Is involuntary incarceration of TB patients justifiable?

Results of a Union survey*

The issue of whether it is justifiable to subject people with tuberculosis to involuntary incarceration is a highly controversial one. It pits individual human rights against the interests of public health and raises questions about who should have the power to make such an important legal and ethical question – doctors, health officials or the courts?

In recent years, the high mortality and population-level impact of multidrug- and extensively drug-resistant TB have placed pressure on health systems to consider such strategies, and World Health Organization (WHO) guidance says that forcible detention may be considered appropriate, but only in “exceptional circumstances”. What constitutes circumstances is contested, along with related questions such as detained by whom, where and for how long.

To foster debate and reflection within The Union, the Ethics Advisory Group (EAG), which provides ethical oversight for all Union activities, conducted a survey of Union members regarding this issue, and the results have been published in the February edition of the International Journal of Tuberculosis and Lung Disease.

The 194 respondents to the survey were all members of The Union’s Tuberculosis Scientific Section and represented all seven Union regions. They were 66% male, 40.7% doctors and 42.9% in other health-related professions, and 91.2% between the ages of 30 and 69.

The survey included both multiple-choice questions and the opportunity for written comments. The responses showed a wide range of attitudes, with significant variances by region. For example:

• 17% said that, as a matter of principle, the involuntary incarceration of TB patients was inappropriate on any grounds.
• Of those who thought involuntary incarceration was justifiable in at least one situation, 97.5% based their opinion on the need to prevent transmission to the patient’s contacts or the general community. Opinions varied on the duration of incarceration required.
• Respondents most strongly supported the policy of incarceration for patients known to have multidrug-resistant TB (49.7%) or a past history of defaulting from their treatment (47%). Other factors, such as a past history of mental illness, received far less support.
• Regionally, members from Europe Region had the highest percentage of respondents objecting to the policy as a matter of principle (26.2%) while the North America Region had the lowest (3%).
• Many commented that this strategy should only be used as a “last resort”, when all voluntary approaches had failed.

In analysing the survey responses, the EAG noted that an ethically defensible policy could only developed by keeping the focus on the tension between the principles of public health protection and human rights. In addition, they pointed out that, while only one in seven respondents identified judges as the most appropriate person to decide who should be incarcerated, in fact international and most domestic laws consider this a legal, not a medical, decision.

Ultimately, they concluded, ensuring respect for human rights and expanding access to quality care are both needed to advance ethical and effective TB policies.

Read the survey: Access to this article is free for Union members and UJTLD subscribers; non-members can download the article using the pay-per-view option.

Denholm JT, Amon JJ, O’Brien R, Narain A, Kim SJ, El Sony A, Edginton ME. Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members. Int J Tuberc Lung Dis 18 (2): 155–159.

* Results from this survey should not be taken as reflective of Union policy or necessarily representative of Union members as a whole.

Source: The Union