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.
Should MW be forced into treatment against his will?
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.