Mycobacterium tuberculosis, the causative agent of tuberculosis. Obtained from the CDC Public Health Image Library. Image credit: CDC/ Elizabeth "Libby" White (PHIL #8433).

Reciprocity and Multidrug-Resistant Tuberculosis

In That Case Comment on “The Ethics of Isolation for Patients With Tuberculosis in Australia” by Jane Carroll, published in the Journal of Bioethical Inquiry 13(1).

J.-G. Cho
Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, The University of Sydney, P.O. Box 533, Wentworthville, NSW 2145 Australia

A. L. Byrne
Centre of Research Excellence in Tuberculosis Control (TB-CRE), The University of Sydney
Building 93, RPA Hospital, Missenden Road, Camperdown, NSW 2050 Australia

G. Radford
Liverpool Hospital, South Western Sydney Clinical School, UNSW, Elizabeth Street, Liverpool, Sydney, NSW 2170 Australia

M. Keller
Liverpool Hospital, South Western Sydney Clinical School, UNSW, Elizabeth Street, Liverpool, Sydney, NSW 2170 Australia

C. C. Dobler
Liverpool Hospital, South Western Sydney Clinical School, UNSW, Elizabeth Street, Liverpool, Sydney, NSW 2170 Australia

Abstract Patients with multi-drug resistant tuberculosis (MDR-TB) suffer many hardships, including prolonged treatment with potentially irreversible side effects from medications and solitary confinement for extended periods in a foreign environment, often without social support. MDR-TB treatment and patient isolation are expensive, and the disease usually has financial implications for the patients themselves, who often already belong to vulnerable groups within society. MDR-TB patients are asked to make enormous sacrifices with regards to their autonomy and psychological and social well-being when they have to stay in isolation to protect the general community until they are deemed non-infectious. We argue that we have a moral obligation to pay for the cost of treatment for these patients, independently of their nationality, and offer what we believe to be a just suggestion for the welfare of Xiang’s dependents affected by his serious medical condition.

Multi-drug resistant tuberculosis (MDR-TB) is associated with poor treatment outcomes and threatens global tuberculosis control (Horsburgh, Barry, and Lange 2015). Up to two years of treatment may be required to cure MDR-TB, and prolonged hospitalization in solitary isolation is often necessary to prevent transmission of infection to other people. Xiang’s case highlights the complicated ethical problems that MDR-TB treatment creates, namely weighing the loss of the patient’s autonomy and the economic, psychological, and social harms caused by being in solitary confinement against the benefit to the general public by preventing disease transmission.

It would be morally irresponsible to send Xiang overseas by plane while he remains potentially infectious, as it may place other passengers at risk of being infected. It is necessary, therefore, that his ongoing treatment occurs within Australia until he is non-infectious. Given the extremely small number of MDR-TB cases in Australia (Lumb et al. 2013), it is most likely that Xiang contracted MDR-TB from his country of origin, either by primary infection or re-activation of latent MDR-TB. Some may argue that as a consequence, it is not Australia’s responsibility to pay the costs of his MDR-TB treatment. However, tuberculosis differs from many other medical conditions in that treatment of the disease benefits not only the individual (by cure) but also the community (in Xiang’s case, prevention of spread of infection in Australia). In view of these community benefits, the cost of Xiang’s treatment should be borne by the treating hospital, which in turn receives state funding for TB treatment. The ethical principle of reciprocity—that is, governments bearing the cost of TB treatment in return for imposing a burden (isolation) on an individual for the benefit of society in general—is supported by guidelines from the World Health Organization (WHO 2010). For this reason, we believe it would be unethical to ask Xiang or his family to bear the cost of his treatment. It may also be argued that Australia has a moral obligation to look after Xiang until his MDR-TB treatment is completed, if there is doubt that his condition would be adequately treated in his home country.

The principle of reciprocity extends to our duty of care for Xiang’s family overseas. As Xiang’s work is the primary source of his family’s income, imposing a restriction on his ability to work in order to protect society from disease harms his family. If Xiang were an Australian resident, he would be eligible for Sickness Allowance, which could support his family while he is unable to work. As Australia is preventing him from travelling back home and imposes isolation on him, it would seem just that he would receive similar support compared to the Sickness Allowance for Australian permanent residents and citizens for the duration of time that he remains unable to work while residing in Australia.

Would Australia be absolved from its duty of care if migrants were explicitly warned of the risks of long-term or indefinite isolation for resistant strains of TB before entering the country? We believe that given the very small risk that a migrant would develop MDR-TB while in Australia, it would be unreasonable to assume that migrants would give such a warning much consideration. The principle of reciprocity would still apply under these circumstances, and Australia would not be absolved from its duty of care.

In 2010, 1,051 cases of bacteriologically confirmed TB were diagnosed in Australia, of which only 19 (or 2 per cent) were MDR-TB (Lumb et al. 2013). In the same year, approximately 300,000 visas were issued (Australian Bureau of Statistics 2013) and there were 5.9 million short-term international visitor arrivals (Australian Bureau of Statistics 2012). Theoretically, any visitor to Australia, whether on a tourist or temporary resident visa, could become ill with MDR-TB while in Australia and could be affected by forced isolation. Should thus all international visitors be notified of this potential risk prior to entering Australia? Based on the numbers provided above, the potential fear and concern generated by providing explicit warnings regarding MDR-TB treatment to people entering Australia would seem to far outweigh any benefit that this knowledge may provide to the vast majority of migrants and visitors to Australia.

Australian Bureau of Statistics. 2012. 1301.0 – Year Book Australia, 2012. Accessed November 23, 2015.

Australian Bureau of Statistics. 2013. 3412.0 – Migration, Australia, 2010-11.  Accessed November 23, 2015.

Horsburgh, C.R., C.E. Barry, and C. Lange. 2015. Treatment of tuberculosis. The New England Journal of Medicine 373(22): 2149–2160.

Lumb, R., I. Bastian, R. Carter, et al. 2013. Tuberculosis in Australia: Bacteriologically confirmed cases and drug resistance, 2010. Communicable Diseases Intelligence 37(1): E40–E46. Accessed December 7, 2015.

World Health Organization (WHO). 2010. Guidance on ethics of tuberculosis prevention, care and control. Geneva: WHO, publication no. WHO/HTM/TB/2010.16. Accessed November 18, 2015.