Romanian Journal of Bioethics, vol. 6, nr.

2, april june 2008

ETHICAL DILEMMAS IN THE ACTIVITY

OF TUBERCULOSIS CONTROL
Antonela Chec*, Felicia Dogariu**
Abstract
The article presents some particularities of the medical and bioethical standards regarding the
ethical dilemmas in the activity of tuberculosis control. We described and analyzed ethical
principles in the medical practice, specific to physicians in their relationships with their patients.
These relationships often determine conflicts based on different interests that physicians need to
reconsider and solve. The article reveals rules of the clinical practice in which ethical conflicts
occurring from the physicians' duties refer to the confidentiality in environment, their
responsibilities for dealing with patient abuses, their role in the clinic and their relationships
with the patients having immunodeficiency diseases. The ethical principles sustain the basis for
solving the problems faced by the physicians.
Key words: tuberculosis, ethical dilemmas, public health

Introduction
The overall approach of tuberculosis
is carried out by coordinating the
activities of various functional services,
in order to establish exactly the diagnosis,
to provide the appropriate treatment and
for the social rehabilitation of the
individual. Moreover, specialized forms
of nursing are required to all the levels of
the medical activity in the field. This
generates the necessity to assume a

mutual responsibility by all the members

of the medical team towards the
achievement of the complete treatment
plan. As well, it facilitates every persons
freedom to decide in his/her own field of
professional ability. Again, it implies
taking the most appropriate actions
integrated in the general context of the
medical act. A feature of the overall
medicine resides in the fact that the
patient is no longer considered as a case

Junior Lecturer Md. PhD, the Faculty of Medicine Brasov, Transilvania University of Braov, The Hospital
of Pneumophtysiology Braov email: anto_ chesca@yahoo.com;
**
Sociologist, The Hospital of Pneumophtysiology Braov.

133

of diseases but as an ill person. This

allows a more detailed exploration of the
disease causes, of the conditions and
consequences,
of
social
and
psychological nature [6]. The global
character of nursing facilitates a wider
understanding of the patients needs and
aspirations, of the social situation thereof
within the family or professional group.
Thus we create favorable conditions to
the passing from the disease-oriented
treatment to the recovery process, by
means of which we intend to recover the
functional abilities of the patient.
The central feature of the social
activity in this context resides in the
direct concern for the personal and family
problems of the patient, the assessment of
his/her material needs, the assessments of
the emotional condition and the provision
of optimum recovery at the family level.
It is necessary to define both the type of
social problems that the patient confronts
with and the ability to find the most
appropriate solutions to accelerate the
recovery process. In case of tuberculosis,
an essential role is incumbent upon the
social worker in the increase of the
patients adherence to the long-term
treatment and then to the social /
professional reintegration thereof [4].
Ethical Dilemmas Interfering in the
Activity of Tuberculosis Control
The ethical dilemmas appear in the
situations in which the specialist must
choose between two equivalent desirable
or undesirable alternatives [3]. In the
following lines we shall analyze the
ethical problems that appear in the
tuberculosis control, in the relationship
between therapy efficiency and justifying
the limitation of the individuals
autonomy, part of the tuberculosis
control. Within this context, the
traditional medical ethics was focusing on

the physician patient relation and on

keeping the human autonomy and
dignity, these being strongly individualist
perspectives. On the other hand, the
ethics of the public health focuses on the
health protection and promotion in
communities. A central ethical problem
related to the tuberculosis control, resides
in the balance between patients rights
and the protection of public health. The
interventions such as the treatment under
strict observation and mandatory
hospitalization while the patient is being
contagious
assume
a
substantial
diminution of the individuals freedom.
Within this context, the ethical dilemmas
focus on specific objectives.
1. Reporting new cases to the
public health authority, balancing the
physician patient relationship and the
need to obtain exact information on the
incidence and prevalence of the infectious
disease.
If the testing of the infection
condition
brings
forward
the
circumstances in which, on the behalf of
the public health, justifies the body
integrity of a person, cases reporting
generate the analysis between the right to
intimacy, confidentiality and the public
welfare. The state is entitled in certain
circumstances to require the physicians
and the medical institutions to nominally
report certain data on the patient or on the
disease itself. These requests violate the
confidentiality representing the fundamentals of the relationship between
physical and patient.
Those who pleaded approximately
three decades ago for the need of
nominally reporting the persons with
contagious diseases brought as argument
the need to configure a real image of the
incidence and prevalence of such diseases
and the State implication in the protection

