APRIL 15, 2007


When's it OK to lock patients up?

Ethics of forced confinement for noncompliant TB patients

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.



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