus seem to catch the public’s attention in a way that infections in other places do not. This is perhaps partly due to the nature of a cruise ship – a large number of people who would not normally come into prolonged contact with each other are grouped together for multiple days. Furthermore, the passengers on board are usually travelling for recreational purposes in a friendly climate. It is somewhat understandable for a stressful business trip to an area where cold viruses are known to be common to result in illness. Conversely, no one expects a prepaid holiday that is focused on rest and relaxation to end with a disease infection. Even though they offer seemingly-dangerous shore excursions and activities, cruise ships are often advertised as being safer vacations, further bolstering passengers’ confidence that they are unlikely to return home having experienced a need for medical attention during their vacation.
This paper’s goal is to briefly examine the issue of disclosing patient information to the public regarding outbreaks of norovirus on passenger cruise ships. While the answer to the question may seem to be obvious to some, one must remember only medical professionals are bound by medical privacy rules. Individual passengers and journalists may feel ethical standards apply differently in their cases.
Norovirus
Norovirus is the colloquial name for norovirus gastroenteritis, a common gastrointestinal disease. Biologically speaking, the term norovirus refers to “a genus of closely related RNA viruses in a family of viruses called calcivirus” (Goodgame, 2006, p. 401). There are various strains of norovirus viruses, based upon variations in their RNA sequences. One of the strains was originally named Cruise Ship, because it first caused an epidemic upon a passenger ship, but is now referred to by the genogroup into which it falls (Goodgame, p. 403). The disease norovirus, which can be caused by one of the norovirus viruses, can occur in a variety of places and is generally relatively harmless, causing only mild discomfort (exceptions occur if it strikes in places such as hospitals or nursing homes). In fact, the actual number of cases each year is probably underreported, due to the relatively mild symptoms. About sixteen per cent of cases occur on cruise ships or at vacation venues (Goodgame, p. 403). On occasion, epidemics on board cruise ships have infected forty per cent of the ships’ passengers, but this is not always the case (Goodgame, p. 406).
In fact, this is rarely the case. For the three year period of 2000 to 2002, there were only four outbreaks of gastroenteritis on board cruise ships entering U.S. waters in 2000, seven in 2001, and twenty-one in 2002 (as cited in Widdowson, et al., 2004, p. 28). Moreover, these outbreaks were defined as involving as little as three per cent (or more) of the passengers and crew on board (as cited in Widdowson, et al., p. 28). Wikswo, et al. (2011) report an average of twenty-seven norovirus outbreaks annually were reported to health authorities by cruise ships entering U.S. waters, again using the three per cent definition of an outbreak (p. 1117). The median attack rates for passengers in the 2002 study conducted by Widdowson et al. varied between three per cent and eighteen per cent (depending upon how the outbreak was investigated) (p. 29). For the outbreak investigated by Wikswo, et al. (2011) it was fifteen per cent (p. 1121). A forty per cent disease rate, therefore, is not the norm.
The Question of Publishing the Information
So it is clear that not everybody on board gets sick. But what about those who do? Is it appropriate to release the names of those who do get sick, or to show their faces as they get off the ship even if they are not identified? More specifically, what about those whose names are released unofficially – and perhaps unknowingly? Is it appropriate to then publish those names?
Imagine, if you will, that a friend is a passenger on a cruise ship stricken by an outbreak of norovirus. The outbreak is large enough that the cruise has been terminated early so the ship can return for a thorough scrubbing (i.e. cleaned thoroughly from top to bottom). Your friend emails you a message grousing about the now-truncated vacation and blames it all on the person who first came down with the symptoms, whom everyone assumes is the source of the outbreak. You, in turn, pass this message on to several of your own friends, along with the introductory sentence, “Hey, one of my friends is on that cruise ship where everybody got sick that’s been on the news and just sent me this message saying what it’s like.” And one of them passes it on to a friend of theirs, who happens to be a journalist.
Professional journalists working for news organizations are usually bound by journalistic standards. Most likely, the journalist probably will have to obtain some sort of confirmation about the information contained in the email (if the journalist can) before reporting the information. A brief perusal of several randomly-selected news stories covering norovirus outbreaks on cruise ships or in hotels found no sick persons’ names were mentioned in those news stories[i] (although it’s possible the reporters did not know the names of any of the people who fell sick). One article (McDowell, 2003) did interview a person who had been sick on board a ship two years earlier, but that person had presumably given permission to use his name in the story.
