In January this year Dr Elizabeth
Rae, a Toronto medical officer, had a tough choice to
make. She had a patient on her hands who was transferred
to Toronto to be treated for a highly virulent strain
of TB: extensive drug resistant tuberculosis (XDR-TB).
The trouble was the man wouldn't or couldn't
follow his treatment regimen and Dr Rae was facing
a potential public health disaster. She asked a judge
for a court order to lock the man up in a hospital detention
centre for 11 months.
"When he was transferred to Toronto
he was already drug-resistant and continued to have
difficulties complying fully with treatment," says Dr
Rae. His ongoing noncompliance caused his disease to
become more and more resistant to drugs, making him
one of Canada's first XDR-TB cases and the first to
be forcibly confined by public health officials.
The emergence over the past year of XDR-TB in South
Africa and around the world, including several confirmed
cases in Canada already, has prompted widespread fears
of a pandemic. And emerging in parallel to the spread
of XDR-TB has been a renewed focus on the ethical issues
inherent in the forcible confinement of patients.
XDR-TB is an extremely dangerous
type of multi-drug resistant TB (MDR-TB) that was only
identified last year. It describes patients who have
become resistant to the basic TB drug combination rifampicin
and isoniazid as well as at least three of the six second-line
TB drug classes as well. All but one of the 53 cases
identified by the WHO in the rural town of Tugela Ferry,
South Africa, last September have proved fatal. Patients
can be treated aggressively with second-line antibiotics,
should wear a mask and avoid human contact as much as
possible especially with susceptible people like
the HIV positive. The treatment regimen is gruelling,
but is it ethical to lock up sick patients? That depends
on who you ask.
The Arizona Republic recently
broke the story of a 27-year-old Russian-American man
named Robert Daniels who has been quarantined in the
detention ward of an Arizona hospital for almost nine
months now a state of affairs that could quite
possibly last until he dies of XDR-TB, which he contracted
in Russia two years ago. The court order was issued
after he violated his voluntary quarantine when he stopped
his medication and left, unmasked, to visit restaurants
and stores in Phoenix. He argues he's being treated
like a criminal; the wardens say that's exactly what
he is, which is why they won't let him use the phone
or have access to a computer or TV.
Meanwhile, in late January, experts
(including Dr Ross Upshur, the director of the University
of Toronto's Joint Centre for Bioethics) published an
essay in Public Library of Science Medicine arguing
that South Africa, the epicentre of the current XDR-TB
outbreak, should adopt a much tougher policy of forcible
confinement for patients diagnosed with the disease.
The TB sanitoria of the 1940s and 50s are gone, but
forcible confinement is still used occasionally by Canadian
provincial authorities if patients represent a serious
risk to the public. "We have an obligation as a society
to treat people decently, to make sure people get good
medical care, that they are not being tossed in jail,
that the level of restriction is the least necessary,"
says Dr Rae, who emphasizes that quarantining is a last
resort and that cases are extremely rare ("maybe one
or two every year a huge majority of people want
to get better").
"I do think it is important we
don't use our powers lightly, that we do everything
possible before we take away a patient's rights," says
Dr Patricia Daly, a medical officer and director of
Communicable Disease Control with the Vancouver Coastal
Health Authority. "We in public health are unique,"
Dr Daly says. "Healthcare workers advocate for their
patients, but we have to think of the public at large."
Dr Rae adds, "When it becomes clear
that there is a true risk to public safety, then it
is part of the mandate of the public system to intervene.
As a clinician you have a legal and moral duty."
Lisa Schwartz, a McMaster University
healthcare ethicist and professor of epidemiology and
philosophy, points out that the civil liberties questions
often stem from systemic social problems. "Historically,
the people most likely to be quarantined and have their
civil liberties taken away are the poor, the marginalized,
the less well-off, who don't understand the circumstances
and have the most to lose by being quarantined."
The trend today is more or less
the same. Although forcible confinement is necessary
in some cases, says Dr Schwartz, Canada has largely
failed to address the root causes of some of the diseases
that have led to quarantines for TB in certain vulnerable
populations like aboriginals or intravenous-drug users.