134

of such identification data [2]. The

opponents of nominal reporting brought
forward the societys hostility to the
persons
infected
with
HIV
or
tuberculosis, as well as the possibility of
a gap in the system that would allow the
possibility of information leaking having
consequences on the ill persons. These
include job loss, stigmatization and
discrimination. In these circumstances, it
is possible that certain person refuse the
testing, for fear of a positive result and
subsequently, its knowing by the public
health authority.
2. Investigation of contracts and
the duty to draw their attention and
protect them; patients duty to keep
personal information and the obligation
of those in the health system to help those
in risk situation.
The
control
of
contacts
accomplishes two functions, namely
finding new cases and interrupting the
chain of infection transmission. In the
case of a contagious tuberculosis patient,
the family doctor thereof must be
informed on the existence of the case, the
latter having the obligation, within three
days from the notification, to start the
epidemiological investigation, namely to
inform the family members as well as the
individuals the person in cause was in
direct contact with. This is necessary so
that all the contact undergo a specialty,
medical control, namely a pneumological
one. The specialist doctor is the one who
may indicate a radiological examination
for adults or PPD testing for children. As
well, we must inform the family doctor
who, in his/her turn, starts the epidemiological investigation at the patients
work place. In fact, he/ she send for
special investigations the colleagues in
direct contact with the person in cause.
We must take into account the normal

working schedule, the time spent in the

locker rooms and in pauses, spent with
those in the working environment. These
measures need to be taken considering
the infection transmission way via air and
the large risk of infection exposure of
such persons. The purpose of the
epidemiological investigation is to
discover if a new case of tuberculosis
emerged among those around the patient
and to administer the prophylactic
treatment to those exposed to the risk of
undergoing from the infection condition
to the one of disease.
In this context, the identity of the ill
person was revealed and this represents
the exposure of the person to risk of
being stigmatized and left aside. These
problems may be prevented through the
education for health of the persons who
are called for a specialty medical control,
focusing on the curable character of the
disease.
As far as the sexually transmissible
diseases are concerned, it refers to
encouraging the individuals to reveal the
name of the sexual partners, the
anonymity observance being guaranteed.
In this case, the contacts control is
voluntary done and it is based on the rule
of confidentiality. If the patients express
their intention of not revealing the sexual
partners, the medical team faces the
dilemma referring to the duty of
confidentiality keeping versus the
obligation of protecting the sexual
partners [6].
3. Therapy
under
direct
observation highlights the right to refuse
the treatment versus the risk that these
untreated
individuals
spread
the
infection.
The failure of correct and complete
execution of an anti tuberculosis therapy
is the main cause of the emergence of the

135

resistance to antibiotics and implicitly of

the morbidity and mortality by
tuberculosis. The implementation of the
strategy of treating tuberculosis by
treatment under direct observation started
from the need to increase the adherence
of the patients to the treatment. Yet, the
way of administrate treatment under
direct observation does not always lead to
superior outcome to the one by self
administration and does not raise the
issue of legitimacy of imposing such a
limitation to the individuals freedom.
Moreover, this way of administration
implies certain costs for the patient, costs
that are not taken over by the society. Of
this last category we mention the
patients transport to the medical room to
take the medicines if there is no person
who can come to his/her residence and
the delayed social professional
reintegration. In the specialty practice, it
is had to establish exactly what patient is
actually adhering to the treatment and
who is not. The treatment of all patients
suffering from tuberculosis, starting from
the premises that they are compliant and
that a coercive regime is necessary, by
exercising the power of an authority,
interferes with the individuals rights.
4. Quarantine imposed to contagious
persons, the individuals right to personal
freedom and the risk to which the persons
around him/her are exposed to.
The nowadays society acknowledges
the right of the state to interfere in case of
patients with contagious diseases, due to
the danger they represent for those
around them. This right of the state
deprives the individual of his/her right to
freedom. In our country, a person
suffering from tuberculosis who does not
come to a medical facility for
hospitalization is sanctioned according to
the criminal code. Therefore, in case of

