In That Case
The Ethics of Isolation for Patients With Tuberculosis in Australia
Centre for Values Ethics and the Law in Medicine
Level 1, 92-94 Parramatta Rd
Camperdown, NSW 2050, Australia
School of Public Health, University of Sydney, NSW, Australia, 2006
Abstract This case study examines the ethical dimensions of isolation for patients diagnosed with tuberculosis (TB) in Australia. It seeks to explore the issues of resource allocation, liberty, and public safety for wider consideration and discussion.
Keywords Tuberculosis; Migration; Public health; Clinical ethics
Drug-resistant tuberculosis (TB) represents an ongoing concern in Australia, with 2 per cent to 3 percent of cases confirmed to be resistant to both of the first-line anti-TB drugs that are available, isoniazid and rifampicin (defined as multi-drug resistant TB or MDR-TB). In any one year, dozens of people in Australia will be diagnosed with MDR-TB, with this number likely to increase in line with global trends.
Xiang is a twenty-nine-year-old IT professional working as an expatriate in Australia. He has been sponsored by a large multinational IT company and has come to its Sydney office to oversee a project. He plans to stay in Australia for twelve months and then return home, where his wife, baby, and extended family live. Before being granted his visa to come to Australia, Xiang has a chest X-ray that shows no signs of pulmonary tuberculosis.
At the end of his twelve-month stay, Xiang is offered an extension of his contract and decides to go home to visit his family before returning to Australia for another year. He books his flight to Shanghai, and several days before his departure date, he attends a Visa Medical Clinic in Sydney for the medical examination required for his visa extension. He again undergoes a chest X-ray but is told by the doctor that this chest X-ray indicates a diagnosis of active pulmonary tuberculosis. Xiang has recently noticed a cough, but he had put it down to a normal winter respiratory tract infection. He also reported a five kilogram weight loss during the past six months, which he attributed to a stressful period at work. He is given a mask and is advised to stay home from work and avoid social situations until the nearest available Chest Clinic has reviewed his case. Investigation and treatment for tuberculosis through public Chest Clinics in Australia is provided free of charge. Visa Medical Clinics have established referral relationships with all public Chest Clinics to ensure that all potential cases of active tuberculosis detected in migrants are quickly followed up and managed. The doctor at the Visa Medical Clinic makes the referral to the Chest Clinic, and Xiang is sent home.
Later that afternoon, the Chest Clinic calls Xiang to set up an appointment for the following morning. His chest X-ray is once more repeated and again shows signs consistent with active pulmonary tuberculosis. Sputum is sent for bacterial culture and drug-sensitivity testing. He is admitted to hospital and isolated in a negative pressure room while standard oral induction medication for tuberculosis is commenced. He is told that he will need to remain in hospital for two weeks, so he postpones his flight to Shanghai by three weeks.
At the end of two weeks, his cough has increased and Xiang has had two episodes of coughing up blood. He remains in hospital and again delays his flight home. After six weeks, with no improvement of his chest X-ray or cough, sputum culture results indicate multi-drug-resistant tuberculosis (MDR-TB, a tuberculosis infection that has developed resistance to, at minimum, the first-line anti-tuberculosis drugs rifampicin and isoniazid), and he is changed onto a regimen of second-line intravenous and oral drugs.
Doctors now suggest to Xiang that he may be in hospital for some months. But when he tries to delay his flight further, he is told that no more changes are allowed and the ticket will be forfeited. He contacts his employer, who tells him that he has exhausted all his leave entitlements and that they are unable to hold his job open any longer. He no longer has an income source and thus cannot continue to pay for his mobile phone service and associated data charges. His contact with his family is reduced to a short weekly Skype call and then stops completely.
Due to the nature of his infection, hospital staff have minimal contact with Xiang, and he is often unable to understand what they are saying to him as they are wearing face masks. He does not understand when he will be able to go home, and with no income from Xiang, his family is unable to afford to come to Australia to see him. They also depend on his income and are soon unable to afford repayments on their home. His wife, now two-year-old son, and his parents are forced to move to a temporary shelter and lose contact with Xiang altogether.
After four months of treatment, Xiang is still not improving, and doctors advise Xiang that his treatment will be indefinite. He is not eligible for Medicare (a publicly funded health service available to all Australian citizens and permanent residents), and his private health insurance has reached its maximum payout figure for hospital treatment. The finance committee at the hospital is unsure whether it should be asking Xiang’s family, the Chinese government, Xiang’s Australian employer, or the Australian government to pay the mounting bills for Xiang’s care. At one case conference, a staff member flippantly asks, “Can’t we just send him home?” At this point, six months into treatment, Xiang’s medical costs have been estimated at approximately AUS$250,000. The hospital administrator has been asked to determine who will fund Xiang’s care indefinitely.
For many of those involved in the case conference, Xiang’s situation is deeply distressing. In part this is because Xiang is not improving clinically, despite optimal medical care, and he now appears to be disconnected from everything that provides him security and joy. But this distress is also because they feel that Xiang’s case raises a series of fundamental moral—rather than simply medical—questions that do not lend themselves to clear or easy answers.
Because Xiang remains potentially infectious, aviation standards state that he is unable to leave Australia by air. Given this, who should bear the costs of Xiang’s treatment and why?
In restricting Xiang’s liberty by isolating him for treatment, his lack of access to employment and money has directly affected his family back home. In accepting migrants and issuing visas for them, should a country’s social and economic duty of care extend to overseas dependents?
Should migrants be explicitly warned of the risks of long-term or indefinite isolation for resistant strains of tuberculosis before they enter a country?
Call for Responses
The case outlined above will be the basis for the “In That Case” section in the 13(1) issue of the Journal of Bioethical Inquiry (JBI) that will focus on “Tuberculosis and Ethics” in recognition of World Tuberculosis Day 2016. We invite interested readers to share their expertise and experiences and provide responses to the case for possible publication.
Responses should be 500–800 words, although longer manuscripts will be considered, and should conform to JBI style (see the Style Guide and/or the JBI Instructions for Bloggers). The editors reserve the right to edit contributions; however, editorial changes will be cleared with authors prior to publication. Responses should be submitted via the “Leave a Reply” commenting feature below. (You also may contact Consulting Editor and In That Case Editor Michael A. Ashby directly.)
Accepted responses will be published here at bioethicalinquiry.com. Additionally, online responses will be collated and summarized in an editorial commentary to be published in both the The JBI Blog and the next print issue. We also will encourage authors of some online posts and selected scholars with expertise in the topic area to write longer responses for the print version of the journal.
Please join the dialogue and debate. We look forward to hearing from you!