Public Health Ethics

Public Health Ethics: Case 2

Forced Treatment for Multidrug-Resistant Tuberculosis

MW is a 33-year-old man with multidrug-resistant tuberculosis (MDR-TB). He is homeless, and has a pattern of missing many of his scheduled clinic visits. Upon starting a multi-drug regimen for his condition, MW initially comes to his scheduled clinic visits, but after a few weeks begins missing them. The provider contacts the social work case manager, who arranges supervised drug administration (also known as “directly observed therapy”). Nevertheless, MW often cannot be found and this approach is deemed to be failing.

Public Health Ethics: Case 1

Sexually Transmitted Diseases and Contact Tracing

MG is a 27-year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and Pap smear. During the course of the exam, the gynecology resident performing the exam obtains the Pap smear, but also obtains cervical cultures for gonorrhea and chlamydia. The examination concludes uneventfully.

Public Health Ethics

NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion.  Please check back soon for updates!

 

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CASE STUDIES

Sexually Transmitted Diseases and Contact Tracing

MG is a 27-year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and Pap smear. During the course of the exam, the gynecology resident performing the exam obtains the Pap smear, but also obtains cervical cultures for gonorrhea and chlamydia. The examination concludes uneventfully.

Several weeks later, MG receives a postcard indicating that the Pap smear was normal, with no evidence of dysplasia, but that the cervical culture for gonorrhea was positive. The card instructs her to come into the clinic to discuss treatment, and that "public health authorities" have been notified for contact tracing, which refers to the identification and diagnosis of sexual partners, as required by law. The young woman is terrified that her husband will be contacted.

Is contact tracing ethically justified?
 

Case Discussion

Yes. Her sexual partners have a right to know that they were exposed to gonorrhea. Notification has positive public health benefits that outweigh the young woman’s concerns about violation of privacy. First, those notified can be tested and treated. Second, they can take precautions to protect others from contracting gonorrhea (like using condoms). Third, their sexual partners can be notified to further reduce the spread of infection. To address the young woman’s concerns, she can seek advice from her doctor and public health officials and may choose to tell her husband herself. Should she fail to inform her husband, public health officials will be obligated to do so.

Forced Treatment for Multidrug-Resistant Tuberculosis

MW is a 33-year-old man with multidrug-resistant tuberculosis (MDR-TB). He is homeless, and has a pattern of missing many of his scheduled clinic visits. Upon starting a multi-drug regimen for his condition, MW initially comes to his scheduled clinic visits, but after a few weeks begins missing them. The provider contacts the social work case manager, who arranges supervised drug administration (also known as “directly observed therapy”). Nevertheless, MW often cannot be found and this approach is deemed to be failing.

Should MW be forced into treatment against his will?
 

Case Discussion

This is a case in which the health of the public is clearly and seriously threatened. Multidrug-resistant tuberculosis has the potential of causing substantial morbidity and mortality for the population, particularly in large urban areas. Thus the need for the individual patient to be treated for the good of the public is high.

Similarly, the patient himself stands to benefit from the treatment. Ordinarily, patients have the right to refuse potentially beneficial treatment, provided they are competent and make an informed decision to do so. The tension created in this case is that the patient's refusal to follow the medication regimen puts others at substantial risk of harm. Hence it may be justifiable to compromise his autonomy to protect the health of others.

In such cases, every effort should be exhausted to enlist the patient's cooperation with the medical regimen. Interventions such as directly observed therapy are often effective ways to achieve the desired result without compromising the patient's autonomy. Failing this, it would be justifiable to seek court permission to confine and treat the patient against his will. In the legal process that ensues, considerations will include the magnitude of harm, the degree to which specific individuals are exposed to harm, and the probability of harm.
 

Health Care Disparities and Priority for Treatment
(From BH509: When Life Makes You Sick: Ethics and the Social Determinants of Health, Erika Blacksher, instructor)

Samuel Banks is a 54-year-old accountant with a college degree and health insurance. He was the first of four children and a first generation college graduate. Having worked hard all of his life, Mr. Banks has been exposed to a variety of chronic stresses, including racism. As an African American growing up in the southeast United States, Mr. Banks was exposed to a steady stream of slights and insults as well as institutional forms of racism. Despite these challenges, he had been healthy much of his life even though he put on an extra 25 pounds in his late 40s. Over this past year he began to have heart issues. Initially, he thought he was just having heartburn, but the discomfort persisted. Mr. Banks visited his physician, who was new to him because his employer had just switched insurers. He had waited an hour in the waiting room and was agitated by the time he got to see Dr. Susan Mott. The visit did not last long. Dr. Mott was polite but hurried, facing a full waiting room of patients, and Mr. Banks perceived the doctor as rushed and rude. He left Dr. Mott’s office frustrated and determined to find a new physician. Before he could find one, he had a heart attack. He was rushed to the emergency room where he received medical treatment that included a physical exam, ECG, chewable aspirin, supplemental oxygen, nitroglycerin, and monitoring through the night. What he needed and did not receive, however, was coronary artery bypass graft surgery (CABG). This is not an uncommon experience for minorities. Members of racial and ethnic groups receive less and lower quality health care than their white counterparts. The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documents the extent of these disparities in health care and their potential sources (Geiger HJ et al. 2003).

