Confinement for extensively drug-resistant tuberculosis: balancing protection of health systems, individual rights and the public's health

Abstract

In the context of an expanding tuberculosis (TB) and human immunodeficiency virus (HIV) epidemic in South Africa, enforcing involuntary admission for extensively drug-resistant TB raises many ethical and human rights dilemmas, principally because it trades off the human rights of individuals for the public good. However, the dichotomy may as well be conceptualised as being about competing rights claims and the rights obligations of the state to control infectious diseases. Superficial analyses of the ethical and rights issues in managing drug-resistant TB patients are more likely to do harm than good. This paper argues for a more nuanced dialogue about these difficult policy choices, providing a more careful human rights analysis, using established analytical frameworks, to tease out the possible criteria that could justify limitation of individual rights. Generally, only in very restricted situations, where there is a clearly defined risk to one or more third parties, based on evidence, and conditional on careful consideration of available alternatives, should involuntary admission be considered. Community-based strategies will need to be developed to cope with infection control without forced admission for most cases, particularly in high-prevalence settings typical of many developing countries. Even when involuntary admission is indicated, strict adherence to administratively just procedures would be required. Confinement has no place as a strategy for the broader control of the epidemic, which is contingent on sustained commitment to improved health system functioning and action to address the abysmal investment in research and development for drugs for neglected diseases worldwide.