Leitmotif

Reason as the Leading Motive

Medical Ethics and Moral Dilemmas

Posted by Jerry on December 19, 2007

A story came up on Yahoo! News today about 49 highly infectious tuberculosis patients in South Africa who escaped from their hospital isolation units where they were being forcibly confined for treatment.

The last paragraph of the story evoked some interesting thoughts on the moral nature of this situation:

Although forced confinement of patients violates most medical ethics, authorities say they have no choice but to put the wider public good above individual rights. Confinement for XDR-TB is at least six months.

I can reasonably assume that the South African authorities are functioning on a utilitarian ethical system in their decision-making: individual rights are dispensable in the name of “public good” as defined by authority. 

Is having an infectious disease grounds for limiting–or even denying–the right to liberty? Is it a crime to live in a society with a highly infectious disease?

I am not entirely confident of the answers I am about to offer and of all their implications. My aim, however, in writing this post is to clarify the moral and legal dilemmas that arise from health-related conflicts of interest. More importantly, I wanted to examine these apparent conflicts from an Objectivist perspective because, largely, the field of medical ethics has been dominated by utilitarian, altruist, and religious moralities–often proposing grotesque solutions that makes one wonder if the situation hasn’t been worsened further.

I believe that the Objectivist theory of rights offers by far the most robust framework of principles against which such moral dilemmas can be analyzed and successfully resolved. Having said that, what follows is my own application of the Objectivist ethics to the situation being discussed; this does not mean that my application is accurate or that this is what Objectivism prescribes.

The Yahoo! news report only states that the individuals have highly infectious tuberculosis. There are several kinds of tuberculosis and it should be clear that to have a highly infectious disease is not necessarily to have a contagious or communicable disease. Tuberculosis of some kinds are highly communicable, but not all of them are.

Individuals with fatal, life-threatening, and communicable diseases pose a real and direct threat to the lives of healthy individuals in their normal surroundings. In this sense, the existence of such a disease in a general environment can be thought of as the existence of force or threat to individual rights in society. To illustrate:

A person who walks on a busy street with a knife in his pocket has not committed any crime and is well within his rights. However, the moment he draws his knife menacingly at another unsuspecting and innocent individual and stands poised to attack, he has created a context of force, introduced a threat to life, and has abandoned the context of freedom that makes rights possible. Therefore, at this moment, even if physical contact between the attacker’s knife and the other individual has not occurred, and even if he has not lunged forward with his knife to attack, the man has committed a punishable crime.

Likewise, an individual with a highly infectious but non-communicable disease existing in a public environment has committed no crime and remains well within his rights: he is like a man walking with a knife in his pocket. However, if the individual is aware that his infectious disease is communicable and life-threatening, then he properly should choose to or be forced to separate from healthy individuals in his environment.

Further, despite his knowledge that his disease is life-threatening and communicable, if the man makes a deliberate, careless, or negligent act of transmitting the life-threatening disease to another unsuspecting or unwilling person, he has introduced the threat to life and relinquished his right to live freely among healthy individuals in a non-threatening environment in society.

Yet, this does not mean that the person with the disease should be imprisoned as a criminal; it certainly does mean, however, that such a person with a life-threatening and communicable disease must be isolated and quarantined. And then, it is up to the victim of this person’s actions whether or not to pursue criminal or civil charges against the infected individual for his negligent or deliberate endangerment.

Going by the above framework, a communicable disease that is not life-threatening does not meet the criteria for isolation from society or legal charges, because there is no actual threat to life, which is necessary to invalidate the existence of rights. Likewise, a highly infectious individual with a non-communicable disease poses no threat to the lives and rights of other individuals and therefore cannot be denied any of his own legitimate legal rights.

Thus, it is not matter of public good versus individual rights but an issue of force (or threat to life) versus rights.

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8 Responses to “Medical Ethics and Moral Dilemmas”

  1. jonolan said

    When people suffering from active pulmonary TB cough, sneeze, speak, kiss, or spit, they expel infectious aerosol droplets. A single sneeze can release up to 40,000 droplets. Each one of these droplets may transmit the disease, since the infectious dose of tuberculosis is very low and the inhalation of just a single bacterium can cause a new infection.