Many people argue that health care disparities constitute an injustice. The argument can be made on a number of moral grounds, including the idea that people should be treated equally, regardless of race or ethnicity, receiving treatment only on the basis of medical need. Some commentators, however, have raised the question of whether disadvantaged patients should be given priority at the point of care.

Should the health care system prioritize care for members of disadvantaged groups over that of other patients? 
Should clinicians attempt to redress injustices in the social determinants of health by prioritizing the disadvantaged when they enter the health care system?

Case Discussion

These allocation questions have received scant attention in bioethics, despite considerable attention to other resource allocation problems (Daniels 1994). There are arguments for and against giving priority to socially disadvantaged patients at the point of treatment. Some of the reasons in support of prioritizing members of socially disadvantaged groups include the view that it would constitute a form of compensation for the unjust disadvantages, including poor health, that poor and minority groups suffer, and, in doing so, promote social cohesion; and that better off groups are to some degree responsible for the conditions of worst off groups, given their contribution to the institutions and policies that unfairly distribute the social determinants (Hurst 2009). Reasons against priority include the view widely held in medicine that social attributes should not be taken into consideration within medicine, that everyone should be treated equally, based only on medical need, and that doing otherwise would demonstrate disregard and disrespect for the needs of those who are better off; and that such a practice would alienate more powerful and privileged groups and risk strong support for health system funding. Another important consideration is that disparities in health should be addressed at their source, which many locate in the non-medical determinants of health (Williams et al. 2008).

Childhood Obesity and Parental Responsibility
(From BH509: When Life Makes You Sick: Ethics and the Social Determinants of Health, Erika Blacksher, instructor)

Joe lives with his mother and aunt and her two children, both under age 6, in a small duplex south of Seattle. Average height for his age, Joe is 9 years old and weighs 184 pounds. His two cousins are not obese, but they are overweight. The mothers of the family work a number of jobs to make ends meet. They do not have much money for material things or extra curricular activities, and increasing gang activity in the area has made them reluctant to let the children play on their own in the nearby park and soccer field. What the family does not do in the way of ‘fun’, they make up for with food. The school nurse has brought Joe’s obesity to his mother’s attention twice, each time suggesting several approaches to helping him lose weight. They include buying healthier foods and healthier cooking. Joe’s mom has been slow to take up these practices because the foods are more expensive than what she usually buys, the recipes seem strange to her, and she suspects they will not taste very good to Joe or her niece and nephew, who she often also cooks for. At a recent pediatric check up Joe’s physician cautions the mother that she really needs to get Joe’s weight under control. He is developing elevated blood sugar and has experienced difficulty breathing in his sleep. If she does not take action, he says he might be obligated to alert child protective services.

As childhood obesity has become an epidemic problem in the United States, such cases increasingly are being reported. The rate of childhood obesity has more than tripled in the last three decades with serious short- and long-term health consequences. Obese children are significantly more likely to experience a wide range of poor health outcomes, including type II diabetes, cardiovascular conditions, asthma, sleep disordered breathing, anomalies in foot structure, low self-esteem, depression, and high-risk behaviors. Studies suggest that as many as half of all obese children remain obese as adults, leading to further health risks-elevated risk of heart disease, stroke, diabetes, osteoporosis, lower-body disability, some types of cancer, and premature mortality in general.

Public health leaders emphasize structural and environmental interventions to remedy the U.S. obesity epidemic, but even they acknowledge the role parents play in contributing to children’s healthfulness, including normal weight (Frieden et al. 2010). Increasingly, state intervention in severe cases of childhood obesity is being called for under certain circumstances (Murtagh, Ludwig 2011).

Are clinicians obligated to report parents of obese children to child protective services?

Case Discussion

Although parents have significant discretion to rear their children according to their own values and practices, society may justifiably intervene when it deems parental behaviors expose their children to serious harm. This “harm principle,” discussed above, is often appealed to as the basis for intervention (Murtagh, Ludwig2011). There have been legal cases in which a child has been removed from the home in cases where parental practices are judged to have contributed severe morbid obesity, in states that include California, Indiana, Iowa, New Mexico, and New York. Similar cases have also been reported in the United Kingdom. Commentators on the subject, however, urge caution, as removing a child from the home can seriously harm a child in other ways (Black et al. 2011). Commentators encourage using intermediate options, such as in home support services, parent training, and financial assistance, and seeking a second medical opinion before any action is taken.