Ethical aspects of directly observed treatment for tuberculosis: a cross-cultural comparison

Abstract

BackgroundTuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective.DiscussionResearch from Ethiopia and Norway demonstrates that the rigid enforcement of directly observed treatment conflicts with patient autonomy, dignity and integrity. The treatment practices, especially when imposed in its strictest forms, expose those who have Tuberculosis to extra burdens and costs. Socially disadvantaged groups, such as the homeless, those employed as day labourers and those lacking rights as employees, face the highest burdens.SummaryFrom an ethical standpoint, we argue that a rigid practice of directly observed treatment is difficult to justify, and that responsiveness to social determinants of Tuberculosis should become an integral part of the management of Tuberculosis.

Tuberculosis elimination in the post Millennium Development Goals era

“…(5) Establishing a reliable monitoring, recording, and reporting system for program supervision and evaluation. 15 Yet, the central element for the patient is the direct observation of treatment, which has been questioned because of the imposition on patient autonomy, 16 and this approach has not been found to be more effective than self-supervision of treatment. 17,18 Further, in terms of effectively combating TB and leading the path towards elimination, DOTS alone will likely be a very insufficient measure; 19,20 a number of approaches will be needed.…”

Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions

“…Consider DOT (Table1), which requires a person with TB to swallow medication under supervision. [31][32][33] Under a decisional conception this unavoidably diminishes people's choices-they must take and be observed taking the medication-and is thus likely to be paternalistic. A relational conception, in contrast, is more nuanced.…”

“…For example, DOT has been criticised for restricting opportunities for people with TB to seek or continue in employment, and then, because of the consequential loss of income, closing down other opportunities for them and their families. 32,33 The ability to work and earn income is a freedom basic to self-determination, and thus one of the external, structural conditions for self-determination in a relational account. A relational account also encourages attention to the effects of intervention on self-authorisation, which relies on self-respect, self-trust, self-esteem, believing oneself worthy to give reasons for ones actions, and being recognised as worthy.…”

Türkiye’de tıp etiği bağlamında tüberküloz tedavisi

“…Information about literature shows us in many countries like Turkey, patients with TB were deprived of their autonomy and lacked the opportunity to influence the delivery of their own health care. Patients were never given reasons why their treatment was organized in such a way, and nor was the inherent element of force or involuntariness ever explained or justified (16).…”