therapeutic abandon, the Police join the

medical team, the individual being forced
to get hospitalized. In case of tuberculosis
with resistant germs, the patients sign a
contract that implies the hospitalization
during the entire treatment term that may
last one year or more. [5]
5. Monitoring the association
between the HIV infection and the
tuberculosis infection generates tension
between the right to body integrity and
the imperative of discovering those
infected in order not to transmit the
aforementioned diseases to other persons.
In the past century, persons testing
in order to highlight the potential
presence of occult infections or diseases
was the center of the public health
departments concerns. This testing was
imposed as a condition for certain
actions, such as testing the presence of
venereal diseases before marriage, testing
the children who joined collectivities for
transmissible diseases in order to protect
such institutions, testing new-born for the
presence of metabolic diseases that may
be thus remedied, tuberculosis testing by
X rays and PPD testing in schools or
collectivities. Each of these cases, the
decision to impose the testing was the
result of the judging the way in which the
body integrity of the individual may be
subordinated to public health. The same
time with the increase of the incidence of
HIV infection, the problem of testing
HIV-infected persons was exposed. This
was imposed with the aim of discovering
an occult tuberculosis infection that may
make the treatment even harder to
administrate. Moreover, HIV testing of
the person suffering from tuberculosis is
important for the establishment of an
appropriate therapeutic regime for this
morbid association. [1] In the present,
HIV testing of the patients with

136

tuberculosis is made after a pre-testing

counseling and obtaining the patients
consent.
The decision to test a certain group
of persons to highlight the presence of an
infection is taken by the public health
authorities. In this context, we must take
into consideration the risk of that
population to make that disease, the
increased incidence of that disease and
the stigmatization risk of those involved.
Conclusions
The central ethical problem in case
of tuberculosis resides in maintaining the
equilibrium between the observance of
the patients rights and public health
protection.
The traditional medical ethics was
preoccupied by the relation between the
physician and the patient, in order to
preserve human autonomy and dignity,
from an individualist perspective. On the
other hand, the ethics of the public health
also took into account the aspect of the
health protection and promotion within

the community. Nowadays, tuberculosis

control generates, besides economic
consequences, the stigmatization, the
isolation and discrimination of the
affected individuals. [2]
The decline of tuberculosis in the
industrialized countries, long before the
development of antibiotics therapy,
showed that the true cause thereof was
the transformation of the social
conditions people lived in. Moreover, at
present, tuberculosis is a disease
associated to the limited access to social
services. Tuberculosis and poverty form a
vicious circle. Poverty may lead to
tuberculosis and tuberculosis points out
poverty. If health is so much influenced
by the social conditions, the role of the
public health authorities interventions is
crucial. Within this context, if these
interventions are absolutely necessary for
the protection of public health, it is
unavoidable that those making the
decisions take into account both the
individuals rights as well as the public
welfare. [6]

Bibliography
[1] Gandy M., Zumla A., The Return of the White Plague: Global Poverty and the New
Tuberculosis, Editor New York, Verso London, 2003;
[2] Geneva: World Health Organization, A human rights approach to TB guidelines for social
mobilization, Stop TB Secretariat, 2001;
[3] Lazr G., Deontological Aspects in the Counseling Process, Lecture notes, Bucharest
University, 2006;
[4] Neamu G., Treaty of Social Work, Iai, Polirom Publishing House, 2003;
[5] Popescu G., Rdulescu S., Medicine and Human Collectivities, II-nd revised and amended
edition of the work Sociology of medicine, Medical Publishing House, Bucharest, 1981;
[6] Rdulescu S., Sociology of Health and of the Diseases, Nemira Publishing House,
Bucharest, 2002.

137