Now, suppose the name of this hypothetical passenger who was the source of the outbreak is also posted on a blog. Should the journalist be able to include this passenger’s name in the story? The information is already public, thanks to the blog post. The journalist may even be able to get reliable independent confirmation that the person in question really did bring the virus on board the ship – probably from an anonymous source. With independent confirmation, the journalistic standards of many news organizations would be met. Yet, assuming the person is indeed the source, should the journalist – and the news organization he or she works for – release the information to the public in a news story?
The very fact of getting independent confirmation from an anonymous source might be enough to give one pause. After all, chances are the source is requesting anonymity because of the possible repercussions he or she could suffer for saying what was said. Perhaps the person is requesting anonymity out of fear of releasing the person’s name. If so, it could be either because the repercussions from the person’s employer (likely either the cruise company or the port health officials) would impact the person’s career path or because of possible legal liability. It’s also possible the person is requesting anonymity to avoid disclosing how easily the cruise line’s pre-boarding health screening policy could be thwarted. Yet, at the same time, one must remember the anonymous source is only confirming what was already publicly posted on the Internet. The information is already out there.
One might also consider that releasing identifying information about an infectious person has precedent. In the nineteenth century, a common way to prevent the spread of a dangerous disease was to quarantine the diseased person – typically at home. In the process of reporting on the disease’s outbreak, newspapers sometimes printed identifying information. For instance, an 1888 news article stated, “Mrs. Davis’s 5-year-old daughter is now lying ill with the dread disease [smallpox]….The house in which are confined all cases so far reported is under a strict quarantine, and everything will be done to avoid an epidemic” (Smallpox in New-Haven, 1888). Sometimes, newspapers did the same thing when covering infections on board ships. Several months before the 1888 smallpox article was written, the same newspaper, while reporting on a measles outbreak on board a passenger ship, printed the names of underage children who were infected. “Two children, Antonetta Marca and Pedro Marca, were taken yesterday from the [quarantined steamship] Britannia to the Swinburne Island hospital suffering from the disease” (Measles at quarantine, 1887). I don’t know whether the newspaper had obtained the permission of the children’s parents or legal guardians to release their names – let’s assume for the moment it had – but I suspect most parents nowadays would not want the names of their sick children printed in The New York Times.
However, smallpox and measles were both far more dangerous in the 1880’s than norovirus is today, so perhaps the editors of the time felt there was a public health justification in printing the information. After all, no one wanted to come into contact with the infected people. Norovirus may spread fairly easily aboard cruise ships,[ii] but its overall dangerousness pales by comparison. Therefore, the public health justification that might have been used to print infectees’ names in the 1880’s really does not apply when reporting on cruise ship norovirus outbreaks. Particularly when one considers that, by the time the ship reaches port, the outbreak either may already be controlled and/or the infectees already may have recovered.
An editor might still believe a story should include the infectees’ names, particularly if the information is already public (as it would be if it were already posted on a blog). Privacy concerns do not seem so pressing when the information is already in the public sphere. After all, if the reporter can get an independent confirmation before any other reporter does, it is part of the editor’s job to find and publish exclusive stories. However, the names should not be published.
It is true the names are already published on an Internet blog. The person who posted that information ought to be held to the same high standards of ethics as the newspaper ought to be, since both are publishing information in the public sphere that could be damaging to a person’s (the infectee’s) reputation. Unfortunately, holding the blogger to this standard, particularly if he or she hosts the blog on their own website, may be impossible – other than by simply shaming the person into compliance. Nonetheless, the newspaper should still be held to this standard. As Bennett and Raab (2003) point out, “We each have a right or claim to be able to control information that relates to ourselves” (p. 15). Certainly, an infectee – particularly one who might be considered the source of the shipboard outbreak – might want to control the release of that information to the public, even if his or her name might need to be announced to various medical and public health authorities. Rachels (1975) quotes a former president of the American Medical Association explaining the damage that can be caused by releasing medical records (p. 324). However, when it comes to norovirus outbreaks, a better case for privacy might be made using another of Rachels’ (1975) arguments for preserving privacy, “someone may want to keep some aspect of his life or behavior private simply because it would be embarrassing for other people to know about it” (p. 323).
The point is simple. An individual has a right to decide who should know their medical information. A news organization ought to respect this as part of its ethical standards. Even if the name of the person who first brought the virus on board the ship becomes known, it should not be published. A person who brings norovirus onto a cruise ship is unlikely to start infecting many people with the disease after they get off the ship, even if the cruise is a short one. Furthermore, the person may not have even known he or she had norovirus when boarding the ship. Publishing the person’s name is likely to create a permanent record of the person’s bringing (or alleged bringing) of the virus aboard. If the person is no longer contagious, there is no reason the person’s friends and neighbors need to know about this – not to mention his or her potential future employers. Consequently, it is not necessary for news organizations to publish the name of a person who either carried the virus for or was infected by norovirus while on board a cruise ship.
