After the Dallas Ebola patient Thomas Eric Duncan died last week, public comments ranged from expressions of sadness and condolences to his family to vitriolic condemnations of his behavior for lying to airport screeners. It may be helpful to revisit the rationale that likely brought him here, especially in light of the Centers for Disease Control and Prevention’s new airport screening procedures, as well as Liberia’s and Texas’ earlier proposals to prosecute Duncan for evading airport checkpoints. Thinking carefully about his mindset can help us understand how better to address this outbreak and keep it from spreading further.
Ebola is a disease that is terrifying for many reasons, not the least of which is that it kills gruesomely and is easily transmitted. It is also terrifying in part because it preys on caregivers and loved ones, parasitizing the humanity of those who care for and come into close contact with the ill. Duncan himself was a firsthand witness to the horrors of this disease. He briefly assisted his neighbor, a 19-year-old Ebola-infected pregnant woman, as she climbed into a taxi.
It is hard to blame someone for such a brief and noble encounter. Here is a sick young woman who needs help getting to a hospital, but who is too weak to climb into a cab on her own. There he is, standing nearby. Who would not help? Who would recoil and refuse to assist an ailing friend?
And besides, it was just a brief encounter. The opening of a door. The holding of an arm. The making comfortable.
There was little reason for Duncan to suspect, from this one minor interaction, that he would become ill. It is unfathomable, but true, that a single, fleeting touch is enough to pass the disease from one person to another. Duncan probably found this fact similarly unfathomable. He may not have known for certain that his neighbor was infected with Ebola rather than some other illness. He knew that she was sick, that much is clear. He apparently did not believe himself to be infected with Ebola, and certainly did not want to bring the disease to the United States. Indeed, before his passing, Duncan expressed remorse for having brought the disease to the “love of my life.” It is most certainly not true that Duncan brought Ebola here maliciously or intentionally.
Nevertheless, some have suggested that Duncan ought to be prosecuted for lying to airport screeners about this brief contact with his sick neighbor. The logic is that lying in these circumstances puts other lives at risk, and also that lying is wrong. In most circumstances, we punish wrongdoers partly for justice reasons, but also partly for deterrence reasons: It would be very bad for the world if individual travelers could get away with lying to airport screeners. The screeners are in place to contain the outbreak, and if they do not have good information, containment grows that much harder.
This much is true. You should not lie to airport screeners.
But what is not true is that this is always such an easy decision. It is also not true that Duncan is guilty of putting more lives at risk because of this decision.
The fact is, Duncan probably put fewer lives at risk by coming to the United States, and he certainly stood a greater chance of surviving this terrible disease by coming to a Western medical hospital. If he had stayed in Liberia, there is very high likelihood that he would've transmitted Ebola to more people than he did.
In many respects, then, those who heartlessly suggest that he "deserved to die," or that he was selfish for lying to airport screeners, are not actually seeing the full picture. The most important thing for Duncan to do was to get to a hospital where he could be treated. There are currently no available beds in Liberia, where there are plenty of available beds in the United States.
Duncan faced a classic “lesser evil” choice that cannot easily be answered by appeal to mere proscriptions on dishonesty: Should I tell the truth to screeners and risk being detained, falling ill in Liberia, and exposing everyone around me? Or should I lie to screeners in order to get to the United States on tickets that I have already purchased, to see people I love, knowing that if I fall ill, I will likely be hospitalized quickly and the disease can be contained?
It is probably safe to assume that the latter rationale drove him to take his flight and lie to screeners.
What would you do in this case? It seems the safest route, for everybody, is to get through the barricades and gatekeepers to be treated by doctors in one of the most reputable medical systems on the planet. This is true for self-interested reasons as well as for moral reasons. Life will go better for you if you are treated in a Western medical hospital than if you are treated in a makeshift, local isolation ward. Life will go better for others if you can isolate yourself from them in the safest containment unit possible.
I’m not saying that it was right for him to lie to screeners, or even that it was right for him to come to the United States. I am pointing out that it is incorrect to suggest that by lying he put more people at risk. Such logic only computes if you don’t include Liberians in the “people” category, or if you’ve completely written West Africans off as doomed to die.
The lesson here is an important one. Some airport screening procedures clearly will do the work of identifying people who are already exhibiting symptoms—taking temperatures, personally assessing a travel history, inquiring into prior contacts—but many of these screening procedures depend on honesty. In this current situation, there are strong reasons to lie to screeners, some of which are self-interested and others of which are more moral.
One method of encouraging honesty is to change the self-interest calculus: to penalize those who lie, as was proposed by Liberia and Texas. But if that calculation is off—if, for instance, the stakes are so high that the penalty is not a real penalty in comparison—then there is little risk to the self-interested party. “If I lie, I may survive. If I don’t lie, I stand a much greater chance of staying behind and dying.” Even if you do not believe that you have contracted the disease, there are plenty of excellent reasons, including the collapsing infrastructure of Liberia and ongoing risk of contracting the disease, to leave the country immediately.
A different, but no less important, method of encouraging honesty, however, is to change the moral calculus so that there is no reason to lie. This, remember, is not about shifting one’s calculations of self-interest, but rather about demonstrating that the best, most careful way to keep other people safe is to seek help from competent medical professionals immediately.
This is yet another reason why it is critical to address the Ebola epidemic swiftly and immediately in West Africa. We need to set up non-threatening isolation units and care facilities so that the clearest path for keeping other people healthy—families, loved ones, neighbors—is to enter isolation voluntarily and not to make the trip to other better facilities. What this means, frankly, is that to keep the infection in West Africa we must bring the full expertise of our medical system to West Africa. Any lesser option will permit and encourage more accidental transmissions across borders.
Having said all this, Thomas Eric Duncan’s death is a terrible, tragic loss, and I am very sorry for him and his family. We are better served by trying to understand his rationale than we are by vilifying him in his absence.