    I’d say that people are most definitely a risk to the public health and need to be quarantined.

  2. rambodoc said

    XDRTB is now a horrendous threat to humanity. The nineteenth century sanatoriums for TB patients are probably going to be needed all over again, as this disease spreads like cancer within the patient’s body and fells him in a few weeks.
    A patient of XDRTB should definitely be quarantined. Letting a guy free to roam around in a city is like a germ attack by an enemy country. After all, a bioterror attack is just like this in practical terms, if not intent. So, pre-emptive quarantining is quite rational.

  3. jonolan said

    Rambodoc,

    Amen! When you add both the fact that XDR-TB has a vicious synergy with AIDS and the fact that Africa has a huge population of IADS /HIV victims, this could be even more devastating.

  4. Ergo said

    Rambodoc,

    I know that TB’s rather prevalent in India. But I’ve also heard something about how most Indians test positive for TB even when they don’t actually have the disease, due to some kind of vaccine or other antibody that most Indians have from their early childhood. So, how true is this? Do we have more false-positives for TB in India? And if so, how can one ascertain for sure the number of genuine TB infections, in order to take the necessary steps?

    Btw, the germ attack analogy is spot-on. Wish I’d have thought of it. :)

  5. rambodoc said

    Ergo,
    The Mantoux test is a virtually useless test that tests positive in most people because of the BCG vaccine that everyone takes in infancy. The need to take this vaccine at all has itself been questioned. A Mantoux test report should not be taken as proof of TB, though it still is wrongly believed by many physicians to be so. A proof of TB (very difficult in some cases) rests on hard evidence like seeing the bacillus in microscopic stains of pus, urine, sputum, etc., or in biopsies that show the classic lesion of a specific type of inflammation called a ‘caseating granuloma’.
    MDRTB is not regular TB. It is a fearsome scourge. We don’t have it yet. If it does come, I fear for all of us, with such primitive infrastructure in public health prevention and care. Thanks.

  6. Ergo said

    Rambodoc,

    To my knowledge, the mantoux test is administered almost always for all patients suspected with TB in India. Many years ago, I briefly dated a Canadian pharmacist guy who told me about the BCG vaccine and that this vaccine is mostly given to Indians and is not particularly prevalent in Western countries.

    Also, in a similar kind of case, I’ve heard that testing for HIV also results in a remarkably high number of false positives (somewhere in the range of 60%), even when using what is known as the Gold Standard of HIV testing, the PCR. Apparently, some of the people falsely tested positive for HIV might actually be having antibodies for other viruses or infections. And when they are administered anti-retroviral therapy, many of them succumb to the harsh side-effects of the drugs than to the illnesses associated with HIV/AIDS.

    Anyway, there’s so much conflicting and incomplete information out there; it’s naive to think that science is scrupulously conducted without any socio-political agenda. Scientists–like anyone else–function on the basis of a philosophical framework (explicitly or implicitly); the problem arises when their philosophical framework is grossly incorrect, contradictory, mistaken, or downright inimical to human life (like environmental and religious scientists).

    Well, thanks for your contribution here Rambodoc.

  7. Teddy D said

    Ergo, I’ve enjoyed viewing your site – lots of great ideas and well-reasoned views!

    All I would add to your post on *Medical Ethics and Moral Dilemmas* is the following: To paraphrase AR, there is no such thing as the *right* to violate the rights of others. If the best available scientific information determines that an individual’s unrestrained access to others poses a health threat, then medical quarantine is the proper and moral action to take.

    Regarding *rights* in general, I would go further to say that any individual has the right to take *any* action he/she wishes (rational or otherwise) *except* an action that violates the rights of other individuals. Of course, *application* of this principle is a complex undertaking but as a basic statement of the nature of rights, I believe it is valid. Thank-you for providing a forum for posting such views.

  8. Ergo said

    You’re welcome, Teddy; and thanks for visiting!

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