Norovirus is a disease that affects many people in many places, not just on board cruise ships. Even when the disease does strike a cruise ship, it rarely incapacitates many people. However, shipboard outbreaks often capture the popular imagination, resulting in strong news coverage of these outbreaks. News organizations should not indulge this popular imagination by releasing the names of infected persons, and neither should bloggers.[iii] The privacy issues far outweigh the possible justifications for releasing this information.
References
200 Cruise passengers struck by norovirus. (2012, February 6). USA Today. Retrieved from http://travel.usatoday.com/cruises/story/2012-02-04/200-cruise-passengers-struck-by-norovirus/52963710/1.
Associated Press. (2007, November 13). Hawaii: Virus sickens ship passengers. The New York Times. Retrieved from http://query.nytimes.com/gst/fullpage.htmlres=9907E5D61539F930A25752C1A9619C8B63&scp=17&sq=norovirus%20AND%20ships&st=cse.
Barton, J. L. (1900, January 28). The control of tuberculosis. The New York Times (1857-1922). Retrieved March 10, 2012, from ProQuest Historical Newspapers The New York Times (1851-2008). (Document ID: 101047471).
Bennett, C.J. & Raab, C.D. (2003). The privacy paradigm. In The Governance of Privacy: Policy Instruments in Global Perspective (pp. 13-31). Burlington, VT: Ashgate Publishing Co. Retrieved from http://books.google.com/bookshl=en&lr=&id=FIhPEcp6ZdAC&oi=fnd&pg=PR6&dq=privacy+AND+publishing&ots=9oKAoe7t8h&sig=EBZJbDEo9XXagDESc1cgsd_harA#v=onepage&q=privacy%20AND%20publishing&f=false.
Goodgame, R. (2006). Norovirus gastroenteritis. Current Gastroenterology Reports, 8, 401-408.
McDowell, E. (2003, February 2). Virus outbreaks don’t rock boats. The New York Times. Retrieved from http://www.nytimes.com/2003/02/02/travel/virus-outbreaks-don-t-rock-boats.html.
Measles at quarantine. (1887, November 1). The New York Times (1857-1922). Retrieved March 10, 2012, from ProQuest Historical Newspapers The New York Times (1851-2008). (Document ID: 103149785).
Newman, M. (2006, November 16). For 700 on cruise, queasiness not due to sea. The New York Times. Retrieved from http://www.nytimes.com/2006/11/16/us/17cruisecnd.html?scp=7&sq=norovirus%20AND%20ships&st=cse.
On their way to Utah. (1885, November 6). The New York Times (1857-1922). Retrieved March 10, 2012, from ProQuest Historical Newspapers The New York Times (1851-2008). (Document ID: 106178475).
Rachels, J. (1975). Why privacy is important. Philosophy and Public Affairs, 4, 323-333.
Sloan, G. (2012, February 7). Outbreak of illness forces early end to Princess cruise. USA Today. Retrieved from http://travel.usatoday.com/cruises/post/2012/02/crown-princess-cruise-ship-norovirus-outbreak/622300/1.
Smallpox in New-Haven. (1888, April 23). The New York Times (1857-1922). Retrieved March 10, 2012, from ProQuest Historical Newspapers The New York Times (1851-2008). (Document ID: 106318956).
Spalding, D. (2012, January 21). Number of norovirus victims jumps to 165. The Victoria Times Colonist. Retrieved from http://www.timescolonist.com/health/Number+norovirus+victims+jumps/6031944/story.html.
Stomach flu hits hundreds on QE2. (2007, January 25). The Philadelphia Inquirer. Retrieved from http://www.philly.com/philly/news/nation_world/20070125_In_the_Nation.html.
The death rate much less: Condition of the Nursery and Child’s Hospital. (1888. January 6). The New York Times (1857-1922). Retrieved March 10, 2012, from ProQuest Historical Newspapers The New York Times (1851-2008). (Document ID: 106308299).
Three cruise ships cleaned after norovirus outbreaks. (2012, February 6). The Philadelphia Inquirer. Retrieved from http://www.philly.com/philly/health/topics/HealthDay661500_20120206_Health_Highlights__Feb__6__2012.html.
