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).

Jane Batt, M.D., Ph.D.
St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
e-mail: jane.batt@utoronto.ca

Sarah Brode, M.D.
West Park Healthcare Centre, University of Toronto, Toronto, Ontario, Canada

Elisabeth Rea, M.D., M.Sc.
Toronto Public Health and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

This is a dilemma faced by all industrialized countries that issue visas for foreign workers or students. We discuss these issues in the context of our experience in Ontario, Canada, where 80 per cent of tuberculosis (TB) cases are among the foreign-born.

While the scenario described by Carroll highlights the monetary costs of respiratory isolation, the personal costs are also considerable. Respiratory isolation is an effective technique to reduce the spread of TB. Isolation of infectious patients, while an infringement of individual rights, is ethically justified on these grounds, given the severity of TB disease. However, this intervention for the public good should be the least restrictive necessary and seek to mitigate the associated harms (the reciprocity principle). In Ontario, West Park Healthcare Centre is a specialized referral centre for TB inpatient care. The entire ward is negatively pressured with private grounds, which enables TB patients to socialize and go outside. Staff are highly experienced working with infectious patients; assistance with social and financial issues is a routine provision. Telephone interpretation services are used when necessary, as is computer-based communication with family abroad. Industrialized countries have the capacity to provide such specialized centres and should do so. Xiang’s loss of contact with his family and minimal contact with and inability to understand hospital staff could thus be avoided. Multidrug-resistant tuberculosis (MDR-TB) care in home isolation also has proven effective, may help to mitigate the negative impact of isolation, and should be considered as a far less expensive alternative to long-term hospitalization among those who are well enough.

To ensure prompt management of respiratory isolation and treatment to cure (for public benefit), plus universal and timely access to high-quality TB care (for patient benefit), all TB patients in Ontario without health insurance are covered for outpatient investigation and TB treatment by the provincial government, at no personal cost. Xiang received care under the similar Chest Clinics system in Australia. Such coverage should be adopted in all industrialized countries accepting migrants from high TB incidence countries. However, in Ontario (as in Australia), inpatient costs for uninsured TB patients are not covered. When families are unable to pay, hospitals (which are publicly funded) negotiate partial payment and absorb the remainder of the cost. It is nonsensical that government-based coverage is not extended to inpatient TB care and drug-resistant TB, i.e., the sickest patients who pose the greater threat to public health. Effectively, the cost of uninsured inpatient TB services is already borne by the public purse, but in an indirect, fragmented manner.

At the same time, health insurance for migrant workers should be mandated at a realistic “catastrophic” level and paid by the employer or individual. When unavoidable costs exceed the allotted insurance or ability to pay, as in Xiang’s case, we believe the costs of TB care while infectious should be borne by the hosting government. Migrants who are ill/injured abroad can normally return to their home country for medical care; Xiang would probably have preferred to do so when his insurance ran out, but we prohibit infectious TB patients from flying on commercial airlines. The unique aspect of this disease and related public health aspects require special consideration by the hosting country.

Xiang has lost considerable income due to his inability to work while under isolation. There are two ethical considerations here: minimizing harms and ensuring equity. If the nature of the job permits, the ability of the individual to work remotely by computer/phone should be facilitated to minimize the economic consequences of isolation and is undertaken in Ontario. Concomitantly, infectious patients should be monitored closely so that isolation can be discontinued immediately once non-infectious. In the principle of fairness, all employees should be treated equally, whether local or migrant. In Ontario, it is illegal to release a worker due to illness, unless the employer can demonstrate undue stress and hardship due to frustration of contract. This means Xiang would have fifteen weeks of sick benefits under the mandatory employment insurance in Canada and sick-time pay from his company, if available. This would provide some short-term relief for Xiang.

However, it is not, and it should not be, the responsibility of the employer or the government to replace lost income during respiratory isolation (other than sick-time benefits as above) because the individual cannot work, nor to cover the costs of dependents. In Xiang’s case, there would be no replacement income or dependent benefits paid had he lost the ability to work due to another illness or injury-induced disability, such as, for example, a motor vehicle accident and brain injury.

It is only fair to inform foreign workers of potential costs should be they become ill, and disability insurance (for income replacement) should be available and encouraged—but not mandated. Realistically, though, the majority of foreign workers will have no way to predict their likelihood of developing MDR-TB; many will feel they have no choice but to take the risk regardless.