Proposing Coerced Treatment Compliance

02-18-2007 | Categories:

The Issues

In a drama that one can imagine scripted by John Kani or Tony Kushner, the post-apartheid politics of South Africa, the physiological and psychological dynamics of AIDS, a life and death struggle with a potentially global impact, the clash of national and ethnic traditions, cultures, and mores, medical research, the concept of individual freedom and dignity of the individual, the reality of clinical healthcare practice in places like KwaZulu-Natal, the sovereign authority of a recognized nation Vs the needs of the world community, the role of international public opinion, the pronouncements of a self-described institution of bioethics, and the socio-economic forces associated with poverty, homosexuality, and race are joined together in agonized battle by a paper issued in a forum with the prosaic, even by bureaucratic standards, title of the “Public Library of Science Medicine.”

The Proposal

In the January 2007 (Vol. 4) issue of the Public Library of Science Medicine Journal, Drs. Jerome Amir Singh and Nesri Padayatchi of the Centre for AIDS Programme of Research in South Africa and Dr. Ross Upshur, the director of the Joint Centre for Bioethics at the University of Toronto, propose that patients with XDR-TB, a drug-resistant form of tuberculosis, who refuse treatment be involuntarily detained in hospitals or other health care facilities in South Africa.

The following excerpt from that paper accurately reflects, I believe, the authors’ thinking, but has been significantly truncated. I heartily recommend reading the original paper, which is freely available at XDR-TB in South Africa: No Time for Denial or Complacency and is just over six pages, including references.

The emergence of XDR-TB indicates that the WHO strategy of allowing the patient to assume responsibility for mixing with the general public may be too permissive and more attention to strategies of infection control in the community is required. In general, from both an ethical and legal perspective, measures that rely on voluntary cooperation and are the least restrictive in terms of interfering with human rights are preferred. However, if such measures prove to be ineffective, then more restrictive measures may need to be contemplated. Such measures should be taken with due consideration for the possibility that they may increase disincentives to seek care. However, if due care is taken to provide for the rights and needs of those so detained and therapeutic goals are kept paramount, such measures could play an important role in containing XDR-TB before it spreads more generally in the population globally. The use of involuntary detention may legitimately be countenanced as a means to assure isolation and prevent infected individuals possibly spreading infection to others. However, South African officials have raised human rights concerns in dealing with the country’s XDR-TB and MDR-TB outbreaks, although they have conceded that forcible treatment may be a viable option in tackling the outbreak. … We believe that the forced isolation and confinement of individuals infected with XDRTB and selected MDR-TB may be an appropriate and proportionate response in defined situations, given the extreme risk posed by both strains and the fact that less severe measures may be insufficient to safeguard public interest.

The Public Library of Science Medicine Journal paper carefully discusses the pragmatic difficulties of treating patients in South Africa, the epidemiology that threatens populations far outside the borders of that country, the criteria for determining when the risk to public safety abrogates individual freedoms and rights, and more.

The proposal specifically recommends that South Africa end its policy stipulating that those hospitalized at state expense lose their social welfare benefits, a regulation that encourages patients to avoid hospitalization and, all too often, treatment of any sort.

According to South Africa’s Medical Research Council, about half of adults in South Africa with active TB are cured each year, compared with 80% in countries with better resources. Moreover, nationally, about 15% of patients default on the first-line six-month treatment, while almost a third of patients default on secondline treatment.

The Reactions

Official reactions to the proposal range from cautious agreement to cautious opposition.

The South African Department of Health released this supportive statement from its adviser, Ronnie Green-Thompson, “The issue of holding the patient against their will is not ideal but may have to be considered in the interest of the public. Legal opinion and comment as well as . . . the opinion of human rights groups is important.”

These excerpts from South Africa may lock up “killer TB” patients, written for the Associated Press (24 January, 2007) by Maria Cheng, is representative of the latter perspective:

“The government hasn’t yet done the most obvious things to shut down transmission,” said Mark Harrington, executive director of the Treatment Action Group, a health advocacy group in New York. “Starting to imprison patients is a step very far downstream from where we are now.”

Others worry that involuntarily detaining people would result in “driving patients underground,” said Dr. Tido von Schoen-Angerer, of Medecins Sans Frontieres, the international medical aid group.

Tuberculosis experts at the World Health Organization believe XDR-TB is as serious a threat to global health as either bird flu or SARS. But Dr. Mario Raviglione, director of WHO’s Stop TB department, isn’t certain involuntary confinement is warranted just yet. Without proper patient data from South Africa, Raviglione says it is unknown whether lack of compliance is a significant factor.

Commentary

While the threat to world health and the tragedy of those currently afflicted with XDR-TB are themselves compelling, even broader and more fundamental concerns are raised by this situation. The long-debated conflict between individual rights and the good of the community, the authority and responsibility of the state to protect all its citizens, personal morality and accountability, and the large scale economics of public health, among others, are unavoidably and usefully raised by a thoughtful review of this paper.

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