Trejos, N. (2012, January 23). More than 100 ill after norovirus outbreak at a Canada hotel. USA Today. Retrieved from http://travel.usatoday.com/hotels/post/2012/01/norovirus-outbreak-hits-a-victoria-canada-hotel/609764/1.
Widdowson, M., Cramer, E., Hadley, L., Bresee, J., Beard, R.S., Bulens, S., Charles, M., et al. (2004). Outbreaks of acute gastroenteritis on cruise ships and on land: Identification of a predominant circulating strain of norovirus-United States, 2002. The Journal of Infectious Diseases, 190, 27-36.
Wikswo, M., Cortes, J., Hall, A., Vaughan, G., Howard, C., Gregoricus, N., Cramer, E. (2011). Disease transmission and passenger behaviors during a high morbidity norovirus outbreak on a cruise ship, January 2009. Clinical Infectious Diseases, 52, 1116-1122.
[i] Spalding, D. (2012, January 21). Number of Norovirus Victims Jumps to 165. The Victoria Times Colonist. Retrieved from http://www.timescolonist.com/health/Number+norovirus+victims+jumps/6031944/story.html.
Trejos, N. (2012, January 23). More Than 100 Ill After Norovirus Outbreak at a Canada Hotel. USA Today. Retrieved from http://travel.usatoday.com/hotels/post/2012/01/norovirus-outbreak-hits-a-victoria-canada-hotel/609764/1.
Sloan, G. (2012, February 7). Outbreak of Illness Forces Early End to Princess Cruise. USA Today. Retrieved from http://travel.usatoday.com/cruises/post/2012/02/crown-princess-cruise-ship-norovirus-outbreak/622300/1.
200 Cruise Passengers Struck by Norovirus. (2012, February 6). USA Today. Retrieved from http://travel.usatoday.com/cruises/story/2012-02-04/200-cruise-passengers-struck-by-norovirus/52963710/1.
Stomach Flu Hits Hundreds on QE2. (2007, January 25). The Philadelphia Inquirer. Retrieved from http://www.philly.com/philly/news/nation_world/20070125_In_the_Nation.html.
Three Cruise Ships Cleaned After Norovirus Outbreaks. (2012, February 6). The Philadelphia Inquirer. Retrieved from http://www.philly.com/philly/health/topics/HealthDay661500_20120206_Health_Highlights__Feb__6__2012.html.
Newman, M. (2006, November 16). For 700 on Cruise, Queasiness Not Due to Sea. The New York Times. Retrieved from http://www.nytimes.com/2006/11/16/us/17cruisecnd.html?scp=7&sq=norovirus%20AND%20ships&st=cse.
McDowell, E. (2003, February 2). Virus Outbreaks Don’t Rock Boats. The New York Times. Retrieved from http://www.nytimes.com/2003/02/02/travel/virus-outbreaks-don-t-rock-boats.html.
Associated Press. (2007, November 13). Hawaii: Virus Sickens Ship Passengers. The New York Times. Retrieved from http://query.nytimes.com/gst/fullpage.htmlres=9907E5D61539F930A25752C1A9619C8B63&scp=17&sq=norovirus%20AND%20ships&st=cse.
[ii] Although no easier than it would at hotels, conference centers, or other facilities of a similar nature where a number of people come together and often touch the same surface.
[iii] Admittedly, it’s much harder to encourage bloggers, who may not feel beholden to any journalistic standards, to comply with this than it is news organizations. A code of ethics for bloggers (if one does not already exist) would be useful. One possible initial method of encouraging compliance with such a code might be by shaming violators, perhaps through people writing comments criticizing the post’s lack of respect for privacy in the blog’s comments fields. Another possible method might be for news organizations to verify the credibility of other posts on the same blog. If a number of the blog’s posts are of questionable credibility (or are downright wrong), the news organization might state it is refusing to publish the information despite the information’s being available on the Internet (without saying where on the Internet) because of serious questions regarding the credibility of the source. Alternatively, the news organization could also consider running a separate story regarding the other posts’ lack of credibility – thus implying all of the blog’s posts may lack credibility. If a blogger knows that nobody believes what he or she is posting is true, the blogger will have a strong motivation to behave more appropriately. There are probably other, better means of dealing with bloggers than the ones listed here. However, the question of how to police bloggers is beyond the scope of this paper; suffice it to say they should not be violating a person’s privacy any more than a news organization should and, since information posted on blogs usually is also in the public domain, should be treated appropriately if they do.