Reciprocity and Ethical Tuberculosis Treatment and Control

Abstract

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis (TB) treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means of justifying the use of reciprocity through appeal to different moral and political theoretical traditions (i.e., virtue ethics, deontology, and consequentialism). We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others (even if they derive a benefit themselves). We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally.

COVID‐19 in the public housing towers of Melbourne: upholding social justice when invoking precaution

“…The precautionary principle has been explicitly used on countless occasions in the context of health and public health; examples abound, including its use in environmental health law 2 to provide residents of the towers with food and other provisions 4 -though some question the execution of these measures 5 -is an example of addressing these risks of harm that are created by acting on the basis of precaution. Doing so is in keeping with the principle of reciprocity 6 and fits with the views of Australian residents. 7 Second, evidence exists (and is often overlooked) to strongly suggest that it is persons who are socially and politically marginalised who are often subject to coercive measures in the name of public health.…”

How mandatory is the mandatory reporting of children at risk?

“…The experience of public health authorities in adults with TB who are failing to comply with anti‐TB treatment suggests that better communication and ongoing persuasion are more effective in improving compliance than attempts at compulsion, for example, via a public health order. Compulsion infringes the competent adult's autonomy but may be ethically justifiable to reduce the risk of TB to others . However, compulsion is likely to alienate the TB sufferer, resulting in worse compliance.…”

Eliminating latent tuberculosis in low-burden settings: are the principal beneficiaries to be disadvantaged groups or the broader population?

“…In contrast, recent proposals to systematically screen populations in high-burden settings for active disease are more closely aligned to providing benefits to individuals, with the anticipation that populations will also reap rewards from lower transmission rates and burdens of morbidity 17. In the case of LTBI screening programmes, encouraging individuals to take on burdens for the good of society mandates some form of reciprocal arrangements 27. It is laudable, therefore, that the guidelines of the WHO's End TB campaign insist that enhanced social protection and health coverage for disadvantaged groups subject to targeted LTBI screening must be part of the intervention—as pay off for participation 4 5.…”